I am new here and I have two questions in my mind:
1. Biopsy data of right side is (left side no cancer):
- 5/6 cores contains cancer
- Gleason 4+5
- percentage of tissue with carsinoma is 21%
If I understand correctly 21% is not very bad value. Does it make situation any better?
2. So far we have only PSA-value 40, biopsy results and normal ct-scan. Waiting for more bone scans and meeting with doctors will be after that. Ct-scan result was that couple of lymf nodes are bigger than normal but he had same time somekind of inflammatory (crp>200) so maybe it can also affect lymf nodes. Other organs are ok and not any signs of metastases. Bones also ok. I am wondering that is normal ct poor to show bone metastases or can we be a little bit relieved regarding to bone involvement?
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Daughter17
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1. No. The Gleason 9 and PSA=40 means he is "very high risk," whatever the percent cancer is.
2. The lymph nodes are probably inflamed because of the cancer in them. If the bone scan was negative, that is favorable. He should still have a PSMA PET/CT scan before deciding on next steps.
As Tall-Allen mentioned, you are still considered very high risk. I too am a Gleason 4+5 with only 5% category 5. Unfortunately, due to the biopsy being random which leads to sampling errors, the actual percentage is not considered. For example, suppose for a moment that the biopsy needle was placed a few mm in a different direction and returned a value of 90%. This could have easily been the true situation. So they do not not consider the percent when stratifying risk classification.
We are high Gleason. PSMA PET scan was ordered to check for distant cancer cells.
with a Gleason 9, very high risk. One side clear? To me that means that the stick to that side simply missed cancer cells. This is common. Continue on with testing. Not a time to panic, however be realistic.
Follow advice from your prostate cancer pro. Learn about micro-metastasis and how systemic treatment can possibly halt spread and kill the little bastards. Good luck.
Not necessarily, I have unilateral GS 4+5 proven on biopsy, MRI and F-18 PSMA scan. You just can’t discount the aggressiveness of the tumor by looking a the reported percentage of core value. Even a low percentage, such as mine, still means that I have an aggressive tumor. As such, I elected ADT (2 years) + HDBT + EBRT. I have tolerated the Lupron very well. I am one of the very lucky ones who have experienced zero side effects thus far. The HDBT was more than I thought it would be. Finally, I have had two EBRT sessions so far. Again, these have been difficult for me. You have to report to the center with a full bladder but EMPTY rectum. Otherwise, stool in your rectum will push the rectal wall closer to the prostate. Keep in mind, they take a very limited scan of both your bladder and rectum before proceeding. On both of my treatments, they had to abort the treatment, get me off the table so I could go use the bathroom, then rehydrate and patiently wait for my bladder to refill. Everyone, including both staff and other patients, fall behind in schedule. I was embarrassed. Probably too much information but things you should know if you choose the same treatment.
I thought I was the only one who had some dreadful IMRT radiation sessions (I had 25 in all). A couple of times they stopped the session and made me go have a bowel movement, which was really embarrassing. And some of my sessions lasted an hour, instead of the usual half hour, because my bladder kept twitching, making it hard for the CyberKnife robotic radiosurgery guidance system to function. It was so aggravating at times that it helped me make the decision to go with LDBrachy instead of getting another 5 weeks of IMRT sessions. I even started making the sign of the cross for luck before the IMRT sessions, which got a big laugh from the radiation techs initially, but then they started reminding me to do it because I actually did have more uneventful sessions after doing it. Go figure! 🦊
I was Gleason 9 PSA 20 9 years ago. Did radiation and was fine but there were obviously micro mets and now I have stage 4 CRPC. If I had been treated with one of the new treatments such as LU 177, at the time, I could be cured now.
I highly recommend seeking any additional treatments that can be done now for micro mets. I do not know how you would qualify or if there are clinical trials, just suggesting that you check all possible treatments available now.
Daughter17, before any treatment and with the PSA values your Dad has he should ask for a PSMA PET scan...at PSA of 40 the specificity (finding tumors) and sensitivity (that those tumors are prostate cancer, PCa) are both very high. See this ART;
Also consider some genomic testing....Gleason for me is the 'direction' of the cancer; a 4+5 score is not a good path...but genomic testing can tell you the 'speed' of that travel. The cores that were taken can be tested for the genetic make up of the cancer and that can help your Dad finetune the treatment...I would suggest Decipher testing...if the cancer has a low Decipher and a high Gleason that is a different condition that you should know of...here is a good article on genomic testing and Decipher in specific....
This study is specific to cancer-specific survival for men with pattern 4-5 Gleason...it states in the study the following; "...the percent Gleason pattern 4/5 and lymph node status were found to be the only parameters that were predictive of cancer-specific survival. In the absence of any components of Gleason pattern 4 or 5 cancer, patients were essentially cured of prostate cancer after radical prostatectomy. The 10-year cancer-specific survival was 100%, 85%, and 67%, respectively, for those patients with 0% high-grade prostate cancer, 1% to 20% high-grade cancer, >20% high-grade cancer (Fig. 2)." Note that in the worst case your Dad has a 70% chance of being OK...pretty good all things considered. But find out what percent pattern 4-5 he has! Here is the article;
...this is a very stressful time and I remember those early days well...its important to take the time to know the disease, choose testing wisely and then adjust the treatment to match the conditions you actually have; there is no one-size-fits-all scenario with PCa. For me without a PSMA PET and some genomic testing you dont know what you dont know...also, find out what percentage pattern 4-5 Gleason your Dad has...let us know what happens and keep in touch...TNX
RMontana, thank you for providing the articles. I have sought long and hard to find similar publications, always coming up empty. Please note however that the prognostic value of the percent of tumor comprised of 4 or 5 Gleason pattern was not determined via biopsy. In this study, all patients underwent RP and the removed tissue was examined in the laboratory by a pathologist. The percent of total tumor that was comprised of Gleason 4 or 5 was determined. Additionally, the authors stated “ Recent studies have found that the volume of tumor present in biopsies does not correlate with the postoperative radical prostatectomy Gleason score, emphasizing the significance of small-volume, high-grade elements”. In my situation, I have 3/12 cores positive for cancer. The first two cores show GS of 4+5 (30% and <5% respectively) while the third core shows GS 4+5 (95% and <5% respectively). Yet, I have no ECE, SVI, Lymphadenopathy or metastasis as confirmed via DRE, MRI, CT SCANS, bone scans and F-18 PSMA. However, since I have a high Gleason score, my treatment has to include ADT + HDBT + EBRT to give me the best chance for survival. I think Daughter17 was underestimating the significance of the Gleason 4+5 cancer by relying to heavily on the 21% reported value for tumor/tissue ratio. As far as I understand, the reported value of 21% is useless. Great articles though and SOC treatments have evolved since the publication date.
I am not sure that you must have the triple combo therapy to give you the best chance. I think the studies include a broad spectrum of high risk patients with different diagnostic values, and may not reflect expected results for men VERY similar to your diagnostics. Theoretically, I agree the triplet therapy would seem to be most extensive and thus better probability of success. I have noticed that many of these studies find superiority for BCR -free and metastasis-free after certain periods of time, but fly in ointment is no observed significant difference in OVERALL SURVIVAL, which can be hard to understand, but fact is fact.
What warnings di your RO give concerning the ncreased probability of side effects when HDBT is used? Assume they are also including whole pelvic radiation? Congrats if you have found a convenient and highly experienced HDBT person!!! I think that TA has mentioned that HDBT with an experienced RO may have a better SE profile than LDBT option.
On your point of biopsy percent findings are not useful.....many nomograms, including I believe UCSF's Capra nomogram, the MSKCC nomograms and the British PREDICT nomogram, include cores taken, number positive, and highest Gleason core value. I don't recall that they include an overall percentage, but do place an importance on number of cores positive for PCA......but maybe not number of cores positive for highest Gleason score. Myself , I'd prefer fewer cores of Gleason > 3+4 as opposed to more cores of Gleason>3+4.
were it not for the possible toxicities of the various treatments, there would not be that much to discuss for men with PCa .....sigh the toxicities!
I think the core samples are not the greatest in determining much other than they got lucky and found some cancer. There should be some better way of finding out where the best place is to target. I know they have MRI but I think that doesn't always works out. My cores were 7(4x3) with 7 of 12 cores positive but my pathology was 9(4x5) and 40% of the prostate was cancer. I am glad I got it removed and could see how serious it was rather than getting radiation and thinking it wasn't aggressive.
Yes, a saturation biopsy that didn't pose such risks would be the best. Hopefully someday something like a PSMA PET will be very accurate..as I undersand, not there yet. Liquid biopsies someday? Once a concerning area is found by MRI, the combination of a one shot targeted plus 12 systematic cores seems to yield 25% more significant cancer diagnoses than 12 core systematic alone
I think 7 cores of 4+3 was considered serious by your Docs? If you discussed radiation, did they suggest ADT? If so, radiation may be OK, even with 4+4 or 4+5.
Jancapper...true the estimate in the article was from surgical pathology but in my view the prognostic value of knowing your percent 4-5 holds true even for core samples...dont know if a pathologist could look at the cores and estimate the percent 4-5 pattern presented and this could replicate, with a smaller sample, what is found after RP dissection of the gland...that would be my view. The good news for me is that even with the worst of cases your odds of beating this beast are good!
Also see if you can get some genomic testing, like Decipher, if you have not done so. It helped me make decisions on being more aggressive in my treatment because I had a genome pattern that was off the charts (0.97 out of 1.00 max for aggressiveness).
Thank you for the suggestion. None of my three physicians (Urologist, radiation oncologist x2) have even suggested the genomic testing. Initially, my UO did run a 4k test prior to my biopsy. This test placed me in the 19th percentile for having aggressive cancer. At this time, my UO actually told me that if I were a betting man, the odds were good (81% or better) that my suspicious cancer was non aggressive. But I was not satisfied and I requested the necessary biopsy. 3/12 cores positive with Gleason 4+5 cancer. I will have to ask about the Decipher test. I do like to look ahead and formulate a plan. I have completed my HDBT (15 Gy) and have begun my IMRT. Once complete, the waiting game begins. As I wait, it would be nice to complete the genomic testing so if I should encounter a biochemical relapse, new therapies can be initiated without delay.
How do you define % pattern 4+5? My results were....6 targeted cores of PIRADS 5 MRI area = all benign, plus of 12 systematic cores one was " < 10% 3+3 ", another was " <10% 4+5", and the other 10 were all benign. Neither the 3T MRI, or any of 3 scans including PSMA PET, found SVI ,ECE,etc. 2 radiologists at 2 institutions read the 1st MRI before biopsy......one is Hopkins trained. Only 1 Kaiser radiologist read the post-biopsy MRI. Prostate SUVmax was 8.
Lead prostate surgeon at MSK suggested genomic test to possibly help with decision on duration of ADT if I chose radiation and not RP. I think Medicare now covers genomic for high risk? NCCN also mentions for high risk....though I guess not yet SOC for a diagnostic tool? Would 4+5 found in only I believe 1/8" = 3 mm.....so one mm very small?
I'm definitely concerned about not only the most frequently discussed side effects of ADT, but also the bone weakening that can occur , as I'm already osteopenic, and not that far from osteoporotic at age 74. Been dosing 3000 IU vitamanin D for a number of months since DEXA scan....only done at my request!!!!!!!!!!!!!!!!!!!!!!! Blood calcium OK, D VERY low!!
Hopefully any comments on this will help some other men with similar circumstances!
Maley2711, I would think that the % 4-5 would be calculated/estimated by the pathologist who looks at all the cores and their GS representation...it would be (like Gleason itself) subjective, but based on expert judgement...I would ask and see what they tell you. If you can get a % of 4-5 it may give you some comfort to know where you are and given your age could provide relief from this monster we bear within us...regardless, even if you were >20% pattern 4-5 your odds of succumbing to PCa are about 30% in 10 years, so it could only improve from there by knowing your actual numbers.
ADT is a fantastic treatment with significant metabolic impacts (and severe effects on penile tissue health). Regardless, it saves lives for sure...I would use it again knowing that it did to me. Here is a good article on its effects; to be forewarned is to be aware;
Definitely get genomic testing...as I have concluded Gleason gives you the direction of the PCa; Genomics (especially Decipher) give you its speed...if you have a bad direction but a tortoise is carrying you there, you take a different approach to the journey.
Here is a great article on Vitamin D...amazing outcomes...I take it daily...
"Vitamin D deficiency prevalence is high in cancer patients ref 25,26, with 1 study reporting vitamin D deficiency in 72% of cancer patients; ref 19,27 Removing prostate cancer from analyses did not attenuate the observed effect of vitamin D supplementation on advanced cancer, suggesting the results were not driven by prostate cancer alone. Our findings suggest that vitamin D supplementation may be operating through a general, rather than site-specific, mechanism to reduce the risk of advanced cancer."
Thanks much for your caring and informative reply.....were that also the case with our Docs who seem just to be in a rush to see the next patient.....I suppose the system's fault, not individual Docs.
Hi maley2711, your question is the very essence of what we are debating here. Maybe your situation is a little different. Did you have an MRI before your biopsy? How did they do a targeted biopsy of suspicious PIRADS 5 lesions? My biopsy was completely random with no targeting. I may be wrong but most initial biopsies are similar. Therein lies the problem. Because the core samples are randomly obtained, the percent presence is not useful. That is how it was explained to me. If the needle was moved slightly, in any direction, you can not be assured that the same numbers would be obtained. So if you have a high Gleason core, the percentage of it is less important than the fact that you have a small high Gleason core sample. Aggressive little tumors have to be treated aggressively regardless of the percentages.
Yes, pre-biopsy MRI showed transition zone PIRADS 5 of significant size. 6 cores all negative!! an additional 12 systematic cores contained one core of < 10% 4+5 and a 2nd core of <10% 3+3. Yes, nomograms generally don't ask for %, but many well-known nomograms do ask for total number of cores taken, and number that were positive......implying some type of outcome probability associated with those specific numbers.....perhaps an estimate of how dispersed in the organ the PCa is? My 20-30 yr experienced uro said he couldn't recall having anyone else with 4+5 with so few cores containing PCa or 4+5.
Maley2711, after reading this, if you were me, I would get a second opinion from another pathologist on your Core samples. Get another set of eyeballs to read the cores again. I would also get genomic testing of the cores that were positive; a 4-5 GS with a low Decipher is a different beast all together...
Finally, as you go forward and consider therapy check out this lively debate between the two camps on which is best; RT or RP (radiation vs surgery)...its a balanced debate and has the pro and cons of each. Have these metrics in the back of your mind as you move forward.
I had a Transition tumor that grew to 1/3 the size of my prostate and NO ONE felt it. I had two Urologists and neither felt it; its on the front side of the prostate. You are very, very much better off now that you have an MRI and know its there. Get another one in 6 months, then again 6 months later. Find out if its growing. Keep it the heck away from the sides of your prostate and act before it gets there. I did not and by the time I found it via an MRI it was pressed up and growing against my bladder; you dont want to wait that long. ACT before it presses against and jumps outside your prostate. For what its worth and in case I have not shared it, this is my 'Woulda-Coulda-Shouda' list of what I would do, if by some miracle I could start over again...let us know what happens...TNX Rick
Thank you for caring, and an excellent suggestion that I should have considered or one of the 2 Docs should have mentioned. I think both Uro and RO in most such cases, including mine, just assume that the patient will listen to each Doc for 30 minutes, be terrified, and quickly decide on one or other immediaely. On other hand, some here have some understanding of the confusion a man my age would feel on gambling good current QOL for the hope of a cure but with substantail probability of immediate lower QOL ......and 2 years from now, kaput with heart attack.
Don't misunderstand..... a horrible cancer death also terrifies me. Seems like a Catch-22!!
Hi Rick, I’ve been visiting this site now for many months. This is the first time I’ve read your ‘woulda-coulda-shoulda’ post. It is excellent and should be pinned to all of the prostate communities.
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Elgie's bone scan and CT scan
PSMA PET-CT Ga68 Scan results
47yrs old 4.46psa Gleason 4+5=9
new and looking for resources Stage 4 metastatic. Gleason 9
Aggressive form of prostate cancer PSA 11.8 and Gleason score 9.
