Fathers biopsy reports

[MBguy]

Hello all, it's official..my dad has prostate cancer. He's 65 years old and in great health otherwise. He did not experience any symptoms that are associated with prostate cancer such as painful urination, polyuria etc. He is a very active guy and works construction. I finally got our family doctor to accept him as a patient, the DRE and physical went fine, however the PSA levels were 14.4, then 14.5 a week later. Two months after his PSA was 16.5. I've been doing as much research as possible to decide on the best procedure. My dad has his diagnostic imaging on Nov 18th and that will determine if his cancer is contained or has spread.

The following are the biopsy results

A) left paramedian apex (G 3+3=6) percentage of core involved with tumor 10%

B) left lateral apex (G3+3=6) percentage of core involved with tumor 3%

C) left paramedian middle (G3+3=6) percentage of core involved with tumor 30%

D) left lateral middle (G3+3=6) percentage of core involved with tumor 35%

E) left paramedian base (G3+3=6) percentage of core involved with tumor 30%

F) left lateral base (G3+4=7) percentage of core involved with tumor 20%

G) right paramedian apex (G3+3=6) percentage of core involved with tumor 30%

H) right lateral apex (G3+3=6) percentage of core involved with tumor 15%

I) right paramedian middle: High prostatic intraepithelial neoplasia (PIN)

J) right lateral middle (G3+3=6) percentage of core involved with tumor 1%

K) right paramedian base: High prostatic intraepithelial neoplasia (PIN)

L) right lateral base (G3+4=7) percentage of core involved with tumor 35%

Comments: The percentage of pattern 4 overall is very low (approximately 1%)

Perineural invasion present

We live in Toronto, ON. Any feedback, advice or experience would be greatly appreciated at this time! Stay well everybody

[Tall_Allen]

I suggest that he gets a second opinion on the biopsy results from Epstein's lab at Johns Hopkins. This is a very common thing to do. The cost is about $300 US:

pathology.jhu.edu/departmen...

There is no rush to come to a treatment decision. In fact, for now, I hope he will decide not to decide. Taking his time now does not increase risk and may prevent treatment regret later.

This is about the best patient guideline:

nccn.org/patients/guideline...

Your father is classified as "unfavorable intermediate risk" and there are many curative therapies available in Toronto.

The odds of his being cured by surgery are shown in this nomogram:

mskcc.org/nomograms/prostat...

As you can see for yourself, the odds that surgery will be curative for him is only about 42%. His odds get much better with certain kinds of radiation like brachy boost therapy or SBRT. That brings his odds of a cure up to over 85+%.

I suggest he make appointments to speak to Patrick Cheung and Andrew Loblaw at Sunnybrook to learn about brachy boost therapy and SBRT respectively.

[MBguy in reply to Tall_Allen]

Thanks for your very informative reply! Im interested in getting a second opinion done for sure. I don’t have the physical samples however, just the paperwork of the pathology. I would love to get in touch with Patrick Cheung and Andrew Loblaw, do you have any suggestions how I could book an appointment with either of them?

[Tall_Allen in reply to MBguy]

Call your urologist and ask his office to send the slides to Epstein. This is a common practice. Read the link on what to do if they don't do that regularly.

Here's contact info:

radonc.utoronto.ca/content/...

My mistake-- Gerard Morton is the RO at Sunnybrook who does brachy boost therapy:

radonc.utoronto.ca/content/...

[MBguy in reply to Tall_Allen]

Thanks again for your reply! I will definitely call the secretary and have her send the slides to Epstein. Thank you for the links, I'm not sure if I can just call the doctors at Sunnybrook and get an appointment or if I have to go through my urologist / GP. I will giving them a call regardless, cannot hurt.

[maley2711 in reply to Tall_Allen]

Allen - EXCELLENT links for the newcomer!! You say that Dad is unfavorable intermediate risk.......is that based on perineural invasion> the report states that grade 4 pattern makes up less than 1%.....without considering perineural invasion, would Dad be considered Gleason 3+4, or does unfavorable result from PSA>10, even for a man who is graded 3+4? would you rather be 3+4 with PSA 14, or 4+3 with PSA 7??

Interesting comment re improvement with radiation treatments vs surgery. Any studies at hand re that conclusion....valuable for all those, maybe yours truly, who may soon be facing that decision after biopsy.

[Tall_Allen in reply to maley2711]

Maley2711- I'm confused -- are you also MBguy?

The NCCN intermediate-risk group is currently defined as having any of the following:

- Stage T2b or T2c, or

- PSA 10- 20 ng/ml, or

- Gleason score = 7

(If multiple risk factors are present, the clinician may optionally deem it high risk)

To be "favorable intermediate-risk" one must be:

- NCCN intermediate risk, as above, but only those with

- Predominant Gleason grade 3 (i.e., Gleason score 3+4 or 3+3), and

- Percentage of positive biopsy cores <50%, and

- No more than one NCCN intermediate risk factor

To be "unfavorable intermediate-risk" one must be:

- NCCN intermediate risk, as defined above, plus

- Predominant Gleason grade 4 (i.e., Gleason score 4+3), or

- Percentage of positive biopsy cores≥ 50%, or

- Multiple NCCN intermediate risk factors

So because your father is GS 3+4, PSA is 16.5, more than half of biopsy cores are positive and there are multiple intermediate risk factors, he is unfavorable intermediate risk on several accounts. The PNI adds to the risk too.

This article has some source data on surgery vs radiation for unfavorable intermediate-risk:

prostatecancer.news/2018/10...

[MBguy in reply to Tall_Allen]

We are not the same people! Different cases I presume

[Tall_Allen in reply to MBguy]

My response was to MBguy. I don't know about your Dad's case.

[maley2711 in reply to Tall_Allen]

Allen -

What is Dad's clinical tumor stage as is requested in the nomogram?? Not sure I see anything for that in the post.

[maley2711 in reply to Tall_Allen]

Allen - Sorry! Upon review, looks like he would be rated T1c.....tumor detected using biopsy tissues

[maley2711 in reply to Tall_Allen]

Allen -

One more. Does cancer specific survival after surgery assume that a man undergoes additional treatment , eg radiation or ADT or chemo, after recurrence. I notice that progression-free survival probability is much lower than CSS! That wou;ld seem to indicate that CSS numbers include the expectation that a man will undergo additional treatments after recurrence occurs? Or alternatively, not undergo additional treatments but die of some cause other than prostate cancer?

[Tall_Allen in reply to maley2711]

More men progress after treatment than die of their prostate cancer. They may die of something else. The nomogram makes no assumptions. It is based on actual data among all men who had those characteristics before their prostatectomy.

[maley2711 in reply to Tall_Allen]

Allen - Interesting to play with that nomogram...which I had buried somewhere in my bookmarks! At my age 72, running the life expectancy without treatment shows little difference in prostate cancer death at 10 or 15 years , whether initial PSA is 8 or 15. Also, whether Gleason 3+4 or 4+3......no difference in expected number of PCa deaths. The big difference comes when Gleason is 8 or higher....pretty much doubles the number of deaths from prostate cancers. For 15 years out, which would be age 87 for me, with no treatment and Gleason 7 and PSA 8-15, 11 men with my numbers would die from PCa. However, with all numbers the same, but Gleason 8 or higher, 24 men expected to die by age 87. A risk taker at my age might might bet that something other than PCa would kill me by age 87....as there are only 11 PCa deaths , of 100 men, if initial PSA is 8-15 and Gleason 7 or lower. Surprised to see that 3+4 and 4+3 yield same Pca death rates!! I assume the difference shows up for younger ages?

The one question I have is...How would a man pre-surgery be able to know if evidence of metastases or lymph node involvement? The expectancy calculator asks for those variables?

[Tall_Allen in reply to maley2711]

If he is M1 or N1 on bone scan/CT, he probably would not have surgery.

[doc1947g in reply to Tall_Allen]

Excuse me to contradict you, but he is a G(3+4=7) Grade 2 so he is a Favourable Intermediate Risk.

[Tall_Allen in reply to doc1947g]

Nope. See reply above.

[doc1947g in reply to Tall_Allen]

Sorry, I made my comment before I read the other ones.

[MBguy in reply to Tall_Allen]

Hey Tall_Allen, do you have a link to the journey that you underwent or your specific cancer diagnosis and details ?

[Schwah]

TA is right. Epstein is considered the best pathologist for PC in the country by virtually everyone in the know.

Schwah

[Justfor_]

Diagnostic imaging should be multi-parametric MRI (mpMRI). In recent times it precedes biopsy. Old school doctors just do the opposite. The fact is that during biopsy the needle sampling of the prostate results in internal bleeding of the gland that subsequently obfuscates the following mpMRI. A minimum of 2 months between the two is claimed enough for healing. Probably, you have this time-distance already, yet I am mentioning this in order to make you aware of an outdated medical care.

[MBguy in reply to Justfor_]

appreciate the comment!

[maley2711 in reply to Justfor_]

Ye...even the AUA has updated its recommendation that MRI be performed 1st......but I think Docs are still not advising because most insurance still does not pay for MRI prior to biopsy.....also, are there enuf MRI machines to do the hundreds of thousands of additional mRIs that would be done for PCa suspects? Microultrasound TRUS would seem to be a vast improvement with a much lower cost to implement?

[Justfor_ in reply to maley2711]

I suspect it mainly has to do with professional segmentation. Urologists probably prefer maintaining the case within their professional boundaries than handing it over to another discipline, aka radiologists.

[maley2711 in reply to Justfor_]

Sadly, could be....for some. But Docs don't like to advise tests that they know are not covered by insurance...biggr factor IMHO. Also, admittedly there is a problem with training to achieve ACCURATE reads of prostate MRI. Here, I just learned that Kaiser urologists have thrown in the towel and succeeded in sending prostate MRI candidates outside.....t o local med school radiology. Too many disgareement re the correct PIRADS reading......more trust in radiology expertise at the med school facilities. My PIRADS 3 was upgraded to 5 at med school!! quite a depressing shock!! and I wasn't informed until 4months later!

[dadzone43]

Calm.

Plenty of time to read, learn more and select a treatment pathway.

[wuwei37405]

I have been dealing with prostate cancer for 20 years and have seen many doctors, urologists and oncologists. My advice is to put more faith in PSA readings and less in biopsies.

[Justfor_ in reply to wuwei37405]

Sound advice. Totally agree!

[MBguy in reply to wuwei37405]

Regardless , both PSA and biopsy reports suggest intervention is required

[wuwei37405 in reply to MBguy]

I have had two biopsy. Neither one produced what I would call useful information. However, both caused pain, bloody semen, and possibly spread the cancer beyond my prostate. My advice? Don't submit to biopsies. Also, it has been my experience that the treatment options offered are based on PSA and scans.

[Benz_16]

Hi - I had SBRT treatment Oct 2019 at Sunnybrook with a favourable outcome. PSA dropped from 14 to 1.3. My Oncologist was Dr William Chu. They are very professional!

[MBguy in reply to Benz_16]

Very interesting! Glad to hear that your PSA dropped so much. How was your experience at Sunnybrook / overall? Can you tell me anything about your cancer?

[Benz_16]

If you look at my 2 other posts, I give a summary of the diagnosis and a summary of the treatment and results. I was very happy with the Sunnybrook experience. The Urologists were keen on the surgery option, but made sure I considered the variety of radiation treatments, arranging a consultation with Dr Chu.

[MBguy]

Appointments booked with St.Josephs hospital

Bone total body with SPECT on Wednesday Nov 18th

CT- Abdomen/Pelvis enhanced 300 on Nov 22nd

[jkm100]

I had HDR brachy at Sunnybrook over a year ago. No complaints. Loblaw was great. So far so good.

[MBguy in reply to jkm100]

Thanks for replying. Nice to see a couple people that have replied have had good experiences at Sunnybrook! I will be asking for a second opinion from Andrew Loblaw and Gerard Morton for sure

[MBguy]

The bone scans came back negative, still awaiting the CT scans.

[MBguy]

The CT scans came back negative, the urologist is pushing for surgery. We have set up a meeting with the urologist next Thursday at 3:30. We will try to get an appointment with an oncologist at Princess Margaret or Sunnybrook hospital. I have started to get the paper work together and in motion to get a second opinion on the biopsy (Jonathon Epstein at John Hopkins). Things are coming along! Prognosis is not bad as of right now

[MBguy]

Got an appointment with Dr. Andrew Loblaw on Dec 10th at Sunnybrook hospital

[Murk]

Urologists always recommend surgery. If your traveling from Canada to USA then you're outside of the Government health care systems.

If so I would listen Tall_Allen above as well as search out the best here in the USA. Get second opinions don't treat this like simple operation. There are options but the good news is you have time, PCa moves slow so step back, relax and investigate...

I am a patient at Hopkins with Dr. Pavlovich who is freekin great, but you need to talk to Oncologists / Radiation oncologist etc

[MBguy in reply to Murk]

Appreciate it, the appointment at Sunnybrook is with an oncologist