"Officially" joining the club

[Jay4546]

I am unfortunately "officially" joining the club after getting my biopsy results today. Eager to hear what everyone thinks or has anything they see in the report I wouldn't have thought of. I'll post the whole thing, my doc and my own comments, and then cut/paste all my MRI results in case anyone REALLY liked data. Thanks!

TRANSPERINEAL MRI GUIDED BIOPSY RESULTS

1. Prostate, right lateral apex:

Benign Processes:

Benign fibromuscular stroma; no prostatic glands are identified

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2. Prostate, right lateral base:

Benign Processes:

Benign prostatic tissue

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3. Prostate, right medial apex:

Benign Processes:

Benign fibromuscular stroma; no prostatic glands are identified

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4. Prostate, right medial base:

Benign Processes:

Benign prostatic tissue

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5. Prostate, left medial apex:

Benign Processes:

Benign prostatic tissue

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6. Prostate, left medial base:

Benign Processes:

Benign prostatic tissue

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7. Prostate, left lateral apex:

Benign Processes:

Benign fibromuscular stroma; no prostatic glands are identified

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8. Prostate, left lateral base:

Benign Processes:

Benign prostatic tissue

Atrophy

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9. Prostate, left anterior MRI lesion:

Adenocarcinoma:

Prostatic Adenocarcinoma

Prostate Cancer Grading:

Primary Gleason grade: 3

Secondary Gleason grade: 4

Total Gleason score: 7

Grade Group: 2

Tumor Quantifications:

The total number of cores identified is 3

The total number of cores with carcinoma is 3

The percentage of tissue with carcinoma is 70%

The linear amount of tissue with carcinoma is 23 mm

The percentage of Gleason grade 4 and/or 5 is 5 %

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10. Prostate, right anterior MRI lesion:

Adenocarcinoma:

Prostatic Adenocarcinoma

Prostate Cancer Grading:

Primary Gleason grade: 3

Secondary Gleason grade: 3

Total Gleason score: 6

Grade Group: 1

Tumor Quantifications:

The total number of cores identified is 3

The total number of cores with carcinoma is 3

The percentage of tissue with carcinoma is 45%

The linear amount of tissue with carcinoma is 11 mm

Other Features:

Perineural invasion is identified

MY THOUGHTS AND ANYTHING DOCTOR NOTED:

* Asked and Dr. said he isn't overly concerned about perineural finding with the grade and it won't impact treatment options or overall prognosis. Noted that some don't even include on report and should be looked as something to note but not obsess about.

* He said probably not candidate for watchful waiting because of tumor volume shown and seen on MRI. TZ zone more beneficial, but fairly large compared to whole gland and proximity to capsule edge would likely mean treatment would be suggested. He also said I would tolerate any option well based on my age and health.

* I guess I now believe in the value of MRI first and targeted biopsy next then take note that my systematic biopsy cores showed 0 positive in 8 cores and my MRI guided core samples were 6 for 6 being positive. Then again the positive cores might have still been hit with an ultrasound biopsy since the lesions were so big.

* Should still go for a Johns Hopkins second opinion on the pathology or is that overkill since the first one was done at MSKCC? I guess TWO national centers of excellence are better than one? Wow, I sound like a snob now! Let me know what everyone thinks if you see anything interesting or of note here or just have some advice. THANKS!

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PREVIOUS MRI RESULTS (LOTS of them)

BASE DATA:

53 years old

very active...run/cycle 6 days a week

24.5 BMI

2/13 PSA 5.2/fPSA 12.5% taken AFTER DRE (negative DRE) (lab #1)

2/23 PSA 4.7/fPSA 12% taken for 4K score (lab #2)

3/3 4K score 19% (high end of intermediate)

4/16 3T MRI performed (reports/re-reads below)

5/10 PSA 4.2/fPSA 9% taken at MSKCC (lab #3)

ORIGINAL MRI REPORT (local radiology group):

Prostate volume: 17.58 cc

Prostate dimensions: 4.1 x 2.8 x 3.4 cm

PSA: 4.7 ng/ml/PSA density: 0.27 ng/ml2

Transition Zone: In the left base, mid and apical transition zone there is a large mass measuring 2 cm in size which has

poorly defined margins and intermediate to low T2. This shows very high signal intensity on the diffusion-weighted

images and markedly reduced ADC. The lesion also shows focal increased permeability. This is a PI-RADS 5 lesion in

the transition zone.

Peripheral Zone: The peripheral zone is of normal homogeneous prolonged T2 and there are no suspicious focal areas of

restricted diffusion.

Seminal vesicles: The seminal vesicles are normal and symmetrical bilaterally.

Extracapsular extension: The prostatic capsule is preserved. The neurovascular bundles are intact. There is no evidence

of tumor in the rectal prostatic angles.

Bladder: Normal.

Lymph nodes: There is no suspicious lymphadenopathy in the pelvis.

Bones: There is marketed marrow heterogeneity in the pelvic bones are not in the femoral heads. Question anemia.

Metastatic disease considered less likely for this pattern.

Other: There is trace ascites in the mesosigmoid.

(PZ) - normal

(TZ) One suspicious area - lesion size: 2cm x 1.4 cm

Extraprostatic extension: negative

Intensity: min 148 / Max 459

ADC: mean 879 / median 839 / st dev 223

MRI RE-READ #1 (well known radiologist, but free advice over phone, but no written report):

Interesting differences:

Using the Bullet Volume gives you gland of 25.55. Using an Ellipsoid Volume the dimensions would give you a volume of 20.44. Both of which are normal volumes, the Bullet Volume is considered more precise in prostates smaller than 55ml. NOTE: THINK THIS LOWERS MY PSA DENSITY SOME IF MY GLAND ISN'T a 17CC PEANUT!

Dr. said pirad-5 and to prepare for bad news and probably around a Gleason 7 and that he is rarely wrong. However, he also said it's treatable even at a 2cm size and the transition zone is a favorable spot.

MRI RE-READ #2 (VERY VERY well respected radiologist):

The prostate gland is slightly enlarged secondary to transition zone hyperplasia (25cc total)

prostate volume). The peripheral zone has a patchy signal pattern.

Lesion 1: Left mid-base transition zone.

Greatest dimension 2cm. No extraprostatic extension.

T2W MRI score= 5, DW MRI score= 5, DCE MRI score=positive

Overall PIRADS Score: 5/5

Lesion 2: Right mid anterior transition zone.

Greatest dimension 0.7cm . No extraprostatic extension.

T2W MRI score= 2, DW MRI score= 3, DCE MRI score=positive

Overall PIRADS Score: 2/5

Seminal vesicles are normal. Low volume post-void residual urine is present in the bladder.

Axial T1-weighted images of the pelvis show no bony or bulky nodal disease.

IMPRESSION:

1. MRI obtained outsideon 04/16/2021.

2. Left mid-base transition zone (PIRADS 5). There is no extraprostatic extension.

3. Right mid anterior transition zone (PIRADS 2). There is no extraprostatic extension.

4. Slight BPH findings. Seminal vesicles are normal. Low post-void residual volume is

present in bladder.

5. There is no bony or bulky nodal disease in the pelvis

MRI RE-READ #3 (National Cancer Center of Excellence):

MEASUREMENTS:

* Prostate size: 3.9 x 2.8 x 3. cm

* Prostate volume: 22 cc

* Membranous urethral length: 1.2 cm

PROSTATE ADDITIONAL FINDINGS: Benign prostatic lesion. Diffusely decreased

peripheral zone signal intensity on T2-weighted images. Slightly

asymmetric central zone tissue more pronounced on the left.

PROSTATE LESIONS:

LESION 1

* PIRADS v2 Score: 5

* Size: 1.5 cm

* Location: Left, anterior, base to apex, transition zone

* Extracapsular extension: Possible involvement of the anterior

fibromuscular stroma, anterior prostatic contour is smooth.

* Seminal vesicle invasion: None.

* Adjacent organ invasion: None.

LESION 2

* PIRADS v2 Score: 3

* Size: 1.1 cm

* Location: Right, anterior, apex, peripheral zone

* Extracapsular extension: None.

* Seminal vesicle invasion: None.

* Adjacent organ invasion: None.

PELVIC LYMPH NODES: No adenopathy.

BONES: No suspicious osseous

lesion.

OTHER: None.

IMPRESSION:

1. Suspicion for malignancy left anterior base-to-apex transition zone;

probably organ confined disease. PI-RADS v2 score: 5.

2. Possible additional organ confined malignant lesion in right apex

transition zone.

3. Diffuse probable benign peripheral zone changes limit evaluation for

focal peripheral zone lesions.

[Justfor_]

Soft landing for PIRADS 5. Rejoice.

[Tall_Allen]

I think MSK is good enough.

Normally, you would be a good candidate for active surveillance, but your urologist raises some good points. I actually disagree about the PNI - I think it precludes active surveillance:

prostatecancer.news/2018/03...

If you are on the fence, you can ask for a Decipher or a Prolaris report.

Here are questions to ask the urologist who did your biopsy:

prostatecancer.news/2017/12...

The good news is you have plenty of time to make an informed decision. I hope for now and for at least 3 months you will decide not to decide. A year would be fine.

If you are at MSK, you have some of the best doctors in the world to choose from. Definitely talk to Michael Zelefsky. If I lived in NYC, I'd talk to Ash Tewari at Mt. Sinai about RP. He is an innovator.

[PCInPA]

Certainly a club none of us want to join but your results do indicate a high likelihood of favorable outcome. Given that your prostate size is normal, you have many options.

You will find lots of support and knowledge here. Guys like TA are extremely knowledgeable.

Take time to explore your options with an open mind.

Youu are already at a center of excellence which is great but don't hesitate to seek other opinions.

Thee hardest part is deciding which route to go down, none are great and they all have pros and cons.

Ass in my case, some may be eliminated for you so keep an open mind.

Whatt is right for one person may not be right for you. Don't make a decision based on what happened to a single relative or friend.

Seek out experienced specialty practitioners but do not underestimate the importance of bedside manner.

Be wary of those who will gladly charge you big $$$ for unproven therapies based on anecdotal evidence. You want to be a doctor's patient, not just his next customer.

Good luck. As I snarkily say to myself in this case, "may the odds be ever in your favor".

[Fabio_08]

Good to hear that things are looking up!

If you don't mind me asking, why did you have so many different MRI's taken?

[Justfor_ in reply to Fabio_08]

Don't think he had multiple MRIs. He just had the same MRI read by two additional radiologists to get a second and a third opinion. Very prudent movement for his part.

[Jay4546 in reply to Justfor_]

Right. I moved my care from my local urologist to Memorial Sloan in NYC. That is GREAT, but it also meant a 3 week wait for a consult and then a 3 week wait for a biopsy. During that time I figured why not get some more eyes to see the MRI scans and see if they saw anything different or worth mentioning. I was getting the MRI guided biopsy either way. I thought it was interesting that two people found a lesion on the right side, where two didn't. I also found it interesting that my prostate size (and subsequently PSA density) was slightly different with who was doing the reading (from 17cc to 25.55 cc).

[Magnus1964]

Getting aggressive now could save you years of long battles in the future.

[CHPA]

Welcome to the club. Lots of good info on the Prostate Cancer Foundation page. But bottom line will be a choice of surgery or radiation. I chose the former at 57 and no regrets a couple years later.