Follow-up biopsy at MSK

[rosenjpj]

I was diagnosed with PCa in October with G6 in 5 of 12 cores. Prolaris molecular score was 4.3 which is more aggressive than patients in the same risk category (low/very low risk). I had a follow-up MRI in November but it was inconclusive with a single PIRAD 3 lesion.

After doing a lot of research and getting great advise here (especially from Tall Allen), I decided to go with Memorial Sloan Kettering and Dr. Behfar Ehdaie. I have also been following a plant-based, whole foods diet since my diagnosis and my last PSA in January 2021 was 3.6 ( down from 5.5 in in March 2020).

I had my follow-up biopsy on 5/26 at MSK. The experience was night and day compared with the first one done by my local uro doc. MSK is a world class institution and you can tell the moment you walk in the door. I can't say enough about the professionalism and compassion of the entire staff. Based on everything I read here and elsewhere, I had a transperineal biopsy instead of transrectal procedure to minimize the risk of sepsis. Also, unlike the first time, I had general anesthesia for this procedure which made it sooo much easier. Recovered quickly from typical symptoms (blood in urine and semen).

RESULTS: Systematic biopsy of 10 cores. 7 were benign. Two were G6 (6% and 45% with carcinoma) and one was G7 (3+4). The core with 3+4 was 50% with carcinoma of which 2% was G4+. Based on the G7, my NCCN risk changed from low/very low to Intermediate/favorable risk. The doctor ordered another Prolaris report to see how aggressive my cancer is compared with the norm for intermediate/favorable risk. I will visit with Dr. Ehdaie on July 2 to discuss his thoughts moving forward. I also asked for a second opinion from Jonathan Epstein at Hopkins on the pathology report. Hopefully we will have the Prolaris and Epstein report by the time I meet with Dr. Ehdaie.

The Doctor's initial assessment is that I can stay on AS since 1) the G3+4 was present in only one core; 2) the percent with g4+ in that core was low; 3) the other two cores with carcinoma were G6; and 4) 7 of 10 cores were benign.

I look forward to continuing on this path assuming there are no negative consequences from the Prolaris or Epstein reports.

[Tall_Allen]

MSK is actually one of the few institutions where I think their pathology report is as good as Epstein's. AS still sounds good, even with a moderately good Prolaris score. IDK how long you'll be able to stay on AS, but with Ehdaie monitoring, I think you can feel comfortable.

[Hope4Happiness]

Very glad to hear of your satisfaction with MSKCC. I am currently on AS there (since 2017) and have Dr. Ehdaie as my doctor. I have a transperineal biopsy schedule at the end of this month -- My first one of this type as my previous seven (!) have been transrectal. I had an MRI recently and it revealed a PIRADs-3 lesion -- in addition, my PSA, my free PSA, and my prostate size keep rising... So, this could be a change in my cancer situation or an increased case of BPH.

During the 10 years I've been a patient at MSKCC, I've been very impressed with the amount of information they provide the patient and the focus on the options best suited for the patient more so than having just one doctor talk about his/her expertise. When I was first diagnosed, I ended up consulting with a surgeon and two ROs (one discussed brachytherapy; the other, MSKCC's version of SBRT) there.

[rosenjpj in reply to Hope4Happiness]

Good luck with your upcoming biopsy. There was a huge difference between my prior TRUS biopsy in October and the Transperineal approach last month. It was so much better being asleep through the procedure and having near zero risk of sepsis. Plus, Dr. Edhaie and the MSK team are wonderful. I hope your experience will be as good as mine was.

As I understand PIRADs 3, it is inconclusive and therefore not necessarily an indication of a lesion. Your PSA density (PSA divided by the prostate size) is something to consider. If your PSA is rising is proportion with the gain in prostate size, your PSA may not be cause for alarm.

I don't know about you, but I have a hard time avoiding projecting into the future. So try to do as I say and not as I do and stay in the moment as best you can. I'll be thinking of you.

[dentaltwin]

Things apparently have changed at MSKCC since my adventure there in 2018. Dr. Edhaie did my (transrectal) Bx; and while I didn't think general anesthesia would have been necessary I wish that the local had been--better than it was. My clinical picture was somewhat more involved than yours, and I opted for RP/PND. My surgeon there was Dr. Touijer. The recovery actually was much easier than expected.

After a year I started getting monitored locally as each time I went to MSK it killed half a day. It was a mistake; inconsistencies between labs resulted in a scare earlier this year, but it seems now things are fine.

Best of luck to you!

[Hope4Happiness]

My current prostate density is .13. Being on AS since 2017 has given me a lot of time to practice "mindfulness" (a concept first introduced to me by Tall Allen). Spending time worrying about every future scenario defeats the purpose of being on AS -- you've got to enjoy the great aspects of your life as they are happening. Being on AS and constantly worrying about the future diminishes and degrades the time AS has given a patient. Yes, easier said than done, but practice helps.

I'm in my 50s, and I was hoping to hold off treatment until my 60s -- the advancements in treatments and knowledge in the past 10 years alone have been major -- so future treatments will only get better with this disease. If my next biopsy changes my situation, I'll deal with my options then, but hopefully the biopsy results enable me to continue on AS.

[Cramlingtonboy]

Excuse my lack of knowledge; what is AS?

[Justfor_ in reply to Cramlingtonboy]

Active Surveillance, i.e. do nothing but watch it before/until radical treatment

[rosenjpj]

The key word in Active Surveillance is "Active." It is not simply watching. It involves a protocol of frequent testing (PSA, DRE, MRI, Biopsy) in close coordination with your doctor.

[Jay4546]

Wow lots of similarities. I also had my transperineal biopsy at MSK on 5/26! Maybe you were in the next room! I agree about their professionalism and level of detail with just about everything. I had 8 random cores benign, one targeted area (TZ/right) had cores of 3+3 with 40% carcinoma, but the other targeted area (TZ/left) had 3+4 with 5% 4 and 70% carcinoma (large 1.5-2cm lesion on MRI). Sent slides to Epstein and have a MSK consult with Dr. Goh (who did biopsy) and a RO. I'm betting they will say I am a good candidate for either at 53, but will stick with their specialties. Maybe I should add a medical oncologist to break the tie Anyway...had to comment from the biopsy room next door.

[rosenjpj in reply to Jay4546]

Glad you had a positive experience too. Timing is amazing. I think my procedure was at 2PM or so on 5/26. Eager to hear more about what MSK does next for your case. Please keep me posted and good luck!