Opinions requested – biopsy pathology report

[climb4blue]

I felt my biopsy pathology report was light on details:

LT Anterior Base, Biopsy: Prostatic adenocarcinoma, Gleason score 3+3=6, involving 6mm and 70% of the submitted tissue

RT Anterior Base, Biopsy: Prostatic adenocarcinoma, Gleason score 3+4=7, involving 4mm, 1 mm and 60% of the submitted tissue

RT Lateral, Biopsy: Prostatic adenocarcinoma, Gleason score 3+3=6 involving 1mm and 10% of the submitted tissue

My pathology report leaves out the following information:

1. how many cores were taken (22 cores because I asked during report review)

2. how many were positive, how many were negative

3. how many were taken of the PRAD4 lesion

4. highest percent of cancer in any core

5. % pattern 4

Q1: Is it normal for pathology reports to leave out the above information?

Q2: Because I had a MRI guided biopsy, would that not skew the number of positive cores in comparison to the typical non-MRI guided biopsy and would that not then skew the nomogram results?

All opinions welcome.

Thanks for your help.

[Tall_Allen]

Yes, it's normal, unfortunately. You can pay for a second opinion from the world's biggest expert that will include all that info:

pathology.jhu.edu/patient-c...

They count the extra cores taken from a suspicious area as a single core.

[climb4blue in reply to Tall_Allen]

I will get that second opinion from Dr Epstein. Actually, I have already begun the leg work after getting my first report, because of what I have learned from you over that past several months on this forum, and your prostatecancer.news articles. Thank you Tall_Allen.

I hope to be able to use risk stratification nomogram tools, like STAR, but can't really do that with my first report. For example, how to count the extra cores taken from a suspicious area as a single core and as a single positive core.

I hope to be able to use % pattern 4 to determine risk stratification for AS.

Is it often a 3+4 patient with PNI observed to option for AS?

[AlanMeyer Moderator in reply to climb4blue]

I don't have enough knowledge to advise you on this however, since you did say that all opinions are welcome, I did try some Internet searching for ( pni prostate cancer). Four of the articles I looked at found what the authors believed to be significant indications that PNI indicates higher risk, more aggressive disease with worse outcomes.

Given your relatively younger age (57 indicated in a previous posting), I would think you have the possibility of a long enough life ahead of you that prostate cancer could become a life shortening factor.

What did your doctor say about the biopsy results? Was he advocating treatment? Why?

Whatever he said, I think you're doing the right thing by trying to get more information and second opinions.

Best of luck.

Alan

[climb4blue in reply to AlanMeyer]

Thank you very much for your support Alan. It is true, I am 57 and told when doctors see me that I look like I have 30 years ahead of me.

My doctor said the GS 4 was likely under 5% based on his conversation with the pathologist, and he thought I was a good candidate for AS as long as an Oncotype DX genome assay result reinforced low risk.

The PNI was not identified as a risk factor during our review of the pathology report.

I've read Tall_Allen's prostatecancer.news about PNI risk studies.

No one rules out AS for PNI patients with 3+3 or 3+4, but its seems like PNI needs some special consideration and special treatment, and if consideration and treatment is not heeded, outcomes can be quite different for PNI patients.

[Tall_Allen in reply to climb4blue]

You might try Prolaris or Decipher instead of Oncotype DX because of this:

ascopubs.org/doi/10.1200/JC...

[climb4blue in reply to Tall_Allen]

Yes I learned about this cohort. I also found one from their own website reference. I was able to find it on NIH, “A 17-gene assay…” Klein 2014. The Oncotype DX study for AS actually excluded (Gleason score 3+4) in their cohort study, and did not quantify the negative predictive rate nor the AUC information gain.

Decipher assay: I was able to find the study found in Nature, “validation of the Decipher test for predicting adverse pathology in candidates for prostate cancer active surveillance”. The Decipher study for AS actually includes (Gleason score 3+4), and did quantify the negative predictive rate of AP and the AUC information gain: NPV 91% for 0.45, NPV 96% for 0.20, AUC 0.65.

I have asked my doctor to order Decipher. I hope he will agree.

[Tall_Allen in reply to climb4blue]

PNI on a biopsy probably excludes you:

prostatecancer.news/2018/03...

[climb4blue in reply to Tall_Allen]

Unclear - it begs the question, clinically I mean, why intermediate-risk patients would not also correlate, as do low-risk and high-risk patients, to higher biochemical failure if they have PNI.

I get there may not have been a study, but given a patient in my circumstances, an assumption of correlation seems more appropriate than an assumption of no correlation.

IMHO, favorable intermediate-risk patients, would be well-advised to treat cancer more aggressively, in spite of the higher side-effects, because of needle-biopsy detected PNI.

[Tall_Allen in reply to climb4blue]

I think you should wait for Decipher. One doesn't have to speculate about correlations when there is biopsy data. In the Cohn study, 43% of men on AS were able to stay on AS in spite of their PNI because there was no grade group progression. It is grade group progression (and genomics) that should guide your decision.

[sryoung44]

Get that second opinion from JHU. The lab my urologist used showed that I had one 4+3 and JHU retested it and concluded that it was actually a 3+4.