Continuing AS?

[KenPe]

I’m creating a new thread after a couple of years when I decided on AS thanks to the support here. I’m 43y. The first biopsy was negative but only 8 cores, then GS3+3 0.6mm 4 years ago, then 3 years ago it was GS3+3 in 3 cores 1mm, 2mm, and 3mm. PSA 1.6-3 up and down (down mainly after biopsy surprisingly). I had strong prostatitis symptoms for years but got rid of them a year ago, still, the latest PSA was 2.5.

The recent 3T mpMRI showed PIRADS4 lesion. Fusion biopsy found nothing in there but GS3+3 in again 3 cores 0.12mm, 0.2mm and 0.5mm, right apex and mid-right.

The doctor says AS is still an option. I have some new concerns about AS and seek your opinions. I’ll also consult with the doctor.

1) How troubling is PIRADS4? I read somewhere on this site that fusion biopsy suffers from up to 30% misregistration. Should I be worried samples weren’t taken correctly? Is there a special protocol to deal with negative PIRADS4?

2) As I understood it apex area is not easily sampled with transrectal biopsy (my case) giving a worrying degree of false negatives.

3) My prostate volume is quite small, 17mm. I read an article saying lower volumes, when cancerous, are prone to more aggressive cancers. My urine flow has been weaker for years, it isn’t BPH, and prostatitis symptoms are gone for a year, so could it be cancer?

4) The lengths of samples from the older biopsy were significantly higher (mostly 12-19mm, only 3x 9mm) compared to the latest one (mostly 8-9mm, one 10, 11, 12, and 15mm). A sign of under-sampling, not covering the prostate to its length? The blood after-effect of biopsy is also much milder after the latest one.

5) And one more to the essence of AS. If not mistaken, it’s said that men on AS do not worse for many years compared to treatment. Survival was the metric but was also keeping the possibility of the easiest curate treatment considered? Recently I saw studies stating biochemical failure after treatment comes in like 40% within 5 years (that’s crazy) and that the chances for failure are also increased by higher GS and the presence of PIRADS4+. But that’s pretty much what AS is waiting for to happen to trigger treatment. Are there any stats saying the treatment options and success rates with a single treatment over 5 years+ are the same? Btw. I saw some posts even here of men after RP with confirmed GS3+3 or 3+4 who had the failure. Am I bargaining a few+ years on AS without treatment side effects with more devastating treatment later?

It’s a long one. Thanks!

[Tall_Allen]

1. If a biopsy of the area (4 cores?) couldn't find any cancer there, it is probably not pervasive even if it were there. PIRADS only suggests suspicion. It is only the biopsy that is important.

2. They should have taken 3-4 cores from that area.

3. You only think you got rid of prostatitis. I suspect it never goes away. Did any of the biopsy cores say there was evidence of chronic inflammation? Send the cores to Epstein for a second opinion.

4. No biggie.

5. I have no idea what you're talking about. Provide a link? Over half of low risk men are able to stay on AS without progression for 20 years (so far).

[KenPe in reply to Tall_Allen]

Thanks Allen.

1. 7mm PIRADS4, 2 cores taken. It was 12 cores, including 2 cores from PIRADS.

2. I guess. mid-apex, apex, both left and right.

3. Older biopsy stated inflammation, latest says 'no significant changes in non-cancerous tissue'. Worth mentioning biopsies were done at different institutions.

5. I cannot find the main one I have in mind but can give pubmed.ncbi.nlm.nih.gov/265.... Recurrence hopkinsmedicine.org/health/... (not 40 but 30%). Still gives the impression that AS, if must be stopped, gives a higher grade/PIRADS, and that gives higher recurrence rates. And yes, even with that and follow-up treatments survival goes on but then it's to be considered.

[Tall_Allen in reply to KenPe]

1. It should have been at least 3 cores from that one spot. Next time.

5. Those links have nothing to do with your situation. You are on AS; those links aren't. Men on AS who are treated for progression have much lower risk.

[KenPe in reply to Tall_Allen]

Thanks again Allen.