Perplexed Pathology Report Findings

[FF1072]

I am a 64 year old male with a strong family history of CaP (father and brother). Late last year I experienced a rapid rise in my PSA 2.8-4.7 within six months. I had a MRI early January that identified 3 large lesions: 1 PIRADS 5 (23mm), x2 PIRADS 4 (16mm and 9mm). Two weeks ago I had a 15 core targeted and systematic transrectal biopsy with the following results

Biopsy Findings: Estimated Prostate Volume by DRE: 30g, Clinical Stage: T1c, Calculated Prostate Volume: 29cc, Calcifications: no, Hypoechoic nodule: no, Cyst: no, Seminal Vesicles: Symmetrical - Non-dilated, Capsule: Intact: Yes.

When my urologist gave me the pathology results he said he was quite perplexed since he was expecting like I was a more significant cancer finding. He wrote this morning in my record:

Biopsy showed: GS 6 in 2/15 cores, 10% of each core. Both positive cores were from Right base PZ. I reviewed this information with him and explained the Gleason scoring system and NCNN risk stratification. He would classify as very low risk CaP. However, I also acknowledged his strong family history of CaP, as well as the somewhat discordant MRI and biopsy findings. I would have expected a higher grade and higher volume disease, particularly along the large PIRADS 5 lesion. This may represent understaging versus a BPH nodule located within the TZ. Ultimately, I would like to repeat an MRI and confirmation biopsy within a close interval. We will plan for repeat PSA, MRI and targeted confirmation biopsies in 6 months, Aug 2023. If similar or stable findings, he would be an excellent candidate for initial active surveillance.

I don’t have a problem with his recommendation to repeat the PSA, MRI, and biopsy since so many things don’t add up.  I just can’t believe the MRI and Ultrasound were so wrong grading my lesions. I feel very blessed with these results but still very disconcerted. Has anyone else experienced these type of weird findings? Thanks.

[TylexGP]

I’ll share a conversation I had with the US tech. Prior to and after my MRI fusion biopsy. I was stressing over my Pirad 5 lesion ( which turned out valid). The tech shared on a number of occasions the Pirad 5 lesions ended up being BPH or low grade PC. I understand your concern and I would do what you are proposing and be rebiopsied either with an in bore MRI and at the very least a MRI fusin biopsy.

[FF1072 in reply to TylexGP]

thanks

[Tall_Allen]

MRI is not used to grade the lesion. Only biopsy is used for grading. mpMRI only gives suspicion of cancer.

You can take a Decipher test before deciding on AS. Family history only has a relatively small effect (about 20%) in predicting incidence, but it doesn't predict aggressiveness.

[witantric]

I had a similar situation. Was your biopsy MRI guided (like using UroNav system)? Or just TRUS done by intuition?

[FF1072 in reply to witantric]

MRI guided - UroNav system

[witantric in reply to FF1072]

OK. Then I would trust the biopsy. The SOA is targeted plus 12+ random cores from other areas. Sometimes MRI misses small lesions. Did they do that? I have done a lot of research on this topic Feel free to send me a message.

[FF1072 in reply to witantric]

Yes they did 3 targeted biopsies per lesion and then an additional 12 systematic samples. My PIRADS 4 16mm lesion was the only lesion that was positive. I have also done a lot of research and my MRI results statistically pointed to significant clinical cancer especially for my PIRAD 5 23mm lesion that was totally negative. My urologist was also dumbfounded and was concerned he might have missed something. What other tests other than another Fusion MRI biopsy? Thanks

[witantric in reply to FF1072]

How many cores from each lesion? Standard is 4 or 5. I am try to get urine test like ExoDx and LynxDx. The idea is to gather as many signals as possible to rule out dangerous lesion working. Let us say that probability is 4-5% that there is something lurking despite the biopsy result. The key is to get multiple signals to drive that uncertainity probability lower. Does that make sense?

[TWTJr]

Be in no hurry. Watchful waiting, follow up and reassessment in 3 months or more is warranted.

[LowT]

what were path reports of fatter & brother?

[LowT]

what were path reports of fater and brother?

[adventure4me]

This is fairly similar to my situation, initial MRI/biopsy had 24mm pirads 5 lesion, then biopsy showed 10/16 cores positive, but all gleason 6. Dr's said pirads 5 is 80% to have g7, so I'm in the 20%. Then 10 months later (this month) repeat MRI showed same initial lesion plus new lesion 0.8mm pirads 4-5. new biopsy had 9 of 20 cores positive, 8 of those gleason 7 (3+4).

In Feb I chose AS with a short-term repeat, and that seems appropriate now - I'm deciding how to proceed, leaning toward treatment now. Happy I did not choose longer term AS repeats (PSA stable 6) as a longer time would have allowed more (presuamble) progression.