Followup on friend I mentioned.

[WhatHump]

He just got biopsy back. Lotta 4+3. His wife however, is telling me the Doc is saying it's Stage 1., which is absurd unless I'm woefully ill-informed. There is a good chance of miscommunication here. They go back to Urologist Thursday, so perhaps I'm posting this prematurely. (I have their permission to post this here.)

It seems to me this is a must-act situation. They are in FL (near W Palm Bch), as am I for another month. He is 73 and in good health.

Any comments, advice, recos would be appreciated. My apologies for the awkwardness/clumsiness of this. They are not comfortable posting themselves, so asked me to serve as an advocate/voice for them here. Thank you for your patience.

WhatHump

*************************

From my friend's wife:

Comments from the Doctor's Office

Your gleason score is 4+3=7. Radiation and hormone therapy or surgical removal of the prostate would be options.

Images

Scan on 3/16/2023 4:40 PM

FINAL

DIAGNOSIS

A. Prostate, right lateral base, biopsy:

Prostate adenocarcinoma, Gleason pattern 3+3=6 (grade Group 1), discontinuously 6 mm in length (25% of 1 of 1 core).

B. Prostate, right medial base, biopsy:

Benign prostate tissue.

C. Prostate, right lateral mid, biopsy:

Benign prostate tissue.

D. Prostate, right medial mid, biopsy:

Benign prostate tissue.

E. Prostate, right lateral apex, biopsy:

Prostate adenocarcinoma, Gleason pattern 3+3=6 (grade Group 1), 2 mm, 25% of 1 of 1 core.

F. Prostate, right medial apex, biopsy:

Benign prostate tissue.

G. Prostate, left lateral base, biopsy:

Prostate adenocarcinoma, Gleason pattern 4+3=7 (grade group 3), 7 mm, 80% of 1 of 1 core.

No cribriform pattern identified.

H. Prostate, left medial base, biopsy:

Benign prostate tissue.

I. Prostate, left lateral mid, biopsy:

Benign prostate tissue.

J. Prostate, left medial mid, biopsy:

Prostate adenocarcinoma, Gleason pattern 3+4=7 (grade group 2), 2 mm, 4 approximately 40% of 1 of 1 core.

Gleason pattern 4 < 10%.

K. Prostate, left lateral apex, biopsy:

Soft tissue and muscle tissue, no prostate tissue identified.

L. Prostate, left medial apex, biopsy:

Benign prostate tissue.

M. Prostate, left PZ, biopsy:

Prostate adenocarcinoma, Gleason pattern 4+3=7 (grade group 3), 10 mm in greatest single dimension, 80% of total prostate tissue

involving 3 of 3 core biopsies.

Comment: Multiplex dual chromogen immunohistochemistry (PIN4) with p63, high molecular weight keratin and AMACR was

performed on blocks A, E, G, J and M. The PIN 4 stains show lack of basal cells and positive racemase activity in the prostate

adenocarcinoma (controls appropriately reactive). An intradepartmental consultation and concurrence was obtained for the part G

and M diagnoses.

Diagnosis

Comment Laboratory Developed Test (LDT) Disclaimer:

Performance characteristics of immunohistochemical, immunofluorescent and chromogenic in-situ hybridization tests have been determined by the performing

laboratory within Cleveland Clinic’s Robert J. Tomisch Pathology and Laboratory Medicine Institute (Main Campus Hospital, Akron General Hospital, Florida

Weston Hospital, Mercy Hospital, Indian River Medical Center, or Martin Health North Hospital) in a manner consistent with CLIA requirements. One or more

of these tests have not been cleared or approved by the FDA. RT-PLMI is regulated under CLIA as qualified to perform high-complexity testing. These tests

are used for clinical purposes. They should not be regarded as investigational or for research. Positive and negative controls stain appropriately.

[Tall_Allen]

Stage is confusing because there are different systems. The T stage is based on the DRE, and is almost always stage T1a or T2. More important is the risk assessment. Your friend is probably (assuming his PSA<20) classified as "unfavorable intermediate risk." It is correct that both surgery and radiation+hormone therapy are suitable options, although radiation + hormone therapy has a greater chance of success.

[pakb]

I'd also suggest a 2nd opinion consultation with an oncologist not urologist.

[Teacherdude72]

What does his MO have to add on his condition?

[WhatHump in reply to Teacherdude72]

I don't think he has one yet. This all just hit them two days ago and his wife reached out to me. I'd prepped him/them a bit beforehand, suggesting some resources, including this website, highlighting TallAllen. It's in process. Thank you for your response.

[Teacherdude72 in reply to WhatHump]

Welcome. This site and TallAllen in particular is a great resource. Please point out, gently, that we each are different in action, response, and results. Many on this site are long term survivors, some with fewer treatments and others with many. Choices mad should never be second guessed.

An MO should always be part of the mix, often the lead, and in occasion the only unless urinary complications occur.

At now 75 and beginning my 8th year from diagnosis of G9 I can assure you that life is very much worth living fully and with gusto.

Best wishes to your friends with their journey.

[Teacherdude72]

Reading through your post I noted you stated "gleason score is 4+3=7" But in the biopsy report is included "Gleason pattern 4+3=7 (grade group 3) and was followed by "(grade group 3), 10 mm in greatest single dimension, 80% of total prostate tissue".

This one line is what they need to have clarified and understand. Be persistent and make sure your friends truly really understand this.

As TallAllen has said radiation and ADT has a greater chance of success.

Best wishes for them and check back when you, they, have more.

[WhatHump in reply to Teacherdude72]

Thank you. That really struck me too. A lot of 4+3. I made that point to them too. There are so many variables, choices etc with this disease. Frankly, much more than I was made aware of before I made my choice. HU wasn't tipped to me by a friend until afterwards, and I come here out of intellectual curiousity and so I can perhaps help anyone who comes to me for advice. Though I will admit to the group, and to these friends, that I do NOT have anything close to a full grasp of what's what. That's why I appreciate guys like TA, you and others who share their opinions. (And please know I realize these are opinions. Not infallible. I was in the trading business for 43 yrs and have a long time network of friends with whom we share thoughts. This group has held together because Rule #1 is you'll never hear "But you said....". Same here. I appreciate peoples' honest good-faith opinions. It's all one can ask.

[Teacherdude72 in reply to WhatHump]

I goofed on my paste of numbers, there is one 3+4=7 that is the higher concern. That needs to be explained.

[j-o-h-n]

Geez I was mistaken, I thought we could on post to you on Wednesdays....

Good Luck, Good Health and Good Humor

j-o-h-n Tuesday 03/21/2023 8:06 PM DST

[WhatHump]

Latest from friend. He saw urologist (I believe) today. Sorry it’s rather sparse.

Friend;

Doc thinks ablation is my answer. Want me to do petscan and consult oncologist. I feel pretty good about prognosis.

[Tall_Allen in reply to WhatHump]

Please send him these:

prostatecancer.news/2016/12...

prostatecancer.news/2021/03...

[WhatHump in reply to Tall_Allen]

Thank you for these. We both read them. Very informative. I told him that getting an MO is probably his best path. All specialists think their flavor is the best for most situations. And their enthusiasm and confidence can be powerful. Hopefully, an MO will be more objective. Thanks again.

[Tall_Allen in reply to WhatHump]

I don't agree that MOs are more objective or that it is a good idea to bring in yet another opinion. Your friend is the only person capable of making the decision for himself.

[WhatHump in reply to Tall_Allen]

Fair point. I have run the idea by him and he is mulling it over. Getting more tests done, etc. In the event he decides he'd like to utilize an MO, is there someone you would recommend? Thank you.

[Tall_Allen in reply to WhatHump]

In Cleveland, I recommend Dan Spratt at Case. He's an RO, but really well informed.

[WhatHump]

more:

Doc assessment

He has a PI-RADS 4 lesion on MRI from February 2, 2023

His prostate gland is 28 cc and his lesion is in the left posterolateral peripheral zone

History of hep c, not on Anticoagulation

 

Recommendations:

ASSESSMENT/PLAN:

We reviewed the pathology from his prostate biopsy which revealed GG3 disease. This is considered unfavorable intermediate risk disease given the presence of GG3 disease. All of his cancer appears to be localized to the left side of the prostate. We recommend the strong consideration of treatment because when there is a higher volume of pattern 4 there is a risk of metastasis even though this risk is low. As the next step, I recommend imaging to evaluate for any metastases including PSMA.. 

 

We discussed performing a decipher genomic test on biopsy samples to evaluate the risk of 5-yr metastasis, 10-yr metastasis and 15-yr prostate cancer specific mortality. This testing can help predict the risk of progression of his prostate cancer cells in the future and assist with plan of care. 

 

We briefly discussed treatment options including surgery, radiation, focal ablation, and active surveillance. Active surveillance is not recommended given the presence of GG3 disease which has the potential to metastasize. In general, we usually recommend the initiation of treatment within 6 months from his most recent prostate biopsy. Prostate cancer is generally more slow growing than other cancers. I referred him to Radiation Oncology to further discuss radiation therapy. 

 

- NM PET/CT PROSTATE WHOLE BODY IMAGING

- CONSULT TO RAD/ONC_FL