Biopsy 8-month Change - progression or sampling differences?

[adventure4me]

2/2023, MRI showed 1 large (2.4cm) lesion pirads 5. Gleason 6 in 8 of 12 systemic cores and 4 of 4 targeted cores.

10/2023 Repeat MRI-Biopsy: MRI showed lesion #1 same as previous. Also new lesion #2 0.8mm pirads 4-5. Biopsy with bilateral gleason 3+4 in 5 of 12 systemic cores, 1 of these gleason 6 (5% of core), 4 of these cores gleason 7 3+4. 20/20/20/60% of the cores, all having 5% pattern 4. Lesion 1 targeted cores 4 of 6 gleason 7 3+4, 60/70/80/90% of cores, all 5% pattern 4. Lesion #2, 2 of 2 cores atypical cells, no gleason score.

Other info: Decipher 0.18. PSA steady 6. Second opinion about biopsy slides from JH in process.

So is this progression of cancer, or difference in sampling? On one hand everything I read/am told is that gleason 6 is very slow growing, does not escape prostate, etc… so that would suggest sampling differences. On the other hand, it seems unlikely that all 10 positives from the initial biopsy just happened to land in g6 areas, then 8 of 9 positives 10 months later landed in g7 areas, plus there is the new (smaller, biopsy negative) lesion on the MRI.

Dr. says could be either. Maybe it does not matter, but if I knew it would factor into the decision how to proceed.

[Tall_Allen]

5% pattern 4 is pretty minimal - maybe always there

[climb4blue]

True that Gleason 6 & 7 doesn’t have enough self organization to leave the prostate, however, this most recent biopsy is indicating that these tumors are progressive; Gleason 8 & 9 tumors start as Gleason 6 & 7 and then progress from there.

[MakeItRainbows in reply to climb4blue]

Gleason 7 can leave the prostate FWIW. It is rare, but alas I’m living proof of it.

[adventure4me in reply to MakeItRainbows]

Thank you for sharing your situation. Yeah it seems my case is outside of average in many ways - not the least of which is that I'm nearly all gleason 7 vs 8 months ago all gleason 6. Some seem to go decade(s) on AS with no progression, but not me apparently. There are averages, but they are not tight boundaries on the averages I am learning. Thanks again.

[climb4blue in reply to MakeItRainbows]

Thank you for your response. I read your situational posts and rooting for you. You seem to be doing all the right things in light of the type of prostate cancer you have. It is very fortunate that you chose a prostatectomy given that the biopsy did not inform of the types of cancers discovered until after surgery. Best wishes.

[MakeItRainbows in reply to climb4blue]

That means a lot to me, thank you.