I had Epstein give me a second opinion on my last biopsy, which was at the end of 2022. The original pathology report stated the 3+3 diagnosis was upgraded to 3+4, but didn't give any info about percentages of G4 cancer. Epstein cleared that up stating there was less than 5% G4, but there was perinueural invasion, most likely the G4 cells, but no large cribriform structure. He also changed the core values of two needles from 25% to 40% and 30% to 80%. This was shocking to say the least. When I had the phone interview with him, he stated I shouldn't be too concerned because they way Johns Hopkins analyzes the samples is that if there is some cancerous tissue in the needle followed by a section on noncancerous tissue followed by cancerous tissue, they connect all three sections to be one continuous cancerous section. He said they do this to give the worst case scenario in case the needle missed part of a continuous tumor or lesion.
Epstein went on to say that a strong case could be argued for me to continue on AS considering my age, the amount of G4 (less than 5%) and the quality of life issues that may present from being treated (aka over treated). My new urologist, who came very highly recommended, said that he thinks I definitely need treatment and should not be on AS. He said once cores exceed 50% while there is some G4 present, it's time for treatment.
What does the gallery say about this? Do you think that my new uro is correct in his assessment to get the treatment done out of fear of the G4 spreading/metastasizing through the nerves?
The next step before treatment is to get an updated MRI and biopsy since the previous are over a year old.
Any thoughts are appreciated!
Paul
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IMO with out science / facts behind me is to get a second opinion and from an RO. Travel if you must but find a highly rate RO at an equally highly rated facility. If nothing else it will solidify your current Urologist's recomendation.
Now me personally, I like to take action, when in doubt move out! PCa moves slow unless like me I had a 5+5 Gleason score and was analyzed by Epstein.
With your lower Gleason score you have time and getting a second opinion will make you smarter and help your sanity
Epstein/JH was once known for having the most rigid criteria for AS in the world. If he told you AS is in the cards for you, you can take that to the bank. Not a bad idea to get a Decipher genomic test if you are on the fence. But you should have a confirmatory mpMRI/US fusion biopsy within a year of that first one.
Btw, do you think doing an mpMRI first, then doing the biopsy, or just cutting to the chase of a fusion biopsy (UroNav is the one they use at Kaiser) straight away is the best action to take?
But wouldn't I do an initial MRI first, then do the UroNav biopsy with the results of the initial MRI "overlaid" onto the realtime imaging of the UroNav biopsy? Am I correct in saying that the UroNav MRI is just allowing the doctor to "see" the prostate so needles can be more accurately targeted?
You asked:"do you think doing an mpMRI first, then doing the biopsy, or just cutting to the chase of a fusion biopsy (UroNav is the one they use at Kaiser) straight away is the best action to take?"
Once again, there is no such thing as a fusion biopsy without an mpMRI first - what image would they fuse without it?
I ask because my doctor has only scheduled the UroNav biopsy but not a separate MRI to be done prior to the biopsy.
I haven't had an MRI done in over a year. My understanding is that I need an MRI before I have the biopsy. Also, my understanding is that UroNav MRI guided biopsy procedure requires a separate MRI procedure to be done, then that "map" is overlaid onto the UroNav system which then uses a real-time MRI to "see" the prostate so that the needles can be more accurately targeted. In other words, the MRI guided biopsy does not replace having to do a separate stand alone MRI prior to the biopsy.
We're going around in circles here, Allen. No matter, my doctor's office just confirmed that I must have a separate MRI first, then, if necessary, will schedule a UroNav biopsy.
I would recommend getting a second opinion from Dr. Amar Kishan at UCLA. He took me on as a patient, remotely by video visit, and gave me excellent second opinion advice. Their patient portal and support team is state-of-the-art, very responsive, friendly,, and complete.
I would consider doing this, but I'm not in the UCLA network and they charge a fortune for out of network patients. Also, I already had a 2nd opinion from Epstein, although it's been about 2 years now.
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