Advice on my Situation

[tcott54]

Just finished my first year on AS. My initial biopsy and the most recent one were both downgraded by Johns Hopkins.

Most recent biopsy findings from JH:

Gleason 3+3: Two cores (30%,40%)

Gleason 3+3: Two cores (5%,60%)

My intitial MRI last year was graded as a Pirad 5. My second MRI from this Spring was graded as a Pirad 4. I had a second opinion review of the recent MRI at OHSU and they graded it as a Pirad 5.

MRI findings:

This Year: Last year:

The prostate measures

6.2 CM Transverse 5.8 CM

5.9 CM Anteroposterior 5.3 CM

5.9 CM craniocaudal 5.8CM

gland volume of 112 mL . 93ML

Tumor

A dominant tumor focus is identified in the left posterior lateral apical

peripheral zone:

This Year: Last Year:

0.7 CM transverse

2.3 CM anteroposterior

1.3 CM craniocaudal

Tumor volume of 1.1 mL. .6 mL

The tumor

demonstrates:

Low T2 signal: Borderline

Restricted diffusion: Yes

Early enhancement: Yes

Delayed washout: No

Overall Pi-RADS classification: 5

With respect to tumor stage: (This year's results)

Likelihood of right-sided extracapsular extension: Absent (0-20%).

Likelihood of left-sided extracapsular extension: Indeterminate (40-60%). (same as last year}

Broad-based capsular contact without definite contour bulging. This

observation is in close proximity to the puborectalis.

Likelihood of right-sided seminal vesicle invasion: Absent (0-20%).

Likelihood of left-sided seminal vesicle invasion: Absent (0-20%).

No lymphadenopathy, suspicious bone lesions, or other abnormality

identified. Small pelvic free fluid.

My concern is that the tumor size increasing. I am considering getting another read on the MRI from Andrew Rosenkratz.

I have heard on this board that your biopsy grade trumps all, but am concerned about the growth of the tumor over the past year.

I have a low Polaris score and fall into the AS category.

Do you suggest another opinion on the MRI?

Any other thoughts or considerations about my continuing with AS?

Thanks in advance!

Tim

[Tall_Allen]

MRIs only identify suspicious areas. Only biopsies confirm or deny those suspicions.

[tcott54 in reply to Tall_Allen]

Understood. What I am looking for is a more definitive read on the degree of disease progression from my 2 MRIs, as in the PRECISE score which I understand is now being used to score tumor progression.

[Macigman in reply to tcott54]

You shouldn't try to read anything into the change in PI RADS scores. They just tell the person doing the Biopsy where to look and provide a priority. The only things that are going to matter are the pathology results from a biopsy. For example, my pathology report did not agree with where the MRI said it would find cancer. But it was cancer. The important numbers will be the Gleason Score/Gleason Grade (coming from the biopsy). Other points of interest will be whether there is involvement outside of the prostate. I'm not a doctor, but have been told that with Gleason 3+3, traveling outside of the prostate is rare.

You should speak with your doctor about the specifics in your case if you're unclear.

Good luck.

[Tall_Allen in reply to tcott54]

You say you understand, but your reply makes it clear that you do not. ONLY your biopsy matters.

[tcott54 in reply to Tall_Allen]

I DO understand the key importance of the Gleason 6 score and am grateful for the 2 downgrades that JH has made in my biopsy results. I plan to continue on AS.

With regard to the PI-RADS 5, my understanding is that about 25% of PI-RADS 5 scores end up being graded Gleason 6. So it looks as though I fall into that group for now. Since I have now have had 2 MRIs, what I am interested in getting is a read on how the MRIs compare with regard to lesion progression and any other impressions from a quality radiologist. You might say, why do that with a Gleason 6? Well, to me. it's another important data point to consider while I pursue AS.

JH is the apparent gold standard when it comes to biopsy grades, but at the same time, it is still possible that my biopsies have missed some pattern 4. Why not better understand the status of my lesion progression from the MRI results as another factor to consider while I am on AS? For me, I don't think it's as simple as "don't pay attention to what the MRI says because I'm GG 6".

Since studies show that 30% of GG6 is upgraded to something higher after RRP, I think it's reasonable in the meantime to try and best understand what the MRI progression shows: lesion size growth, any change in signs of extracapsular extension, etc.

[Tall_Allen in reply to tcott54]

Your "understanding" is not sufficient reason to do anything. The only reason to do any tests is to potentially change therapy. AS protocols have been worked out over the last 30 years. It is safe to follow the protocol. Your anxiety is not reason to change the protocol.

[Starr15 in reply to tcott54]

In general if a lesion is PIRADS 5 and the biopsy result is Gleason 6, the discrepancy raises concern that the biopsy samples taken at that area do not represent the actual pathology. Two targeted biopsies of the MRI visible lesion help allay that concern.

You could ask your doctor to ask the reading radiologist of the latest MRI to review the study to confirm if he thinks the lesion has increased in size. Sometimes measurements of lesions and determining progression are not as straight forward as it would seem they should be.

If the lesion has actually nearly doubled in volume over the time period, ask your doctor if that would change his management.

[tcott54 in reply to Starr15]

That’s what is puzzling to me. Both biopsies were targeted, but they weren’t MRI fusion. I will ask my doctor about either getting a more specific reading from the doc who read the latest MRI or have Dr. Rosenkratz, who specializes in MRI readings to do do a comparative review and get his opinion. I may need to pursue a MRI fusion biopsy next year.

[leach234]

My radiologist told me MRI’s are wrong 20% of the time.

[witantric]

I am in a similar situation. Have you got another read on your mri? Lesion size is quite subjective and depends on the radiologist.

[tcott54 in reply to witantric]

I haven’t decided yet. Will consult again with my urologist before I decide.

[jethrotullag]

If you are unsure get a second opinion from an oncologist.

[AnOrangeADay]

if the mri scored a pirads 5, you should do a targeted mri biopsy on the tumor plus a systematic sextant. looking for pattern 4.

biopsies are looking for needles in a haystack. some pirads4 mris are followed by negative biopsies. but the psa can be 20+. targeted Bx is the best course of action. give you more peace of mind.

also, know this--tumors in the anterior are hard to biopsy from the rectum. perineal biopsy can reach that.

what are your psa numbers?

[tcott54 in reply to AnOrangeADay]

I have had 2 targeted biopsies - both downgraded to GG6 by Johns Hopkins.

PSA is 3.9 and has never been above 4.

[AnOrangeADay]

yeah, those two mri pirad scores are weird. but the psa is low.

any palpable lump with DRE?

your doc might say continue AS, watching the psa, and an annual mri.

maybe your decipher score will be high, and make up your mind for you.

have u heard of the PCA3 urine test?

healthline.com/health/prost...

[Larry954]

I am facing differing biopsy readings: one reading is a 4+5 at a local center of excellence and JH is 4+3. I’m curious what your initial reading was and what considerations you made to decide which results you and your team are using for the decision on treatments? Thanks

[tcott54]

My initial reading was 3+4. At this point I am going with the JH reading of 3+3.