Biopsy Shows Tumor Infiltrating Fat - Suspicious EPE?

[PTvsPC]

Hey all

I met with my doctor today to discuss my recent biopsy. Originally diagnosed with G3+3 in 2017, then upgraded to 3+4 with less than 5% G4 in Dec 2022. The last 2 MRIs showed about the same, but then the new biopsy from a week ago stated:

Left Base: G3+4. Carcinoma involves 2 out of 2 cores and comprises 40% tissue. Focal tumor infiltrating fat suspicious for extra-prostatic extension. Perineural invasion identified.

I won't lie, I'm panicking a little bit....

Also in this biopsy:

Left Apex: G3+3 / 5%

Left Mid: G3+4 / 50%

Left Mid: G3+4 / 30%

Right Base: focal high-grade intraepithelial neoplasia (pre-cancerous?)

Questions:

Should I get a 2nd pathology opinion from Johns Hopkins again? Or am I just wasting time at this point?

Should AS be off the table at this point?

Should I move quickly into treatment to stop the spread outside the prostate?

I don't recall my uro mentioning the EPE or PNI in our meeting and he suggested that HIFU was a viable option in my situation. That's confusing to me especially if there's EPE and/or PNI. What am I missing here?

In 2022, Epstein said he wasn't too concerned about the PNI as it didn't exhibit large cribiform morphology. He also stated there was less than 5% G4.

Thanks for any and all input!

[Murk]

Second opinions are always good, they confirm and bring bring clarity and help in your going forward decision, which also brings comfort & calmness.

If your Doc is an Urologist, I would meet with a Radiation Oncologist.

[Tall_Allen]

Yes, I agree that a second opinion on the biopsy from JH is a good idea.

IMO, you are no longer a candidate for AS. I would not have surgery or HIFU with known EPE. Talk to a radiation oncologist.

[PTvsPC in reply to Tall_Allen]

I agree with you. If there is indeed EPE, I will get treatment. And in your opinion, what would be the most effective treatment?

At this point, there's no known EPE - just suspicion. It could be scar tissue, for example. The MRI of less than six months ago states no EPE. I know JH will give a better indication of whether or not there is EPE.

Also, I need to know what the % of G4 is. I don't know why Kaiser doesn't provide that information. Providence, who I was with before, also did not provide that information.

[Tall_Allen in reply to PTvsPC]

If the outer end of the core found cancer outside of the capsule, it is the most definitive diagnosis you can have right now:

prostatecancer.news/2020/04...

[PTvsPC in reply to Tall_Allen]

This article states that a needle biopsy is not particularly reliable for discovering EPE even with a high level pathology expert. I am sending off the slides to JH in the next few days hopefully.

It seems the best detector of EPE is mpMRI.

[hrdc69 in reply to PTvsPC]

My doctor told me that a EPE cannot be diagnosed by pathology, only a MRI. But I see a couple posts here saying that a pathology can determine it so I am confused.