Biopsy pathology report - what to make out of it

I got hold of my biopsy pathology report today.

Clinical results (Dec 2019):

Adenoma grade 1

PSA 7.16

fPSA/PSA 14.94 %

Pathology report (biopsy Feb 2020):

Right side of the prostate: 5 samples between 0.4 and 2.5 cm

Diagnosis: All five samples have adenocarcinoma, Gleason values 6 (3+3), covering 25%, 15%, 10%, 5%, 5% of the samples. Grade group 1.

Left side of the prostate: 5 samples between 0.8 and 2 cm

Diagnosis: 2 samples with adenocarcinoma, Gleason values 7 (3+4), covering 15% and 10% of the samples. Grade group 2.

No mention of TNM values.

What do you make of this? How bad is it? Do I need treatment now?

I am also wondering if I, before possible treatment, should have another biopsy or scan to find out possible metastases?

If there are metastases, would I have any symptoms? Which?

And finally then I would have to choose between the most appropriate treatments. How would you consider going only for active surveillance at this stage?

Any input to this will be highly appreciated.

[Tall_Allen]

Fortunately, you have low volume of cancer (5 positive cores ranging from 5 to 25%) in your prostate and it is all low grade. The Gleason 3+3 is the lowest grade of cancer possible (also called Grade Group 1), and the Gleason 3+4 is the second lowest grade possible (also called Grade Group 2). The first number, 3, means that more than half of the cancer in those cores is the lowest grade possible. The second number (3 or 4) is the highest Gleason grade or pattern that takes up less than half of the core.

The presence of any Gleason pattern 4 makes active surveillance (AS) controversial. The top expert on Active Surveillance believes that men with a small amount of pattern 4 (e.g., 10%) may still safely use AS, while men with a large percent of pattern 4 (e.g., 40%) should opt for treatment. Your biopsy report does not tell you the percent pattern 4 (it only tells you the percent of the core that has any cancer at all). Lacking that information, it is a good idea to look at treatment options. You have plenty of time. I took 7 months and interviewed 6 doctors. Take your time. Decide not to decide until you have completed your investigations.

You do not need any further biopsies or a bone scan. The doctor you eventually choose to treat you may request an MRI and CT just before you are treated to help him plan the treatment.

Fortunately, your risk level is called "favorable intermediate risk." It means that all treatments have an excellent chance of curing you completely. The best treatments for "low intermediate risk" are SBRT, brachytherapy, and surgery.

SBRT, often known by the brand name CyberKnife, is done in only 5 treatments. There are two places in Madrid that offer it. Try Dr. Rafael Garcia Garcia at the Ruber International Hospital, or Dr. Rafael García at GenesisCare.

There are two kinds of brachytherapy. Low dose rate brachytherapy (often called seeds) are radioactive pellets that are left inside and decay over time. Try Pedro Prada at Hospital Sagrado Corazón in Valladolid or Feran Guedea at Institut Catala` d’Oncologia, L’Hospitalet de Llobregat, Barcelona

High dose rate brachytherapy are radioactive wires that are inserted for a short time and taken away - nothing is left inside. Try Luis Larrea at Hospital NISA Virgen del Consuelo in Valencia. or Jose Luis Lopez Guerra at Virgen del Rocío University Hospital, in Seville.

You can find experienced prostate surgeons almost everywhere.

There are lists of questions to ask in the links of this article:

pcnrv.blogspot.com/2017/12/...

[Hidden in reply to Tall_Allen]

Thank you.

You mentioned earlier getting a second opinion.

I suppose that you need the actual biopsy slides for that? Or can they use digital images (of the slides)?

[Tall_Allen in reply to Hidden]

They need the actual slides. When I wrote that, I wrongly assumed you were in the US. It wasn't just any second opinion, it was a second opinion from the acknowledged expert in reading biopsy slides. While many pathologists have to be able to read all sorts of tissue samples, Epstein's lab is devoted only to prostate cancer. I have no idea who you would use in Spain. If you find a pathologist there who is really an expert at reading prostate cancer biopsies, it would be useful to know what is the percent pattern 4 in the GS 3+4.

[Hidden in reply to Tall_Allen]

Thanks. I now have enough information I think to move forward.

[Tall_Allen in reply to Hidden]

As I said, no rush. Your type of prostate cancer progresses very slowly.

pcnrv.blogspot.com/2016/08/...

[Yehonatan]

Hello Mark: I had a Gleason score of 7 which was rated medium cancer. However a Gleason score of 8 was major cancer which means it has probably spread outside of the prostate (which is worse than 7). The doctor's thought was to remove the prostate now before it has chance to spread to surrounding lymph nodes. Hope this helps. Yeho

[Hidden in reply to Yehonatan]

I'm thinking right now, of course, in the same lines, to get rid of it before it spreads. But have to read more.

[Leeaussie5]

Hey that is a pretty good result - although its still cancer. You can't ignore it or it will kill you.

The result was in many ways similar to mine. First is it looks like everything is contained and reasonably slow growing. So you have time. Perhaps you can wait out the coronavirus overload of the health system. Take that time to work out what you want to do. And have as much fun as you can.

Second the left and right results makes cancer look widespread inside the prostate. I was the same. I initially had hopes of one of the localised treatments that doesn't involve treating the entire gland. This didn't work - as one doctor said to me: "look at this...the whole dna of the prostate is in a state of change."

Not common in the US, but seemingly standard in Australia, for prostate cancer is a PSMA PET scan. This is a whole body scan that looks for cancer outside the prostate. Its pretty new and not covered under Australia's public health system. But wasn't really expensive ($AUD600).

The other test I had was a high quality MRI. This was before the biopsy and indicated where the cancer was inside the prostate to make sure the biopsy hit the mark.

Keep well. Keep safe. Enjoy life.

[Hidden in reply to Leeaussie5]

Yes, the corona situation is making everything more difficult. Hopefully it will be over by summer.

Good to know about the scans, thanks.

I'll keep reading. And living.

[LoganMA]

First thing I'd do is send the slides over to Johns Hopkins to see if the scores of your pathology "gleasons" would be the same. At the very least, it's peace of mind knowing that they concur or they don't. If they don't, sometimes a third one is needed. All treatment decisions are made from your pathology. For 275.00 as Tall Allen pointed out, it's worth the peace of mind. If you can get your doctor to back a second opinion, sometimes it's covered by insurance as well. But even if it isn't covered, 275.00 is a small price to pay!

[Hidden in reply to LoganMA]

Yes, right now I'm thinking about a second opinion. Thanks