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Thread: Diagnosed with Prostate Cancer, Gleason 6

  1. #11
    Quote Originally Posted by Sammy5512 View Post
    @Wifeofgolfer
    Thank you for the kind thoughts and for the information. Also glad that everything went well for you and your husband.

    @DjinTonic
    Thanks for the review article. I downloaded it to read over this weekend. I've come across this author, Laurence Klotz, before in my investigation of "Gleason 6". Do you know how widely shared his view that Gleason 6 has "little or no metastatic potential" and that active surveillance is the way to go for many of these cases is among other urologists? I ask because I can already tell that the urologist who was assigned to me does not share Klotz's views and am wondering how many urologists lean each way if I get additional urologist opinions.
    As to who are the best candidates for AS, criteria vary among the major institutions' programs. Near the top of the main Forum page is our Subforum. Topic (G) there is AS. You can read more studies about various aspects of AS. A good place to start is with review articles which do the searching for you, select the best studies, put them in perspective, summarize the findings, and sometimes draw conclusions. For your own searches, I recommend Google Scholar and PubMed.

    Correct, Gleason 6 cannot metastasize. In every rare case where metastasis occurred in a G6 man, when pathologists reexamined the prostatic tissue, lesions >6 were found that were originally missed. HOWEVER, prostate cancer is heterogeneous in nature: (1) lesions with pattern 4 can form elsewhere in the prostate, giving rise to higher-grade lesions, especially G7 (4+3) and G7 (3+4), and (2) as Klotz mentions, G6 lesions themselves can progress in a small number of men. So while no G6 lesion will metastasize, lesions that can metastasize may be missed by a biopsy or can arise later. Klutz discusses this in his article. The takeaway message is "Geason 6 can't metastasize, BUT..."

    Personally, for what it's worth, I would be more comfortable with strict AS entry criteria (my uro uses strict criteria, closest to Johns Hopkins'). If I were a good candidate, I would also want to be low risk on one of the genomic tests that can be done on biopsied tissue.

    There are many sources of information for you, however the emphasis today is on joint decision-making between the patient and his docs. Remember, we Forum Brothers and Sisters are not docs, although we collectively have much experience and can highlight findings and facts and point you to information. Don't worry, after your consults and study, you will make the decision that's right for you.

    Djin
    Last edited by DjinTonic; 05-11-2019 at 11:54 AM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) path. neg. for cancer; then 6-mo. checkups
    6-06-17 DRE: nodule R and PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

  2. #12
    Quote Originally Posted by Sammy5512 View Post
    I'm "young" at 59? LOL! Thanks..

    In Prostate Cancer Universe, that sounds crazy but is true.

    Although Gleason 6 is the least aggressive PC, you do have a lot of positive cores and that isn't a good sign. It might be prudent for you to get a 2nd opinion on the pathology report. A pathologist by the name of Epstein at Johns Hopkins knows more about prostate cells than anyone really should be allowed to and will be glad to take a look at them and give his own opinion.

    Another option is genomic testing, like that which is shilled for by Atlanta catcher and PC patient Joe Torre on the radio.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3

  3. #13
    Sammy, I would second the suggestion of sending the biopsy slides to Johns Hopkins, here is a link to the information you need: http://pathology.jhu.edu/department/...ndopinion.cfm# . You may also be able to just ask your Dr to have the slides sent to Dr Epstein at Johns Hopkins. He will know Of Epstein. It’s easy, although not covered by insurance (about $250)
    This is such an important step that I would say, particularly in your case, your due diligence is not complete without this step.
    I was originally told I was a Gleason 8, but Epstein downgraded me to G6. (I was ultimately upgraded to G7 after surgery, not because Epstein was wrong but because a biopsy only samples a tiny fraction of the prostate.

    I would also ask your Dr , based on the high volume of cancer, to ask for genomic testing on the tumor tissue, either Decipher, OncoDx, or one of the other genomic tests available. They have proven not perfect, but VERY helpful in determining just how aggressive your tumor is.

    Good luck
    Diagnosed at age 64 (in November, 2014), PSA 4.3
    Nov 2014 BX 3 of 12 cores positive original pathology G8. Johns Hopkins second opinion, G6
    Surgery with Dr Ash Tewari Jan 6, 2015
    Post surgical pathology, stage T2c, bilateral disease, upstaged to G7(3+4)
    5% of Prostate involved in Tumor. Organ confined, Margins, SV, lymph nodes (9) all negative, PNI positive
    PSA <.02 until (uh-oh), 2/17 .02. Then 5/17-.033, 8/17-.033, 11/17-.046, 4/18-.060, 6/18-.068, 7/18- .082, 8/18-. 078.
    Decipher score low risk, .37
    ADT/Firmagon started August 2018. SRT to start SEPT 2018. Finished SRT November 2018, Finished ADT Feb 2019
    T=7, PSA <.05

  4. #14
    Sammy, both Dr. Klotz, who has been running a large AS group for 20 years, and Dr. Jon Epstein, the dean if prostate pathologists, have stated that Gleason(3+3) lesions do not metastasize. That said, higher grade lesions can form nearby, and more tests will be needed to monitor for them.

    IMHO, you are in the middle of the various AS criteria. You would qualify with Klotz, but not at Johns Hopkins.

    My advice would be for you to proceed with the next steps in an AS protocol. That would be to have an MRI, and then another biopsy which would include extra cores from any suspicious areas seen on the MRI. Those tests, and perhaps a genomics assay, would go a long way towards confirming if AS or some form of interventional treatment is appropriate for you.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  5. #15
    Sammy, you are young in the sense that your cancer has good chances of killing you if it's aggressive, and old that you might be fine doing nothing if not. As others say, more checks and 2nd opinions are good choices.

    All best, good luck!

  6. #16
    Newbie New User
    Join Date
    May 2019
    Posts
    7
    Thanks everyone for all the input. The information that you all provided has lifted a bit of the anxiety that I had been feeling because I didn't know what to make of all of this and was walking around in a fog. The help is much appreciated. And, yes, I'll definitely ask for a 2nd opinion concerning the rating of the biopsy samples.
    Age 59, PSA: 5.5 (3/2019), 4.7 (12/ 2018 ), 2.8 (5/2012), 1.1 (1/2009)
    Biopsy: Gleason 6, six of fourteen cores positive. Prostate volume of 41 cc.

  7. #17
    Newbie New User
    Join Date
    May 2019
    Posts
    7
    One more question about something that has confused me. I thought that the fact that my biopsy was Gleason 6 made active surveillance the automatic default, preferred option, but now I'm learning here that the total amount of core samples which came back as Gleason 6 is also important. Why would that be? If Gleason 6 is in fact an 'indolent' type of non-threatening cancer, then why should it matter how much of it is observed in the prostate? Or is it that there is a positive correlation between the appearance of Gleason 6 material and the appearance of more threatening cancers in the prostate? I suppose that that's plausible and could well be true, but I've never actually seen that claim explicitly stated. So Gleason 6 material, although non-threatening in itself, serves as a warning of an increased probability that there is also a more threatening cancer region nearby? Is that true?
    Age 59, PSA: 5.5 (3/2019), 4.7 (12/ 2018 ), 2.8 (5/2012), 1.1 (1/2009)
    Biopsy: Gleason 6, six of fourteen cores positive. Prostate volume of 41 cc.

  8. #18
    Quote Originally Posted by Sammy5512 View Post
    One more question about something that has confused me. I thought that the fact that my biopsy was Gleason 6 made active surveillance the automatic default, preferred option, but now I'm learning here that the total amount of core samples which came back as Gleason 6 is also important. Why would that be? If Gleason 6 is in fact an 'indolent' type of non-threatening cancer, then why should it matter how much of it is observed in the prostate? Or is it that there is a positive correlation between the appearance of Gleason 6 material and the appearance of more threatening cancers in the prostate? I suppose that that's plausible and could well be true, but I've never actually seen that claim explicitly stated. So Gleason 6 material, although non-threatening in itself, serves as a warning of an increased probability that there is also a more threatening cancer region nearby? Is that true?
    Sammy, see Post # 11 above.

    From the article by Dr. Klotz:

    Based on these concepts, AS should be offered to most men with Grade group 1 (Gleason score 6) prostate cancer. The limitation of this approach is misattribution of grade, that is, that 25%–30% of these men diagnosed on the basis of a systematic biopsy actually harbor higher grade cancer. While most of these misattributed cancers are Grade group 2 (Gleason score 3 + 4), and may still have a low metastatic potential, the presence of any Gleason pattern 4 cancer confers an increased risk of eventual metastasis. Thus the crux of managing men on AS is to evaluate the patient further for the presence of co-existent high grade cancer, and once higher grade cancer is excluded, monitoring them subsequently to ensure it does not develop.
    If you look at the signatures of Forum Brothers here you will see the proof that prostate cancer is heterogeneous in nature. Most men have an initial positive biopsy with multiple positive cores, and many present with cores with different Gleason grades (I had two lesions, a G9 and a G10). To reiterate: even though a biopsy shows no cores above a G6, there are two questions: (1) Are there any current lesions >G6 that were missed in the biopsy?, and (2) Will lesions >G6 arise going forward? Just as a biopsy can miss existing cancer entirely (a false negative), a biopsy that finds only G6 lesions can miss higher-grade lesions.

    Klotz:

    High-volume Gleason pattern 3 is important primarily as a marker for patients at higher risk for harbouring higher grade cancer. If higher grade cancer can be excluded in a patient with higher volume Gleason score 6 cancer (based on magnetic resonance imaging [MRI], targeted/template biopsies, and/or biomarkers), such patients are unlikely to require treatment.
    [Emphasis mine]

    As ASAdvocate pointed out above, different AS protocols have different eligibility criteria with regard to both the amount (tumor burden) of G6 and whether they permit the presence of any G7 (3+4) lesions. (The G6 tumor burden criteria can use various parameters: number of G6 cores, % of G6 vs healthy tissue in each core, location & laterality of the cores)

    (Dr. J. Epstein, the PCa pathology guru, says that it's not uncommon for the # of positive cores to be overcounted: sometimes several cores are taken (and counted) from what is actually a single lesion and would more accurately be counted as one).

    If you are seriously considering AS, I agree with the others that with multiple cores you should have Dr. Epstein at JH review your biopsy slides: the more cores, the higher the risk that one or more was actually a G7.

    Djin
    Last edited by DjinTonic; 05-12-2019 at 12:41 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) path. neg. for cancer; then 6-mo. checkups
    6-06-17 DRE: nodule R and PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

  9. #19
    Senior User
    Join Date
    Jan 2019
    Posts
    325
    “Dr. Joniau identified 1,037 patients with biopsy Gleason 6 and 444 with pathologic Gleason 6 prostate cancer. In patients with biopsy Gleason 6 prostate cancer, estimated 14-year CSS was 90.8%, demonstrating that a subpopulation with biopsy Gleason 6 prostate cancer are at elevated risk of dying from their disease when having additional clinical high-risk prostate cancer features. The reason for this may be partly explained by a 64% upgrading to pathological Gleason score 7-10. However, in patients with pathologic Gleason 6 prostate cancer the estimated 14-year CSS was 96.6%, again demonstrating that not all patients with pathological Gleason 6 prostate cancer have a benign disease course.”

    https://www.urotoday.com/conference-...-harmless.html
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 R-LESS (Robotic Laparoendoscopic Single Site Surgery) outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk. 38% risk 5 year metastasis.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)

    ADT started 6/3/2019

  10. #20
    Quote Originally Posted by Duck2 View Post
    “Dr. Joniau identified 1,037 patients with biopsy Gleason 6 and 444 with pathologic Gleason 6 prostate cancer. In patients with biopsy Gleason 6 prostate cancer, estimated 14-year CSS was 90.8%, demonstrating that a subpopulation with biopsy Gleason 6 prostate cancer are at elevated risk of dying from their disease when having additional clinical high-risk prostate cancer features. The reason for this may be partly explained by a 64% upgrading to pathological Gleason score 7-10. However, in patients with pathologic Gleason 6 prostate cancer the estimated 14-year CSS was 96.6%, again demonstrating that not all patients with pathological Gleason 6 prostate cancer have a benign disease course.”

    https://www.urotoday.com/conference-...-harmless.html
    Their criteria for inclusion selection is nowhere near what North American AS standards would permit.

    The 15 year results from both Sunnybrook and Johns Hopkins show 50 percent or more of their AS enrollees are still in the programs. Sunnybrook's PCa specific mortality rate was 5 percent and Johns Hopkins was half of one percent. Those European studies allowed far more men than they should have.

    From the article: "Furthermore, they suggest that patients with biopsy or pathologic Gleason 6 prostate cancer and who have PSA >20ng/ml or clinical stage cT3-T4 are a subgroup at elevated risk of dying from their disease and should be counseled for active local treatment."

    Seriously, anybody with a PSA > 20 or a clinical grade cT3-T4 certainly has a higher grade of cancer than the Gleason 6 found on one "blind" TRUS biopsy.

    A "subpopulation" that a credible assessment would have excluded.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

 

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