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Thread: Location of positive cores in biopsy.

  1. #1
    Experienced User
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    Location of positive cores in biopsy.

    Hi there...new member here. My husband (aged 51) was just diagnosed last week and we are in research/learning mode while we wait for additional results/testing.
    He had 4 of 12 samples positive in TRUS biopsy. One 40%, one 20%, one 5%, and one 4%. Gleason 6.

    My question is does location of positive cores have any impact on treatment decisions?
    He’s positive in left base, right apex, right lateral mid, and left lateral apex. So basically all 4 quadrants if you will.

    Thank you for having me here and I appreciate so much that so many are willing to give their time and effort to discuss all aspects of this disease. It’s very comforting to have others to communicate who are on the same path.

  2. #2
    Quote Originally Posted by star0210 View Post
    ...
    My question is does location of positive cores have any impact on treatment decisions?
    ...
    Welcome to the Forum, star, although we're sorry that you have to be here! To answer your question -- sometimes, yes. However, this usually applies to higher-grade PCa that may have grown out of the prostate. Gleason 6, which cannot metastasize, only rarely grows out of the prostate into neighboring stuctures.

    The typical first G6 question is: Is there too much cancer to be a good candidate for Active Surveillance (AS). The tumor burden is estimated by both the number of positive cores and the percent cancer in these cores. If there is a decision to treat, surgery and radiation are usually both feasible for G6 men.

    With regard to prostate-confined disease, the latest pathological staging guide (8th ed.) has done away with subdividing pT2 (prostate-confined PCa) into pTa, pT2, and pTc according to lesion location, because studies have shown there is no correlation between lesion location and cancer outcomes and, therefore, no clinical utility to specifying, e.g. whether one or both prostate lobes are involved. After surgery, my cancer was staged as pT2c two years ago (cancer in both lobes), but now would be labelled just pT2 by labs using the latest TNM Guide.

    As you may know, a biopsy samples only a tiny amount of prostate tissue, and about one-third of G6 men choosing surgery are upgraded to a higher Gleason score after the whole prostate is sampled after removal simply because the higher-grade lesion(s) were missed in the biopsy. This issue comes into play for G6 men who are candidates for AS, knowing they may be harboring higher-grade disease.

    You can discuss with a surgeon whether the lesion at the Left Base might involve the nerve bundle on that side. Unless compromised by PCa, the nerve/blood vessel bundles responsible for the blood flow responsible for erections are left intact by the surgeon.

    There is a Sticky Post near the top of the main Forum page on adding your stats to your signature. You can include age, relevant family history, PSA history, biopsy and imaging results, etc. This saves you from typing them each time you post a question, and gives Forum Brothers info that facilitates replies.

    Hope that helps,

    Djin
    Last edited by DjinTonic; 10-23-2019 at 03:55 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 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 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  3. #3
    Quote Originally Posted by star0210 View Post
    Hi there...new member here. My husband (aged 51) was just diagnosed last week and we are in research/learning mode while we wait for additional results/testing.
    He had 4 of 12 samples positive in TRUS biopsy. One 40%, one 20%, one 5%, and one 4%. Gleason 6.

    My question is does location of positive cores have any impact on treatment decisions?
    He’s positive in left base, right apex, right lateral mid, and left lateral apex. So basically all 4 quadrants if you will.

    Thank you for having me here and I appreciate so much that so many are willing to give their time and effort to discuss all aspects of this disease. It’s very comforting to have others to communicate who are on the same path.
    In your situation I do not believe the locations will have an effect on treatment options.
    YOB 1957

    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.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  4. #4
    Here’s my take on this.

    The longer I’ve gone with AS and walked my journey, the less I trust AS. There is a real gap in being able to tell a patient how much cancer is there, what degree it is and where it is.

    Part of the reason PCA is so “curable” compared to other forms of cancer is early detection which allows the patient a lot more options for treatment which are largely effective if undertaken in time. Given that there are no absolute tools to tell where the cancer is, how much is there and what degree it is, using AS takes away the one tool we have….early detection. I have been through every test known to man and some pointed towards cancer, others away. My first biopsy was clean, no cancer or pre-cancer, and the doc wanted to put me on a year rotation between PSA checks. I switched docs and my new doc wanted to do the 3T MRI just to prove the first biopsy and the MRI found a suspicious PIRADS 3-4 which the fusion biopsy showed was pre-cancer. The random they did at the same time as the fusion biopsy found cancer that didn’t even register on the MRI---a 2mm G6 in the right apex (big yawn…the doctors were sort of spiking the football that I’d be the perfect AS candidate). Well along came biopsy 3 in Sept of this year (only six months after the biopsy that found the tiny bit of cancer) and it found three spots of much more significant G6 PLUS pre-cancer in the base, which was new. How much cancer is really there and how bad is it and where is it? We will find out mid-December after I have my prostate removed.

    I just simply do not trust AS given our lack of technology or imaging to confidently prove where the cancer is and isn’t. Others will undoubtedly disagree with me and that’s fine I’m not here to crap on anyone’s treatment choices. Your husband is 51 with multiple spots of cancer that was found so far. I think—per my understanding—that most official AS programs would push towards treatment and removal from AS. Your husband might find a doc willing to do informal AS…but at what potential cost? You have to ask yourself “what is the real risk?”.

    -Is there a risk that your husband is too aggressive moving to treatment and misses out on some technological advancement just around the corner that would provide a cure or new treatment option? Possible, but not likely.

    Or

    -Is the real risk that there’s more cancer or higher degree cancer there that wasn’t found on biopsy that escapes and spreads?...in my opinion this is the real risk.

    At 51 unless you choke him (my wife joke), he’s probably not going to make it out of this life with the prostate on board given what was already found. So why take the risk? That answer is obviously up to you guys.

    My best to you both. I know it’s scary but you’ll quickly settle into your action groove and find your ‘sea legs’. It gets better the farther you get from diagnosis, we were totally freaked out. Now I’m just annoyed. 😁

  5. #5
    Senior User
    Join Date
    Apr 2019
    Posts
    104
    Quote Originally Posted by star0210 View Post

    My question is does location of positive cores have any impact on treatment decisions?
    He’s positive in left base, right apex, right lateral mid, and left lateral apex. So basically all 4 quadrants if you will.
    It's worth asking the Uro if they think the tumor is in the transition zone, there is a propensity for Gleason 6 tumors in that area to get really big and invade the bladder neck. If surgery is the choice, knowing this, the surgeon can be more aggressive in resecting the bladder neck, which can avoid an upgrade to pT3a post-surgery. An MRI for planning purposes pre-surgery is generally a good idea IMO, as they can predict risk of long term incontinence too.

    https://www.tandfonline.com/doi/abs/...20310001619154

    https://onlinelibrary.wiley.com/doi/...1111/bju.13173
    Wife Posting, Husband D.O.B. 1975
    2/2018 - routine physical PSA 15
    3/2018 - PSA 13
    4/2018 - PSA down to 11.6, free PSA, 18%
    6/2018 - PSA 10, free PSA 20%
    7/2018 - mp- MRI done, prostate volume =22cc, "inflammation consistent with prostititis"
    11/2018 - PSA 14, free PSA 11%,
    3/2019 - PSA 12, free PSA 17%, 2nd opinion on MRI = PI RADs 3 lesion
    4/2019 - Cognitive Fusion Biopsy
    5/12 cores positive
    4 Gleason 3+3
    1 Gleason 3+4 5% (Where PIRADs 3 lesion IDd)
    Decipher Biopsy score: .07 very low risk

    Bone scan negative
    MRI 6/19 said PIRADS 4 lesion, no definite EPE

    RRP 7/19 Final Path: pT3a
    G6 - 75-90%
    G7 (3+4) - 11-25%
    24mm tumor, 30% of prostate
    EPE+, BNI+, SM + (at bladder neck), LVI-, SVI -, PNI-, Nodes -
    Decipher Post RP score: .78, high risk
    6 week PSA = .015 (ultra-sensitive Labcorp)
    12 week PSA = .014
    ART underway (no ADT)

  6. #6
    Experienced User
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    Oct 2019
    Posts
    81
    Thank you all for your quick replies. I’ll work on putting info in my sig, limited as it is at this time.

    DJinTonic, he does have PNI in the left base.

    His last PSA just prior to biopsy was 4.5. His 4K score was 12%. His %free PSA was 9%.

    His uro had the slides sent off for genomic testing. We are waiting for the results which will probably be another couple of weeks. We don’t know which company he uses. He’s supposed to call us when the results come in but we don’t see him again until the day before Thanksgiving.

    The plan is to have MRI in December and then probably another biopsy using MRI taking 36 samples instead of just 12.

    We are hoping the G6 score verifies (as much as it can be with these methods) and the he can do AS. That’s where he is mentally today. He’s not afraid of dying from this, he’s scared of having to treat it. He says he recognizes that he will likely have to have it removed at some point but if he can have a few more years without dealing with the side effects, he’d rather do that. But he’s still researching like crazy. We both are. And we are in no hurry to make a decision although the waiting for more info is so hard. Hubby is a lot more patient than me!

    Ice...I have many of the same thoughts as you. I’m scared there are places where they didn’t find that are going to be higher than a 6. I’m afraid of how much it could get worse if left untreated. I’ve read your previous posts.

    It sucks that any of us need this group, but I’m sure thankful for it!

  7. #7
    Experienced User
    Join Date
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    Can you post images in this forum?

  8. #8
    Quote Originally Posted by star0210 View Post
    Thank you all for your quick replies. I’ll work on putting info in my sig, limited as it is at this time.

    DJinTonic, he does have PNI in the left base.

    His last PSA just prior to biopsy was 4.5. His 4K score was 12%. His %free PSA was 9%.

    His uro had the slides sent off for genomic testing. We are waiting for the results which will probably be another couple of weeks. We don’t know which company he uses. He’s supposed to call us when the results come in but we don’t see him again until the day before Thanksgiving.

    The plan is to have MRI in December and then probably another biopsy using MRI taking 36 samples instead of just 12.

    We are hoping the G6 score verifies (as much as it can be with these methods) and the he can do AS. That’s where he is mentally today. He’s not afraid of dying from this, he’s scared of having to treat it. He says he recognizes that he will likely have to have it removed at some point but if he can have a few more years without dealing with the side effects, he’d rather do that. But he’s still researching like crazy. We both are. And we are in no hurry to make a decision although the waiting for more info is so hard. Hubby is a lot more patient than me!

    Ice...I have many of the same thoughts as you. I’m scared there are places where they didn’t find that are going to be higher than a 6. I’m afraid of how much it could get worse if left untreated. I’ve read your previous posts.

    It sucks that any of us need this group, but I’m sure thankful for it!
    I hear that worry a lot about the side effects of treatment. I think that most guys who have surgical removal end up with limited long-term side effects. Find an expert in robotic surgery and get a second opinion on the surgical route, today's RP isn't the wrecking ball it used to be.

    Maybe I'm too pie in the sky but my surgeon is sure he can save the nerves and that a few months from surgery I'll be back to normal, just without the cancer growing inside me.

    I would strongly caution you to have your husband talk to some people whose loved on died from pca. I think that he is greatly underestimating the pain involved. I would gladly never have another erection or wear depends the rest of my life if it meant I could avoid the death by pca. But I don't anticipate those side effects being anything but transitory.

    But best of luck. We men are stubborn models 😁

  9. #9
    Top User
    Join Date
    Aug 2016
    Posts
    1,918
    A couple of comments. Your husband is too young for any of this indicating his future likely includes a higher grade cancer, if not already. Any cancer profile beginning at an early age implies a more aggressive nature and future status. He is no longer a candidate for the garden variety experience of this disease. He's missed that train. If he is using testosterone supplements or boosters I suggest he consult with his doctors about discontinuing it.

    If his PSA was and is continuing on a steady rise (regardless of spiking) he probably has more than G6, especially, if it is showing an increase in velocity. A reliable PSA history and behavior is now your best friend. Fortunately, mine was an accurate representation of my cancer's progression.

    Does the genomic testing provide a seccond opinion on the Gleason grading? Labs can disagree on this based on their experience.

    Any reputable AS program has rigid standards for confirming and ongoing monitoring including PSA and it's velocity, volume of cancer, MRI's, and additonal biopsies. Make sure your doctor is clear on this and is not just offering the idea of AS as an informal wait and see. Some doctors are not good at advocating PCa risk. Some are.

    Additional risk factors to age are family history, a BMI of overweight or more, and adverse ethnicity. Thay all contribute to assessing the overall risk, not just one favorable biopsy, and I say that because many men struggle to find the cancer and are tempted to dismiss the risk with one negative biopsy. TRUS biopsies have a high false negative. You've dodged that bullet and have your warning flag on the first go around.

    Cancer at the base, which is the top of the prostate just below the seminal vesicles and bladder is at higher risk to move up and out of the prostate. The prostate anatomy is reverse of what we would expect, the apex is the bottom towards the feet, and the base is at the top towards our head and bladder.

    Early detection early treatment is the hallmark of success with this and any cancer. Denial and delay are the two demons of cancer. This cancer is very treatable and survivable if you deal with it. It's not something you want to play chicken with.

    I have had successul treatment and have recovered from the side effects. The risk never goes away. I will be testing for recurrence ongoingly and am preapred for radiation as my back up if required. Once begun it's never over until and if something else overtakes it as a more serious threat to QOL.

    The youger you are the higher the risk, but also the easier the treatment and quicker and more complete the recovery. Early detection is a blessing squandered by many sorry tales usually generated in fear. Fear is not a power position. Responsible healthcare is something you take charge of and pursue with ruthless persistence. It is an aging shift in being that many men struggle with.
    Last edited by Another; 10-23-2019 at 05:24 PM.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  10. #10
    You have time to investigate further. Keep in mind that some men who are candidates for AS choose to treat mainly because they would not be comfortable waiting.

    You can upload images (up to 5 per post, I believe). Be sure to first remove or black out any PHI -- personal history information -- names, addresses, etc.

    • Click the "Go Advanced" button at the bottom of the post Edit window.
    • Click the Image (picture frame) icon, fourth from the right on the second row.
    • Select the image source (your computer or a url).

    (I'm not sure if newbies have the image-upload ability. If you don't, the icon will be grayed out.)

    Djin
    Last edited by DjinTonic; 10-23-2019 at 05:07 PM.

 

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