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Trying to Understand Biopsy Report

davidp46
Posts: 11
Joined: Mar 2011

I'm not sure of the rules for these forums. I just joined today, and I'm very glad to have found this site. I picked up some stuff today from the last 65 days: Prostate MRI imaging, CT imaging, Bone scan imaging, Biopsy report, Bone scan report, and CT scan report. While I've spent much time reading internet material about PCa, most of these technical reports are confusing.

My immediate concern is how to decipher the biopsy report. While I've had three prior biopsies, they found no cancer so I never asked for a copy of those reports. The latest biopsy (2/14/11) was done after getting a Prostate MRI in which the radiologist identified 2 "areas of concern" in the imaging. Happily (for me) he assisted the urologist doing the biopsy by confirming the location of the biopsy gun to concur with the MRI. 31 cores plus 20+fragments went to the pathologist, taken from 8 locations all on the right side of the prostate: Right Mid 1 through Right Mid 4, and Right Apex 1 through Right Apex. I presume that the middle section and the apex section of the right side of the prostate was subdivided into 4 zones/areas and that is was these location reference pertain to. Is this the case??? Is each zone a "slice" of the section? Is the section "quartered" in 4 parts? I'm trying to understand the actual location of the cores in the report.

The first area/zone report is as follows:

A: Right Mid 1: Prostatic adenocarcinoma, Gleason score 8 (4+4), 6mm focus, involving 1 of 3 biopsy cores, and representing 10% of the biopsy cores.

Similar reports using the same format follow for all 8 zones.

The specific items that confuse me are "6 mm focus", "... 1 of 3 biopsy cores",
and "... 10% of the biopsy scores".

Any help decoding this report format is appreciated.

Thanks for any assist.

hopeful and opt...
Posts: 1278
Joined: Apr 2009

It is very, very important for you to get a second opinion of your biopsy slides by a another pathologist....since reading gleason scores are very complicated, there are only a few that excell such as Boswick.......you need to do this so you are not over or undertreated.

Additionally, I also suggest that you have an MRI with an Endorectal....that will indicate where the cancer is - one lobe or two, or outside the capsule.....this is very important for you in a treatment decision....some of the major hospitals have what is called a tesla machine 1.5 or 3.0 which provides better definition than those found at regular hospitals.

Additionally the american urological association recommends a bone scan for those who have a gleason of at least an 8.

I wish you the best

VascodaGama's picture
VascodaGama
Posts: 1508
Joined: Nov 2010

David

Your view is correct in interpreting the “zones”. Your reference to “31 cores plus 20+fragments“ may indicate that you did a transperineal template-guided stereotactic saturation prostate biopsy, which typically uses 30 to 80 cores, according to what is written in these sites;
http://www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=73&abstractID=30254
http://www.aetna.com/cpb/medical/data/600_699/0698.html
This is typical in cases of high PSA levels but were previous biopsys have been negative.

The “6 mm focus” refer to the length in the core that a Gleason pattern of 4 was identified. That happens in only one of the cores of a set of 3 taken from that specific area, meaning 33% in the area is cancerous. The “10% of biopsy cores” may be referring to 1 core in 30 was positive (?). Your total pathologist report of other zones will hold the information you need.
In this pdf file you may see graphical divisions of the prostate into zones.
http://urology.ucsf.edu/patientGuides/pdf/uroOnc/Prostate_Biopsy.pdf

Hope this helps in your quest.
VGama

tarhoosier
Posts: 180
Joined: Aug 2006

Your doctor can provide you with all the explanation necessary when you next visit him (her). Vasco has given his experience. "10% of the biopsy scores" is a typo, I presume. It must read "10% of biopsy cores". Each needle removes a tiny core, like geology drilling and tree cores. The cancer identified in this core made up 10% of the total tissue removed with that needle. This is a small amount of cancerous material (in a single core). If many of the cores contain 10% that makes for a more serious situation. The second opinion from an expert prostate pathologist is absolutely the best option to pursue. You have had at least three biopsies and only now does something appear. Without the full report I (we) cannot give you an opinion about the overall import of the biopsy report. Nor should we. Another expert pathologist can do so. It appears that you are not in a situation that requires immediate treatment. Any rush to judgment is wrong and potentially dangerous. One step at a time. It would have been difficult for me to follow this advice at the time of my diagnosis, but still I offer it:

Breathe deeply and then exhale. You are alive and will remain so for an indefinite period. Think clearly. Find your local Prostate Cancer support group and attend. Consider their advice and remember it is amateur. Go for the emotional support.

mrspjd
Posts: 688
Joined: Apr 2010

Once again, excellent advice from Tarhoosier. Most of all, I concur w/ the "breathe deeply, then (slowly) exhale" and, I would add: repeat several times as needed. Thanks for the post.

davidp46
Posts: 11
Joined: Mar 2011

Thank you all for the quick response. I'll check some of the offerred links.

The "X% of the biopsy cores" numbers was making no sense to me until now.

Where the pathologist had more than 3 cores (plus frags) available, he selected only 3 cores from the site to form his report for the biopsy sites (A through H).
Maybe the links provided will shed some light on this selection process.

Again, thank you all.

davidp46
Posts: 11
Joined: Mar 2011

Thank you all for the quick response. I'll check out these links.

The "X% of the biopsy cores" numbers was making no sense to me until now.

Where the pathologist had more than 3 cores (plus frags) available, he selected only 3 cores from the site to form his report for sites A through H.
Maybe the links provided will shed some light on this selection process.

While the Uro. did not say he was doing a "saturation" procedure, if felt like that was his goal. My condition was as one of you surmised. Three "normal" biopsies with elevating PSA (last one ~~60 fPSA total). In this case, I had the Prostate MRI on 1/19/11 to determine if there were any possible biopsy targets. The MRI showed two "areas of concern" plus one other very small target. This biopsy focused specifically on the MRI "areas of concern". So, the use of the Prostate (endorectal) MRI demonstrated its utility. Unfortunately, the GS8 precludes any consideration of surgery as a possible therapy per my Uro.

Again, thank you all.

Klemon
Posts: 26
Joined: Jun 2010

Biopsy reports can be tricky . My husband had rising PSA over 3-4 years (3.7 to 8.2 over time), two traditional biopsies, revealed no cancer. The third revealed 1 positive core of 12 at 3+3=6. Got a second opinion on the path report at Mayo who's pathologists disagreed with the two pathologists who read it at home. Saturation biopsy revealed postive cores on the left at 3+3=6, positive cores in the middle at 3+4=7 and on the right at 4+4=8. We had already decided on surgery but the Gleason 8 brought us a bone scan and CT scan first (prior MRI and DREs all normal)... they will not recc surgery unless they can do their best to rule out any spread first, whisch is statistically more llikely in a 8-9 than a 6-7. Those scans were clear.
Surgery went well, tumor area 3 cm.x 1 cm x 1 cm.....involved both sides, frontal apex. confined, had not broken the capsule. , but margins involved at 1 mm on each side,..which they consider not an issue because of the size and area they burn.
He had an extended pelvic lymph node dissection to remove all pelvic nodes instead of simply the regional ones....luckily all were negative. This is for diagnostic and therpeutic reasons, since they can contain mico metastises that cannot yet be detected, so by removing them all, less chance of going anywhere else in the body. The 8 Gleason score allowed for the more aggressive surgery as 8 is more aggressive than say 7 or 6.
That being said, as in all cases of prostate cancer, you cannot get a true Gleason score unless they remove the prostate and grade the entire thign ... it is common for Gleason score to change once it is removed. We were lucky he was downgraded to a 3+4=7. (less agressive than the 4+4=8 or a 4+3=7)... meaning the majority of cancer cells were 3, which are much less agressive than 4 or 5. ...and less likely to have left the prostate.
We were initally told we had low volume, non aggressive and all kinds of time to decide. Turns out, being agressive was the best decision for us...as the doctor advised it likely saved his life, in that there was alot more cancer there than thought.
Dont ever be afraid to get a second opinion, and look at all of your options... the more information you have the better equipped you will be to make a decision that works best for you.
On that note, surgery was really not that big of a deal and recovery was speedy and not too uncomfortable at all. Will be happy to share more details if you decide to go with the surgery.

davidp46
Posts: 11
Joined: Mar 2011

Klemon, thanks for reply.

I repeatedly see that getting a second opinion on the slides is most prudent; unfortunately, I'm not sure how to go about it.

As you note, when you have a GS of 8+, surgery is not a likely option due to the risk of mets. I had the upper body CT scan and fully body bone scan done about 10 days after biopsy-4. I'm visiting with my orignal uro. and my internal medicine md tomorrow to try to decode the biopsy-4 reports as well as the CT. The bone scan was nonremarkable. I can't seem to find an express finding of metastasis in the CT however it may be there and I just don't know it. Maybe she'll give me some insight tomorrow.

The primary Uro. gave me a very fuzzy description of my current status indicating that he would not consider doing surgery, and was referring me to a very good Rad.Onc. to pursue RT.

I have a second opinion visit scheduled in two weeks with another uro.

The biopsy-4 report includes 8 sites in right midsection, and right apex. Of 8 sites, 2 have GS(4+4=8) and 6 have GS(4+3=7). If the reports are overstating the severity of my PCa and there are no mets, then surgery may still be viable.

Hopefully tomorrow, I can try to reconcile the biopsy 4 results with numbers 1,2, and 3 to determine if the current PCa has emerged after the prior three or if it may have been present but missed.

Your lucky to have access to a place like the Mayo. I never before believed that a medically ignorant patient like myself would have assume a highly proactive case management role in my own case! I've heard that the major Ca centers do a great job of facilitating the entire process for the patient as well as the patient's family (the other survivors).

You mention the importance of timely response to this stuff. I can appreciate that as it ultimately took 30 months to find the PCa with biopsy-4. Because of a very enlarged prostate (~~ 110 gm/cc), we repeatedly attributed the elevating PSA to the BPH plus some type of prostatitis. Unfortunately, wrong DX and a lot of lost time! Hopefully, not too much time was lost.

Good luck and take care.

mrspjd
Posts: 688
Joined: Apr 2010

David,
The importance of obtaining a 2nd opinion on your biopsy lab slides cannot be stressed enough. It is the first of many crucial steps in understanding your unique PCa before making any tx decisions, as each man's PCa profile is different. (The next step will be to add an oncologist specializing in PCa to your team of doctors, but one step at time, as Tarhoosier points out.) There are a few nationally known, well-respected pathology labs that specialize in analyzing prostate biopsy core samples.

Recently, another user posed the same question: "How do I obtain a 2nd opinion on my biopsy?" Here's the link to that thread where several options are discussed:
http://csn.cancer.org/node/212732

In my husband's case, he made arrangements with his urologist to have the local lab (that did the initial biopsy pathology read) release his slides to him personally. The slides belong to you and are yours upon request. After obtaining the info from the website of one of the well-known PCa path labs, like Johns-Hopkins, PJD packaged and sent the slides out himself for the 2nd opinion path report. He included completed paperwork and a ck for the fee. It is possible to have your doctor arrange to have your lab slides sent out for a 2nd opinion as some labs will only accept the request if it comes directly from your doctor (if you choose this route, you should instruct your doctor about which lab YOU want them sent to).

Also, if you can locate and attend a few PCa networking groups in your community, I strongly recommend doing so, the sooner the better. While it's true that the PCa info you might recieve from this face to face group will be from non-professional laymen and women, if you're lucky enough to find a good group with a trained facilitator, their combined experience will be a great source of info/tests/superior doctors, etc. that you need to consider prior to making any tx decisions. Some more established PCa networking groups may have lending libraries offering PCa books, videos, and other media resources.

Congrats on recognizing a critical theme in dealing with PCa--you are your own best advocate and need to be assertive and proactive in doing your own research, asking questions, and seeking many 2nd opinions from experienced and skilled doctors in all PCa treatment modalities PRIOR to making a tx decision that will be right for you, your lifestyle and stage of PCa.

Wishing you all the best as you begin your PCa journey,
mrs pjd

tarhoosier
Posts: 180
Joined: Aug 2006

David:
I am certain that the prostate enlargement in your case added to the psa situation. Prostatitis also could add to the psa increase and complexity and confusion of values. It is common for men of our age to have all three conditions simultaneously. Notwithstanding, you now have a diagnosis and if the expert opinion confirms the G8 then perhaps radiation is the better idea. If so, then prepare for a stint of hormone therapy to reduce gland size to make a smaller more focused target and to reduce the collateral damage from the radiation.

I have discovered that most men (and people) I have encountered on this journey have been relatively healthy in their life. To us this medical "dithering" is frustrating. I have another friend who has had serious lifetime asthma, with COPD, infections, and lots more which has put him near death several times. He is used to the situation where doctors are unsure of the best route, which drug(s) could work, what side effects restrict which treatment, patient choice, and so on. I have learned from him and his sanguine approach. It is not just me, or this disease, or these treatments. It is the extent of not knowing, and patient variation which makes doctors uncertain of the very best, true path. So it goes.

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