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Active Surveillance update

hopeful and opt...
Posts: 1313
Joined: Apr 2009

As a 70 year old in excellent health, I have been involved in expectent management, active surveillance with delayed treatment if necessary since 2009.  Initially I had been diagnosed with 2 cores, less than five percent involvement, G 3+3=6. there were 12 cores taken. (Complete details of my case are listed in the About Me section which you can reach by clicking my name)..

In 2010 I entered a program where an MRI 3T is done. Suspicious lesions are sought out, ranked by suspicion and the results fused with a 3 dimensional ultra sound (versus the standard 2 dimensional) used to  biopsy  in order to determine potential cancers in the prostate. Some of the cores that are taken are targeted and the rest are systematic. Generally there are about 15 or so cores taken.

The first two tests in this program did not identify any cancers.

In June 2013, I had my lastest MRI fused with the Artemis biopsy machine.

These are the results:

Target cores:

M1 target(central mid) 13-1  10 percent    3+3=6

M2 target(central mid)  13-2  20 percent    3+3=6

Systematic core:

E left mid                              40 percent  3+3 = 6


Second pathology opinion:

M1 target                               10 percent 3+3=6

M2 target                               10 percent  3+4=7

E left mid                               30 percent   3+3=6


My doctor recommends that I stay  in the Active Surveillance program.

I have   scheduled an appointment with my doc  

These are some of my questions. I am grateful for any inpu tto these questions, or any other appropriate questions or comments that fellow members of this forum can provide.


Is a third opinion appropriate?


In the MRI that was done, Lesion 3 (Central Mid gland) shows the longest diameter to be 1.5 cm. , I wonder if when considering a tumor ;  is size significant in making a treatment decision, and are the cores (M1 and M2) that were found to be positive reflective of the entire tumor?

Is a Myraid/Prolaris genetic marker test appropriate at this time?


Thank you



















VascodaGama's picture
Posts: 1550
Joined: Nov 2010


I do not think that you need a 3rd opinion if the second comes from a reliable laboratory.

Surely the results indicate an increase in the Gleason which you should accept. It also provides a different aspect in volume/size but that would not influence the purposes of the results.
In any case, such does not mean that you should discontinue AS.

Having a DNA maping of your type of cancer cells is good if you can afford it. It will provide you with more info about the aggressivity of your cancer.

I would try to get as much info as I could with other markers even if you are already diagnosed with PCa.

Best regards.


Posts: 239
Joined: Sep 2010


You know so much more about AS and “markers” than I, so I will not try to answer your questions concerning those matters.  



From my understanding of the information that you put forward, you no longer have an indolent PCa (i.e. G7 with significant volume).  If the PCa is not indolent, why is the doctor recommending further AS?  I am sure there is a good answer to this question and that I just don’t see it; however, I would recommend another opinion.



Well the fish burgers are about to go on the grill, have a good 4th of July.



Best wishes and good luck! 


hopeful and opt...
Posts: 1313
Joined: Apr 2009

Beau.......I hope that you enjoy the fish burgers.......I just had a great veggie burger.

This was just published in uro today. This study from Johns Hopkins expands the criteria to identify men eleigible for Active Surveillance


Additionally , I came across an article, "Clues Found To Prostate Cancer Upgrading" in the April 2013 US Too Prostate Cancer Education and Support Hot Sheet that states that at Sunnybrook Health Science Center "Eligibility for AS required a biopsy Gleason score(GS)equal or less than 6 and a PSA level equal or less than 10ng/ml. For men older than 70, the criteria cosnsisted of a GS equal or less than 3+4 and a PSA level equal or less than 15ng/ml. Men had a repeat PSA every 3 months for 2 years and then every 6 months thereafter. Scheduled follow -up biopsies biopsies occurred after 1 year and then every 3 years until age 80."

Site: www.ustoo.org



Not saying that I am not concerned with this increase to 3+=7....I am. I want as best a decision as possible to be made.

My knowledge is limited about which  markers will add to showing how aggressive my cancer is. Aside from PSA, about two years ago I had a PCA3 that was negative.I am interested in any thoughts about markers .

The original pathology was done at UCLA. My second opinion was from J. Epstein at Johns Hopkins. Both institutions with excellent reputations....since analyzing gleason scores are subjective, my guess is that the score is on the border of 3+3=6 and 3+4=7. It would be nice if each of these gleason scores were quantified, however I don't think that this is done. Vasco you are probably right, and I may as well accept the information that was provided.

 Any thoughts about my above question,

"In the MRI that was done, Lesion 3 (Central Mid gland) shows the longest diameter to be 1.5 cm. , I wonder if when considering a tumor ;  is size significant in making a treatment decision, and are the cores (M1 and M2) that were found to be positive reflective of the entire tumor?"

Thanks again

VascodaGama's picture
Posts: 1550
Joined: Nov 2010


Dr. Strum (one of the authors of The Primer) uses other markers to access aggressivity. The higher or existence of any of the markers in sampling, the aggressive the cancer is. He opinions that Gleason score >9 PCa would secrete these biomarkers in higher values:
PAP (prostatic acid phosphatase)
CEA (Carcinoembryonic Antigen)
NSE (Neuron Specific Enolase)
CGA (Chromogranin A)
There is some explanation in the second edition of the Primer. My opinion is that these and any other marker or image study requires a base line to use for comparing, so that proper judgement is done. In your case at least these markers may provide a clue on the aggressivity at the first stage and a comparison from the second tests.

My GP doctor used PAP to test me annually for PCa, since I become 45 yo. The tests all were negative during the 5 year period but in 2000, when I was 50 yo, the first PSA taken (22.4 ng/ml) lead me to a biopsy and to the diagnosis of cancer. I regard this fact (low PAP and high PSA) for the type of cancer cells found in my gland (patterns of 2 and 3).
If the G pattern were higher, therefore more aggressive, the PAP would express itself higher.

A particular in your case is the bouncing PSA. Your latest comes at PSA=3.8 ng/ml lower than the ones done last year (in calendar reverse; 4.3/4.1/3.9/4.2/…….). Probably we could relate the volume of cancer to the jump in PSA. Theoretically you had in the beginning a medium PSA of 2.5 with 5% of core involvement in two out of twelve cores and now you have a medium of PSA 4.0 with 10% of core involvement in a three positive out of fifteen cores taken. This would be conclusive to a progressive case but not in regards to aggressivity.

Other “markers” for judgement is the PSA velocity, PSA density and PSADT. The thresholds for aggressivity established by many researchers are; PSAv =< 0.40 to <0.75 ng/mL/y {the o.40 is for young guys, the 0.75 is in PSA=4 to 10 group ( I think your case)}; PSAd =< 0.18 ng/mL/cm3 in positive cases and PSA level divided by prostate volume {measured as an ellipsoid with maximum length × width × height × 0.52}; PSADT =>3 year, respectively.

DNA profiling is new but very developed. Many genes have been identified to the aggressiveness and positiveness of prostate cancer. Though there are already several laboratories providing the test cheaply, only a few number of physicians can reliably interpret the results. If you decide that route for getting an “answer” you have to research for the best and try obtaining approval from your insurance.

My lay opinion regarding the shape or size of a tumour in treatment decision is that a fewer number of localized colonies may provide better outcomes. I believe that PCa may be caused by more than one defected gene and that the duplication of cells in the same line will create one tumour (cells glued together), meaning that other groups will form other tumours with other defected genes. Both are prostate cancers but they increase in size in two separate tumours which could be made of different Gleason patterns. This may justify the method used in genetics to access and distinguish between indolent and aggressive types.

1.5 cm in diameter is a large tumour. It can be seen in the MRI and I wonder about its location. You refer to “central mid” that could mean central zone of the gland. This is not the peripheral zone where most of cases occur. Cancers in the central zone are “deep” and in conventional biopsies are hard to find. M1 and M2 were targeted because they were seen. If smaller probably the 3T MRI would not detect them. The overall context is still the importance of the negative biopsies done in 2010 and 2011 and again the other 12 needles negative to cancer, this time, which leads to think that you are not confronting a micro metastatic type. It seems that you got a contained PCa case that could have equal results from any radical therapy. The side effects would make the difference.

I believe that you can still continue AS with the periodical testing. You know that I am not a doctor, so that you should investigate and get the opinions from recognized AS specialists.

There are other factors that you should care for apart of the veggie-burgers. Testosterone test and bone density is proper I young fellas of 70+.

I hope my opinion helps you in this delicate moment of your vigilance.

Best wishes.


Kongo's picture
Posts: 1167
Joined: Mar 2010

Ira, my personal feeling is that while you can over analyze a situation, a 3rd opinion in your case makes sense.  Hope everything continues in your favor.





hopeful and opt...
Posts: 1313
Joined: Apr 2009



Thank you for the inputs. I came to the right place to get excellent answers.

I will ask for all appropriate information to describe my cancer to include all base line information. This will include a 3rd opinion of the biopsy results by a world class expert (one of the ones referenced in the Primer on Prostate cancer book by Strum) ,and a Prolaris genetic marker test.

Although I do not think my doc will be receptive to ordering , I will  ask for the PAP, CEA, NSE and CGA tests. I have had a series of 3.0 T MRI's.  The doc may place more importance on these MRI's along with the biopsy , PCA3 test and genetic test to explain what is happening. At any rate I will ask him and see what he says.

I have had a testosterone blood test that was done  3 years ago when I entered this research program

11/11/09  I had an x ray of the lumbar and pelvis, (L) Hip which showed  bone density of those areas. I do regular weight bearing exercise on a regular basis to include walking and resistence training. Is this suficient for a base line bone density test? 

Thanks again.

VascodaGama's picture
Posts: 1550
Joined: Nov 2010

There are more detailed tests to get the "perfect" bone density, but for the purposes of judging bone health the traditional methods are sufficient. Your physical activity may not be sufficient to keep the osteoblast in check. Though it may be enough to be fit and maintain muscle mass. PCa likes deteriorated bone.

Can you describe the previous results of T test and B-density.



hopeful and opt...
Posts: 1313
Joined: Apr 2009

5/04/10 Testosterone    @101ng/dL     range 200-1000

The x ray was to diagnosis spinal stenosis in L4/L5. The doctor said that my leg bones were dense, and my back was moderate.


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