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Just Got Biopsy Results

WJS
Posts: 3
Joined: Oct 2017

My PSA crept up over 4 recently and my urologist told me it was time for a prostate biopsy.  Results of the biopsy were:

4 cores Gleason 3+3=6 involving 5 to 10% of each core

1 core Gleason 3+3=6 discontinuously involving 80% of that core

2 cores atypical small acinar proliferation

5 cores no tumor seen

My age is 68.

The urologist said that with those gleason scores he normally would recommend waiting, but in my particular case he recommended taking further action, either radiation or surgery.  He is sending me to a radiation oncologist for further discussion, then to a surgeon, in order to assist me in my decision.  He said it was not a rush, but that he felt that we needed to take action on it rather than just wait for it to get worse.

This is all new to me, and any advice anyone has would be greatly appreciated.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

Your case is pretty typical here WJS.

Your results are very similiar to what mine were n 2015 when I was diagnosed as Stage 1, except that you show a larger volumn of involvement than I did. My biopsy showed only one core, and it at 5%. All other cores were negative for any disease.

I went strainghtaway and had surgical removal the next month, at age 58.  But the pathology report after removal came back with a lot more cancer than the biopsy showed -- significant Stage II disease.  Biopsies routinely underestimate the extent of disease, but virtually never overestimate it.

At the age of 68 you are approaching the upper age recommendation for surgery against non-metastatic diesease. Most guys would likely suggest that radiation (RT) is more reasonable in your case, and certainly a lot easier.  I say this as a "surgery guy" myself.

max

 

Old Salt
Posts: 720
Joined: Aug 2014

Your urologist deserves a feather on his cap for recommending that you consult with both a rad oncologist and a surgeon. Good for him!

Study all the options and come to a decision that is right for you. Once you decide on a treatment, don't look back as that serves little or no purpose.

hopeful and opt...
Posts: 2226
Joined: Apr 2009

A Gleason 6 does not metasize outside the prostate, however when a large amount of Gleason 6 is found, a more significant cancer that can metasize can be found. This may be true in your case.

July 2017 Interview with Dr. Klotz https://www.urotoday.com/video-lectures/advanced-prostate-cancer/video/mediaitem/778-embedded-media2017-06-02-13-54-01.html?utm_source=newsletter_4652&utm_medium=email&utm_campaign=uroalerts-prostate-cancer-weekly

Since determining Gleason scores are subjective, I would seek a second opinion on the pathology by a world class pathologist. Johns Hopktins is a great place for second opinion.

I would also ask for a 3 T multiparametric MRI. This type MRI may show extracapsular extension, and is valuable in making a treatment decision.

If in fact the second pathology opinion confirms extensive Gleason 6, I would ask the radiation oncologist about SBRT.  SBRT is more convenient with only 4 or 5 treatments versus 40 for IMRT with similar outcome and side effects.

Here is a study about SBRT.

https://prostatecancerinfolink.net/2016/01/06/nine-year-outcomes-after-treatment-with-sbrt/

Surgery of all active treatments has the most severe side effects that happen more frequently than other active treatments, ie radiation.

ASAdvocate
Posts: 117
Joined: Apr 2017

As the others have stated, you are in a common low risk classification, but with enough positive cores that treatment should be considered.

Everthing else I would mention has already been stated by Hopeful.  Please carefully consider his advice.

WJS
Posts: 3
Joined: Oct 2017

Max, Old Salt, and Hopeful, thank you all for your input! It's great to have a support group like this to turn to when things like this happen.  I will look into the 3T MRI and the SBRT, among other options.

By the way Max, just a few months ago I had a routine colonoscopy done, and they found a large flat polyp that they could not completely remove during the procedure.  The biopsy of the removed portion came back as high level precancerous out to the margins of the specimen, so my doctor recommended that I have the rest of the polyp removed.  Being naive, it sounded llike a simple process to me.  I found out very quickly it was not simple.  It meant having a sizeable portion of my large colon cut out (with the side benefit of taking out the attached appendix along with it).  A few weeks later, I had the surgery with no complications other than quite severe wandering shoulder and neck pain for several days, apparently a side effect of the gas they used to inflate the abdominal area during the surgery.  The biopsy of the removed colon section and lymph nodes revealed that I did indeed have stage 1 colon cancer.  So you were right, these biopsies many times understimate the extent of the disease.  Luckily, the cancer was completely contained in the removed colon section, and no lymph nodes were affected, so no further action was necessary other than increased frequency of future colonoscopies.

I wonder if having this surgery to my abdominal area would have any effect on the ability to do robotic prostrate surgery now?  It left a 6" vertical scar in the middle of my belly, right across my belly button. 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

WJS,

You will have to ask the surgeon if DaVinci is still possible for you. 

The main DaVinci incision is vertical, just above the navel. Mine is about 2 or 3 inches long.  I had had laproscopic removal of the gall bladder a few years before my DaVinci. The gall bladder is removed actually through the navel, and the side holes were virtually indentical to the side access holes required for the DaVinci, but the DaVinci went well.  Within a year after DaVinci my incision herniated; the hernia surgeon said most likely because the area was weakened from so much cutting and stretching.  He installed a large mesh almost as large as a wash cloth, so now I have had 3 lapro surguries in that exact area (DaVinci is a robotic form of laproscopic surgery).

Short answer: The urology surgeon will have to look at you and answer that question himself.

max

airborne72's picture
airborne72
Posts: 276
Joined: Sep 2012

WJS:

We share a similar disease history, but in a reverse sequence and with a differing treatment plan.  I'll briefly outline mine and then provide some thoughts.

My first ever PSA test in March 2009 was 17.  An immediate biopsy revealed 10 out of 12 cores positive, with the highest Gleason score measuring 4+3.  After three consults I elected to have a radical prostatectomy with the use of the DaVinci robot in June 2009.  I was 57 years old.

The surgical outcome was a success, except for permanent impotence.  I did not need chemo nor radiation.  My PSA has remained not detectable since.

This May I was diagnosed with Stage II rectal cancer during a colonoscopy that I requested.  I endured 25 sessions of neoadjuvant chemo/radiation in July/August.  Last week I had a portion of my rectum removed and I am now living temporarily with an ileostomy.  The reversal of my ileostomy will occur after I complete 12 weeks of mop-up chemo.

What I have learned from the detection and treatment of these two separate and unrelated cancers:

1) Early detection is critical to all subsequent activities and their success.  We must listen to our bodies and take advantage of the current medical technology.  Both of my cancers were detected by chance but early enough to allow the medical community greater flexibility in treatment options.

2) Getting a second and third opinion is not only a good practice, you should make it an absolute.  My urologists were all over the map.  My gastro surgeon was myopic.

3) In my situation, colorectal cancer dwarfed my prostate cancer in terms of treatment and post surgery effects.  Because my PCa was contained I only had to recover from surgical pain and then resume a normal life, yet impotent.  Not so with this CRC.  This one has kicked me to curb several times and I still have three months of chemo and another surgery before I return to the normal flow of intestinal discharge.  I entered the ring weighing 145.  Today I weigh 132 and I fear continued weight loss.

4) All cancers, their treatment and the outcomes vary.  Consequently, I recommend that comparisons between them be avoided.  Each should be approached as a unique issue.

OK, enough of that.  I guess what I am trying to say is that between the two cancers, and considering your current situation, I would allocate 55% of your resources against the CRC and 45% of your resources against the PCa.

As you know, cancer sucks.  For those of us who have developed multiple cancers, it sucks even more.  Hang tough.  I wish you luck in the decision making process and a successful outcome.

Jim 

WJS
Posts: 3
Joined: Oct 2017

Jim, thank you for sharing your experiences with me.  I feel very lucky that my colon cancer issue worked out so cleanly. I do have a medical oncologist that is following me for that, but he assures me that I will probably not ever see any further issues from that particular episode. 

Actually, most of my available time right now is spent taking care of my wife, who has numerous new and ongoing (non-cancerous, so far) medical issues that have to be attended to and evaluated.  I'm trying to fit my prostate cancer research and future therapy plans into her schedule as best I can.  I know, I hear it from everyone, it shouldn't be that way, but it is.  Unfortunately, convenience will probably be a big factor in my decision-making-process for prostate therapy.

JJO
Posts: 10
Joined: Sep 2017

Thanks, Hopeful, for the link to Dr. Koltz's talk.  As  guy on AS, that was very informative as to the state of the art.  

GeorgeG
Posts: 127
Joined: May 2017

Good advice here covering most of my thoughts. Side effects are about the same rate for surgery vs radiation. They come sooner for surgery and later for radiation and are a little different. Sometimes the choice is made based on some of your particular medical conditions/status. An example would be a person who is a high risk for surgery due to a heart condition. best of luck.

George

 

Swingshiftworker
Posts: 1013
Joined: Mar 2010

OP:  I do not agree that the side effects of surgery vs radiation are about the same.  Here is the my sticky on the topic that I post whenever a newbie is considering the choices to consider when deciding upon a treatment.  Although this post reflects my bias, it does present the most common choices that you need to consider when you make your decision.  Do your own reseach and make the choice that is best for you.

The following is a duplicate of one that I have posted in various threads on this forum to give men newly diagnosed w/lower risk prostate cancer (Gleason 6 or 7) an overview of the treatment options available to them.

Anyone newly diagnosed with prostate cancer rated Gleason 6 (and usually Gleason 7) has all treatment options available to him and, since this cncer is considered "low risk", he has time to decide which choice is best for him.  So, the first thing a new prostate cancer patient should do is to do research on the available options before he actually has to make the decision regarding which treatment to choose.

The following is my response to other men who asked for similiar advice about the treatment choices avilable to them.  It's a summary of the available treatment options and my personal opinion on the matter.   You can, of course, ignore my opinion about which treatment choice I think is best.  The overview of the choices is still otherwise valid.

 . . .  People here know me as an outspoken advocate for CK and against surgery of any kind.  I was treated w/CK 7 years ago (Gleason 6 and PSA less than 10).  You can troll the forum for my many comments on this point.  Here are the highlights of the treatment options that you need to consider:

1)  CK (SBRT) currently is the most precise method of delivering radiation externally to treat prostate cancer.  Accuracy at the sub-mm level  in 360 degrees and can also account for organ/body movement on the fly during treatment.  Nothing is better.  Accuracy minimizes the risk of collateral tissue damage to almost nil, which means almost no risk of ED, incontinence and bleeding.  Treatment is given in 3-4 doses w/in a week time w/no need to take off time from work or other activities.

2) IMRT is the most common form of external radiation now used.  Available everythere.  Much better accuracy than before but no where near as good as CK.  So, it comes with a slightly higher risk of collateral tissue damage resulting in ED, incontienence and bleeding.  Unless things have changed, IMRT treatment generally requires 40 treatments -- 5 days a week for 8 weeks -- to be completed.  I think some treatment protocols have been reduce to only 20 but I'm not sure.  Still much longer and more disruptive to your life than CK but, if CK is not available, you may have no other choice.

3) BT (brachytherapy).  There are 2 types: high dose rate (HDR) and low dose rate (LDR).  HDR involves the temporary placement of rradioactive seeds in the prostate.  CK was modeled on HDR BT.  LDR involves the permanent placement of radioactive seens in the prostate.  1/2 life of the seeds in 1 year during which time you should not be in close contact w/pregnant women, infants and young children.  The seeds can set off metal/radiation detectors and you need to carry an ID card which explains why you've got all of the metal in your body and why you're radioactive.  Between HDR and LDR, HDR is the better choice because with LDR, the seeds can move or be expelled from the body.  Movement of the seeds can cause side effects due to excess radiation moving to where it shouldn't be causing collateral tissue damage -- ED, incontinence, bleeding, etc.   Both HDR and LDR require a precise plan for the placement of the seeds which is done manually.  If the seeds are placed improperly or move, it will reduce the effectiveness of the treatment and can cause collateral tissue damage and side effects.  An overnight stay in the hospital is required for both.  A catheter is inserted in your urethra so that you can pee.  You have to go back to have it removed and they won't let you go until you can pee on your own after it's removed.

4) Surgery -- robotic or open.   Surgery provides the same potential for cure as radiation (CK, IMRT or BT) but which MUCH GREATER risks of side effects than any method of radiation.  Temporary ED and incontinence are common for anywhere from 3-12 months BUT also sometimes permanently, which would require the implantation of an AUS (artificial urinary sphincter) to control urination and a penile implant to simulate an erection to permit penetration (but would not restore ejaculative function).  Removal of the prostate by surgery will also cause a retraction of the penile shaft about 1-2" into the body  due to the remove of the prostate which sits between the interior end of the penis and the bladder.  Doctors almost NEVER tell prospective PCa surgical patients about this.  A urologist actually had the to nerve to tell me it didn't even happen when I asked about it.   Don't trust any urologist/surgeon who tells you otherwise.  Between open and robotic, open is much better in terms of avoiding unintended tissue cutting/damage and detection of the spread of the cancer.  Robotic requires much more skill and training to perform well; the more procedures a doctor has done the better but unintended injuries can still occur and cancer can be missed because the doctor has to look thru a camera to perform the surgery which obstructs his/her field of vision.

5) You may also want to consder active surveillance (AS), which is considered a form of treatment without actually treating the cancer.  You just have to get regular PSA testing (usually quarterly) and biopsies (every 1-2 years, I believe) and keep an eye out for any acceleration in the growth of the cancer.  Hopeful and Optimistic (who has already posted above) has already mentioned this and is your best source of info on this forum about it. 

I personally could not live w/the need to constantly monitor the cancer in my body.  Like most other men, I just wanted it delt with.  Some men gravitate to surgery for this reason, thinking that the only way to be rid of it is to cut it out, but I did not like the risks presents by surgery and opted for CK, which is a choice I have NEVER regretted.  I am cancer free, there is no indication of remission, there were no side effects and my quality of life was never adversely affected.  Other men on this forum have reported similiar results.

So, for obvious reasons, I highly recommend that you consder CK as your choice of treatment.  The choice seems obvious when you consider the alternatives but you'll have to decide that for yourself.

Good luck!

 

SubDenis's picture
SubDenis
Posts: 130
Joined: Jul 2017

I wish you well in your journey. We have similar disease stage. I am evaluating the options and leaning towards surgery.  Denis

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