Low Gleason, not aggressive, mets to bone?

Tdoyle

Hello, new here. I am 53 years old and in June I had my yearly check up and found to have a PSA blood test of 5.56. Was refered to a urologist and she wanted to do a biopsy. This biopsy showed 1 of 12 cores positive with a gleason score of 3+3 .... After finding this out I went to my doctor again to keep him up to date. Me being paranoid about the spread of cancer after losing 2 friends in the last year, my doctor refered me to an oncologist that scheduled me for a ct and bone scan....well the radiologist findings have multiple sclerotic lesions consistant with bony metastasis... After this wanted a 2nd opinion and another doctor did a biopsy of 24 core and 7 were positive with all being a gleason score of 3+3 and not an aggressive cancer.... so now waiting on a pet scan result.....Question, can it spread to the bone at those low readings ?? Like I said I'm confussed on all this as I am sure everyone has been and just can't stop worring and wondering what the future holds....Anyway thank you all for taking time to read my rambling

Clevelandguy

More tests??

Hi,

I would think you would want to run more tests to verify that the lesions are cancerous.  From what I read briefly some lesions can be cancerous, some not.  Need to get a definative diagnosis before moving forward.  To answer your question I guess it could spred to your bones but a 3+3 is not very agressive.  A MRI might also help pinpoint what the lesion is.

 

Dave 3+4

Max Former Hodgkins Stage 3

Pathology

Tdoyle,

Do you have a copy of your biopsy reports ? If not, get them.  

The report will state whether capsular escape appears to have occured. It will also state if there is perineural involvement (potential escape inside the sheathing around the nerves in the gland).   If both are negative with a saturation 24 core biopsy, then the lesions being cancerous is profoundly unlikely with your low Gleason and PSA.  As Cleveland noted, your case demands additional testing,

max

VascodaGama

Be positive

Tdoyle,

I think you should wait for the PET report and probably get a second opinion on the BS results. Can you tell the location of the lesions (which part/s of the body)?

What did the urologist comment on the DRE?

This is a scared moment that we all PCa survivors also have experienced. You will overcome it. Be positive. By tradition, surgery and radiation are the recommended therapies in contained cases (cancer whole within the gland). When it is localized but not contained (for instance with confirmed mets in bone) then radiation is the best to assure cure. Some guys decide on a palliative approach for avoiding the risks and side effects of the radicals. Hormonal treatment is recommended when the spread is wide.

Let us know about the contents of the reports to provide you with better advices.

Best wishes,

VG

Tdoyle

Clevelandguy said:

More tests??

Hi,

I would think you would want to run more tests to verify that the lesions are cancerous.  From what I read briefly some lesions can be cancerous, some not.  Need to get a definative diagnosis before moving forward.  To answer your question I guess it could spred to your bones but a 3+3 is not very agressive.  A MRI might also help pinpoint what the lesion is.

 

Dave 3+4

MRI

My doctor has scheduled a MRI in Feb. for just the prostate because he said right now it would be full of blood nd could'nt tell anything about it....I am still waiting on results from the PET scan from last Thursday.

Tdoyle

Max Former Hodgkins Stage 3 said:

Pathology

Tdoyle,

Do you have a copy of your biopsy reports ? If not, get them.  

The report will state whether capsular escape appears to have occured. It will also state if there is perineural involvement (potential escape inside the sheathing around the nerves in the gland).   If both are negative with a saturation 24 core biopsy, then the lesions being cancerous is profoundly unlikely with your low Gleason and PSA.  As Cleveland noted, your case demands additional testing,

max

The biopsy report says. No perineural invasion, No Tumor in the extraprostatic adipose tissue is identified......Do not see anything about capsular escape.  Hoping to hear back from the doctor on pet scan today.

Tdoyle

VascodaGama said:

Be positive

Tdoyle,

I think you should wait for the PET report and probably get a second opinion on the BS results. Can you tell the location of the lesions (which part/s of the body)?

What did the urologist comment on the DRE?

This is a scared moment that we all PCa survivors also have experienced. You will overcome it. Be positive. By tradition, surgery and radiation are the recommended therapies in contained cases (cancer whole within the gland). When it is localized but not contained (for instance with confirmed mets in bone) then radiation is the best to assure cure. Some guys decide on a palliative approach for avoiding the risks and side effects of the radicals. Hormonal treatment is recommended when the spread is wide.

Let us know about the contents of the reports to provide you with better advices.

Best wishes,

VG

Trying to be positive

I have had like  2 urologist and a prostate urologist do a DRE in the last 2 months and all say everything is good, they dont feel anything wrong and it isnt enlarged... The sclerotic lesions were  on a couple ribs and sternum and 2-3 mm seen in L5 and L1 , the radiologist said the spots are to small to do a biopsy.

Clevelandguy

Rib lesions

Hi,

 

If you look into bone lesions they can come from old injuries also, so that could be the ones in your case(I hope).  Just a thought.......

Dave 3+4

Tdoyle

update

Got the call from my oncologist about the pet scan. they are curious about a spot on the right 9th rib...They said it doesnt add up and they think like yall do about a previous injusy...But he is going to scheduke me an appointment with an orthopidic oncologist to maybe do a biopsy of that rib to find out for sure....so holding of  on treatment for prostate cancer until those results. So hopefully it is good and I can breath again... Thanks for all replies , its comforting hearing from you guys

hopeful and optimistic

Of course follow through by

Of course follow through by doing a biopsy based on the results of the pet scan......be advised that the American urological association does not recommend a bone scan for patients with a Gleason under ,8, since it is very unlikely for prostate cancer to spread to the bone

 

 

In the cores that were positive with a Gleason 6, I wonder what was the involvement for each core, that is what percent of each core was cancerous.

 

Many do not consider a Gleason 6 to be a cancer, and Gleason 6 ,does not metastasize , however more significant cancer can be found when there is a large amount of gleason 6 cancer found.

 

Tdoyle

hopeful and optimistic said:

Of course follow through by

Of course follow through by doing a biopsy based on the results of the pet scan......be advised that the American urological association does not recommend a bone scan for patients with a Gleason under ,8, since it is very unlikely for prostate cancer to spread to the bone

 

 

In the cores that were positive with a Gleason 6, I wonder what was the involvement for each core, that is what percent of each core was cancerous.

 

Many do not consider a Gleason 6 to be a cancer, and Gleason 6 ,does not metastasize , however more significant cancer can be found when there is a large amount of gleason 6 cancer found.

 

percentage

of the 7 positive cores 2 were 40% , 1 at 15% ,  3 at 10%  and 1 at 2%

ASAdvocate

Your 7 cores out of 24 equate

Your 7 cores out of 24 equate to about 29 percent of the total. Because the original guidelines used only six core biopsies, there are newer criteria that use the percentage of total cores that are positive, not the actual number. I have seen active surveillance criteris that specifiy selection if under 34 percent.

So, you may have a low risk case of prostate cancer, and not be in any rush to treat it.

Were all the positive cores on one side of the prostate, or both?

Tdoyle

ASAdvocate said:

Your 7 cores out of 24 equate

Your 7 cores out of 24 equate to about 29 percent of the total. Because the original guidelines used only six core biopsies, there are newer criteria that use the percentage of total cores that are positive, not the actual number. I have seen active surveillance criteris that specifiy selection if under 34 percent.

So, you may have a low risk case of prostate cancer, and not be in any rush to treat it.

Were all the positive cores on one side of the prostate, or both?

cores

right lateral and right apex and right mid

hopeful and optimistic

Second opinion on pathology by world class expert

Determining Gleason scores and the amount in each core are subjective....there is a difference between the skills of,  and facilities that pathologist use.

Here is a very recent discussion with a man under similar circumstances as you.

Second opinion of pathology is important when low risk disease is found.

He was advised to have a second opinion with Johns Hopkins.

https://csn.cancer.org/node/312499

Max Former Hodgkins Stage 3

Tdoyle said:

The biopsy report says. No perineural invasion, No Tumor in the extraprostatic adipose tissue is identified......Do not see anything about capsular escape.  Hoping to hear back from the doctor on pet scan today.

Different terminology

Tdoyle, 

The statement "No tumor in the extraprostatic adipose tissue..."  in effect means "no capsular escape," just different terminology.

I read through to the bottom of your thread today, and more and more it seems likely that you have a mild case of early stage PCa, with no metastasis.  We are not doctors, and cannot give medical advice. But impressionistically, this makes sense.

Continue with all of the tests. I wish you continuing good reports,

max

Tdoyle

update

After having the PET scan the results showed a suspicious spot on my right 9th rib and I went to a bone oncologist taday and he is sending me to a radiologist for a biopsy of this small spot on my rib.. They say its possible to spread with such a low gleason of 3+3 and my psa 5.56...but still need to find out what is going on with this rib....also I forgot to say that the first opinion I got from local oncologist and urologist was that it has spread to the bone and my urologist started me on a 4 month Lupron shot....wasnt sure whether to take the shot at that time or not because I was going for second opinion in Little Rock........the urologist and oncologist I go to now in LR say that the Lupron is ok to have taken

hopeful and optimistic

.

Hi Troy,

 

Troy,

I am responding to your question at the thread that you started, since I believe that there is a synergistic effect at this site among those who post here.  

I suggest that you attend local support group(s).  ustoo.com supports local support groups worldwide, so google them for a location if available.

You need to research, read books, internet searches, continue to ask questions here.

Knowledge will allieviate some of the stress that you are experiencing..

You need to wait until the Nov 20 to see the results of the bone biopsy. If nothing found, you need to get another image test, the 3T MRI which may show extracapsular extension, and suspicious lesions within the prostate; one lobe or two, the radiologist will rank the suspicious lesions be potential aggressiveness...as you mentioned this will be done in February......so no treatment until after the MRI.

Your urologist recommends surgery (Well is there a bias from the urologist ...urologist do surgery....additionally if you decide to do surgery...there is a difference among surgeons......and outcome.......

Read about and Interview doctors iof various specialties to include but not limited to radiation onclologist (ask about SBRT---this would be my choice of an active treatment), etc. Speak with a doctor at major center of excellence who specializes in Active Surveillance for an opinion.

At any rate READ, READ and READ...ask questions here...we are here for you.

 

"Hello, My name is Troy and you have replied and been helpful with some of my concerns, I have 7 of 24 cores that are a 3+3 gleason score my last psa was 5.56....I had a pet scan done out of my own fear...It showed a suspicious spot on a rib, well I am scheduled for a bone biopsy on the 20th of this month...My urologist I go to said that if the bone biopsy comes out good....He still would recommend removing the prostate... I was wanting your opinion on my situation.....this has all hit me in June of this year and my head swims with what ifs and what needs to be done...I know all cases are different but would like an opinion from someone living this aweful stuff...

Thank you for your time

Troy"

bassoneman

Head swiming in what ifs...

Head swiming in the what ifs..  Wow that is a song I think we all sing here.. 

VascodaGama

What are the full PET results?

I think that by now you already got the bone (9th) biopsy result, but I wonder about the full report on the PET exam. Can you print here their conclusion? Where did the PET locate the highest SUV suggestive of PCa? Also what was the radiopharmaceutical used for the PET exam. Was it PSMA?

The results from above exams will provide you a conclusive clinical stage from which you can decide on a treatment. Surely the Lupron is OK and would not affect any option on a radical.

Best wishes in your journey,

VG

 

Tdoyle

VascodaGama said:

What are the full PET results?

I think that by now you already got the bone (9th) biopsy result, but I wonder about the full report on the PET exam. Can you print here their conclusion? Where did the PET locate the highest SUV suggestive of PCa? Also what was the radiopharmaceutical used for the PET exam. Was it PSMA?

The results from above exams will provide you a conclusive clinical stage from which you can decide on a treatment. Surely the Lupron is OK and would not affect any option on a radical.

Best wishes in your journey,

VG

 

PET Results

Here are the PET scan results, the bone biopsy is to be done the 20th

 

 Impression

Intense radiotracer activity fusing to right 9th rib sclerotic changes,
consistent with metastatic disease.


------------------------------------------------------------------------
--------------------------------------------------
FOR THE PATIENT:
PET/CT STUDIES ARE COMPLEX, STATE-OF-THE-ART EXAMS WHICH PROVIDE BOTH
FUNCTIONAL AND ANATOMICAL INFORMATION. THE REPORT BELOW HAS BEEN
PRODUCED BY THE NUCLEAR MEDICINE PHYSICIAN TO COMMUNICATE IN MEDICAL
LANGUAGE THE DETAILS OF YOUR FINDINGS TO YOUR DOCTOR. THE RESULTS ARE
IMPORTANT, BUT ONLY A PART OF YOUR COMPLETE CLINICAL PICTURE. YOUR
PHYSICIAN CAN BEST HELP YOU UNDERSTAND THEIR SIGNIFICANCE.
WE ARE HONORED TO PARTICIPATE IN YOUR CARE. THANK YOU.

THE DIVISION OF NUCLEAR MEDICINE, DEPARTMENT OF RADIOLOGY, UAMS




Electronically Signed by: Xiaofei Wang on 10/19/2017 at 17:18:14

Narrative

EXAM DESCRIPTION:
PET-CT (NAF) SODIUM FLUORIDE BONE SCAN

COMBINED PET/CT SCAN:

10/19/2017

CLINICAL INDICATION:
53-year-old gentleman with history of prostate cancer, Gleason score 6,
initial staging

RADIOPHARMACEUTICAL (F18-FDG), INJECTION SITE, INJECTION TIME AND SCAN
TIME, BLOOD SUGAR, HEIGHT, WEIGHT, AND CT RADIATION DOSE (CTDI - MGY),
DLP (MGY*CM):
Dose PT 1->13.77mCi NAF; SITE PT1->RAC; INJ Tm-> 2:20 PM; SCN Tm-> 3:20
PM; BS ->99MG%; HT ->5'8; WT ->175LBS; Oral->Yes; CTDI PT1->2.30; DLP
PT1->439.37

PROCEDURE:
Approximately 60 minutes after intravenous administration of
18F-FDG, a non-IV-contrast CT was obtained from the Skull vertex to the
Feet for use in attenuation correction and anatomic localization
of radiotracer activity. Emission scans were obtained over the same
anatomical regions. Images were reconstructed and reviewed in the axial,
coronal, and sagittal planes.

A low dose CT scan protocol is used for this exam.

DEVIATIONS FROM STANDARD PROTOCOL:
No

COMPARISON:
No

CURRENT PET/CT SCAN FINDINGS:
SUV measurements presented are based on lean body mass unless specified.
Background metabolic activity with a mean SUV of 0.5 measured in the
liver.

Intense radiotracer activity fusing to right 9th rib sclerotic lesion,
consistent with metastatic disease.

Moderate radiotracer activity fusing to left 5th and 6th ribs laterally
with linear pattern, likely post-traumatic changes, correlate patient
history or evaluate on followup scan.

Moderate radiotracer activity fusing to left medial epicondyle cortex
region without definite sclertic changes, nonspecific

Intense radiotracer activity fusing to right side nasal sidewall,
nonspecific, likely related to posttraumatic changes.

Attenuation CT: No suspicious for nodules. No pericardial or pleural
effusions. No lymphadenopathy. Enlarged prostate. Mild
atherosclerosis changes.

 

VascodaGama

Tdoyle said:

PET Results

Here are the PET scan results, the bone biopsy is to be done the 20th

 

 Impression

Intense radiotracer activity fusing to right 9th rib sclerotic changes,
consistent with metastatic disease.


------------------------------------------------------------------------
--------------------------------------------------
FOR THE PATIENT:
PET/CT STUDIES ARE COMPLEX, STATE-OF-THE-ART EXAMS WHICH PROVIDE BOTH
FUNCTIONAL AND ANATOMICAL INFORMATION. THE REPORT BELOW HAS BEEN
PRODUCED BY THE NUCLEAR MEDICINE PHYSICIAN TO COMMUNICATE IN MEDICAL
LANGUAGE THE DETAILS OF YOUR FINDINGS TO YOUR DOCTOR. THE RESULTS ARE
IMPORTANT, BUT ONLY A PART OF YOUR COMPLETE CLINICAL PICTURE. YOUR
PHYSICIAN CAN BEST HELP YOU UNDERSTAND THEIR SIGNIFICANCE.
WE ARE HONORED TO PARTICIPATE IN YOUR CARE. THANK YOU.

THE DIVISION OF NUCLEAR MEDICINE, DEPARTMENT OF RADIOLOGY, UAMS




Electronically Signed by: Xiaofei Wang on 10/19/2017 at 17:18:14

Narrative

EXAM DESCRIPTION:
PET-CT (NAF) SODIUM FLUORIDE BONE SCAN

COMBINED PET/CT SCAN:

10/19/2017

CLINICAL INDICATION:
53-year-old gentleman with history of prostate cancer, Gleason score 6,
initial staging

RADIOPHARMACEUTICAL (F18-FDG), INJECTION SITE, INJECTION TIME AND SCAN
TIME, BLOOD SUGAR, HEIGHT, WEIGHT, AND CT RADIATION DOSE (CTDI - MGY),
DLP (MGY*CM):
Dose PT 1->13.77mCi NAF; SITE PT1->RAC; INJ Tm-> 2:20 PM; SCN Tm-> 3:20
PM; BS ->99MG%; HT ->5'8; WT ->175LBS; Oral->Yes; CTDI PT1->2.30; DLP
PT1->439.37

PROCEDURE:
Approximately 60 minutes after intravenous administration of
18F-FDG, a non-IV-contrast CT was obtained from the Skull vertex to the
Feet for use in attenuation correction and anatomic localization
of radiotracer activity. Emission scans were obtained over the same
anatomical regions. Images were reconstructed and reviewed in the axial,
coronal, and sagittal planes.

A low dose CT scan protocol is used for this exam.

DEVIATIONS FROM STANDARD PROTOCOL:
No

COMPARISON:
No

CURRENT PET/CT SCAN FINDINGS:
SUV measurements presented are based on lean body mass unless specified.
Background metabolic activity with a mean SUV of 0.5 measured in the
liver.

Intense radiotracer activity fusing to right 9th rib sclerotic lesion,
consistent with metastatic disease.

Moderate radiotracer activity fusing to left 5th and 6th ribs laterally
with linear pattern, likely post-traumatic changes, correlate patient
history or evaluate on followup scan.

Moderate radiotracer activity fusing to left medial epicondyle cortex
region without definite sclertic changes, nonspecific

Intense radiotracer activity fusing to right side nasal sidewall,
nonspecific, likely related to posttraumatic changes.

Attenuation CT: No suspicious for nodules. No pericardial or pleural
effusions. No lymphadenopathy. Enlarged prostate. Mild
atherosclerosis changes.

 

PET/CT (18)F-FDG is not proper for all types of PCa

Tdoyle

You need that bone biopsy for a final conclusion on your diagnosis. Unfortunately, the PET/CT (18)F-FDG you did above may not provide the full truth on your PCa case. The Fluorodeoxyglucose (FDG) is not well metabolized by prostate cancer, in particular in cases with confirmed low grade Gleason type which seem to be your case. Your doctor’s choice in this exam may have been to rule out aggressive tumour. On the other end, FDG is superior in diagnosis of very advanced metastasized cases with castrate resistant type of cancers. A ^99mTc-labeled-methylene-diphosphonate bone scan may seems to be better for a Gleason 6 patient, when checking for bone metastasis.

I agree with ASAdvocate comment above. You should not be in any rush to treat without a proper diagnosis. You may even be eligible for AS (active surveillance), postponing a treatment, if such is advisable by a AS specialist.

Please read below links for better understanding my opinion on the PET/CT exam;

“…Currently there is no established role for ¹⁸F-FDG PET/CT in the assessment of prostatic cancer, since it has a low accuracy owing to the relatively low metabolic rate of the tumor as well as the interfering adjacent urinary excretion of the tracer. However, other new PET radiotracers such as 11C-choline and ¹⁸F-fluorocholine have shown promising results in the management of prostate cancer.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101722/

“…(18)F-FDG uptake overlaps significantly between malignant and benign prostatic conditions. Subsequent patient management was not affected by the reporting of incidental focal prostatic uptake in this cohort.”

https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/99800-clinical-significance-of-prostate-18-f-labelled-fluorodeoxyglucose-uptake-on-positron-emission-tomography-computed-tomography-a-five-year-review.html

http://emjreviews.com/wp-content/uploads/Role-of-Positron-Emission-Tomography-with-Fluorodeoxyglucose-in-Prostate-Cancer.pdf

https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/79099-18-f-fdg-pet-ct-and-18-f-naf-pet-ct-in-men-with-castrate-resistant-prostate-cancer-abstract.html

 

Best wishes,

VGama