Second Biopsy results
Last November at 67 after an MRI my first fusion biopsy was done transrectally at local hospital. It indicated (as far as I could figure) a single tumor residing in the right side of my prostate. I had a NM bone scan in January which did not show any bony metastases. Also a Prolaris test which indicated for single modal treatment. I went to Fox Chase Cancer Center for a second opinion hoping that I might be a candidate for focal therapy which they can offer. I was thinking Focal therapy (having less side effects) as a first treatment would leave me the option of RP or Radiation if the focal therapy failed. A recent (Feb. 27th) Fox Chase transperineal biopsy however shows some GG1 involvement in the left (left lateral wing #2) side of the prostate (wherever that is?). I'm now wondering if this is recent cancer growth or was it missed at the first biopsy? I have not yet spoken with the Fox Chase doctor to see if I'm still a candidate for focal, but I'm thinking these latest biopsy results are not good? I'm struggling to understand this stuff and make a wise choice, but seems like the more I learn the more confused I become. My PSA has risen from 4.3 last November and is now 5.7. It's been almost four months since first diagnosed and I still can't make a decision on course of action. 😒
I don't completely understand the different biopsy results. Seems like different formats which are (for me) difficult to compare. If I'm understanding it at all, there are discrepancies like tumor sizes and mention of cribriform pattern in the 4+3 sample in the latest biopsy? Perhaps some here might notice something I'm missing? Opinions would be greatly appreciated.
November Local Hospital 2023 Biopsy
A. Prostate, LEFT LAT BASE: Benign prostatic tissue. No tumor seen.
B. Prostate, LEFT LAT MID: Benign prostatic tissue. No tumor seen.
C. Prostate, LEFT LAT APEX: Benign prostatic tissue. No tumor seen.
D. Prostate, LEFT MED BASE: Benign prostatic tissue. No tumor seen.
E. Prostate, LEFT MED MID: Benign prostatic tissue. No tumor seen.
F. Prostate, LEFT MED APEX: Benign prostatic tissue. No tumor seen.
G. Prostate, RIGHT MED BASE: Benign prostatic tissue. No tumor seen.
H. Prostate, RIGHT MED MID: Focus of high-grade prostatic intraepithelial neoplasia (HGPIN).
I. Prostate, RIGHT MED APEX: Benign prostatic tissue. No tumor seen.
J. Prostate, RIGHT LAT BASE: Benign prostatic tissue. No tumor seen.
K. Prostate, RIGHT LAT MID: Prostatic adenocarcinoma (Gleason score: 3+4 = 7; GG 2) involving 90% of the tissue core.
L. Prostate, RIGHT LAT APEX: Prostatic adenocarcinoma (Gleason score: 3+3 = 6; GG 1) involving 7% of the tissue core.
M. Prostate, LES1 TAR1: Benign prostatic tissue. No tumor seen.
N. Prostate, LES1 TAR2: Benign prostatic tissue. No tumor seen.
O. Prostate, LES1 TAR3: Prostatic adenocarcinoma (Gleason score: 4+3 = 7; GG 3) involving 33% of the tissue core.
P. Prostate, LES1 TAR4: Benign prostatic tissue. No tumor seen.
Q. Prostate, LES1 TAR5: Benign prostatic tissue. No tumor seen.
TUMOR CORE MAPPING:
Location Grade Tumor size (mm)
Right lateral mid 3+4=7; GG2 9 mm
Right lateral apex 3+3=6; GG1 1 mm
Lesion 1, target biopsy 4 4+3=7; GG3 5 mm
February 2024 Fox Chase Biopsy
A. Prostate, right posterior medial #1, biopsy: -Benign prostate tissue.
B. Prostate, right posterior medial #2, biopsy: -Benign prostate tissue.
C. Prostate, right posterior lateral #1, biopsy: -Benign prostate tissue.
D. Prostate, right posterior lateral #2, biopsy: -Adenocarcinoma, Gleason patterns 3+3.
-There is 3% biopsy core involvement.
-Linear tumor extent = 0.5 mm.
-Grade group 1.
E. Prostate, right lateral wing #1, biopsy: -Benign prostate tissue.
F. Prostate, right lateral weight #2, biopsy: -Benign prostate tissue.
G. Prostate, left posterior medial #1, biopsy: -Benign prostate tissue.
H. Prostate, left posterior medial #2, biopsy: -Benign prostate tissue.
I. Prostate, left posterior lateral #1, biopsy: -Benign prostate tissue.
J. Prostate, left posterior lateral #2, biopsy: -Benign prostate tissue.
K. Prostate, left lateral wing #1, biopsy: -Benign prostate tissue.
L. Prostate, left lateral wing #2, biopsy: -Adenocarcinoma, Gleason patterns 3+3.
-There is 5% biopsy core involvement.
-Linear tumor extent = 0.6 mm.
-Grade group 1.
M. Prostate, right peripheral zone, biopsy:
-Adenocarcinoma, Gleason patterns 4+3 (pattern 4 = 80%).
-There is a cribriform carcinoma pattern.
-Tumor involves 3 of 9 biopsy core fragments.
-There is 16% total tissue involvement.
-Linear tumor extent = 16 mm.
-Grade group 3.
N. Prostate, right anterior medial, biopsy: -Adenocarcinoma, Gleason patterns 3+3.
-Tumor involves 1 of 2 biopsy cores.
-There is 4% total tissue involvement.
-Linear tumor extent = 0.5 mm.
-Grade group 1.
O. Prostate, left anterior medial, biopsy: -Benign prostate tissue.
P. Prostate, left anterior lateral, biopsy: -Benign prostate tissue.
Q. Prostate, right periurethral region, biopsy: -Benign prostate tissue.
Comments
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Hello,
I empathize with the volume of information received and the attempt to make the right decision. With that in mind I approach the biopsies with the mindset of supporting active surveillance or supporting immediate intervention.
Both of your results supports GG3 disease with cribiform changes and significant % core positive. GG1 disease can be found on repetitive biopsies sporadically, and in your case, does not change the fact you have significant disease that will require intervention.
I understand you are comparing the results with focal therapy in mind. In my opinion, Focal therapy does not have the data to support longterm results when compared to conventional therapy. I am not sure I would play around with GG3 disease, due to the risk that sporadic multi-focal disease may exist (and very well may in your second set of results).
I wish you well and hope you get answers at your follow up with Fox Chase
jc
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Let it be known that cribiform is radiation RESISTANT..i an living proof I had radiation treatment six years ago I was 57 years old, 3+4 crib form pattern seen All the grade three cancer is gone. The 4 is still there. It is radiation resistant. Don’t let anybody tell you anything else either freeze it with cryotherapy or you have it removed, dont take a chance with radiation you’ll end up like me ..imam now going for salvage surgery…not looking forward to it and I’m really upset with the radiologist. I asked him about cribiform and radiation. Could it be resistant and back then and he just blew me off and he still won’t admit it but I have other doctors that told me that it is resistant.
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Hi,
Good advice from the two survivors above. Sounds like you have 4+3 and cribriform which are not desirable forms of Prostate cancer. If it was me I would make the decision soon to deal with this. If you really want to do the focal therapy I would seek out the best in the field even if it means travel. Like jccoata said there is not a lot of procedure history on the success rate of focal therapy so find the best doctor and facilities. I would also look into the best methods of killing the cribriform cancer.
Dave3+4
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It's complicated; cribriform prostate cancer, that is.
First of all, there seem to be two kinds with the one that is associated with intraductal carcinoma being the more aggressive one. In other words, the finding reported by the (Fox Chase) pathologist (sample M) needs to be refined. Moreover, IMHO the cribriform pattern in this sample should be confirmed by yet another pathologist.
We really need AI to do the pathologies...
Conclusions: Cribriform pattern with intraductal carcinoma was associated with adverse outcomes in men with Gleason 7 prostate cancer treated with external beam radiotherapy while cribriform pattern without intraductal carcinoma was not so associated. Future studies may benefit from dichotomizing these 2 histological entities.
The above conclusion is from this paper:
J Urol. 2019 Oct;202(4):710-716. doi: 10.1097/JU.0000000000000316. Epub 2019 Sep 6
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This is what I’m being told about cribform. Yes, it’s resistant to radiation plain and simple. Yes it has adverse outcomes but that is for patients not like you and me. The reason I say that is because I have a focal tumor like you very very small. My PSA is only 1.9 is contained to the prostrate so the chances of beating this are still good like you. Now if it was multifocal if PSA was 20 if 15 out of 18 came back positive and it was cribiform then the outcome might not be favorable but right now we’re still in good shape to beat this thing.
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Thanks to all whom have responded thus far. Very much appreciated!
If I'm understanding correctly, it sounds like there is consensus of opinion to treat this soon and radiation might not be the best choice for initial treatment considering cribriform pattern? I've been trying to apply my simple logic to my dilemma, but every time I think I've got a plan, I learn something new (never good) that derails my plan. Since my initial diagnosis, I've been frightened by the well documented likely and potential side effects of both RP and radiation. Hence my attraction to the focal therapies. Focal may now be off the table? My biggest fear is living with incontinence or rectal issues. At PCRI, Dr. Mark Scholz champions radiation over surgery and what he says makes sense to me. https://www.youtube.com/watch?v=Pya8N78bR7s
In my case however, I have other extenuating issues; minor diverticulitis, internal hemorrhoids, and an anal fistula which was diagnosed a couple years ago. Because it does not give me much grief, I choose not to have it repaired. It's unclear how radiation would impact the fistula which I can't seem to get any answers. I've also been told that using spaceoar to protect the rectum is problematic with fistulas. If the material gets into the fistula channel it could cause serious infection. So with these factors in mind, I'm now again looking at RP which I was really hoping to avoid. 😒
My abilities to remember and discern information is limited. Trying to assess a first course of action is daunting. Almost seems like it's a crap shoot. Pick any treatment, roll the dice and see where lady luck takes me.
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Hi,
No matter what procedure you choose you really don’t know the outcome. The only thing you can do is pick the best doctors+best facilities to get the best outcome and educate yourself. If you take these steps you should have peace of mind that you did your best. Sounds like you are doing your homework…….
Dave 3+4
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Hi swl1956 -
I can't speak to "cribriform" as that wasn't part of my diagnosis. However, I CAN give you some feedback on radiation.
I had a trans-perineal biopsy at Cleveland Clinic in late 2022. My PSA was 20 at that time and the biopsy found a couple of 3+4 areas of concern with a high moderate Decipher score (more likely to metastasize). Due to my age (75 at the time) my urologist said surgery was pretty much "off the table." I met with a radiation oncologist who sent me for a PSMA PET scan which determined that the cancer was contained in the prostate. He said my best outcome would be with radiation plus ADT (three 6 month Lupron injections).
I had my first Lupron injection in April 2023 followed by 28 radiation treatments (May thru the end of June 2023). The radiation routine was annoying but I handled it OK. No issues during the radiation or for 6 months following. The good news was that my PSA dropped from 20 to <.03 (undetectable) and has stayed there since I finished the radiation. I have had no urinary issues at all - actually have been peeing better than I have in years. I had a second Lupron injection in October of 2023 and am scheduled for the final one next month (April 2024). IMHO, Lupron is a necessary evil. I have had lots of side affects since starting it - I started a thread concerning Lupron a while back - https://csn.cancer.org/discussion/327535/lupron-living-with-the-side-effects (hope that link works).
Starting in January 2024 I started having issues with bloody mucous in my stool. I was referred to a gastroenterologist and scheduled for a colonoscopy that found "moderate radiation proctitis." I am currently being treated with nightly Mesalamine suppositories which seem to be helping. I have a follow-up with the GI doc next week. I have no idea if this is going to be an ongoing issue or not. Fortunately I have had no other bowel issues and no affect on my quality of life.
Overall I am happy with the results of my treatment. My PSA has remained at <.03 for multiple checks since the completion of radiation. If the cancer has been destroyed, the side affects are worth it.
Good luck on your journey swl1956
Oldernow
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Update: Just had follow up meeting with Fox Chase Oncological Surgeon that did my latest biopsy. Posted above indicating 5% 3+3 found in the left lateral wing which did not show up on the first biopsy. My first biopsy had shown cancer only in the right side, I was certain he was going to tell me the focal treatment that I've been interested in would be a bad idea. In fact, that's not what happened. He still concludes that I am a good candidate for focal ablation of the primary 4+3 tumor mostly due to its location. He says it's positioned away from urethra and rectum so that it could be ablated with minimum risk of damage the surrounding structures. I was hoping for IRE Nanoknife which sounds safer to surrounding structures, but he says insurance won't pay for it. They can do it at Fox Chase, but out of pocket he mentioned 20K or more. He says Cyrotherapy is covered and will do the job. He explained that partial gland ablation will require ongoing surveillance and subsequent biopsies which for some individuals would be a non starter. My feeling is that at worst, it may kick the can down the road a bit to avoid RP or RT with the known side effects of those two treatments. At best, it may totally ablate the 4+3 tumor and then I just deal with active surveillance which seems to me I'd be doing no matter what treatment I choose. I'd still be watching and worrying anyhow. I guess with RP or RT no more biopsies? If I were 75 or older, I'd just go the radio therapy route, but at 67 I'm scared of the long term QOL side effects that may be in my future. Am I making any sense?
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Hi,
I totally get what you are saying with repeated biopsies or take care of it now withRP/RT. If it was me I would be looking into Proton radiation which should give you the least amount of lasting side effects . Proton has a fixed beam length which means it does not go past the intended target limiting damage past the target. It’s totally your choice but I am not sure I would want to go through the maybe yearly? biopsies. Don’t understand if you go with Cryo why you would need extra biopsies unless something shows up on a scan. Both Cryo and Proton will not kill the whole gland, just the cancer. You would think you would just monitor your PSA then if it rises do a biopsy. Good luck……
Dave 3+4
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I'm uncertain of the exact protocols after the Cryo procedure. I would think due to still having a prostate it would entail monitoring for a stable PSA. If PSA is rising, next would come imaging and then a biopsy like you suggested? I'm getting my first PSMA PET scan next week which I specifically requested. Two docs have told me PSMA PET scans are great but they can confuse the staging process? Both docs told me the bone scan was sufficient in my case, but I figure more info is best? I'm hoping the PSMA PET scan will confirm cancer is still within the gland. If not, IMRT will likely be the next choice. If cancer is outside the gland focal treatment or surgery doesn't make sense to me because I'm likely to need radiation anyhow. From what I've been reading about Proton therapy, it's an effective treatment, but not necessarily better than IMRT. https://www.youtube.com/watch?v=i1US-dIc9ho In my case being it's looking like I'm a good candidate for Focal treatment, I figure why not try it first. Perhaps I'm being naive, but avoiding the radical treatments even if it's just for a while makes sense to me. And who knows, perhaps with a bit of luck kick the can down the road for an extended period. Make sense?
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I can see your point(s). As long as you are mentally and physically prepared that follow-up treatment is likely, you can try the focal treatment first.
Personally, I would choose radiation in an attempt to get rid of all cancer once and for all. Especially with SBRT or brachytherapy, the chances of long-term side effects are pretty small.
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I'm trying to learn about all my options. I'm hoping my upcoming PSMA PET scan shows no spread outside the gland, (fingers crossed!) If no spread, I am thinking of making an appointment with another doctor at Fox Chase specializing in HDR Brachytherapy. From what I can ascertain, HDR Brachytherapy has a higher success rate when compared to EBRT. The side effect chances seem about the same when comparing those and much better than the potential side effects from surgery. The inclusion of cribriform on my last biopsy report has me concerned and perhaps a proven more effective approach might be wiser? From what I'm reading online, Fox Chase currently no longer does the seed implants LDR Brachytherapy. "Since 2015, the radiation oncologists at Fox Chase have been performing only the HDR prostate implants because patients continue to achieve excellent clinical results and are experiencing fewer side effects compared to the permanent seed implants." If the PSMA PET result is not good, I'm not sure what the next strategy would be? Perhaps I should have done what my local urologist suggested months ago (IMRT) and call it a day? LOLS!
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Update:
Had a PSMA PET scan today. Only a few hours later got the preliminary report. "Focus of hypermetabolic activity along the right lateral aspect of the prostate gland at the level of the mid gland consistent with neoplasm. This corresponds to the finding on prior MRI of pelvis. No evidence of metastatic disease."
This is good at least. I just wish I could make a decision for a treatment. I just can't seem to pick. 😒 All options suck!
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the choice is yours ….buttt remember my radiation treatment failed because of cribiform.. the radiation also damaged my bowls and when I did Breaky therapy I had the bloodiest hemorrhoids I thought I was gonna bleed out for five days straight and I also had fecal leakage for about six months after so there you have it when it comes to radiation. If you really are thinking about it, I would not do external beam. I would do the seeds for sure. Good lu ck . start asking around since I was diagnosed I found out that I know over six men all had surgery all are cancer free still 678 years later all of them were older and all of them said it really wasn’t that big a deal having the surgery so there you go I wish you luck.
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let me just add this to me and I bet a lot of men will agree. There’s three steps to prostate cancer one if you’re young enough and the cancer is still can find the prostrate you remove it hands down if something goes wrong, positive margins, or they see that some escaped then you have Plan B which is radiation and a lot of times that will really knock it all out cause it’s microscopic and then if all fails the dreaded plan C which is hormone treatment .. now me I went from plan B. Now to plan A which is remove it, but my Plan B is gone,cant so radition twice so if something goes wrong, and I have microscopic mastisis then I have to go to plan c which is kind of a drag that’s just my opinion but when you think about it and you ask around it makes a lot of sense
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The outcomes are the same for both surgery and radiation. Yes, for some, one therapy can fail, leading them to second guess themselves forever, but universally, the outcomes are that same.
@swl1956 , the choice is your and your alone to make. Once you make it, do not look back, look only forward.
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I've been vacillating over several modalities, but keep coming back around to the Focal approach. Mostly because I've been told I am a good candidate and side effects are minimal. I was very much hoping for the IRE technology mostly due to it does not thermally destruct surrounding structures. Fox Chase was part of an IRE study (no longer recruiting) but IRE not being FDA approved would not be covered by insurance. My Fox Chase doctor has offered Focal Cyrotherapy as an alternative. He claims they can ablate the tumor with less risk for Quality of Life issues when compared to RP or RT. Even though Cyro is FDA approved, it's still new enough in the focal application to not have long term efficacy data. It's a bit out of the conventional, but seems to me may be worth the risk to avoid the well known potential and likely peripheral damage of conventional treatments even if just for a while. I keep thinking if it fails, It can be repeated and salvage radiation can be plan B. I'm uncertain as to salvage prostatectomy because I believe the cyroablation process leaves scar tissue? Another worry for me is that although many institutions are offering focal therapies, because it's not the norm, they don't do lots of them. My Fox Chase doctor says they average 4 focal therapies a month. There are specialist clinics in focal treatments, but would take more research time and travel to utilize. I've been fooling around since last November trying to decide a first course of action and need to pull the trigger soon one way or the other. 😒
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