Gleason 8 with PNI

phcarty58 · February 23

Hi all. I have been diagnosed with Gleason 8 and PNI. I am scheduled for PMSA Petscan and Exactscan in two weeks to see if and where the cancer has spread. The cancer is too big for prostatectomy (unless it can be shrunk) and will get recommended treatment once the tests are done. Anyone had similar diagnosis and any tips or helpful thoughts? Many thanks!

Wheel · February 23

Sorry that you have joined our club, but members are wealth of information and support. It would be helpful to get some additional information that would help members in their sharing and thoughts regarding treatments. If you could share more details from your biopsy such as number of cores that showed cancer and their individual Gleason scores. You are given a Gleason score based on your highest of any one core, but I only had one core of Gleason 8 and the rest were primarily 6, but treatment protocols are for Gleason 8. My cancer had breeched the capsule but I was still able to have a robotic laparoscopic prostatectomy. The PET showed no lymph node involvement and that was confirmed at surgery with several removed and final pathology after surgery turned out unfavorable Gleason 7. Also your prostate size and density. Larger prostates can be more difficult for surgery and you mention your cancer is to big unless can be shrunk. I assume you may be referring to the size of your prostate since you refer to shrinking of it and not the Gleason score. Your PNI is certainly of concern, but does not necessarily preclude surgery. The PET is the next step, and I am not familiar with Exactscan. You may ask to have your biopsy tissue sent for genomic testing such as Decipher testing to see likelihood of intermediate or advanced .

Good luck.

Clevelandguy · February 23

Hi,

The PNI is concerning but I had PNI and I am cancer free 10 yrs later. Never heard of Prostate tumor so large they would not recommend surgery. Was the cancer a 4+4,3+5, or 5+3 with the later being the most aggressive? If the PET shows cancer outside the Prostate capsule radiation might be a better path. Depending on what path you choose your doctor team might put you on one of the ADT drugs to reduce the tumors size. Might not be a bad idea to get a second opinion from a different set of doctors/hospital organization if available.

Dave 3+4

phcarty58 · February 23

Thank you @Wheel. I appreciate your input! Here are high level MRI results and I've added the Biopsy results further below. Thanks for your good wishes!

FINDINGS:

The prostate gland measures 5.5 x 4.7 x 5.5 cm.

The prostate volume is 63 cc.

PSA Density is 0.1 ng/mL2.

Peripheral Zone: Diffuse T2 hypointense replacement throughout the peripheral zone of the prostate gland spanning from the right base through the apex spanning a total approximate distance of 3.4 cm.

There is direct invasion into the right posterior and lateral transitional zone at the level of the mid gland as well as direct extension into the right seminal vesicle insertion site.

Extraprostatic extension by approximately 0.4 cm at the level of the mid gland with possible abutment/tethering of the anterior rectum best visualized on series 3 image 20.

Transitional Zone: See above.

Seminal vesicles and ejaculatory ducts: See above.

Lymph nodes: No adenopathy.

IMPRESSION:

Peripheral Zone: Diffuse replacement throughout the right transitional zone with extraprostatic extension and focal tethering of the rectum..

PI-RADS 5: Very high (clinically significant prostate cancer is highly likely to be present)

Here is high level results on 20 cores that were done in the biopsy:

Aggressive Cancer in the Right Lobe:
- Multiple high-risk (Gleason 8) cancer sites occupying large portions (80-90%) of the core samples.
- Presence of perineural invasion (suggests potential spread along nerves).
Limited Involvement in the Left Lobe:
- Only one core (I) from the left lobe shows a very small amount of cancer (<2%).
Potential Cancer Spread Concerns:
- Perineural invasion in cores E and F could indicate potential for local extension.

Clinical Implications & Next Steps:

High-Risk Cancer (Gleason 8) Requires Prompt Medical Attention.
- Gleason 8 cancer is considered aggressive, and treatment decisions should be made quickly.
- Options may include surgery (radical prostatectomy), radiation therapy, or hormone therapy depending on further staging.
Further Staging Tests May Be Needed:
- MRI, Bone Scan, or PSMA PET Scan to check for local or distant spread.
Consultation with a Urologist & Oncologist for Treatment Planning:
- Given the extent and aggressiveness, a multidisciplinary approachis recommended.

Here are the pathologist's summary:

Surgical Pathology Report -2/11/2025 15:46 EST - Auth (Verified)

Diagnosis

A. PROSTATE, RIGHT LOBE, TZ ANTERIOR CORE 2, NEEDLE CORE BIOPSY: • Benign prostatic tissue.

B. PROSTATE, RIGHT LOBE, TZ POSTERIOR, NEEDLE CORE BIOPSY: Benign prostatic tissue.

C .PROSTATE,RIGHTLOBE,P ZANTERIOR,NEEDLECOREBIOPSY:

• Prostatic adenocarcinoma, Gleason Score 8 (4+4), (Grade Group 4) occupying approximately 80% of the biopsy length.

• See comment below.

D. PROSTATE,RIGHTLOBE,P ZPOSTERIOR LATERAL, NEEDLE CORE BIOPSY:

Prostatic adenocarcinoma,Gleason Score 8 (4+4), (Grade Group 4) occupying approximately 20% of the biopsy length.

E. PROSTATE, RIGHT LOBE, BASE PZ, NEEDLE CORE BIOPSY:

• Prostatic adenocarcinoma, Gleason Score 7(4+3), (Grade Group 3) occupying approximately 80% of the biopsy length.

Page 1of 7

7 2/11/2025 15:48

C(610) 768-3300 Universal Health Services, Inc

RRD -+19417025598 2/7

Diagnosis

F. PROSTATE, RIGHT LOBE, APEX PZ, NEEDLE CORE BIOPSY:

Prostatic adenocarcinoma, Gleason Score 8 (4+4), (Grade Group 4) occupying approximately 90% of the biopsy length.

Focal perineural invasion is identified.

See comment below.

PROSTATE, RIGHTLOBE, PZ PL, MRI TARGET NEEDLE CORE BIOPSY,#1:Prostatic adenocarcinoma, Gleason Score 8 (4+4), (Grade Group 4) occupying approximately 80% of two out of two cores.

PROSTATE, RIGHT LOBE, PZ PM APEX, MRI TARGET NEEDLE CORE BIOPSY, #2:

Prostatic adenocarcinoma, Gleason Score 8 (4+4), (Grade Group 4) occupying approximately 90% of two out of two cores.

1.PROSTATE,LEFTLOBE,PZ PM APEX, MRI TARGET NEEDLE CORE BIOPSY, #3:

Prostatic adenocarcinoma, Gleason Score 8 (4+4), (Grade Group 4) occupying less than 2% of the biopsy length.

PROSTATE, LEFT LOBE,TZ ANTERIOR, NEEDLE CORE BIOPSY: •

Benign prostatic tissue.

K. PROSTATE, LEFT LOBE, TZ POSTERIOR, NEEDLE CORE BIOPSY: • Benign prostatic tissue.

L.PROSTATE,LEFTLOBE,P ZANTERIOR,NEEDLE CORE BIOPSY: • Benign prostatic tissue.

M. PROSTATE, LEFT LOBE, PZ POSTEROLATERAL, NEEDLE CORE BIOPSY:

phcarty58 · February 23

https://csn.cancer.org/discussion/comment/1721256#Comment_1721256

Thank you! Very good comments. Much appreciated! Mine is a 4+4

Wheel · February 23

certainly not much ambiguity in your MRI and Biopsy results and the involvement outside the capsule. It seems their recommendation for a multi disciplinary approach is a good one. I would recommend regardless that you obtain 2nd opinions on treatment recommendations once you receive your yours from your Doctor, and if you live anywhere near a university cancer center that you consider seeking your treatment there if it is practical. This is important not just now for your initial treatment but for the future. These cancer centers have Doctors engaged in the latest technology, and research along with clinical trials that often open treatments not yet available. I entered a clinical trial 20 years ago after being diagnosed with non Hodgkin’s lymphoma at a major university cancer center and it was the best thing I ever did. All the best and prayers in your journey. I am on my second cancer with the prostate unless you count actually needing Mohs surgery on Basel Cell skin cancer, then I am three time survivor of cancer.

phcarty58 · February 24

Three times makes a trend, and a good one. Congrats and thank you again for your advice and insights!

Steve1961 · February 25

what was your psa and how old are you ..where are you located .. with all you have going on I mean radiation and hormone therapy can only do so much you know like a few men have said I never heard of them not being able to remove the prostate because the tumors too big sure they can remove the prostate and maybe 8090% cancer then hopefully radiation and hormone treatment. Can knock The rest of it out that is why i asked what was your PSA in your age and where are you located? I know some excellent surgeons down at UCLA Los Angeles, California one by the name of Dr. Robert Reiter who saved my life this man is not just a surgeon. He is the head of the urology department. The head of the prostate cancer division he is a professor. He has many YouTube videos. There’s a lot of options out there time to do your homework and we will help you out… the PSMA scan you need to do. Hopefully it has not spread then you have many options.

Old Salt · February 25

Did I miss it, but I don't see a statement that the cancer is too big for surgery. However, there are several findings that are indicative (to me at least) that surgery may not be the best option for you.

phcarty58 · February 25

https://csn.cancer.org/discussion/comment/1721278#Comment_1721278

Thank you Steve! My age is 66 and most recent psa is 8.8. I’ll need to clarify the read on surgery can’t happen at front end of the process. It might be that it’s large and oddly shaped and it’s potentially tethered to the rectum. The surgeon was clear that it has to be “shrunk “ first. I’m on the east coast and am engaged with the team at Mount Sinai. Thank you for your thoughts and glad you got through it!

phcarty58 · February 25

Thank you Old Salt!

centralPA · February 25

The PSMA PET will tell an important tale, and hopefully it’s a boring one (nothing found where it’s not supposed to be).

Sending positive thoughts!

phcarty58 · February 25

Thank you! I like how you think!

Steve1961 · 2:08AM

that just goes to show that no two cases are ever the same wow PSA 8.8 that’s not even that high to have tumors that big. I wish you the best you’ll get through this with flying colors.

Gleason 8 with PNI

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