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2nd Opinion Upgraded Number of Cores

bob4894
Posts: 23
Joined: Feb 2015

 

Spoke to UCLA this morning and their pathologist looked at the slides from USC ( 1 core positive <10% gleason 6) and have upgraded to 4 cores positive. Here is the breakdown:

Core 1 - <10% gleason 3+3

Core 2 - < 5% gleason 3+3

Core 3 - < 15% gleason 3+3

Core 4 - < 25% gleason 3+3

Very concerned about these results. UCLA said I was still a candidate for Active Surveillance but this doesn't seem right to me.

 --------------------------------------------------------------------------------

PSA

Jan 2013 - 2.76

Mar 2014 - 3.12

May 2014 - 3.4

Jul 2014 - 3.5

1/30/2015- 3.46

Color Doppler Biopsy 2/12/15 - 12 cores.  1 core Gleason 3+3 <10

 

 

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

It is most cufusing but still on the same path. In fact those Gleason grades of 3 could be lower at Gr2 (now absolete) which in the opinion of the other pathologist were negligivel.

Here is your story; http://csn.cancer.org/node/292654

VG

hopeful and opt...
Posts: 2224
Joined: Apr 2009

VG thank you for posting Bob's story. It is helpful to see what the history is without having to find and go to other threads.

Bob, you still have a low grade Gleason score, in fact as VG mentioned, the Gleason grading by UCLA versus USC can be a nuance between G3 and G2.

Since UCLA does a high tech MRI and biopsy which you will have in a few months time, you will know more at that time.

Bob, also as a man on active surveillance, I understand where you are coming from. When it's you , you worry about every little thing, and I would be  slightly "nervous" if I was you, but UCLA, VG and I can look at your situation in a more objective manner....To emphasize this, yesterday, I had an appointment for a check up, where a PSA was taken.....last time around although my biopsy was OK, my PSA rose from 4.1 to 5.4, so now I am "nervous" about what this PSA (and free PSA) results might be.

 

 

bob4894
Posts: 23
Joined: Feb 2015

VG,

I really did not see it that way.  My first inclination was that the USC pathologist was not very good at recognizing prostate cancer.  My heart sunk when UCLA told me there were more using the same slides.  I see your point and I thank you for opening my eyes to a different perspective.  Do you think that I should get a 3rd reading of the slides?

 

Thanks

hopeful and opt...
Posts: 2224
Joined: Apr 2009

Bob,

 

Not VG, since you will be having a biopsy in June, a third reading of this will not change what you will be doing.

USc is a well respected treatment center for prostate cancer. Why is it that you think that the USC pathologist is not very good?

There is a book Primer on Prostate Cancer by Strum, a n artist, very worth reading. In this bookhe lists 8 pathologists  that specialize in prostate cancer that are expert experts. The pathologists at USC and UCLA are not on this elite  list, although they are definately not on the bottom.

 

http://www.amazon.com/Primer-Prostate-Cancer-Second-Edition/dp/0965877779

 

Determining Gleason scores are subjective., and there can be a difference of opinion among pathologist, so you want an experts expert that specializes.

bob4894
Posts: 23
Joined: Feb 2015

Hopeful & Optimistic,

I've been reading many posts on this network and was not able to find anything similar where slides that were negative are now found to have cancer.  I guess I was angry that I didn't have the full picture from USC when I made that comment about their pathologist.  Hope you understand.  Thanks for the link to the book.  Do you know if it provides information on how to send slides to the 'elite' pathologists?

 

Thanks

hopeful and opt...
Posts: 2224
Joined: Apr 2009

 The times that i wante d a second opinion, I contacted  the institution that has the slides  I let them know where I wanted the slides sent. I had to sign a release form. They packed the slides and sent them to  pathologist. The pathologist, analyzed the results and sent the results  back to the doctor, and the slides back to the institution of origin.

In your case, I dont know who has your slides now....I think that it iwas probably sent back to USC...you need to check.

ONce again, I think that it is a waste of time and money to have a third opinion on the first pathology, but this is your choice.

If your pathology was upgraded to a 3+4=7, and your treatment choice was affected you might wish to pursue this, but what will happen in your case if you do not get anoither opinion.

If USC was correct you would still biopsy in June.

If UCLA is correct you will still want to have a high tech biopsy in June which will give you a very good idea of where you stand..

To add, the Gleason score that we receive lists the cancer that is most prevelent first, unfortunately the the amount of cancer is not quantified. When the pathologist looks at the pathology it is subjective.....sinceboth  UCLA and USC have high volume P Ca slides that they review, I believe that the difference is a nuance. Approximately 70 percent of the time, a Gleason 6 will not spread, and you will die with, instead of because of prostate cancer.

.....................

In my opinion your time is best spent  researching various treatment options,   so you can be prepared if  and only if your active surveillance program ends, which may never be.

 

 

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

Bob

You are the one to decide, in any case I agree with hopeful comment, you can wait till your next exam for an aditional result.

Molecular profilling may provide another way to certify aggressiveness when in doubt of the pathologist's response.

The difference in the diagnosis with more positive cores of the same grade is that the cancer is voluminous forming micro colonies which would produce more PSA serum than the common average.

Best,

VG

 

bob4894
Posts: 23
Joined: Feb 2015

VG,

Does that mean the cancer is spreading?  My PSA was only 3.46 in Jan 2015.  It was 2.9 back in 2009 so it has'nt grown much since then.

 

Thanks

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3275
Joined: May 2012

Bob,

Cancer is rapidly dividing cells, which undoubtedly you know. "Rapid", is a relative assessment, relative to non-cancerous cell division speeds. Some "normal" cells, like hair and the stomach lining, grow fast with no cancer, which is why chemo kills hair and the stomach lining, causing severe nausea.

Therefore, definitionally, any cancer is "spreading," since it is replicating, and increasing in volume (space).  

The question with using Active Survellance or not is whether it is spreading fast enough to require curative treatment.  Hopeful and Vasco, the two best minds here, seem to feel probably not, since your Gleason's remain low. Your Doubling Rate (PSA velocity) is also, as you note, slow overall.

Deciding what to do going forward is a dynamic between you, your doctors, and the imputs of the experienced guys here who have studied this for years.

Good luck,

max

 

bob4894
Posts: 23
Joined: Feb 2015

Max,

I truly appreciate the guidance and support that you, Vasco, Hopeful and others are providing on this forum.  Thanks for setting my mind at ease.

 

Hopeful,

Let us know how the results of your PSA free turn out.  I will think keep thinking positive thoughts for you and me.

hopeful and opt...
Posts: 2224
Joined: Apr 2009

PSA is an indicator only, various situations can cause the PSA to rise, sex , exercise, even a hard stool. No active treatment is made based on a PSA. it is the biopsy that really counts. In your case a change of 6/10 in six years is nothing. It is not a consideration.

Bob, thanks for the positive thoughts....it's appreciated.

I hope that your concerns have been resolved.

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

Bob

Please understand that we are not doctors and that you should rely on your intuition in any decision.

My lay opinion on the information you have shared here about your case is that you can chose AS or have a quick fix with a Radical. There is a similar situation occurring with another patient whose story you can read here;

http://csn.cancer.org/node/292508

In judging your case you could think the obvious but the way cancer occurs and develops is not yet defined totally and it is full of surprises. Cells behave in various patterns with various characteristics. In theory, we all know that the Gleason grades forming the Gleason scores are important elements in the evaluation of a PCa case because these are used in the prediction of its future status (like an indolent form or fast spreading or risks for possible metastases, etc). Those elements, which apart from the Gleason score, also includes the PSA and the Clinical stage, will directly (Partin Tables, etc) influence and narrow the decisions in the choice of a preferable treatment.
Therefore, each of these elements should be reliable markers obtained from the best available “sources” (best physicians, modern facilities, state of art diagnosis). Errors can exist so that one should follow what one trusts better.

Accordingly, if we trust in PSA as being a reliable marker of cancer progression, then fast increases would represent aggressive forms of cancer that would be prune to spread faster and easily. However, these types of cells could have the characteristics of a low Gleason pattern of 3, meaning that they are more differentiated (closer to the characteristics of normal cells but multiplying faster) than higher patterns of 4 and 5, that are poorly differentiated with independent features of normal cells so that they are prune to produce lesser PSA, but also multiply at different life cycle rates than normal cells.

Logically the amount of increases in PSA (starting from a fixed base line) relates to the activity of that PCa cell which in lower G patterns would provide a higher rate of increase than the occurrence in higher G patterns. All this leads us to think that aggressiveness has tow meanings: the Spreading types that multiply faster independently of the Gleason pattern, and the Distorted types that are not dependent on the normal ways to divide but do such as higher Gleason patterns.

In your case we see a lower Pattern of Gr3 that is multiplying at a slow pace (PSADT > 36 months) which is indicative of low aggressiveness (sort of indolence).

You can read about the above here;

http://en.wikipedia.org/wiki/Gleason_grading_system

http://prostatecanceruk.org/about-us/news-and-views/2014/11/expert-insight-leading-prostate-cancer-scientist-explains-hottest-topics-at-national-cancer-research-conference

http://www.molecular-cancer.com/content/6/1/76

http://urology.jhu.edu/prostate/partintables.php

I think Max above explained well about “Voluminous” cancer.

Best wishes,

VGama

bob4894
Posts: 23
Joined: Feb 2015

VGama,

You may not be a doctor but when I read your feedback I feel like I'm talking to one Smile.  Your knowledge on this subject is greatly appreciated.

 

Thanks

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