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Low Gleason, not aggressive, mets to bone?

Tdoyle
Posts: 36
Joined: Oct 2017

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
Posts: 429
Joined: Jun 2015

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

Tdoyle
Posts: 36
Joined: Oct 2017

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.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3258
Joined: May 2012

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

Tdoyle
Posts: 36
Joined: Oct 2017

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.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3258
Joined: May 2012

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

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

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
Posts: 36
Joined: Oct 2017

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
Posts: 429
Joined: Jun 2015

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
Posts: 36
Joined: Oct 2017

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 opt...
Posts: 2218
Joined: Apr 2009

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
Posts: 36
Joined: Oct 2017

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

ASAdvocate
Posts: 113
Joined: Apr 2017

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
Posts: 36
Joined: Oct 2017

right lateral and right apex and right mid

hopeful and opt...
Posts: 2218
Joined: Apr 2009

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

Tdoyle
Posts: 36
Joined: Oct 2017

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 opt...
Posts: 2218
Joined: Apr 2009

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's picture
bassoneman
Posts: 58
Joined: Apr 2017

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

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

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
Posts: 36
Joined: Oct 2017

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's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

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

 

rogerdlama48@gm...
Posts: 9
Joined: Jul 2017

I had a Gleason score 9 & had open surgery radical prepubic prostatectomy with pelvic lymph node dissection and seven weeks of radiation therapy treatments for cancer spread into my bladder and bone scan and mri of my spine and my radiation doctor said that he thought they looked okay.

Cat scan and bone scan before removal surgery was supposed to be okay also and the lymph nodes that were removed were negative.

I want to request a pet scan. That's what everyone tells me to ask for.

My veterans administration urologist retired last week without notice and gave me prescription for Percocet 10 mg , 150 pills for 30 days and I called for refill like he told me and that's how I found out he retired and they contacted my primary care physician at the local VA outpatient clinic and they refused to write a request for refill and I have been going through withdrawal for three days.

Hopefully the radiation oncology clinic will request the pet scan because I don't know when they will be getting another urologist at the Chillicothe VA hospital that I go to.

My psa before removal was only 4.9 & biopsy was Gleason 9.

So I would say that you probably don't have prostate cancer in your bones but I don't know anything and your doctor will find out for you.

My Gleason score year before was 4 & that is the cutoff for normal and I must have had the cancer then and since the VA doctor don't do digital rectal examination and only the psa tests caused my cancer to get aggressive and fortunately I hope doesn't come back or spread to my bones.

I probably had the cancer even longer than that psa test the previous year and my radiation doctor said that he can't determine if I am cancer free using the psa test and my recent psa test was < .01.

But it was also the same < .01 after removal and before radiation therapy treatments when I still had the cancer in my bladder.

I know someone who had PSA 2.7 & his biopsy was Gleason 9 aggressive cancer. PSA is not accurate for detecting existing prostate cancer and it takes the biopsy to confirm positive for cancer.

Thanks and good luck. My life is miserable and I wish it was detected sooner and I could have had radiation therapy instead of the radical prepubic prostatectomy.

Open surgery gave me a 12 inch incision with over twenty staples and blood clots and fluid in my lungs and hospitalized for two months.

I wish I could have had the davinci robotic surgery but the Wright Patterson Air Force Base Hospital didn't have one.

All we can do is hope and pray.

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Please start a new thread so we can direct our responses to your case only and not infringe on this thread

Tdoyle
Posts: 36
Joined: Oct 2017

Got my results back from the bone biospy from the suspicious spot on my rib and it did not show any cancer there...So I am at the point of the decisionof what to do with my 7 of 24 core of a 3=3 gleason score.....Time to do my reading and research on my best option...

Old Salt
Posts: 720
Joined: Aug 2014

  No metastasis!

contento
Posts: 76
Joined: Jul 2017

Tdoyle, what an emotional  turnaround  for you ! Given that new info essentially  all the treatment options ( or not ) are open to you. Like you said research hard so you could make the best choice for your givin situation.

Does the doc want to rescan in a few months ? or is he/ she satisfied with the biopsy results ?

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

I am glad for the news. I like the way you taking in dealing with the problem. At 53 years old you are risking your well being and quality of life. I hope newbies reading your story follow your style.

I wonder about the location of the seven positive cores identified in the pathologist's report. They are many for the 24 units taken but these could be cores from the same place where the previous biopsy located the solo (1 out of 12) positive core. In such a case your cancer may be a single large tumour (probably a colony of micrometastases for the high PSA they produce), that could be whole contained in the gland (T1c/T2).

In any case you should consider other important information to incorporate in your final judgment. Can you tell us what made you to have the PSA checked/ Was there any symptom like difficulty in urinating or pain? Have you done a DRE? What was the result? Did the pathologist identify any hyperplasia to justify the high PSA? What is the size of your prostate?

The low Gleason patterns provides low risks for existing metastases. Gleason rate 3 could also be a lower rate (ex: rate 2) indicating still a lower aggressive type of cancerous cells. With this diagnosis you may chose to treat or follow AS (active surveillance) postponing the treatment while continuing checking the bandit for any progression. At your age I would take the treatment side effects seriously into consideration. Research the details and consequences and involve your family in the final decision.

Best wishes and luck in your journey.

VGama

Tdoyle
Posts: 36
Joined: Oct 2017

The 7 cores all on the right mid and right side of the prostate.. The urologist thought like you that it is probably a tumer on that side.. I went for my yearly check up and when they did blood work they found my PSA was around 6, I had them check it again a few days later and it was still a 5.6... thats when this all started..I have had a DRE done by 4 differnet doctors along this journey and all said it was normal..I have had non what so ever problems with urination and everything is normal in that area. 

And thank you VGama for the kind words. I am really considering everything and I am involving the whole family in this. I have to stay around a while. I have 2 daughters ages 16 and 22 that I have to see get married and one graduate high school....

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Tdoyle,

Let's be realistic. PCa may be a killing cancer but it takes long and the patient must be in a very advanced status to real get problems from it. This impression comes from the real statistics. One may well expect to die from other causes when his cancer is low aggressive and indolent. In my 17 years as a survivor I have come across of so many cases in all varieties, colors and shapes which makes me to opinion as I do in this forum. Once diagnosed one should try identifying his real status, be vigilant and treat when necessary. Doing nothing is no good and treating thinking that such will close the bad chapter of one's life is a mistake. The bandit is now our unwanted guest. One must do something, done intelligently, timely and in no rush, even if his case is quite advanced.
Some guys die earlier because of the treatment effects. These effects are real and they did not exist before an intervention. Many times we see us caring more for the effects of a treatment than the cancer itself. It is imperative therefore to know the details of what we are involving in our case.

Your added information supports my comment in the above post that you may have a contained case. Negative DRE makes it a T1c and the location of all positive cores turns the initial biopsy results (of 1 in 12 cores positive) and the confirmed Gleason 6 as a leading result to recommend AS as the best approach. Active Surveillance implies a vigilant period in a sort of military disciplinary regiment of testing along the patient's life to check on the bandit's developments. It is like our annual health check up but it involves additional testing in shorter periods. It is not easy for those that do not like to sleep with the enemy in the same bed but it avoids the risks and consequences of an intervention without prejudice on the outcomes of a latter attack. Our families will need to educate on the matter too so that no one is apprehended for the fact of having the bandit in the house.

With the data in hands, any options you chose seem good. I hope you find that peace of mind so deserved after the dramatic period of the diagnosis.

Best wishes,

VGama 

 

Tdoyle
Posts: 36
Joined: Oct 2017

Thank you for your input, you put it in a way I can understand... I spoke with the nurse of the Oncologist that ordered the Pet scan and he wants me to just come back for the MRI of the prostate that is scheduled in Feburuary. He thinks they got a good sample from the suspicious rib on the bone biospy and confirmed what he thought from the beginning that it was rare for my stage to spread. 

Its been a journey from going from a Oncologist and Radiologist here in my town to do the scans and say "well you have bone cancer and we are sorry"  to the point I am now... And also I am on Lupron hormone 4 month shot, and will be very glad for this to wear off...and I am looking serious into AS for now...

Again thank you

Tdoyle
Posts: 36
Joined: Oct 2017

Here are the results from the radiologist on the bone biopsy done on 11/20/17

 

 

Case Report


Clinical Information
53 yo M with hx of prostate cancer, presents with 9th right rib lesion.
 
FINAL DIAGNOSIS
A. Bone, right 9th rib, biopsy:
- Abundant woven bone formation and fibrous stroma, negative for carcinoma in this sample; see comment.
Electronically signed by Matthew R. Lindberg, MD on 11/22/2017 at  1:10 PM
Comment
Immunohistochemical stains for pancytokeratin, PSA, and PSAP are performed with adequate controls and found to be negative, providing no support for metastatic carcinoma. However, there is abundant new bone formation suggestive of an osteoblastic process, and given the reported history of prostatic adenocarcinoma, an osteoblastic metastasis cannot be ruled out from this sample. If clinical concern for malignancy persists, additional sampling is recommended.
 
Gross Description
Specimen A is received in formalin, labeled with the patient's name, Troy D Doyle, medical record number, 003304000, and 3/2/1964.  The specimen consists of three fragment of tan bone measuring 0.6 x 0.6 x 0.2 cm in aggregate.  Specimen A is submitted entirely inside a yellow biopsy cassette A1.  

Tierra Holland 
11/20/2017
 
Microscopic Description
Performed if applicable.
 
Attestation
Matthew R. Lindberg, MD 
Electronically Signed on 11/22/2017, 1:09 PM 

I have reviewed the pertinent gross findings, any and all microscopic slides and the Resident’s/ Fellow’s interpretations.  I have made appropriate editorial changes and have rendered the final diagnosis.
 
Tdoyle
Posts: 36
Joined: Oct 2017

Case Report


Clinical Information
53 yo M with hx of prostate cancer, presents with 9th right rib lesion.
 
FINAL DIAGNOSIS
A. Bone, right 9th rib, biopsy:
- Abundant woven bone formation and fibrous stroma, negative for carcinoma in this sample; see comment.
Electronically signed by Matthew R. Lindberg, MD on 11/22/2017 at  1:10 PM
Comment
Immunohistochemical stains for pancytokeratin, PSA, and PSAP are performed with adequate controls and found to be negative, providing no support for metastatic carcinoma. However, there is abundant new bone formation suggestive of an osteoblastic process, and given the reported history of prostatic adenocarcinoma, an osteoblastic metastasis cannot be ruled out from this sample. If clinical concern for malignancy persists, additional sampling is recommended.
 
Gross Description
Specimen A is received in formalin, labeled with the patient's name, Troy D Doyle, medical record number, 003304000, and 3/2/1964.  The specimen consists of three fragment of tan bone measuring 0.6 x 0.6 x 0.2 cm in aggregate.  Specimen A is submitted entirely inside a yellow biopsy cassette A1.  

Tierra Holland 
11/20/2017
 
Microscopic Description
Performed if applicable.
 
Attestation
Matthew R. Lindberg, MD 
Electronically Signed on 11/22/2017, 1:09 PM 

I have reviewed the pertinent gross findings, any and all microscopic slides and the Resident’s/ Fellow’s interpretations.  I have made appropriate editorial changes and have rendered the final diagnosis.
 
Tdoyle
Posts: 36
Joined: Oct 2017

Here are the results for the bone biopsy...to me it sounds like they are back and forth on the result.

Case Report
Clinical Information
53 yo M with hx of prostate cancer, presents with 9th right rib lesion.
FINAL DIAGNOSIS
A. Bone, right 9th rib, biopsy:
- Abundant woven bone formation and fibrous stroma, negative for carcinoma in this sample; see comment.
Electronically signed by MD on 11/22/2017 at 1:10 PM
Comment
Immunohistochemical stains for pancytokeratin, PSA, and PSAP are performed with adequate controls and found to be negative, providing no support for metastatic carcinoma. However, there is abundant new bone formation suggestive of an osteoblastic process, and given the reported history of prostatic adenocarcinoma, an osteoblastic metastasis cannot be ruled out from this sample. If clinical concern for malignancy persists, additional sampling is recommended.
Gross Description
Specimen A is received in formalin, labeled with the patient's name, Troy D Doyle, medical record number, 003304000, and 3/2/1964. The specimen consists of three fragment of tan bone measuring 0.6 x 0.6 x 0.2 cm in aggregate. Specimen A is submitted entirely inside a yellow biopsy cassette A1.

11/20/2017
Microscopic Description
Performed if applicable.
Attestation

Electronically Signed on 11/22/2017, 1:09 PM

I have reviewed the pertinent gross findings, any and all microscopic slides and the Resident’s/ Fellow’s interpretations. I have made appropriate editorial changes and have rendered the final diagnosis.

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Doyle,

I understand your worries for the end comment by the pathologist, however, this is typical in physicians as they report just what they found not what they think. Their comments are carefully laid down with professionalism conclusions. The reason for him to write "... an osteoblastic metastasis cannot be ruled out from this sample ...", relates to the fact that the sample is from a patient that have been diagnosed with prostate cancer. Once diagnosed positive no one will ever rule a negative status in such a patient. Even after a successful treatment no doctor will ever refer the word "cured".

In the above report it mentions clearly that they used the stains for adenocarcinoma of the prostate which provided a negative result ("... found to be negative."). Accordingly, this lesion relates to an active localized formation of bone which could be due to a variety of other occurrences not identified, and for such a reason he ends the report by saying that

"... If clinical concern for malignancy persists, additional sampling is recommended". In my opinion I would add at the end of his sentence "... in the future if any ...".

I would like to inform you that the Lupron is surely playing a trick on your feelings. One of the typical side effects is mood change. We gain the tendency for easily crying and worrying at any little thing. You are in chemical castration and the hypogonadism makes you to experience a series of unusual symptoms (some are very mild and unnoticed).

I recommend you to take a family member with you when visiting the doctor and take notes of the conversation (taping is also valid). I also recommend you to prepare a list of questions in advance of any consultation including those questions that may seem awkward to you.

I wonder about any other tests you have done. Check the whole lipids panel and include a test on heart health, the PSA and the testosterone to check on castration levels (action of Lupron). Hormonal treatment (Lupron) weakens the bone and that could be one of the causes behing your system to react with bone formation (the cause of the lesion ???).
While waiting for the next appointment you could have a DEXA scan done at your local clinic to verify any osteopenia/osteoporosis.

Best wishes,

VGama

 

Tdoyle
Posts: 36
Joined: Oct 2017

PSA was checked last probably 3 weeks ago and it was 2.12  and that is around 2 months into this 4 month Lupron shot, here are other blood test results.

WBC 6.64 K/uL 3.60 - 9.50 K/uL
RBC 4.62 M/uL 4.50 - 5.70 M/uL
Hemoglobin 13.2 g/dL 13.0 - 17.0 g/dL
Hematocrit 41.1 % 40.0 - 50.0 %
MCV 89.0 fL 80.0 - 100.0 fL
MCH 28.6 pg 26.0 - 33.0 pg
MCHC 32.1 g/dL 32.0 - 36.0 g/dL
RDW 12.2 % 12.0 - 15.0 %
Platelet 195 K/µL 150 - 450 K/µL
MPV 10.9 fL 9.0 - 13.0 fL
ANC 3.6 K/uL 1.4 - 6.0 K/uL
Nucleated RBC 0.0 #/100 WBC #/100 WBC
Neutrophils, Auto 54.5 % 35.0 - 65.0 %
Lymphs, Auto 34.6 % 23.0 - 50.0 %
Monocytes, Auto 5.9 % 4.6 - 12.0 %
Eosinophils, Auto 3.6 % 0.5 - 6.5 %
Basophils, Auto 1.1 % 0.1 - 1.1 %
Immature Grans, Auto 0.3 % 0.0 - 0.5 %
Neutrophils, Absolute 3.62 K/uL 1.40 - 6.00 K/uL
Lymphocytes, Absolute 2.30 K/uL 1.20 - 3.40 K/uL
Monocytes, Absolute 0.39 K/uL 0.20 - 1.00 K/uL
Eosinophils, Absolute 0.24 K/uL 0.00 - 0.50 K/uL
Basophils, Absolute 0.07 K/uL 0.00 - 0.07 K/uL
Immature Grans, Absolute 0.02 K/uL K/uL

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3258
Joined: May 2012

Your blood panels are perfect, T, as Vasco commented.

You might want to ask your urologist if an LDH blood test is warrented (NOT 'LDL').

LDH is a specialty cancer test, usually given for blood cancers, but valid for others.  It detects cell death from cancer or trauma.  A urologist who is not a medical oncologist might not immediately think of administering it,

max

Old Salt
Posts: 720
Joined: Aug 2014

Those tests all look 'normal', which is great.

As Vasco pointed out, a lipid panel and a DXA scan (to assess bone health) could be useful for you at this stage.

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Yes I agree with Old Salt. These markers indicate a healthy immune system. How about the Kidneys (Creatinine, Filtration rate estimated), the Liver (GOT, GPT and enzymes), Diabetes, Cholesterol and BP, and a very important Testosterone test?

Urologists are specialists so that they do not request a full panel of tests because they focus on the problem, the cancer, which by norm and depending on the patient's status would involve the PSA, PAP, CEA, NSE and CGA. However, image studies required in clinical staging will involve contrast substances that would require some of boddy functions to be fit. Anemia is a worrisome condition for all tracers. Some medications also interact with PCa HT treatments justifying a comprehensive investigation on the overall health of the patient.

In Europe this is the work of a GP (everybody has one) which is required by the national health services (NHS) system before one gets into a specialist (urologist). If you do not have one then you proper should take control and request what you want to each doctor when in consultation. You need to investigate/research, take the lead and discuss with the specialist attending your case. A medical oncologist would do the work for you if you feel it better.

In any case, you doing it well. Wait for the next exam and get a clinical stage to help you in that final decision.

Wishes for luck in your journey.

VG

Tdoyle
Posts: 36
Joined: Oct 2017

Thank you guys, I have an appointment with my GP this next friday..He has wanted me to keep him updated on everything since he is the one that found my elavated PSA.. I will ask him about getting these other test. My Oncologist that scheduled the bone biopsy and that has the MRI scheduled in Feb. I will ask many more question as for where I stand in all this. Seems that no matter where I go and the doctors I have seen, no one wants to say anything as far as what needs done besides the Urologist that suggest RP.

Tdoyle

Tdoyle
Posts: 36
Joined: Oct 2017

Just curious, Like I have mentioned above the MRI is scheduled in February which seems like forever to me...If the MRI comes out with the best possible resultss for me, I was wondering what yall think about what treatment if any would be a good move for me... from that point????

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

You need more data on your status before choosing an option. The MRI makes part of the initial exams providing information necessary when judging the location of the cancer. That leads to a clinical stage from which the doctor will recommend a treatment that typically involves his trade. However, it is you that will choose and decide. Doctors do not take that responsibility. In fact, before any intervention, you will sign an agreement relieving the doctor and the hospital from any wrong outcome. You need to educate on the matter and be prepared in advance. This period of waiting can be used for reading a book on PCa so that you may be more comfortable at the time of a decision.

Reaching a decision is not easy. You should do it not rushing. Here is a list of books from where to choose;

www.csn.cancer.org/node/311252

For the moment try to relax and enjoy the season with your kids. You will do it. Be positive.

VG

 

 

Tdoyle
Posts: 36
Joined: Oct 2017

How can I find a place close that has the T3 MRI... ?   Not sure if the one I am scheduled for in Februaury is this type...

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Doyle,

You should contact the nuclear department of the University of Arkansas for Medical Sciences in Little Rock. They have 3t MRI machines doing researches but if not available they can help you to find a place. Please read these links;

http://cancer.uams.edu/glossary/cdr0000658758/  

 

 

Tdoyle
Posts: 36
Joined: Oct 2017

VGama, 

 Thanks I called and they said i am scheduled for that machine but to tell them when I go in, to make sure at that time.

Thanks for the link.

 

Tdoyle
Posts: 36
Joined: Oct 2017

I'm not sure if I should start a new thread or not. I was wanting some input from anyone that has used MD Anderson in their PC fight...I am thinking of going to them for a 3rd opinion...Thanks in advance

hopeful and opt...
Posts: 2218
Joined: Apr 2009

MD Amderson is a world class institution, great choice; can't do better than number 1 for cancer.

US New and World Report ranks hospital by speciality. Here you go.

https://www.usnews.com/info/blogs/press-room/articles/2017-08-08/us-news-announces-2017-18-best-hospitals

Here is the listing for urology

https://health.usnews.com/best-hospitals/rankings/urology

MD Anderson is a great choice; you may also a find another great hospital in this listing nearer to Little Rock, AK

 

 

 

contento
Posts: 76
Joined: Jul 2017

Troy, I had my salvage radiation treatment at MD Anderson and I would definately recommend  them. I also  went to them for a second opinion and I ended up getting treated there.

I don't know anything about their AS program or even if they have one.  They were very through in their evaluation so I hope you have the means or have good  insurance. They did tests that we had to fight with the insurance company to cover that they said was not typical for my situation but ultimately proved invaluble in detecting where my cancer was located. I believe they are very aggressive in their approach. Some want that some don't depending on how they view their specific situation. They did collaborate with each other meaning my case was presented to a team of specialists including other radiation and chemo oncologists on their staff. I did have 7 weeks of radiation along with HT so since I was out of town I had to rent a temp apt which there are many. That was 2 1/2 years ago and I'm still doing fine.

PS - I was stage 3 , gleason 8

good luck -- contento

hopeful and opt...
Posts: 2218
Joined: Apr 2009

"Could you tell me about this test? And it gives a percentage on how aggresive the cancer could spread?  I think my findings are similiar to what you have experienced.

Thanks

Troy"

Troy, you are doing your research by reading my "about me" page.

The Aureon test was a molecular test based on a multi-instituion finding of men who have had radical prostatectomy, that was presented in conjunction with other available information about my situation; Gleason, PSA, etc which added some to the basic information that was available. That company, although the test was a good one, has since gone bankrupt. 

Currently there are genomic tests that are available, that provide finding of molecular information based on amount of markers found that contribute to prostate cancer. There are few out there now; decipher, Prolaris and Genomic Health oncotype DX. There are some differences among these tests. This field is growing and there will be other more refined molecular test that will come on the market.

Troy, In the future if you have any questions about prostate cancer, please post in the public forum. I feel that the csn email is designed for personal messages only..........Best of luck

Tdoyle
Posts: 36
Joined: Oct 2017

Block(s) Analyzed: BL17-0105-0007987 B1 Consistent With Average AUA1 Low Risk This patient's clinical stage is different than that defined by this category, and clinical management should be adjusted accordingly. PROLARIS SCORE 2.9 US Distribution Percentile: 27% (For AUA Low Risk) Interpretation: 27% of patients in the AUA Low Risk* category have a lower Prolaris Score Mortality Risk __________________ __________________ Metastasis Risk __________________ __________________ Mortality Risk: 1.4% 10-Year Prostate Cancer-Specific (with conservative management) Disease Specific Mortality This patient's 10 year risk of prostate cancer-specific mortality is 1.4% (95% CI:0.7-2.6%) with conservative management. Mortality risks could be altered by various therapeutic interventions.*** In a clinical study estimating 10-year prostate cancer-specific mortality risks for men undergoing conservative management, there were no observed prostate cancer deaths in patients with a predefined clinical risk score (CCP combined with CAPRA) corresponding to a 3.2% (95% CI 2.0, 5.2%) prostate cancer-specific mortality risk. ** Metastasis Risk: <1.0% 10-Year (with definitive treatment) Metastasis This patient's risk of metastasis within 10 years of diagnosis is <1.0% (95% CI:0.1-0.7%) after definitive treatment. Individual Mortality Risk Stratification  1.4% ****

Tdoyle
Posts: 36
Joined: Oct 2017

Impression

A 5 mm lesion in the right central gland near the base with imaging
findings suggestive of PI-RADS category 3 lesion. No disruption of
prostate capsule. No concerning pelvic lymphadenopathy.

PI-RADS 1: Very low (clinically significant cancer is highly unlikely
to be present)
PI-RADS 2: Low (clinically significant cancer is unlikely to be present)
PI-RADS 3: Intermediate (the presence of clinically significant cancer
is equivocal)
PI-RADS 4: High (clinically significant cancer is likely to be present)
PI-RADS 5: Very high (clinically significant cancer is highly likely to
be present)

I have read this case with MRI fellow Dr. Gitanjali Bajaj.

Electronically Signed by: Tarun Pandey, M.D. on 02/16/2018 at 16:23:06

Narrative

EXAM DESCRIPTION:
MRI PELVIS W WO CONTRAST

HISTORY
prostate cancer
Most recent PSA date and result: 5.9
Biopsy date and results: 2 cores positive for cancer
Gleason Score: 3+ 3
Prior Treatment or Active Surveillance: Active surveillance

COMPARISON
None available

TECHNIQUE
Multiparametric MRI of the prostate was performed utilizing multiplanar
T2W sequences, diffusion-weighted imaging, and dynamic
contrast-enhanced sequences without an endorectal coil on a 3T magnet.

FINDINGS
PROSTATE: The prostate gland is normal in size. No disruption of the
prostate capsule is noted.

Index lesion (highest PI-RADS assessment category)
Location: Right central gland near the base, best seen on image 14/30
of series 4
Size: 5 mm
T2WI characteristics: Indistinct on T2 weighted images.
DWI characteristics: Minimally hyperintense on diffusion weighted
images and moderately hypointense on ADC maps.
Contrast Enhancement: No early enhancement
Overall PI-RADS score: 3

Additional Lesions:

Other Prostate Findings: Mild diffuse hyperintensity of the peripheral
zone. No T1 hyperintensity is noted to suggest hemorrhage.

SEMINAL VESICLES: Unremarkable.

LYMPH NODES: No pelvic adenopathy.

BLADDER: Unremarkable.

PELVIS: No free fluid.

RECTUM: Unremarkable.

BONES AND SOFT TISSUES: Unremarkable.

Old Salt
Posts: 720
Joined: Aug 2014

It looks to me that the results from your most recent MRI confirm the earlier one. The big decsion is how to treat the Gleason 6 cancers in your prostate; many options!

 

PS: Note that the MRI report has an error; an earlier biopsy reported 7 Gleason 6 cores out of 24 taken.

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