Confused Grade 1 or Grade 2?

Posted by pv001 @pv001, 2 days ago

Here is my first biopsy interpretation from Penn Medicine:
A. Prostate, right posterior, needle core biopsy:
Prostatic tissue, no carcinoma seen.
B. Prostate, right lateral, needle core biopsy:
Prostatic tissue, no carcinoma seen.
C. Prostate, right anterior, needle core biopsy:
Atypical small acinar proliferation (ASAP) .
D. Prostate, left posterior, needle core biopsy:
Prostatic adenocarcinoma, Gleason score 3 + 4 = 7 ( < 5% grade 4) (Grade Group
2), involving 3 of
3 cores/core fragments, a total length of 12 mm, 57% of prostatic tissue .
E. Prostate, left lateral, needle core biopsy:
Prostatic adenocarcinoma, Gleason score 3 + 3 = 6 (Grade Group 1), involving
2 of 2 cores, a
total length of 9 mm, 45% of prostatic tissue .
F. Prostate, left anterior, needle core biopsy:
Prostatic adenocarcinoma, Gleason score 3 + 3 = 6 (Grade Group 1), involving
1 of 4 cores/core
fragments, a total length of 3 mm, 38% of prostatic tissue .
G. Prostate, MRI lesion #1, needle core biopsy:
Prostatic adenocarcinoma, Gleason score 3 + 3 = 6 (Grade Group 1), involving
3 of 5 cores/core
fragments, a total length of 4 mm, 27% of prostatic tissue .
Summary of additional features:
Perineural invasion: present
Cribriform pattern 4: absent
Intraductal prostatic adenocarcinoma: absent
Extraprostatic extension: not identified

Then I had the samples sent to Sloan Kettering as I am seeing the doctor there for 2nd opinion and here is how they interpreted:

1. Prostate, right posterior; needle core biopsy (SH-25-0015669, A, 1 H&E; Collected: 4/3/2025):
Benign prostatic tissue

2. Prostate, right lateral; needle core biopsy (SH-25-0015669, B, 1 H&E; Collected: 4/3/2025):
Benign prostatic tissue

3. Prostate, right anterior; needle core biopsy (SH-25-0015669, C, 1 H&E; Collected: 4/3/2025):
Atypical small acinar proliferation

4. Prostate, left posterior; needle core biopsy (SH-25-0015669, D, 1 H&E; Collected: 4/3/2025):
Prostatic adenocarcinoma, Grade group 1 (Gleason score 3+3=6); the tissue is fragmented.
Percentage of tissue with carcinoma: 60%
Linear amount of tissue with carcinoma: 12 mm

5. Prostate, left lateral; needle core biopsy (SH-25-0015669, E, 1 H&E; Collected: 4/3/2025):
Prostatic adenocarcinoma, Grade group 1 (Gleason score 3+3=6), involving 2 of 2 cores.
Percentage of tissue with carcinoma: 60%
Linear amount of tissue with carcinoma: 9 mm

6. Prostate, left anterior; needle core biopsy (SH-25-0015669, F, 1 H&E; Collected: 4/3/2025):
Prostatic adenocarcinoma, Grade group 1 (Gleason score 3+3=6); the tissue is fragmented.
Percentage of tissue with carcinoma: 40%
Linear amount of tissue with carcinoma: 3 mm

7. Prostate, MRI lesion #1; needle core biopsy (SH-25-0015669, G, 1 H&E; Collected: 4/3/2025):
Prostatic adenocarcinoma, Grade group 1 (Gleason score 3+3=6), involving 2 of 5 cores.
Percentage of tissue with carcinoma: 25%
Linear amount of tissue with carcinoma: 4.5 mm

They did not talk about perinural invasion, extra prostatic extentioni or intraductal or cribriform.

So, 3+4 in sample 4 has been reduced to 3+3 at Sloan Kettering. I am confused as both are great hospitals. Penn inclined towards RARP because of my age (56 years) or to a lesser extent AS (since they interpreted 3+4 and more core samples positive). I'll see what the doc from MSK says.

Any thoughts from the good folks here?

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@surftohealth88

I agree with Survivor regarding biopsy vs. possible actual state of the prostate pathology. Often pathology shows higher grade after prostate is removed and examined. There are cases when grade is lower upon examination, but I can recall reading that scenario maybe once or twice.

If you decide to do AS please make sure to have biopsy again in 2 years, the latest. My husband had 3+3 in just 3 cores and in 5 years developed 4+7 with aggressive components of cribriform and IDC ! If he had biopsy every 2 years perhaps 3+4 would have been discovered on time and we would definitely choose treatment at that time, no question about that. With 3+4 you have so many options for complete cure with excellent results, vs. 4+3 with cribriform and IDC.
Yes, seek all of the opinions but be very proactive and push for what you want to do, we wish we knew more about correct AS and not rely on our urologist for advice and care. On the other hand, you are already talking to doctors that are inside centers of high competence and I am sure that you and your doctor will choose a good and successful path forward.

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Surf, AS is watching the PSA multiple times a year, not every 5. At worst it's generally 6 months, and that's after 2 years of every 3 generally. Also, 4+7 isn't a legitimate Gleason, did you perhaps type that wrong? Not only is 11 not a valid number but usually the two numbers are one digit apart rather than four.

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@pv001

Penn said if I chose AS, then biopsy again in 6 months, then one year after that and then every two years after that if everything remained same. PSA every 3 months. DRE every year. I am still scared with that approach. The chances of me getting some sort of treatment is quite high within 2 to 5 years. Why not just get it done with now? Too many things going on in my mind. Waiting to see what Sloan will say. This group has been so much of help!

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Getting it done now is YOUR choice, not your doctors choice - but it may be their recommendation. Get the Decipher test so you at least know if you are in the aggressive category or not and that will be some peace of mind for you but also more information for determination of treatment.

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@pv001

Penn said if I chose AS, then biopsy again in 6 months, then one year after that and then every two years after that if everything remained same. PSA every 3 months. DRE every year. I am still scared with that approach. The chances of me getting some sort of treatment is quite high within 2 to 5 years. Why not just get it done with now? Too many things going on in my mind. Waiting to see what Sloan will say. This group has been so much of help!

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I completely understand where are you coming from. You just got results and all of this now looks daunting, overwhelming and scary. But your results show very early changes so you can take time to do research, seek other opinions and think about everything with no rush. The AS that your team proposed is very active - remember, my husband had MRI every 2 years and had one single biopsy 2019 and none till 2025. His PSA was going up and down in that period so it was not the perfect parameter. MRI actually showed his lesion in the right lobe getting smaller and guess what - that lesion went berserk. But, my husband is not a typical case and he had bad doctor, so please do not let it be good example for you. I am mentioning his case just so you make sure to have your prostate checked regularly and OFTEN. Your team made great AS plan, in my opinion, remember my husband did not have anything like that. You definitely have 6 mos to think about it all, at least about what treatment would be the best for you. Than you will have another biopsy and/or treatment, you have time to think it over. You seem to be in good hands and I am sure that they would understand if you choose treatment sooner rather than later. You have many options at this point and I am sure that all will be well in the end.
Wishing you the best of luck with whatever choice you make.

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@survivor5280

Surf, AS is watching the PSA multiple times a year, not every 5. At worst it's generally 6 months, and that's after 2 years of every 3 generally. Also, 4+7 isn't a legitimate Gleason, did you perhaps type that wrong? Not only is 11 not a valid number but usually the two numbers are one digit apart rather than four.

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Oh my - sorry, yes, NOT 4+7 , ayayyayyyy, 4+3, I apologize, had very little sleep last night : (...
Also allergies are killing me I can hardly see anything since my eyes are tearing like crazy .
But it is not even just 4+3, it has cribriform and IDC which puts it in very aggressive group. According to some pathology experts gleason in his case is not just 7, it is 7.5 .

Sorry for the typo ...

PS: AS involves PSA, biopsy, MRI in regular intervals . My husband only had PSA checked every 6 mos and MRI every 2 years. He should have had biopsy every 1-2 years once 3+3 was detected .

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Tough call. There's not much cancer there, especially if you subscribe to the notion that 3+3 is not a threat to metastasize. If you go the radiation path, good news a 3+4, intermediate favorable, does not require testosterone therapy. I had a similar situation with a second opinion changing 4+3's to a 3+3 and a 3+4. As previously stated, biopsy interpretation is subjective so receiving conflicting second opinions is probably not that uncommon. For what its worth, I had fewer 3+3 results with one 3+4 < 5% and went radiation. But I also had a 8.3 PSA. The logic for radiation for me was the fact that I am young, healthy, and should weather the treatment well, no testosterone therapy, and radiation destroys the cancer while maintaining your manhood and ability to hold back peeing when you want. It's always tougher to make decisions when the cancer is borderline than when its obvious. Good luck in whatever you decide.

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