Not Good News after prostate biospy when MRI didn't look too bad

The PIRADS 5 Is just a warning that there may be prostate cancer, Sometimes it isn’t actually found on a biopsy. You had a biopsy, which showed what’s really going on.

If seminal vesicle invasion shows up that would change you to a pT3b. It doesn’t look like they considered that a problem.

If it’s large cribriform than you really have an aggressive case and the reason why your Decipher score was so high. At the UCSF meeting, they said if you have large cribriform That adds a five to your Gleason score.

Recent studies have shown that if somebody has large cribriform It is better to have radiation plus ADT rather than have surgery.

Things to talk to your doctor about.

@jeffmarc Why would that be preferred treatment, Jeff?
If large cribriform is so dire, why not go on ADT, remove the gland and do Adjuvant radiation as soon as you can?
Phil

@heavyphil
Well, that’s just it, Used to be they thought surgery was the best option for large cribriform. Recent studies, however, have come out and shown that radiation and ADT are a better option.

I’ve heard this while on one of the ancan.org Advanced prostate cancer weekly meetings. Rick who runs for meeting was talking about how radiation was preferred. Previously, I thought it was surgery, But I check with AI and it definitely shows that radiation is the preferred method as Rick found out with studies he’d read about. Of course, surgery followed by salvage. Radiation would probably be pretty much as good and maybe you could avoid ADT but I wouldn’t bet money on it.

A lot to think about, ADT seems to have lots of side affects such as hot flashes, sexual dysfunction (low libido, erectile dysfunction), fatigue, muscle loss, weight gain, and bone density loss (osteoporosis). It also increases risks for metabolic syndrome, diabetes, and cardiovascular disease according to some research I found.

Still don't understand how they can say it was large cribriform when they just get one small sample about as round as pencil lead and inch long. They don't know how wide it is, but might have idea of length.

Sure is a lot to think about, but still on side of getting cut out. However am going to discuss more with doctors. Surprised the RO wanted me on ADT for 6 mo as prostate is only 68 which is large, but I see a lot larger and density is .06ng/ml/cc with PSA 4.16.

Seems they should have a consultant that wouldn't be leaning toward RO or surgery. Otherwise someone with no skin in game. I just want to get that blasted cancer out of there ASAP before it spreads.
History of my PSA Levels.
1/12/2026 4.16
12/16/2025 5.23
1/28/2025 3.24
6/4/2024 3.27
2/10/2023 3.30
2/11/2022 2.29

Below are part of notes the RO but, surgeon hasn't got around to his notes, went on spring break. The RO mention some things like GU toxicities which can last up to 10 years and said something about stool bleeding after 1 to two years if I remember, but not mention below. Hope the surgeon gets his notes done soon.

ASSESSMENT: 78 y.o. male with unfavorable intermediate risk prostate cancer, cT1c, Gleason 4+3=7 in 5/12 cores, PSA 4.16, group stage IIB. PSMA PET scan with avid lesion in the prostate without evidence of nodal or distant metastatic disease. Decipher score ordered, with results pending.

RECOMMENDATIONS:

We discussed the management of unfavorable-intermediate risk prostate cancer with the patient. The results of the PIVOT trial demonstrated that surgery was associated with lower all-cause mortality than observation among men with intermediate-risk disease; given his Gleason 4+3 (Grade group 3), he falls within the unfavorable intermediate risk category. He is absent significant medical comorbidities, and we would expect him to have >>10 years of life; as a result, we would recommend treatment at this time.

We discussed the pros and cons of various forms of treatment, including surgery, brachytherapy, hypofractionated radiotherapy, and 5 fraction SBRT.

In regard to radiation therapy treatment options there are several randomized trials that moderate hypofractionation (4 to 5.5 weeks) is noninferior (CHHiP, HYPRO/Dutch, Arcangeli Italian, PROFIT, RTOG 0415) to longer 8-9 week radiation treatment courses. Recently the HYPO-RT-PC trial has demonstrated that SBRT or 5 treatments has similar biochemical control and toxicity compared to historical controls with a trend towards higher acute urinary toxicities and possible worse late GU toxicities (Jackson, Meta-Analysis IJROBP 2020).

Given his current urinary symptoms and multiple prior prostate procedures including TURP which he reports had minimal resection, urolift and water ablation most recently in 2024, the patient would be a suboptimal candidate for brachytherapy. 5 fraction SBRT remains an option as he is currently only on once daily flomax and other options to help with urinary symptoms. Treating with moderately hypofractionated radiation therapy to 70 Gy in 28 fractions would be the most gentle approach to minimize risk of more intense acute urinary side effects which can be seen with shorter course treatment like SBRT.

Potential side effects of radiation treatment can include urinary symptoms (increased frequency and urgency, dysuria, and obstructive symptoms), GI symptoms (loose stools and blood in stool), and sexual dysfunction. However, urinary incontinence is relatively uncommon after radiation treatment.

We also discussed the pros and cons of adding ADT. ADT is generally recommended for unfavorable intermediate risk cancer based on the RTOG 9408 and D'Amico, though it does come at the cost of added toxicity. Side effects of hormonal therapy can include hot flashes, night sweats, decreased sex drive, fatigue, changes in lean muscle mass, modest weight gain of 5-10 pounds, possible increase risk of cardiovascular disease. Options for hormone therapy include lupron (two 3 month injections) vs relugolix a once daily pill for six months which may be ideal for decreased risk of cardiovascular events in comparison to lupron.

The patient expressed an understanding of these risks as well as the nuances between different radiation treatments and he has an appointment with urology later this afternoon to discuss surgical intervention. There is also a KU radiation oncology clinic in Topeka and should he desire treatment closer to home I would be happy to place a referral to Topeka. He will consider his treatment options after his meeting with urology and inform us of his treatment decision.

@diverjer
Large cribriform means it is greater than .25 mm, that’s pretty small.

I thought it said T2 In the latest information but maybe it wasn’t that, and is a T1c, The thing is that can be very treatable, but the .86 and large cribriform seem to imply it’s not really T1c

Here is the UCSF video that discusses large cribriform
https://www.urotoday.com/video-lectures/a-journal-club-for-patients-with-prostate-cancer/video/mediaitem/4452-unfavorable-histology-classification-aims-to-reduce-unnecessary-treatment-journal-club-jesse-mckenney-cornelia-ding.html
Good article detailing risk of cribriform larger than .25
https://onlinelibrary.wiley.com/doi/10.1111/his.15102
So the TURP didn’t work for you and you had to have Flomax to get a good flow still. You are still on Flomax now it seems to say. I can’t imagine that radiation would be the best option for good urine flow. Do they mention the reason why the TURP wasn’t completely successful?

You could get your biopsy read by an expert in biopsy analysis. Maybe they wouldn’t come up with large cribriform But since I found it twice, I don’t think that’s likely.

Dr. Epstein is a top guy to use to have your biopsy Read again. It does cost $500. With that payment, you get to call him personally and talk to him for quite a while about the results.
https://advanceduropathology.com
They didn’t find anything else in your biopsy which is good.

@jeffmarc

First I had Urolift that didn't work in June 2019.
Then In Feb 2024 Aquablation, but at same time of Aquablation they said they did a partial TURP because part of prostate had grew into bladder. That was biopsied and negative. The rest of procedure was Aquablation. So guess it was actually a partical TURP and Aquablation in one surgery. Found out later a resident did that surgery.
That didn't work out very well and I was put back on Flomax after a few months. Basically I been on Flomax since around 2014. The prostate is not that large from what I see other report, it's just the median lobe is plugging things up. I think from looking at pathology report that is where the cribriforms are? (LMM and RMM)

The RO in my notes said T1C Stage N0 no cancer in nodes
In print from from reports:
Pathology test I posted saying 6 were 4+3=7 Stage Group 3. Even the 2 that had Cribform which some say would be grade group 4 and Gleason 8, but not report as stage group 4
Then there are nine that say 3+4=7 State Group 2
From a scoring I found on internet called TNM staging, I would be T2c (involves both prostate lobes, and N0 (no cancer in lymph nodes) and M0 (cancer has not spread) so in summary that TNM scoring doctor said they don't use, but I was right, would be T2c N0 M0.
Also found a AJCC score that said I would be Stage 2C

Somewhere I have notes from RO that after treatment I would be put on Flomax 2 times (instead of once) a day and would add 5mg Cialis.

You are definitely a case where surgery may be a better option, Though it is not the best with your large cribriform, but your urinary issues may become worse with radiation. You can always have radiation after, And the prostate usrinary problem is out of the way.

Have you spoken to a urologist about surgery? What do they think about your urinary complications and radiation?.

This is something you might want to see an oncologist about. You need more guidance to make the right decision for you.

By the way, it is referred to as grade group 2 or 3 not stage group.

Well I am about to loose it, don't know how much more I can take. Finely got my clinical note from surgeon and they are not what was said. It took two weeks to get these notes, my appointment was on the 9th of March and I get them at 9PM today. HE DID NOT recommend radiation, my wife was there and took notes which I posted. Below are his clinical notes he finely did after two weeks:

Very complex counseling and decision making. Greater than 60 minutes spent in consultation. Based on the patient's history and risk factors I recommended that the patient proceed with radiation therapy with concurrent androgen deprivation therapy given difficult recovery of incontinence given his age and prior urological procedures. I would anticipate that he would NOT be pad free after surgical intervention.

I explained to him the risks, benefits, logistics, and alternatives to robot-assisted prostatectomy. Risks discussed include, but not limited to infection, bleeding, need for blood transfusion, and injury to surrounding structures including the rectum, small bowel, bladder, ureters, blood vessels and nerves specifically the obturator nerve. I discussed with him risks of urinary leakage from the urethral bladder anastomosis, bladder neck contracture formation, and incontinence. Given his disease status we will plan on proceeding with a bilateral non-nerve sparing procedure. I counseled that patient that given his baseline erectile function and a non-nerve sparing approach that he would have near complete erectile dysfunction. We additionally discussed that based on his risk factors that we would proceed with a lymph node dissection the risks of which include lymphocele and fluid collection formation. Additionally we discussed the risks of wound healing complications, wound infections, conversion to open procedure as well as termination of procedure. We have discussed the risk of long term neuropraxia, air emboli, DVT, PE, stroke, and death.

Patient and his wife are going to consider their options and then let the radiation oncology and urology services know how they would like to proceed.

Then his surgeon's nurse said he was doing bilateral non-nerve sparing procedure because of MRI report, will this is what MRI said on that issue:
Prostatic capsule: Intact.
Neurovascular bundles: Not involved.
Seminal vesicles: Not involved.
Lymph nodes: No lymphadenopathy.
Bones: No acute osseous abnormality.
Other findings: Small fat-containing right inguinal hernia.

Maybe he wants to take nerves and nodes in case of microscopic cancer cell MRI wouldn't catch, but say that and not say because of MRI.

This is suppose to be a good facility. According to research The University of Kansas Cancer Center is a top-rated, NCI-designated Comprehensive Cancer Center, offering specialized, multidisciplinary care for prostate, bladder, and kidney cancers. It is ranked among the nation's top programs by U.S. News & World Report and holds "outstanding" ratings, offering advanced surgical and clinical trials. I check they really are a NCI-designated Comprehensive Cancer Center.

These clinical notes are just wrong, he never said radiation was way to go and ended visit, that he could fix me up and let him know via MyChart to set up surgery date. All that stuff in clinical notes after statement wasn't discussed, but may be cover your butt put in all notes?? This guy is a urologist specializing in cancer as well as other areas.

@diverjer Messed up for sure…he recommends radiation in the first sentence and then says he plans for surgery?
If you are on ADT you’re in a good place to get another opinion.
Look, you already have misgivings about this doctor; how much are you going to kick yourself in the ass if you let him treat you and things go south?? Your anger and regret will never end…
Phil

@diverjer
This really makes it important for you to go to a different center of excellence, and get a second opinion. I realize that where you live makes it difficult to get somewhere else, But you need a real expert to advise you. Getting a Genito urinary oncologist, The ones that specialize in prostate cancer, Sounds like it would be a really good option now.

I really don’t have any doctors that I can recommend in your area, but I know where you can get that information. If you attend next Mondays (8Pm eastern) ancan.org Advanced prostate cancer meeting Rick can give you the name of a Good oncologist in your area. You need to install goto meeting to attend the meetings. Go to the ancan.org Website and you can watch one of the previous meetings so you can get an idea about what’s going on. They can also give you some really good advice on how to treat your cancer.

You do have large cribriform which the more current finding show is better treated with radiation. It used to be they believe surgery was the best choice. You really need a doctor with expertise to advise you. A GU oncologist can refer you To somebody who can properly treat you.