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Need advice on Post RALP Pathology Report that includes cribriform
First a bit of background prior to single port RALP surgery. I am 69 years old. January yearly physical PSA was 5.1 up from 2.5 the previous year. Went to urologist and had it retested and it was 3.5 and he ordered an mpMRI which indicated a PIRADS 4 lesion. Biopsy in March; 13 cores - 8 benign, (3) 3+3, (1) 3+4. and (1) 4+4. Urologist ordered PSMA Pet Scan which indicated the lesion was confined to the prostate and no metastases were observed. Decipher score is 0.9. RALP was performed about a month ago and surprisingly I have had no problems with incontinence. Post RALP pathology report as follows: Downgraded to 3+4 but with 40% pattern 4. Tumor compromises approx. 6-10% of prostate. Tumor is confined to the prostate. No definite extraprostatic extension identified. No seminal vesical invasion identified. No urinary bladder neck invasion identified. No lymphovascular invasion identified. Margins are negative. Perineural invasion is present. Cribriform glands present but the report did not designate large or small, just cribriform. No lymph nodes were taken.
The pathology report is generally quite positive except for the cribriform glands present and that is where my 3 questions lie. Question 1: Should I request that the pathologist review the slides and have them identify if large or small pattern cribriform? Question 2: Should I get a 2nd pathological opinion from Johns Hopkins? Question 3: I plan to question the surgeon if I should have adjuvant radiation and short term ADT (which I would really dread doing but I would if needed) since cribriform is present. Should I also go to a medical oncologist experienced in prostate cancer and get his or her opinion on whether adjuvant therapy is necessary? Question 4 (I added another question for extra credit): Does the lack of lymphovascular invasion somewhat mitigate the existence of cribriform?
I believe I included all background and pertinent information so any advice would be greatly appreciated.
Thanks.
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@frank1964
0.02 is still exceptionally low, and a pair of results of 0.01 and 0.02 does not yet constitute an actionable uptrend.
You should remain vigilant and continue with the ultrasensitive tests at that same lab, ideally every 3-4 months in light of your large cribriform pattern, but there is nothing in the clinical literature that would suggest you should be initiating any salvage treatment at this point.
If you don't yet have a radiation oncologist you're working with, then that would be something to focus on finding. Even if aggressive early salvage therapy is warranted (and it might be, because of the cribriform) then you still have a little ways to go before you should consider starting that. I have high-risk markers myself including cribriform and a 95th-percential genomic risk score, but my RO and I have agreed that we'd want to see a PSA trend that increases steadily and is approaching 0.1 before we take any action.
There is not a single research study I'm aware that shows benefit to initiating SRT before 0.1, so that's still 5x higher than where you are at present. But there is evidence that starting between 0.1 and 0.2 (rather than waiting until after 0.2) shows better outcomes for certain high-risk subsets of patients. Best of luck.
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3 Reactions@frank1964
This is a very minor increase, and it could go back down. Get your next PSA test and see if something is really changing. This is not significant yet..
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3 ReactionsNothing to do for the time being. Yes, I know this is hard to take, but you need more data to see if your PSA is really going up.
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4 Reactions@frank1964 I am 4 months out from radiation and still on ADT after a recurrence post RALP. I recurred within 6 months. I understand very much where you are coming from but just for your reference, Mayo Clinic, and I understand other major US hospital systems, don't even test with the uPSA. .1 is the lowest PSA level on the standard test . Even when you hit that then they will tell you to retest and watch for a trend. Other parts of the body do create PSA in small amounts so you will see some activity. As it was phrased to me, they want to see the cancer "announce itself". Again, trust me, I complelty understand the anxiety, but you are a very long way from actionable information. That is an extremely good result. Dave
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5 ReactionsHello - I am not sure if you have been on this blog very long, but several months ago (six?), I offered an unexpected discovery regarding Cribriform glands: There are "8" different types of Cribriform tissue, two of which are generally regarded as "normal", non-cancerous. A healthy male "without" prostate cancer, can have "normal" Cribriform tissue.
My original surgical pathology report also had "Cribriform: present" as did your report. That was too nebulous for me. I wanted to know more. I started to research Cribriform and stumbled across a medical journal article discussing the "eight" types of Cribriform tissues.
I asked my urologist to contact the pathologist to have my slides pulled and re-examined so I can know exactly what type of Cribriform tissue I had, because again...it is possible to have prostate cancer, but normal Cribriform tissue. I was shocked when my urologist told me that the pathologist "edited" my surgical pathology report to remove the "Cribriform" present" comment. The pathologist - on second review of the slides - said that my cells were merely "stacked" a certain way as to give the appearance of Cribriform, but the tissue was in fact NOT Cribriform tissue. So, I'd like to offer that you should ask for that second slide review (Johns Hopkins), and ask them to classify "which" type of Cribriform tissue you have, and what it means to your case. Hopefully, you'll be pleasantly surprised to find out that your particular Cribriform tissue is in fact "normal" Cribriform tissue. Good luck..Let us know!
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