Newly Diagnosed and Need Help

Posted by cygnus @cygnus, 19 hours ago

First, I would like to extend my appreciation to all those who contribute to this site. I have been an observer ever since I was diagnosed and now have to decide what to do. I would appreciate your insights. I am 75, my wife died from glioblastoma and I moved to PA from FL to help my daughter who is paralyzed on the left side from 2 strokes (genetic veinous interference.) So I have a reason to live. I’m in great shape and work out 4 times a week. No co-morbidities.

This all started sort of cavalierly I insisted on a PSA test with my PCP on 3/15/26. 2 years prior is was 3.7, most recently it was 6.1. His comment was “what would you do if you had PC?” My response was “depends on the score.” Referred to a urologist, insisted on an MRI and that came back PiRads-4 on 4/12/26. Results below. The urologist recommended a biopsy, got it on 5/10/26.) Results on 6/1/26. See below:

My question is, what should I do from here? I plan on a second opinion on the pathology, most likely from John Hopkins, but assuming the initial pathology is correct, what do people think is my best path forward?

I have access to John’s Hopkins, UPMC and UPENN. They are all commutable.

Biopsy:

1. Prostate, right posterior medial, biopsy:
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group: 1), involving 2 of 3 core biopsies.
The carcinoma involves the cores with total linear lengths of 1 mm (10%), and 4 mm (20%), respectively (approximately 10% of the entire tissue submitted).

2. Prostate, right posterior lateral, biopsy:
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group: 1), involving 3 of 4 core biopsies.
The carcinoma involves the cores with total linear lengths of 5 mm (30%), 6 mm (60%), and 1 mm (10%), respectively (approximately 20% of the entire tissue submitted).

3. Prostate, right base, biopsy:
Benign prostatic tissue, no tumor present.

4. Prostate, right anterior medial, biopsy:
Benign prostatic tissue, no tumor present.

5. Prostate, right anterior lateral, biopsy:
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group: 1), involving 2 of 4 core biopsies.
The carcinoma involves the cores with total linear lengths of 1 mm (10%), and <1 mm (5%), respectively (approximately 10% of the entire tissue submitted).

6. Prostate, left posterior medial, biopsy:
Benign prostatic tissue, no tumor present.

7. Prostate, left posterior lateral, biopsy:
Benign prostatic tissue, no tumor present.

8. Prostate, left base, biopsy:
Benign prostatic tissue, no tumor present.

9. Prostate, left anterior medial, biopsy:
Benign prostatic tissue, no tumor present.

10. Prostate, left anterior lateral, biopsy:
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group: 1), involving 20% of 1 of 3 core biopsies.
The total linear length of carcinoma is 2 mm in the core.

11. Prostate,Right middle prostate sole left, biopsy:
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group: 1), involving 4 of 4 core biopsies.
The carcinoma involves the cores with total lengths of 10 mm (80%), 12 mm (discontinuous, 80%), 2 mm (20%), and 5 mm (50%) (approximately 60% of the entire tissue submitted).

MRI:
Impression
PI-RADS version 2.1 Score: 4 , high probability of prostate
cancer in the right posterolateral peripheral zone midgland.
No evidence of extraprostatic extension. Diﬀerential
diagnosis also includes sequelae of infectious/inflammation.
Findings to be relayed and documented by Teleradiology
assistant to the referring physician. A notice that an
imaging finding is present on this exam which may require
follow up will be sent to the patient.
Narrative
EXAM:
MRI PROSTATE WITHOUT AND WITH CONTRAST
HISTORY:
Elevated prostate specific antigen (PSA).
PSA value: 6.4 ng/mL
COMPARISON:
CT abdomen and pelvis May 2024
TECHNIQUE:
Multiparametric prostate MRI utilizing standard sequences
in three orthogonal planes without and with intravenous
contrast.
CONTRAST: 8.2 mL Vueway intravenously.
FINDINGS:
PROSTATE:
Volume: 3.1 x 4.4 x 4.5 cm for a volume of 32.1 mL, PSA
density is 0.2 ng/mL/cc based on ellipsoid calculations.Quality: Good
Hemorrhage: None
Peripheral zone: Diﬀuse linear and wedge-shaped hypo
intensities.
Transition zone: Moderate heterogeneity consistent with
prostatic hyperplasia.
Lesion 1:
Location: Right posterolateral peripheral zone midgland
image 15 series 1007, 1008, image 17 series 801
Size: 5 mm
T2: Moderate T2 hypointense area
DWI: Focus of positive restricted diﬀusion
DCE: Mildly positive
Prostate margin: Abuts the prostate margin for less than 2
cm.
Lesion overall PI-RADS 2.1 category: 4
PELVIS:
Neurovascular bundles: No evidence of involvement is
identified.
Seminal Vesicles: Unremarkable.
Lymph Nodes: No lymphadenopathy.
Urinary Bladder: Unremarkable.
Osseous Structures: Unremarkable.
Other: Trace bilateral fat containing inguinal hernias.

I greatly appreciate your feedback.

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

wheel1 | @wheel1 | 18 hours ago

Active Surveillance

dhasper | @dhasper | 18 hours ago

Hi,. Welcome. Kinda of a tricky one. Good prognosis but certainly can't be ignored. I really like your idea of a second opinion on pathology. Despite the biopsy saying all Gleason 6, the PSA density of 0.2 and the amount of cancer in the targeted/right-sided cores are the reasons. I think you are right not to assume this is simply indolent Gleason 6. I am interested in hearing the recommendations. If they recommend active surveillance, I would want to keep it tight with 3 month psa and mri/biopsy at intervals.

Jeff Marchi | @jeffmarc | 18 hours ago

You only have 3+3 which are not really aggressive, Some Consider it pre-Cancerous. The problem is you have 12 3+3 cores. If you have over six, that is considered something that you should treat even if it’s all 3+3.

Radiation would make a lot of sense. Five sessions of SBRT radiation could knock it out quickly. My brother had it done at 77 and it worked quite well for him. The only problem he had was some difficulty urinating, which was resolved by taking Flomax every other day.

Have you spoken to a radiation oncologist? You could consult with a couple of them, which you already seem to be planning on doing.

You could get a decipher test to see what your chance of reoccurrence is. If it was really low, you could still consider active surveillance.

copyman | @copyman | 18 hours ago

Your results don't look bad at all. I would think you would be a candidate for active surveillance with a Gleason score of 6, getting tested every 3-6 months but let the doctors decide that. I'm from NJ and went to Fox Chase for biopsy and also had the slides read for 2nd opinion from UPenn. With you being in PA you have several great cancer centers, Fox Chase, Univ of Penn, Penn State Health Milton S. Hershey Medical Center. And of course if you want to travel a little further Slone Kettering in NYC or John Hopkins in MD. Like Jeff posted there are several genetic tests that can offer more insight. Like the Protox test to see how you would tolerate short course of SBRT, etc. Bottom line is you do NOT have to rush into any decisions with your test results! Wishing you the best

charlesprestridge | @charlesprestridge | 17 hours ago

You are doing a great job getting information.

1. Appears you had a saturation biopsy with 25 plus cores. With that many cores, appears you have a representation of the amount and grade of cancer.
-All samples graded as 3+3, which is good.
-80% 3+3 of 10mm core (#11 from report) indicates lesion/cancer size is in what I think is medium size range. Not small and not large.
-Based on 3+3 and biopsy info, I think most would indicate Active Surveillence is appropriate.

2. However, You will want to meet with expert(s) to understand/review MRI.
-5mm lesion is not large (if I read MRI correctly. Biopsy indicates at least an 8-10mm length of cancer. Ask questions and work to understand what Biopsy and MRI are indicating.
-Not sure significance of “Mildly positive prostate margin and abuts prostate margin less than 2 cm”
-Radiation Oncologists are usually better at reading MRI’s.

My initial impressions(with my limited knowledge)

-Cancer appears to be confined to prostate
-You should have plenty if time to find good Doctors/Facilities to review your MRI and Biopsy. Do not need to feel rushed.
-3+3 is an indication AS can be appropriate choice
-Understand MRI to evaluate concern(s) lesion may have a chance of breaching prostate capsule. This may be higher risk that multiple cores of 3+3.
-At your age and situation, if treatment is deemed best (after multiple opinions of best doctors), I would think Radiation would be much better than RP.

Best Wishes.

diverjer | @diverjer | 16 hours ago

That is not that bad of results, I know someone who is in that area and does active surveillance, but he has other health issues that are an issue for radiation. I sure wouldn't think you would want RP. Might get another opinion and get a decipher test. Looks like a hard choice, but lots of knowledgeable folks on here, but take your time and look at the after effects of treatment if that is your choice.
Good luck and don't rush.

oxfordrob | @oxfordrob | 6 hours ago

I am amazed at the diagnosis that I'm seeing. Please see a specialist. Believe 1/2 of what you read and ask deep questions of your Dr.
Get a second or even third opinion.

The issue that I see is that you had to insist on a PSA as did I.

That is a major issue for a cancer that is this common and very curable if found early.

All my best

bens1 | @bens1 | 6 hours ago

I agree with @jeffmarc, you have a number of 3+3 that are of concern. Even with testing every 3 months, regarding active surveillance, if you decide to treat, it takes time. Every body is different, of course but from the time you decide to get treatment plus the time of active surveillance, you may have 6-8 months of time of whatever the slow or fast growth is, before you end up being treated. If it were me, I would not wait.

I also agree with @diverjer to get a feel for aggressiveness with a Decipher test. Sounds like you are investigating in a solid way.

texasnole | @texasnole | 2 hours ago

A second opinion is a good idea, but if you are here in Florida, why go out of state for a second. There is a branch of Mayo in Jacksonville, Shands hospital at the University of Florida in Gainesville is first rate, and I can recommend a urologist here in the Panhandle