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Treatment options and cribriform

Posted by tevenw @tevenw, 1 day ago

I am otherwise healthy, active 60 yo, diagnosed 2 months ago with localized PCa. Gleason 4 + 3 = 7, 95% of grade 4 tumor is cribriform. Perineural invasion identified. Single lesion, left posterior medial. PI Rads 5. Decipher.71, PSA 6.7. PET PSMA & MP MRI confirm localized disease. My understanding is options are limited to radiation and RP. Welcome any thoughts.

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bearcat998 | @bearcat998 | 7 hours ago

Cribiform is not well understood. The PROTECT trials mentioned are skewed to the point that it is incredible to me that they were published. They claim it’s a report on cribiform. But if you read it the study says “and or IDC”
Information from the last few years is starting to show that there are 2 critical factors with cribiform-
-Is IDC present?
- is there PTEN loss?

If either are yes, it’s much worse.
This is a study from 2019 on intermediate cancer with cribiform only.
https://pubmed.ncbi.nlm.nih.gov/31059665/
Here is the summary

Conclusions: Cribriform pattern with intraductal carcinoma was associated with adverse outcomes in men with Gleason 7 prostate cancer treated with external beam radiotherapy while cribriform pattern without intraductal carcinoma was not so associated. Future studies may benefit from dichotomizing these 2 histological entities.

Only 237 men were included. So it’s a small study.

However it aligns with what both my RO and MO told me that they see in practice.

Obviously it’s not a finding you want. But until 2016 IDC and cribiform were lumped together. So much of the data we get is old and doesn’t differentiate IDC from cribiform.

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heavyphil | @heavyphil | 7 hours ago

When you consult with different ROs - which you absolutely should - ask them also about brachytherapy ‘boost’ treatment.
This puts very high energy radiation inside the gland for a short period of time followed by conventional external radiation.
It has gained a lot of traction in the past few years.
Phil

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notpetecrowarmstrong | @notpetecrowarmstrong | 2 hours ago
In reply to @jeffmarc "@mozir All I can do is give you the Technical information about the chance of reoccurrence..." + (show)
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@mozir
All I can do is give you the Technical information about the chance of reoccurrence with large cribriform.

Large cribriform pattern in prostate cancer is a significant adverse feature, highly associated with increased risks of biochemical recurrence (BCR) after prostatectomy. Studies indicate large cribriform patterns correlate with higher Decipher scores, 16-fold higher risk of BCR, and, in cases of severe cribriform, recurrence rates can be as high as 75%.

This could be because some of the cancer gets out of the prostate before it gets recognized. Like dormant cells that get sent to many different places in your body, and hide out so they can’t even be seen, but if you get stressed, they can pop up and become cancerous again.

Prostate cancer has weird ways to propagate.

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@jeffmarc wrote:
"Large cribriform pattern in prostate cancer is a significant adverse feature, highly associated with increased risks of biochemical recurrence (BCR) after prostatectomy. Studies indicate large cribriform patterns correlate with higher Decipher scores, 16-fold higher risk of BCR, and, in cases of severe cribriform, recurrence rates can be as high as 75%."

Can you share a citation for this? Those hazard ratios are much higher than I've seen in the publications I've personally reviewed, and would love to review those add'l sources once you share.

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Jeff Marchi | @jeffmarc | 1 hour ago
In reply to @bens1 "I think @jeffmarc provides a reasonable perspective. Cribriform does not make surgery “better” than radiation, nor..." + (show)
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I think @jeffmarc provides a reasonable perspective. Cribriform does not make surgery “better” than radiation, nor does it make radiation “better” than surgery. Cribriform has its own risk scenario. I did not have it but did have 5 MRI guided radiation treatment in 2023 and would do it again even with Cribriform, as my side effects to this day were low. Many of us, thanks to the helpful folks with real life experiences on this web site, understand the risks and rewards of radiation vs removal. I never saw any high-quality randomized trial for comparisons for those with Cribriform.

I was interested in quality of life and side effects and felt that for me, the risk of side effects with removal, were greater than I was willing to accept. When, and if I encounter BCR, I felt it was more likely, from expert discussions, to be outside of the prostate and as much as catheters do not thrill me, I would accept the cold/heat/electrical BCR solutions currently on the market.

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@bens1

Some different perspectives
https://pmc.ncbi.nlm.nih.gov/articles/PMC11534056/
https://www.cancerdiagnosisprognosis.org/article/432/cribriform-pattern-is-a-predictive-factor-of-psa-recurrence-in-patients-receiving-radiotherapy-after-prostatectomy.
In some studies, men older than 60 with this pattern have a significantly lower 5-year progression-free survival (around 50.8%) compared to those without it.
National Institutes of Health (.gov)

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