Recent MRI - Lesion 13mm, Likert 4 maybe 5. Urgency, timelines ?

Had my biopsy as scheduled on Fri 08 Nov.  Trans-perineal, 'fusion guided'.  

Was originally given a time of 7:30am, which was later changed to 9:00am and then 10:30am.   

Arrived 45m ahead of time at 9:45, but quickly moved from reception area to a small waiting room, where a couple of other chaps were already waiting.  Received a gown, disposable underwear and socks (normal, not compression).  

It was actually almost 1pm before I was called into the theatre.  About 7 staff there, mostly female.  It was pretty cool, and after being put in the lithotomy position my legs were shaking, due to a combination of the temperature, adrenalin and apprehension, to the extent that the procedure was impeded. 

However the team brought a heated blanket and some kind of hot air device which allowed me to get much more  comfortable.  

The anaesthetic injections, of which there were at least two, one on each side, plus possibly one further one, certainly drew an audible response from me :).  Painful, but only briefly so.  For me, the 'nail gun' part was fine - there was a sound but no noticeable sensation, so I guess that at that point the anaesthetic was working very well. 

The medical team included a trainee (?) observing member, who was immediately adjacent on my right, so I purposefully chatted to her throughout - I hope that I did not distract the team member who was in the driving seat ! 

According to the briefing doc, the procedure takes 30 - 45 mins to complete, but presumably that includes the prep and the final tidy-up.  The 'hard part' seemed to take no more than 15 mins, and I was pleasantly surprised when it ended.  

I was then taken to a recovery room with about six or so other patients, mostly from other procedures, and given a sandwich, biscuits and tea.  It took quite a long time for me to urinate afterwards, since I went immediately before the procedure.  There was a little blood in my urine, but no noticeable discomfort then or subsequently.   

Left the hospital about 4pm.  Due to just missing a bus, I walked about 1.5 miles of my journey home, no problems. Took it easy on the Saturday but went to a gym session on the Sunday.

The medical team were very friendly and helpful, so that was greatly appreciated.      

So as an overall experience, it was not fun, but in the overall scheme of things it was absolutely fine.  For anyone who has previously had an incident of acute urinary retention, the biopsy procedure is just about nothing by comparison.  

Hi Peroni , thanks for such a detailed and encouraging report on your journey thus far. Your experience of the biopsy was very much the same as mine although I didn't have quite the audience that you had, just three staff present for mine. I likewise joked with my 'hand holder'.

I had an appt yesterday (Wed 20-Nov-2024) with a consultant urologist to discuss the results of my recent (08-Nov) transperineal guided biopsy.

Consultant

The appt lasted, I think, about 10, or perhaps 15 mins. It did not feel rushed. Summary:
- Gleason 3+4. Gleason 4 is low volume.
- Cancer seen as organ-confined, based on consideration of both MRI and biopsy results.
- Good range of treatment options available.

Options available:
- continue with active surveillance.
- surgical, i.e. prostate removal. Lead-time current 4-6 weeks.
- combination of RT and HT.

Options not available: focal therapies, due to the multi-focal nature of my condition.

If preferred option is surgical, outcomes re urinary control at trust level are much better than at national level. Consultant emphasised the importance of good fitness / kegel preparation / positive attitude.  

Nursing Team

Almost immediately afterwards, I met the two cancer-specialist nurses who I understand will be my primary routine contact points going forward. They were very pleasant and helpful. I was given:

- some written key stats on the test results, inc current staging of T2-N0-MX
- a copy of the histopathology report [I don't think this is routinely provided to patients]
- various standard documentation on the treatment options available
- various support-related docs from McMillan.
- a heads up on re a follow-up telephone appt on Mon 25 Nov.

My overall take

- Slightly worse: confirmed presence of Gleason 4. Previously (Apr.2024) 'only' Gleason 3. But in the scheme of things, OK, especially given than the initial diagnosis, based on tissue removed for BPH purposes, was fundamentally incidental in nature.  
- Better: now stage 2. Previously, based on MRI but before biopsy seen as T3a.  Previously had concern that I had at least partially missed the boat and had narrowed my treatment options accordingly.  
- Better: continued active surveillance is a valid option. Previously had considerable concern re possible need for immediate intervention, which would have been very unwelcome.  

HISTOPATHOLOGY REPORT (slightly edited for brevity and clarity)

CLINICAL DETAILS
PSA 4, MRI = bilateral P4 lesion.

MICROSCOPY
Core Cancer Gleas, %Core MM

Right PZ *TARGET* [13mm lesion, Likert 4 or 5]
A1-3    No
A4       Yes 3+3  10   (1)
A5       Yes 3+4  15   (1.5)
A6       Yes 3+3  <5   (0.5)

Right TZ
A7-9     No

Left TZ
A10-12 No

Left PZ *TARGET* [7mm lesion, Likert 3]
A13      No
A14      Yes 3+3  <10 (1)
A15-17 No
A18      Yes 3+3   10 (1)

High-grade PIN present: Yes
Perineural invasion: Yes
Lymphovascular invasion (LVI): No
Capsular invasion No
Extraprostatic extension (EPE): No

Comments:

Gleason 4 accounts for < 10% of the total tumour burden.
Cribriform glands are not seen.

CONCLUSION
- moderately differentiated prostatic adenocarcinoma.
- overall Gleason score 3+4=7 (Grade Group 2) in 5 / 18 cores.
- up to 15% single core involvement (maximum tumour length 1.5mm)

Hello Peroni 

Well that's a pretty comprehensive report both on the biopsy and the results. You look like you have a cracking NHS Team.

I assume that your next follow up appointment on 25 November 2024 will be one where you need to have made a choice as to where you are going - AS/Surgery or RT/HT. Something which is very personal to you. My normal comment at this point is to make a list of the pros and cons of each choice as they affect YOU. Use only trusted sources for your information, Macmillan. Prostate Cancer UK and this Community (Not Dr Google).

For me I always say the younger and fitter you are the easier treatment is and my personal view would be to rule out AS as you are a Gleason 7. It's only a personal view though.

Feel free to ask anything you want (although I think you have done your research already), we are all happy to help.

Best wishes - Brian.

Hello Peroni . The report is pretty comprehensive. Besides what Brian has said, I would add that the perineural invasion would indicate that this may put you at a greater risk of spread.

Hello All

Apologies for my extended absence from the board. This has primarily been due to other commitments, including a significant (and not yet resolved) IT-health issue, rather than the prostate-related issue(s) which we all share.

My details are in my profile, but to summarise in Dec.2024, following an MDT recommendation, I went on the NHS active surveillance path, and am now on my first six-monthly milestone.

Key metrics as of late 2024: Tumours - 2. Total 18 cores, 13 cores ok, 4 cores Gleason 3+3, 1 core Gleason 3+4 (low volume <15%). PSA 4.0, via a private laboratory; NHS consultant referred to this number as 'borderline'. Prostate size ~43cl.

I gave my blood sample yesterday mid-day Tue 29 Apr, in accordance with the timeline that I received. In early afternoon today (impressively quick) I had visibility of the result on the Trust's patient access system: PSA 3.25 ug/L, with a quoted reference range of 0 - 6.5.

I think that the decline, although of course welcome, probably reflects a difference between the laboratories and perhaps a difference in preparation - this time I was very strict about abstaining from any potentially PSA-influencing activities for 48h in advance. So I can't interpret the decline as a trend, unfortunately!

My appt with the consultant is scheduled for Wed 14 May, i.e. two weeks from now.

So, given the good (IMHO) result, I am tempted to contact the cancer specialist nurse team and offer to cancel the appt so as to avoid using scarce consulting time from which someone else may derive much more benefit. I continue to be reasonably well placed to handle the AS uncertainty (or perhaps am just much too busy handling life's other uncertainties!), and don't really have any questions, requiring near-term answers, for the consultant.

Any thoughts, just in case I am overlooking something, before I offer to relinquish the appt ?

Cheers, Peroni.

Hello Peroni 

Thank you again for such a comprehensive post. the PSA level at 3.25 looks good as your Trust has an acceptable range up to 6 so no issues there.

Now you know my personal opinion - I don't believe in AS. You have a partial Gleason 7 Score, Perineural Invasion, and it's not going to get any better. 

I would be asking for an MRI to see where the cancer is - is the Tumour near the edge? (you don't want it going walkabout) and the younger you are, the better you respond to treatment.

However as you say:

Peroni said:

I continue to be reasonably well placed to handle the AS uncertainty

If you are happy - go with your thoughts.

The above are only my personal thoughts and I respect your choice of pathway.

Best wishes - Brian.

My purely personal answer would be...

Leave nothing to chance, follow it all through and request another PSA test and press for an MRI scan.

Your life and wellbeing are far too valuable to leave things to AS, caught early this horrible disease is beatable, don't let it get too far advanced.

Hi Peroni

When was your last MRI scan and what did it say in terms of tumor size in mm.

Steve