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Posted 7/9/2024 2:06 PM (GMT -5)
I finally got my biopsy results back from the Urologist and there is good news and bad news. The good news is that he says it came back negative. The bad news is they found mutated cells that appear to have some characteristics of PC but not enough of them to diagnose them as cancer. The doctor referred to the lesions as "atypical" and do not know what it is.

I logged in to view my health records so that I can see the pathology report itself but it's not online yet. I'm thrilled to get a cancer negative phone call but now they are placing me on strict active surveillance. I agree with the doctor that doing another biopsy to learn more about the abnormal cells is a bad idea and he does not want to turn me into a pin cushion. The more prostate biopsies I have the more the risk of getting a serious infection and its unlikely they would get a different result so soon afterwards anyway. I asked him what these abnormal cells fall under via a Gleason score and there is no result for anything under 6, is that the norm?

I don't know what to make of this yet, cancer negative is good but am I truly in the clear especially after having a PIRADS 4 and PIRADS 3? I really need the full pathology report. Has anyone else on this forum with PIRADS 4 lesions and a negative biopsy ever had to deal with Atypical Small Asinar Proliferation or PIP?
Posted 7/9/2024 3:01 PM (GMT -5)
Time for a second opinion on those slides!

Also: https://radiopaedia.org/articles/atypical-small-acinar-proliferation

More extensive info:
https://www.pathologyoutlines.com/topic/prostatesuspicious.html

Post Edited (Sr Sailor) : 7/9/2024 12:12:02 PM (GMT-8)

Posted 7/9/2024 5:26 PM (GMT -5)
I agree with Sr. Sailor--make arrangements to have your slides sent to Johns Hopkins for a second opinion. Your doctor will know how, or you can go to the JH website and the information is there.

There are actually, 6, gradually changing cell patterns in prostate tissue. Normal is pattern 1, the worst type is pattern 5. The first set of changes that are categorized as cancer is pattern 3. Your abnormal cells are possibly (I'm not a pathologist) pattern 2, which is classed as atypical, but not definitely cancer.

A second opinion, by JH, is a really, really good idea. So is going to strict AS.
Posted 7/9/2024 5:37 PM (GMT -5)
I got my pathology report and I think the results are mostly good but I'm concerned about core F and that is the one the doctor is putting me on active surveillance for. I'm glad that I may not have to join the PC club after all yet it's unfortunate that so many guys here are battling very real and 100% verified cancers. Am I reading into this report correctly? Mostly negative with only one core mentioning suspicious findings but not enough of these cells to diagnose cancer so its back to Active Surveillance - follow up in 6 months. It seems like a good report, but I honestly don't know what to make of it, do any of you guys have any experience reading into a pathology report?

Submitted by: XXXXXXXXXXXXXXXX - MD Date obtained: Jun 28, 2024
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Specimen (Received Jun 28, 2024 13:06):
A. PROSTATE NEEDLE BX RIGHT APEX
B. PROSTATE NEEDLE BX RIGHT MID
C. PROSTATE NEEDLE BX RIGHT BASE
D. PROSTATE NEEDLE BX RIGHT LATERAL APEX
E. PROSTATE NEEDLE BX RIGHT LATERAL MID
F. PROSTATE NEEDLE BX RIGHT LATERAL BASE
G. PROSTATE NEEDLE BX LEFT APEX
H. PROSTATE NEEDLE BX LEFT MID
I. PROSTATE NEEDLE BX LEFT BASE
J. PROSTATE NEEDLE BX LEFT LATERAL APEX
K. PROSTATE NEEDLE BX LEFT LATERAL MID
L. PROSTATE NEEDLE BX LEFT LATERAL BASE
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
BRIEF CLINICAL HISTORY:
PSA 3.44

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PREOPERATIVE DIAGNOSIS:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
OPERATIVE FINDINGS:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
POSTOPERATIVE DIAGNOSIS:

Surgeon/physician: XXXXXXXXXXXXXXXXXXXXXXX
PATHOLOGY REPORT Accession No. SP 24 1981
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
GROSS DEscriptION:
This case was sent in entirety to Baptist Saint Anthony's Hospital for
processing. Their report (VA-24-0779) follows: JSS/ljg

Gross time: 1353

A. Specimen labeled "PROSTATE NEEDLE BX RIGHT APEX" is received with
proper patient identification and fixed in formalin. Specimen consists of
a 0.9 cm core and submitted in one cassette (A1). kgb

B. Specimen labeled "PROSTATE NEEDLE BX RIGHT MID" is received with proper
patient identification and fixed in formalin. Specimen consists of a 1.6
cm core and submitted in one cassette (B1). kgb

C. Specimen labeled "PROSTATE NEEDLE BX RIGHT BASE" is received with
proper patient identification and fixed in formalin. Specimen consists of
a 1.6 cm core and submitted in one cassette (C1). kgb

D. Specimen labeled "PROSTATE NEEDLE BX RIGHT LATERAL APEX" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 0.7 cm core and submitted in one cassette (D1). kgb

E. Specimen labeled "PROSTATE NEEDLE BX RIGHT LATERAL MID" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 1.6 cm core and submitted in one cassette (E1). kgb

F. Specimen labeled "PROSTATE NEEDLE BX RIGHT LATERAL BASE" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 1.8 cm core and submitted in one cassette (F1). kgb

G. Specimen labeled "PROSTATE NEEDLE BX LEFT APEX" is received with proper
patient identification and fixed in formalin. Specimen consists of a 1.5
cm core and submitted in one cassette (G1). kgb

H. Specimen labeled "PROSTATE NEEDLE BX LEFT MID" is received with proper
patient identification and fixed in formalin. Specimen consists of a 2 cm
core and submitted in one cassette (H1). kgb

I. Specimen labeled "PROSTATE NEEDLE BX LEFT BASE" is received with
proper patient identification and fixed in formalin. Specimen consists of
a 1.3 cm core and submitted in one cassette (I1). kgb

J. Specimen labeled "PROSTATE NEEDLE BX LEFT LATERAL APEX" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 1.5 cm core and submitted in one cassette (J1). kgb

K. Specimen labeled "PROSTATE NEEDLE BX LEFT LATERAL MID" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 1.3 cm core and submitted in one cassette (K1). kgb

L. Specimen labeled "PROSTATE NEEDLE BX LEFT LATERAL BASE" is received
with proper patient identification and fixed in formalin. Specimen
consists of a 1.4 cm core and submitted in one cassette (L1). kgb

SNOMEDS: T-77120

MICROSCOPIC DEscriptION:
A complete microscopic examination is performed on each specimen. To
evaluate a discordant glandular focus on specimen F, the PIN4 multiplex
immunoperoxidase stain is performed with appropriate controls. This
reveals the focus in question to lack basal cell markers in the two
remaining glands; however, show non-specific amber staining but no
definitive positive AMACR staining in those residual glands.


PATHOLOGICAL DIAGNOSIS:
A. Prostate, right apex, needle biopsy:
Benign prostate tissue with acute and chronic inflammation and
atrophy.

B. Prostate, right mid, needle biopsy:
Benign prostate tissue with mild chronic inflammation and atrophy.

C. Prostate, right base, needle biopsy:
Benign prostate tissue with chronic inflammation and atrophy.

D. Prostate, right lateral apex, needle biopsy:
Benign prostate tissue with mild chronic inflammation and atrophy.

E. Prostate, right lateral mid, needle biopsy:
Benign prostate tissue with mild acute and chronic inflammation and
atrophy.

F. Prostate, right lateral base, needle biopsy:
Benign prostate tissue with a 0.2 mm focus of small, atypical glands
suspicious for adenocarcinoma, with chronic inflammation and atrophy.

G. Prostate, left apex, needle biopsy:
Benign prostate tissue with mild inflammation and partial atrophy.

H. Prostate, left mid, needle biopsy:
Benign prostate tissue with focal atrophy.

I. Prostate, left base, needle biopsy:
Benign prostate tissue with mild chronic inflammation and partial
atrophy.

J. Prostate, left lateral apex, needle biopsy:
Benign prostate tissue.

K. Prostate, left lateral mid, needle biopsy:
Benign prostate tissue with minimal inflammation.

L. Prostate, left lateral base, needle biopsy:
Benign prostate tissue with chronic inflammation and partial atrophy.
Code 5,6 Class III ICD R97.20, N42.3

COMMENT:
Specimen F was reviewed with a second pathologist (XXX), who concurs

CPT: G0416, 88344, 88305 x12

SNOMEDS:
T-77120 M-40000

Final Diagnosis performed by XXXXXXXXXXXXXXXXXX
Electronically signed 7/5/2024 10:42:09AM

Testing performed at XXXXXXXXXXXXX
AVAMC Comment:
PA XXXXXXXXXX (Urol Clinic) was notified of the above, via secure Teams
message, on 7/5/2024 at 1245 hrs. In addition to the two APG staff
pathologists, this case has been previously reviewed by Dr. XXXXXXXXXX who
concurred with the above findings. Dr. XXXXXXXXXXX is e-releasing in this case
during Dr. XXXXXXXXXXXXX extended absence.

SPECIAL STUDIES:

CONSULTATION Date: JUL 01, 2024
12 SETS OF PROSTATE NEEDLE BIOPSIES
SLIDES SENT TO BSA FOR PROCESSING 7-1-24. KGB

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(End of report)
Posted 7/9/2024 7:13 PM (GMT -5)
Pirads 4 and no cancer found is not uncommon. Remember the MRI can not detect cancer, only a cellular level investigation of actual tissue can do so. The P4 could be due to the areas of inflammation and atrophy noted.

A 12 core biopsy only samples about 1% of the gland and nearly 50% of biopsies are negative. You pursuing AS is a good idea to stay ahead of any potential PCa development. If I am reading the information correctly, your PSA is only slightly elevated and you had a biopsy a couple of years ago. What is your age? Do you have any history of prostate infection or enlargement? I assume the DRE’s have been unremarkable.

As others have said, it is always a good idea to get a second read of the slides at Hopkins or Bostwick as they are the leaders in reading them.
Posted 7/10/2024 4:46 AM (GMT -5)
I also saw that almost every core noted signs of chronic inflammation and cellular atrophy. The inflammation alone could account for the PIRADS 4, along with the bouncing PSA.

I'd get the second opinion from JH to set your mind at ease, but for now, you don't have cancer. Rest easy.
Posted 7/10/2024 6:42 AM (GMT -5)
All this put you in muddy waters.
I had a biopsy with atypical cells and four year later a PIRADS 5 leading to diagnostics. But, honesty, I do not know what to tell you about what you can expect, every case is different.
I only have an advice to you, try to reduce or, better, eliminate anxiety. A diagnostic may take years to arrive or it may never come, just be diligent with the tests and hope the best. And, anyway, understand that the worse is something generally manageable and shared by a good percentage of not very young guys, and it is not the end of world as you may sometimes envision it now.
Posted 7/10/2024 8:28 AM (GMT -5)
1. There was no definitive cancer diagnosis. Breathe
2. I had a similar first biopsy, with atypical cells . Two years later I was diagnosed and had surgery
3. a good friend of mine had a similar biopsy, but even more vague as to whether it was cancer, sent to Johns Hopkins, second opinion said not definitive, had another biopsy a year later and it was G6 cancer. That was 7 years ago, and he still is on active surveillance, no treatment needed. So this could go either way.
4. ABSOLUTELY, UNEQUIVICALLY, DEFINITELY, send the slides to JH for a second opinion.

You are, in a sense, settled into purgatory for now. But for now, you don't have a cancer diagnosis. Try to relax (ha, fat chance, I know)), or at least just let this simmer and digest it until you aren't constantly thinking about it, and just stay vigilant.

If it were me, I would ask for another biopsy in 6-9 months

Final Decision on our club membership application: Membership Denied, pending further information
Posted 7/10/2024 9:07 AM (GMT -5)
**IF** you get further confirmation that nothing amounting to G6 (3+3) or higher was seen but some cores were "suspicious," I would want to be monitored as if I were a G6 on Active Surveillance. I'd follow a strict AS protocol with my uro--meaning another biopsy within a year, especially if your PSA continues to rise. You wouldn't treat until/unless things worsen.

My 2¢ and best wishes,

Djin
Posted 7/10/2024 1:27 PM (GMT -5)
Thanks to all the great advice from so many of the awesome cancer warriors that are here. It does feel like purgatory that my 5 year risk for developing PC exists but to just relax on the fact that right now there is no cancer. You guys that actually have it have shown remarkable resilience in fighting the disease and winning for so many years after such a dreadful diagnosis.
Posted 7/10/2024 8:38 PM (GMT -5)
No sense in sending slides to John’s Hopkins. Epstein is not there anymore.
Posted 7/10/2024 9:44 PM (GMT -5)
Into - Purgatory is a good description for this roller coaster at times. You can not rewind the clock and feel like you did before PCa became possibility. That is one thing we all have in common but eventually deal with it. Enjoy your victory, time to do something fun for a change.
Posted 7/11/2024 6:49 AM (GMT -5)
Chris, Dr. Epstein’s team is still there. He did not do all the reading to begin with as no individual can read the volume at JH. Still,a,good,idea for a second read at either JH or Bostwick.
Posted 7/11/2024 7:08 AM (GMT -5)

JNF said...
Chris, Dr. Epstein’s team is still there. He did not do all the reading to begin with as no individual can read the volume at JH. Still,a,good,idea for a second read at either JH or Bostwick.


Dr. Epstein also trained a lot of pathologists over his many years so it is logical to expect that the JH tradition of great prostate knowledge will continue.
Posted 7/11/2024 8:37 AM (GMT -5)
Regarding more biopsies causing infections, that is very unlikely with transperineal biopsies. No antibiotics either.
Posted 7/11/2024 9:14 AM (GMT -5)

Mumbo said...

JNF said...
Chris, Dr. Epstein’s team is still there. He did not do all the reading to begin with as no individual can read the volume at JH. Still,a,good,idea for a second read at either JH or Bostwick.


Dr. Epstein also trained a lot of pathologists over his many years so it is logical to expect that the JH tradition of great prostate knowledge will continue.

This is true, and I wouldn't hesitate to use the service that he set up at JH. I would only point out that while there, Dr. Epstein did personally review all reports that he did not personally do.
Posted 7/14/2024 7:09 PM (GMT -5)
I figured my comment would draw these responses.

So, here is how I see it....J.H. pathology department is how would I put it, extremely compromised now. It is obvious that when a pathologist at J.H. has a diagnosis challenged by, and I would bet my life on it and did, the best pathologist in the world they get their feelings hurt and cry they are being bullied. You now have to suspect any diagnosis coming from them as possibly being wrong due to the fact that even if they are still "faking" peer review of each others work, anyone speaking up will be accused of bullying.....and you are simple if you don't think other pathologists aren't thinking that.

They all know that if J.H. ran out the best pathologist in the world that J.H. would run anyone else out as well. For all we know, and I would bet $1m on Epstein, that he was right and the snowflake that complained was actually wrong. I can only imagine the thoughts in Epstein's head at the time...."Oh, I am sorry I hurt your feelings, but your mis-diagnosis might kill someone....so I don't care about your feelings...go complain if you want." So, it is extremely obvious that J.H. now prioritizes feelings over a correct diagnosis. I would not have cared how well Epstein "played in the sandbox" with other doctors. I never would have run him out.....fools.

To each his own, but I would no longer trust anything coming out of J.H. as you have no idea if the work was reviewed and then actually challenged if need be.

Can you imagine in the future there....."The pathologist said you have cancer, we know they are wrong but we didn't want to hurt their feelings so your going to have to take cemo anyway."

Good Luck!

Post Edited (ChrisR) : 7/14/2024 4:15:58 PM (GMT-8)

Posted 7/14/2024 7:43 PM (GMT -5)
A hospital with the reputation of JH is not going to collapse because of the departure of one individual.
Posted 7/14/2024 8:46 PM (GMT -5)
ChrisR, The reason Epstein left JH is that he was accused of repeatedly taking his pathologist wife’s side when her judgment was challenged by other pathologists. The investigation had been going for about a year when he resigned, so it must have had substance.

This was a personal favoritism matter that affected the morale of the pathology staff. I don’t recall reading about “hurt feelings” in the news reports of the investigation.
Posted 7/17/2024 1:01 PM (GMT -5)
ASAdvocate.........

How do you know it was a personal favoritism matter? Maybe his wife was right.....you have no idea, none of us do, and are making assumptions. It also appears that the investigation revealed "NO" mis-diagnosis on his or his wife's part. So, I would lean towards the fact that his wife and he were correct and the others were wrong.

Epstein is a person whom the entire world would send "problem" cases to and ask him for a diagnosis when other pathologists were unsure of what they were looking at. I don't care if he was a horse's a??....I would take his opinion over anyone....and if I were J.H. I never would have let him go.....they are nothing more than an "average Joe" shop now and you have to suspect any diagnosis they make now as accuracy is not the top priority there.
Posted 7/17/2024 3:17 PM (GMT -5)
ChrisR, I have been a patient at JH since my diagnosis in 2009. Dr. Epstein has done some of my biopsy pathologies over the years, but most were done by others. I know that he had spent considerable time working with a large AI diagnostic project over the past couple of years. His knowledge has been widely spread among his colleagues.

I had not heard that there were conclusions on the charges against Dr. Epstein. What I read a few months ago was that he resigned because of the ongoing investigation.
Posted 7/22/2024 3:53 PM (GMT -5)
Get a second opinion!!!

Fred in Southern New Jersey
Posted 7/24/2024 8:38 AM (GMT -5)
I have pretty much agreed with ChrisR in other posts on different threads in this matter. JH really screwed up by letting Epstein get away. I do believe that the complaining doctor or doctors to be younger people who don’t know how to blow their noses yet. Also a good chance they have helicopter parents. These days, if there are HR complaints, they are vigorously pursued. Epstein by all accounts was great with patients and I expect he could be a SOB with colleagues. That’s how you developed a great reputation: by asserting your opinion and having the knowledge to defend it. But, times change and patients will suffer because of it. We’re not talking about inappropriate sexual behavior or discrimination. Those would require immediate action. This is a “bullying” accusation, whatever the heck that means these days. JH really screwed up by allowing butt-hurt people to dictate policy because workplace pressure was too much for them.

I would definitely be much less confident in biopsy opinions coming from JH now.

PS, I don’t see how Epstein's wife fits into this. Maybe he favored her, but I doubt it. If anything he may have scrutinized her opinions harder. Maybe he married her because she is a hell of a good pathologist.
Posted 7/25/2024 9:57 AM (GMT 0)
Guys, do you really believe that with the departure of ONE person, for any reason, the JH pathology department has gone from best in the world to third world country status? Really? Whether Epstein is there or not, they are still going to be very, very good. I've always felt the reverence this group places on him, was more than a little displaced. At some point he was going to retire, or die. If that had happened, would you be saying the same things?

Plus, is this discussion really helpful to the OP?
Posted 7/25/2024 7:04 AM (GMT -5)
So mattam and Chris, if not John’s Hopkins, then who do you seek another expert PCa assessment from? Please provide the objective factual basis for the choice. It has become de rigueur to seek a second opinion at JH on this board. Do we now abandon that stance? If we retain that stance, then who/what institution should be recognized as most appropriate to provide the assessment?
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