Biopsies and tumor volume

[Samsun]

I already had a question partly on this theme but now I have more background information and am really puzzled. I have been several times in prostate biopsies during the last less than 4 years, altogether more than 60 needles. In April 2008 the last 20 of these biopsies where taken and one positive core was found from the left side, showing 1 mm and 2 mm cancer nodes (Gleason 3+3). The right side did not include cancer in these biopsies. Now I have received the final pathologial report of prostatectomy and this shows that I have a relatively large cancer e.g. a 15 mm tumor nodulus on the right side and on the left side a 10mm tumor (Gleason for tumor is classified as 3+2). One 'minimal' 1 mm focus is Gleason 4. Carcinoma is also found in apex but not in base. Capsule is intact, vesicles are OK, no metasthases in (obturatoric) lymphas (but a sinushistiocytosis is identified). Doctor said that accordng to these details I do not have any more cancer after prostatectomy. Can I trust on such a statement? I cannot understand how biopsies have missed such an amount of carinoma. Further, no cancer was recognized in numerous rectal exams or Ultrasonic exams --- even after April biopsies. Can cancers of such volume be invisible and felt not at all? How fast do such low grade cancers grow? During the last two years large biopsies were not taken (even if PSAs have ben followed and free-PSA has been between 6 and 9) but when I think the April results, I am still puzzled??Should I ask a re-evaluation of these biopsies? How likely it is that I am really 'clean' of cancer under such tumor volume conditions?

[Ash Tewari, MD, M.Ch.]

Hello sir, it is important to realize that the biopsy needle is quite small and the biopsy tissue only represents a small portion of the prostate gland.  Therefore, it is possible for the biopsy to not concur with the final pathology result (which is the most accurate way of staging your disease).  Also, you have only had a small portion of all the pelvic lymph nodes removed. The fact that the capsule was intact, there was no seminal vesicle invasion, and that the lymph node was negative for metastatic disease is all encouraging.  It also possible for a large cancers confined to the prostate to be no felt on rectal exam, especially if they are at the apex (such as your case).  I do not think you need a re-evaluation of your biopsies.  The final pathology from the prostate specimen is quite sufficient. Did you have an endorectal MRI, CT scan, or bone scan before your prostatectomy.  If not then a CT or bone scan may be necessary.  Endorectal MRI is of no use now since your prostate has been removed.  You should continue to follow up with your doctor and have your PSA levels checked periodically.  

[Samsun]

Bone scan was negative, another doctor made an Ultrasonic evaluation of rectal area and said that the capsule line was clear and vesicles were clear but other exams where not done because PSA was less than 10 (3.9 with Proscar treatment). Hope this was enough. Is there something that I could do more at this stage or just be happy with the results and follow ups? The first post RP PSA was OK and in the limits used in our country.