(Part I)Perineural invasion: Not so scary
But keep an eye on those cells
By Howard Wolinsky
In 2020, Jeff Coleman, 62, of Eldersburg, Maryland, outside of Baltimore, was diagnosed with high-volume Gleason 3+3=6 prostate cancer.
“There was some initial discussion with my doctor about treatment due to the high volume but we both ultimately agreed on Active Surveillance. PSA tests during AS (3.9 and 4.1) were lower than my highest PSA (4.9),” said a Jeff, a recent retiree from Verizon Communications.
I always like to hear from Jeff, a frequent visitor to the AnCan (AnCan.org) Virtual Support Group for Active Surveillance. He’s a quipster and a self-acknowledged smart aleck. He keeps things light even when we have a weighty subject at hand.
But Jeff had some good news and some seeming scary or confusing news from his second (confirmatory) biopsy on May 6, 2022.
He reviewed the results online in the portal at Johns Hopkins. The cancer was “aggregately less than on the first biopsy.” Less cancer sounds good. He remained a Gleason 3+3. Also good.
But then he lost his usual self-confidence.
The pathology report stated that Jeff had “PERINEURAL INVASION” (PNI) in a single core.
Jeff is not the first prostate cancer patient to read that term and freak out. He won’t be the last. First off, maintain your aplomb in the face of a PNI.
“Perineural invasion was a new term for me (sounded like a title of a B-rated sci-fi movie I saw as a kid). I did at first think of the perineum since I had a transperineal biopsy and thought how in the world could cancer have gotten there, especially since that’s outside the prostate!” Jeff said.
“Fortunately, we have the internet and I looked up the term. When I read that PNI was cancer involving nerves and that this can be a pathway for cancer to get out of the organ and metastasize my first thought was, ‘This is it!’ I was certain that my doctor was going to recommend treatment.
It wasn’t “it.”
Jeff’s doctor reassured him: “This time, however, there is some perineural invasion noted - nerves inside the prostate involved with cancer. Chance of progression a bit higher but still not meaning that you have to have treatment at this juncture. Should be a consideration, however.”
Jeff Coleman tackles the “invasion” with his Sport Toure, a 2106 BMW F800GT.
“The fact that he stated I would not have to have treatment at this time was a huge relief even though it seemed contradictory based off what I had read about PNI,” Jeff said.
He got more assurance from a second opinion from pathology top gun Jonathan Epstein, MD, at Hopkins. “Epstein called me and stated he did not feel the PNI in my case was a big issue and said it wouldn’t mean I would have to get off AS. Again, a huge relief! Am I feeling better knowing PNI doesn't necessarily mean automatic treatment? ABSOLUTELY!!”
Then, Jeff had a follow-up in person with his urologist.
He said: “The doctor basically told me the same thing that Epstein did regarding PNI. With Gleason 6 cancer being so slow growing that it is not a huge concern at this time, although they both stated that it is a potential indicator of unsampled higher grade cancer. However, they also say having high volume is also an indicator of potentially unsampled higher grade cancer. So as markers, they are essentially equal. He also said (as did Epstein) that many men have PNI and just don't know it since very often they don’t get nerves on any cores during a biopsy.”
Bottom line: It’s OK for Jeff to stay on active surveillance. The urologist warned Jeff there may be an upgrade sometime in the future and treatment may be needed at that time. “But we know that is what AS is about for many men,” said Jeff.
Jeff will stay on close monitoring with PSA tests every six months, yearly MRIs and yearly DREs.
Jeff said his urologist will use these factors to decide when and if a biopsy is needed. . He said his urologist does NOT want to perform yearly biopsies if they can be avoided.
“So I am feeling pretty damn good about staying on AS! You're not rid of me yet!!” Jeff said.
Time’s up on the AnCan webinar on Wednesday. Register STAT:
Two experts who have made big news on lifestyle and prostate cancer will share their research on diet, including plant-based and Mediterranean plus other lifestyle choices, including exercise and sleep, at an AnCan webinar for all patients with prostate cancer 8-9:30 p.m. Eastern on May 31.
Register: https://bit.ly/3KkxcfC
The webinar, entitled “Optimizing Sleep, Exercise, and Nutrition in Prostate Cancer," features Dr. Stacy Loeb, professor of Urology and Population Health at the New York University School of Medicine and the Manhattan Veterans Affairs Medical Center, and Dr. Justin Gregg, assistant professor of Urology and Health Disparities Research at UT MD Anderson Cancer Center, of UT MD Anderson Cancer Center in Houston.
Active Surveillance Patients International and the AnCan Virtual Support Group for AS are teaming up for a program on BPH (benign prostate hyperplasia), an enlarged prostate, a not uncommon problem in patients on AS with intact prostates. Men who have been treated encounter similar issues,
It’s a drop-in First Wednesday meeting, June 1 at 8 p.m. EST. No registration is necessary. Attend the free program, featuring BPH guru, Mount Sinai’s Dr. Steven Kaplan.
Just enter the AnCan Barniskis Room. And bring your questions .... in fact, if you already have something in mind, send it ahead of time to Joe Gallo at joeg@ancan.org.
Mark this on your calendar: Join me June 7 on Zoom at the Tri-Cities Support Group from outside Vancouver. I will nag you until you sign up. So sign up. Resistance is futile.
No registration necessary. Go to: https://bit.ly/3NGQQob
Here’s what Dale Bryant from Tri-Cities and Richelle Green from ProstateSupport Canada put together:
“Lessons Learned: My Prostate Cancer—and Yours”
JUNE 7TH, 2022 |
7:00 PM Pacific/ 8:00 PM Mountain/ 9:00 PM Central/10:00 PM Eastern
Go to: https://bit.ly/3NGQQob
The Tri-Cities Support Group's speaker will be Howard Wolinsky, a co-founder of Active Surveillance Patients International. Howard is an award-winning medical and science journalist from Chicago, who wrote for the Chicago Sun-Times. He recently started writing a newsletter: TheActiveSurveillor.com
Howard is the author or co-author of three books about medical issues.
Since he has been so willing to speak to people and write about his experience with prostate cancer, he is an ideal choice to introduce the topic of how to talk about prostate cancer to family, friends and those with whom we come in contact. We are hoping that his talk will serve as a springboard for an interesting sharing of information on how comfortable people are to talk about their prostate cancer journey with others.