T2c disease and active surveillance.

User

Posted 02 Jan 2024 at 11:55

Hi Adrian

Clear as mud then.

Doesn't really answer your question unless I am missing something?

I got much the same response when I questioned my Urology team. Under the old rules I would have been deemed high risk, but under the new rules I am low risk.

I also came across some info in the PCUK literature which stated that men with more than 5mm of cancer detected in their prostate should not be considered for AS. I had 10mm and 11mm respectively, so I guess this has changed too?

Edited by member 02 Jan 2024 at 12:03 | Reason: Not specified

User

Posted 02 Jan 2024 at 12:10

Originally Posted by: Online Community Member

Hi Adrian

Clear as mud then.

Morning Ian

Happy New Year to you. Your response was so quick I didn't have chance to send you PM.🙂

I agree, as clear as mud.

In 2020, their guidelines distinctly state T2c disease was high risk and not deemed suitable for AS.

A year later it has been 'down graded" by CPG to low risk and is now deemed suitable for AS.

Despite recent research (link sttached in one of my previous posts) stating bilateral disease, the old T2c, staging, is the most significant factor in AS failure.

What a difference a day (or in this case a year) makes?

Edited by member 02 Jan 2024 at 12:22 | Reason: Typo

User

Posted 02 Jan 2024 at 12:24

Happy New Year to you too Adrian!

When I finally get the letter my consultant apparently dictated on 20th December, I shall contact her to ask for clarification on the question of more than 5mm not being suitable for AS. I hadn't seen this referenced anywhere before. My wife spotted it whilst ploughing through the various PCUK information sheets on their site.

User

Posted 03 Oct 2024 at 23:15

Thanks Adrian for directing me to this thread, it’s interesting. Strange how T2c can now be downgraded! The nurse specialist that gave me the biopsy results wrote to me after the meeting stating T2c. I have my first appointment with the consultant on 15th and so it will be interesting to hear his views on the diagnosis

User

Posted 01 Jun 2025 at 08:37

In another very recent conversation on T2c disease. Including its suitability for active surveillance and change from its once TNM high risk staging to CPG low risk staging was discussed.

I found this link which was helpful in explaining why the old T2a,T2b and T2c sub groups had now been classed into one T2 group.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6375094/#:~:text=Conclusions,confidence%20for%20patients%20and%20physicians.

In the seventh edition, a 3-tier system was used to subdivide pathologic T2 disease (pT2) based on the extent and laterality of disease. The current eighth edition defines a single pT2 category, eliminating the subcategories, for all organ-confined disease. In the present SEER cohort, CSS at 10 years was 99.3% for T2a/T2b, 99.2% for T2c, respectively. The survival differences between T2a/T2b and T2c did not have statistical significance

However, although it doesn't affect mortality rates, I don't think it negates research showing that T2c disease is more likely to result in AS failure than the old sub T2a and T2b groups.

It also shows under the old risk stratification T2c disease was deemed high risk purely on its cancer staging alone but now PSA levels and Gleason score are also taken into account which will account for the apparent downgrades as to its risk.

So in 2020, when I was first diagnosed with PSA 5.6, Gleason 6(3+3), T2c. NICE guidelines said I was high risk, purely because of the T2c staging and was not suitable for AS

Yet only a year later with the same 3 factors I'd have been deemed Grade 1, the lowest CPG risk and was the perfect candidate for AS. Weird ain't it?

Edited by member 01 Jun 2025 at 10:33 | Reason: Additional text

User

Posted 01 Jun 2025 at 18:57

I agree it is all very odd that there has been such a change in advice. I think another factor which is not so often commented on is the size of the prostate. There are some research papers that refer to this. A man’s prostate can vary considerably in size and if you have a small prostate say approx 25cc in size the risk of a tumour breaking through the capsule may be higher than a man who has a prostate say 80cc. A 2.5cc tumour is taking up 10% of the prostate in a man with 25cc prostate but only about 3% in a man with a prostate 80cc. I know where the tumour is growing is a factor but given all things were equal.

The other thing is T2C is frequently diagnosed following surgery. My husband’s tumours one side of the prostate were missed by MPMRI and biopsy and only discovered following surgery.

I know you are an advocate for AS and I fully understand why but it is all these variables that make me worry ie the relative frequent upgrading of Gleason score following surgery, the missed tumours not spotted on MPMRI or biopsy therefore under estimating of tumour and even changes in grading following surgery where tumour thought to be confined even sometimes with Gleason 6 has breached the capsule. Obviously AS is the right choice for many men but I think for many the biggest hurdle is the small degree of uncertainty with which you have to live not knowing if your diagnosis is the full picture. I know there is always uncertainty but with the other options I suppose you can think I have thrown the kitchen sink at it. As you have said before though Adrian perhaps my views are skewed by this forum which may not be reflective of how successful the AS approach is for many men.

User

Posted 07 Jun 2025 at 18:03

Hi all,

Being very much a member of the T3a club, confirmed after RALP and histology, I remain completely bamboozled by the different Gradings and how the medical profession interpret them.

I started this journey with a 4.5PSA back in November 2024. I’d had three x DRE in 2024, all clear and the GP told me that she’d be very surprised if I had PCa, especially with the size of my prostate (I’ve seen 3 x measurements of it, all different, but the final histology proved it to be twice the size of a normal walnut!!!).

Follow up PSA 4.4, then the usual MRI and I’m suddenly T2 but PRADS 5 N0 MX. Given the news that it’s OK as it’s contained and all on one side 👍. Slight caveat that a 2.4mm tumour is big but then it’s not a problem as I’ve got a big prostate (confirmed at this point as 60cc but other readings differ) and it’s all relative in any case.

Biopsy results. 1 out of 12 left hand side and 14 out of 16 right side. Scary. All still OK with a T2 but we are now up to T2c! Gleason 3/4. Surgery still best option confirmed by local MDT (I’ve got diverticula and had IBD in past).

PSMA Pet scan pre op normal (ordered by a specialist MDT… yes 2 x MDTs).

Final histology as above with Gleason 3/4, T3a, EPC and fantastic news clear margins. Surgeon though relieved I didn’t see him any later and so are we!!! But… how can you go so quickly from “oh it’s BPE to T3a in 3 months is still leaving me scratching my head. I’m also told that, at 15% of prostate, the tumour size is 2 the usual level seen. I think I’ve worked out the reasons why the DRE’s failed is the main tumour was sitting at the back of the prostate but other than that, I’m not so sure.

Good news! First post op PSA <0.01 👍👍👍👍👍👍👍👍👍.

So I’m delighted that I “finished” with T3a as I was starting to worry that it was a slippery slope to a far worse situation.

I’m now following the nanograms mentioned in the above as I appreciate that a T3, even with clear margins, is still an elevated risk for recurrence but for now I’m enjoying the moment.

Re the other issues:

12 weeks post op and I’m now down to 1 pad a day and they are weighing in at around 50gms to 100gms depending on how active I am.

Re ED. I had 50% nerve sparing. Well Mr Flopodopolus is still playing catch up. Tadalafil does make him stir a bit but that’s about it for now. It’s work in progress otherwise and I’m getting used to the pump.

Good luck to you all guys and I do find your posts really enlightening and helpful.

User

Posted 05 Jul 2025 at 20:08

Hi all, I'm new to this but the t2c is worrying me. Meeting booked for 25th July.

I have my biopsy results now and a bit concerned given the % and weighting.

Also T2C

Age: 52

PSA: 4.9 ng/mL

PSA Density: 0.15 ng/mL/cc

Prostate Volume (MRI): 32 cc

Clinical Stage: T2c (bilateral, organ confined)

1. Biopsy Results Summary

Total positive cores: 8 out of 19 (~42%)

Overall Gleason Score: 3+4=7 (<5% pattern 4)

Bilateral disease involvement (right and left sides)

Details by site:

Right Anterior: Granulomatous inflammation, no cancer

Right Posterior Medial: Adenocarcinoma, Gleason 3+3, 2/4 cores positive, up to 70% cancer in core, 5mm length

Right Posterior Lateral: Adenocarcinoma, Gleason 3+3, 3/3 cores positive, up to 35% cancer in core, 6mm length

Left Anterior: Adenocarcinoma, Gleason 3+4 (<5% pattern 4), 1/3 cores positive, 20% cancer in core, 3mm length

Left Posterior Medial: Adenocarcinoma, Gleason 3+4 (<5% pattern 4), 2/3 cores positive, 10% cancer in core, 1.5mm length

Left Posterior Lateral: High-grade PIN and granulomatous inflammation, no cancer detected

User

Posted 05 Jul 2025 at 21:15

Hi Steve.

I'm sorry that you've had to join the club, but welcome to the forum, mate.

Despite my concerns over T2c disease, in your circumstances, if active surveillance was offered I'd give it a go, so long as my condition was being correctly monitored. Now all T2a, 2b and 2c disease groups are just classed as T2. However my research search still suggests that you are more at risk of active surveillance failure if you have T2c disease and should be extra careful that your monitoring is done correctly.

Please ensure your PSA checks are taken regularly and if they remain relatively stable, double check your condition and have a follow up MRI at the appropriate time.

Your 7 (3+4) grading classes you at low/intermediate risk. If they deem the 4 part is low enough you will meet the criteria for active surveillance. However I suspect that you would have been offered all options

This is an excellent film on treatment options, the risks of each and the possible side effects.

https://youtu.be/zYTU94-8pTc?si=1Z29_l8rbTwF6DHl

It's well worth watching, mate.

Best of luck. 👍

Edited by member 06 Jul 2025 at 10:50 | Reason: Typo

User

Posted 05 Jul 2025 at 21:40

Thanks, I guess what's also bothering me is mri was clear. He agreed to biopsy based on density being 0.15 and borderline.

Yet 18 samples produce 8 positive, so just how much is in there.

Or would 18/18 be OK if the grade 4 was low.

Main problem is I've always been in control, problem find a solution fix it.

With this I don't know enough and there seems so many variables you have to rely on others.

Main thoughts from family is if you are probably going to need treatment at some stage , surely younger and with less volume offers better recovery.

Anyway that enough for today, my heads spinning. Thanks for your help 👍

User

Posted 06 Jul 2025 at 22:48

Hi Steve738019,

Sorry to hear you have needed to join.

I’m very much like you and not used to letting the grass grow, both personally and in business, and I’m now finding myself very lost at times in a very scary and alien world.

Firstly, seeing your comments re biopsies you might find the predict prostate web site (links also through the Cancer Research UK site) helpful. it’s certainly helped me at times and in a positive way.

secondly, You’ve also made me have another look at my biopsy results. I was upgraded from T2c post RALP to T3a but wasn’t ever given the option of AS even as T2c. I was, however, PRADS 5 after the MRI with a 24mm clinically significantly tumour and, whilst considered contained, I guess there was already suspicion of potential capsule breach (not reported on MRI) as, after some rethinking, was put forward for a PSMA PET CT scan.

My biopsy results were 1 out of 12 left side and 14 of 16 on the other. I’ve estimated 30% of biopsy cores were G4 with the rest all G3. My consultant confirmed to me that the friskier G4 was more likely to and indeed had breached the capsule and I was rightly deemed as High Risk accordingly.

Positively, your G4 is much lower than mine which looks very good news (I’m not a medical person).

I wasn’t given an option and couldn’t have EBRT either but I’d say, with my history and mindset, I would, in any case, have really struggled with AS.

Good luck in making your decision.

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