Roughly 25% of initially diagnosed Gleason 3 + 3 ends up with something more aggressive over time. This is due to the fact that either the initial 3 + 3 was misdiagnosed and/or the biopsy missed the more aggressive cancer. This has little to do with the skill of the person performing the biopsy but rather due to random chance. Its likely the biopsy was both targeted and systematic with the targeted areas finding the cores with PC and the systematic(random) cores finding nothing, but there is always a chance to miss something. Gleason 3 + 3 progressing itself is rare to non-existent.
Question: BPH can also cause a rise in PSA. You didn't mention this as a possibility so I assume it was eliminated as a potential cause. Three months after the biopsy seems out of the general window of after-effects from the biopsy. I am also on AS with 3 + 3 with total volume in two cores of 1.7mm. It seems the request for a 2nd biopsy seems prudent.
Here is some content from some studies I've read on the subject.
Gleason score 6 cancer has little or no metastatic potential. One study of 14 000 men with pathologically confirmed Gleason pattern 6, identified only 22 cases with lymph-node metastases [24]. All 22 men had higher grade cancer on re-examination of the tissue. Thus, the rate of lymph-node metastases in men whose surgical pathology contained no higher grade cancer was zero. Another study of 12 000 men treated with radical prostatectomy whose specimen had only Gleason score 6 cancer [25], found the prostate cancer mortality was 0.2% at 20 years. The few cases who had metastases had evidence of higher grade cancer on re-review. This low level of metastasis is remarkable given the imprecision and between observer variation in the assignment of Gleason score.
Co-existent higher grade cancer is common, but spontaneous grade progression (from Gleason score 3 to 4 or 5) is uncommon. This has been modeled by several groups; the estimate is that 1%–2% of patients per year will undergo grade progression. In most cases, this occurs in the presence of high volume Gleason score 6 cancers [26].
Based on these concepts, AS should be offered to most men with Grade group 1 (Gleason score 6) prostate cancer. The limitation of this approach is misattribution of grade, that is, that 25%–30% of these men diagnosed on the basis of a systematic biopsy actually harbor higher grade cancer. While most of these misattributed cancers are Grade group 2 (Gleason score 3 + 4), and may still have a low metastatic potential, the presence of any Gleason pattern 4 cancer confers an increased risk of eventual metastasis. Thus the crux of managing men on AS is to evaluate the patient further for the presence of co-existent high-grade cancer, and once higher grade cancer is excluded, monitoring them subsequently to ensure it does not develop.
The view that Gleason pattern 3 has little or no metastatic phenotype has had a significant impact on the management of patients with this cancer. Thus, there should be no lower age limit to entering a patient on AS. The quality of life benefits of maintaining normal erectile function and voiding function are greater in young men. Prostate cancers are not rare in young men; microfocal low-grade cancer is found at autopsy in around 40% of men in their 40s [3]. Finding small amounts of Gleason score 6 cancer on a transrectal ultrasound (TRUS)-guided biopsy cannot possibly mean that disease progression is inevitable. High-volume Gleason pattern 3 is important primarily as a marker for patients at higher risk for harbouring higher grade cancer. If higher grade cancer can be excluded in a patient with higher volume Gleason score 6 cancer (based on magnetic resonance imaging [MRI], targeted/template biopsies, and/or biomarkers), such patients are unlikely to require treatment. In rare instances, men under 55 years old present with extensive Gleason score 6 cancer. In these unusual cases, radical intervention, such as surgery, may be appropriate.
Edited by member 21 Oct 2020 at 10:54
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