Thus, wanting to have the nerve sparing operation to save his life and his sex life, he has seen that his normal sex life has stopped and his life may be jeopardized should second line therapy not be successful. There are many educational points about the case. The first is that biopsies can frequently miss grade the Gleason score of the cancer. The patient's point that the previous year's biopsy might well have been positive, had more samples been taken, is reasonable. It may well have been repeated within a shorter period of time although his story is not that unusual.
Many patients are reluctant to undergo repeated biopsies.
Furthermore, biopsies only represent sampling and while his biopsy which showed a Gleason 6 cancer was positive it did not fully represent the Gleason 7 that was found at the time of radical prostatectomy. Gleason produced a pathologic criteria based upon microscopic appearance of the cancer cells. As patients get higher Gleason scores particularly greater than 6 surgical results falter even more precipitously. Yet this patient had the warning sign of the elevated PSA which bodes poorly for surgery. Hopefully stereotactic body radiosurgery will fit the bill for this patient.