According to the doctor it is around 3 mm. Surgical Delay and Pathological Outcomes for Clinically Localized High-Risk Prostate Cancer. After extensive discussion of his management options with his local urologist, primary care physician, and radiation oncologist, he also sought a second opinion at the Johns Hopkins Prostate Cancer Multidisciplinary Clinic at Sibley Memorial Hospital.The patient expressed an overwhelming desire to avoid surgery and any other invasive treatments. Disclaimer. 180 days after treatment PSA was .50. - DWI-ADC = 4/5 I guess the PET scan will be the next step in what type of treatment options are in store.Has this occurred to anyone else? Urologists are trained as surgeons, radiation oncologists administer radiation, and medical oncologists provide cognitive oversight and general management of the cancer. Prostate volume: 17.58 cc Thank you for your participation! I've been on AS for two years after my initial TRUS biopsy showed 3 cores 3+3 (10% volume) on Right side, and 2 cores 3+3 on Left side. Unable to load your collection due to an error, Unable to load your delegates due to an error. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. HHS Vulnerability Disclosure, Help PI-RADS v2 score: 5. Also these lesions did not abut or touch the wall of the prostate. They told me to expect a spike in my PSA sometime in the future, and they told me that studies are showing that a slow, steady decline in PSA is often indicative of superior results (whatever that means. I would feel much more comfortable, if the numbers stay the same, being involved in a recognized Active Surveillance Program. Radhakrishnan A, Grande D, Mitra N, Pollack CE. In circumstances where there may not be a single established standard of care, we can ensure the treatment plan integrates the most current, up-to-date data, Dr. Matasar says. Hi JM "Numerous publications show the clinical and economic benefits of obtaining a second opinion for Pathology specimens. It is OK to not understand all the terminology. Masks are required inside all of our care facilities. Bookshelf 3. Federal government websites often end in .gov or .mil. Grade Group: 2 I am an airline pilot with exposure to radiation, jet fuels/fumes, etc. But I don't want to do a radical prostatectomy or radiation that would have large side effects now if the laser is a viable option given my data set. Our team approach brings together highly experienced prostate cancer experts from across disciplines to collaborate on each patients total care, from diagnosis through treatment and recovery. He wants me to begin the ADT around 5/1. Check Biopsy and Imaging Results for Accuracy. I've had what I would consider a fluctuating PSA since first tested in November 2018. Thanks, BigD. I've been on AS since April 2016. Men often seek second opinions from urologists before they initiate treatment for their newly diagnosed prostate cancer. If youve received a new diagnosis or arent seeing results from your current treatment plan, a second opinion can help you move forward with confidence. * Adjacent organ invasion: None. Research was mixed on PINS, but in those days, many doctors saw them as likely to develop into cancer. ---------------------------------------------------------- Surprisingly, while one in nine men will get diagnosed with prostate cancer in their lifetime1, there are very few doctors who specialize exclusively in treating prostate cancer. We provide second opinions on the full range of gynecologic cancers: Ovarian Uterine Cervical Vulvar Vaginal Fallopian tube Placental tumors Some peritoneal cancers J Am Board Fam Med. And luckily I lived in Chattanooga and had mutual friends with Dr. Joe Busch (my Urologist never mentioned him, yet we could almost see his facility from the exam room in which he broke the news. Those readings were reported on a second opinion by Dr. Epstein. Diffusely abnormal appearance of the prostate may reflect prostatitis, which can obscure underlying prostate cancer. Primary Gleason grade: 3 Anyone else encounter something like this? It is OK to be scared. First 6 week PSA is undetectable. One to a 3+4=7 and the other to a 3+3=6. They confirm everything except question whether one of the core samples is a 3+3 or 3+ 4. Even for men with faster growing, more aggressive prostate cancer, taking the time to seek a second opinion should be a priority. Family history of prostate cancer. Some men will have a very enlarged prostate, whereas others will have a mild enlargement. I could not get a definitive answer from them on how much, how many cells, or any information. Inflammation of the prostate can affect the bladder and result in discomfort and other symptoms. In the rare chance a baby needs highly specialized care, the team at Johns Hopkins is available to treat rare and complex conditions through breakthrough fetal procedures. P60 MD006900/MD/NIMHD NIH HHS/United States, T32 HL007180/HL/NHLBI NIH HHS/United States, K07 CA151910/CA/NCI NIH HHS/United States, P30 CA016520/CA/NCI NIH HHS/United States, K07 CA163616/CA/NCI NIH HHS/United States. In those cases, patients are tremendously grateful for having received the advice and encouragement to get a second opinion, Dr. Matasar adds. Masks are required inside all of our care facilities. JHs just said it was minimal less than 5%. There are also some cases of the test showing no depletion but being wrong. Another type of prostate issue is chronic prostatitis, or chronic pelvic pain syndrome. asymmetric central zone tissue more pronounced on the left. An accurate diagnosis is essential to ensure the most effective treatment. Slightly Potentially inaccurate results can lead to selection of the wrong type of therapy. Surgery seems like overkill for me with too many risks for incontinence and permanent ED, am I overlooking something? Recovery from Prostate Cancer | Bills Story. If I don't meter fluids before bed, I can expect to get up 3-4 times in the night. Three lesions: 1) GS 6 involving 30% of one core; 2) GS 6 involving less than 5% in one core; and 3) GS 6 involving less than 5% in another core. Read Also: What Are The Signs Of Prostate Infection. I will say, the people I dealt with at Johns Hopkins were extremely nice and professional. Secondary Gleason grade: 4 The percentage of Gleason grade 4 and/or 5 is 5 % Hello, I apologize upfront for the length of this post, but I was recently diagnosed with prostate cancer (T2C) and figure more information is better than not enough. Getting a second opinion on a diagnosis can reverse a diagnosis or alter the treatment plan. BONES: No suspicious osseous You may be concerned that the cancer will grow rapidly out of control before you are able to get a second opinion. You think another treatment might be available. Benign Processes: Reasons for obtaining a second opinion from urologists. Same with the amount of how much pattern 4. * He said probably not candidate for watchful waiting because of tumor volume shown and seen on MRI. 2. When facing an intricate disease like prostate cancer, the above scenario is far too simple to have a promising outcome. I was disappointed that only TRUS was being used, but I did find out that this was for screening only and IF you pass screeningthey use MRI guided biopsy for post-ablation follow up. Some men may have an enlarged prostate but not notice it. Benign prostatic tissue I had been carefully watching as my PSA increased to 3.2 from 3.9 in summer 2010. Best wishes to all those whose concerns for the day are far more serious than mine. * Other 12 slides not sent Masks are required inside all of our care facilities. This urologist can get you in for surgery next week. JAMA Netw Open. I would really love to hear from you. One of the problems with second opinions is that insurers may not cover the expense. I made the appointments. The TRUS biopsy is behind me, the second opinion from Johns Hopkins is behind me, and its time for next steps. Whether you want expert confirmation, lack understanding or confidence in your treatment plan, have a rare or unusual type of cancer, your cancer isnt responding to current treatment its reassuring to know that you have options through a second opinion. 9. Centro Diagnostico Italiano , Milan, Italy, Manfred Dietel, M.D.Institute of Pathology Charit, Humboldt University of Medicine, Berlin, Germany, Jonathan I. Epstein, M.D.The Johns Hopkins Medical Institutions, Baltimore, MD, Robert J. Kurman, M.D.The Johns Hopkins Medical Institutions, Baltimore, MD, Elizabeth Montgomery, M.D.The Johns Hopkins Medical Institutions, Baltimore, MD, Manuel Sobrinho-Simes, M.D.University of Porto, Porto, Portugal, Ronald S. Weinstein, M.D.University of Arizona, Tuscon, AZ, Franco VisinoniMilestone Medical Technologies, Bergamo, Italy, Also Check: How Old Can You Be To Get Prostate Cancer. Though, for the most part the reports seem encouraging.I am curious if anyone has had something similar. B. Prostate, right mid, core biopsy: Can it be salvaged or are the risks of cancer too high? The researchers also found that patients who obtained second opinions because they wanted more information, were seeking the best doctor, or had been encouraged to do so by family or friends were more likely to undergo surgery. Unfortunately, monetary incentives create biases that can work against patients best interests. 30%/40% or higher)? It works. Either the patient or the primary physician can initiate the process of getting a second opinion. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Emotional outlook is fragile at times and straight clinical approach of doctors does not help. I am 65 and in excellent general health. Dr. Nour is 100% sure that nothing has spread. The James Buchanan Brady Urological Institute, Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov. Also, in 2018 I had an exosome Dx test which scored 45.34, but I also retook that test this year and it went down to 30.79. In the rare chance a baby needs highly specialized care, the team at Johns Hopkins is available to treat rare and complex conditions through breakthrough fetal procedures. It's really that simple! For these reasons, it is a good idea for HMO members to get a second opinion and make sure they are informed about clinical trials or other promising new treatments. HMO members may also be discouraged from trying expensive treatments that have only a small chance of success, even if that chance is real. Read books and realize as soon as they are published, they are outdated. If they do not cover this cost and you must pay out of pocket, keep in mind that a second opinion could save you from having to pay (financially and physically) for additional treatment down the line. I requested a second opinion from Johns Hopkins and they found 1 lesion was 3+3=6 and the second lesion was 3+4 =7, with less than 5% pattern 4. They find that one of my 5-10% Gleason 6 core is actually a 50% Gleason 7(3+4) and the MRI was so cloudy with blood from original biopsy they said they couldnt determine much. First of all we would like to emphasize that the health of our employees, our patients and their relatives is our first priority. They may defer to the recommendation of the specialist, or refer you to a doctor with limited prostate cancer experience. It would be more convenient to use Mayo but I want the best practitioner regardless. You May Like: Best Treatment For Intermediate Prostate Cancer. They seem to think it'll do the trick.I feel great and I am glad I chose this treatment path. This has raised some questions on all the scans so far. FOIA Men need to be educated on all treatment options to protect themselves from a biased industry. Given that some 3+4 is now evident, I can no longer say that all my PCa is all 3+3 and that I can stay on AS for an extended period. Other Features: Dr. said pirad-5 and to prepare for bad news and probably around a Gleason 7 and that he is rarely wrong. Cancer. Seminal vesicles and other margins are negative for tumor. Study after study confirms that doctors favor the treatment they are trained to do urologists typically recommend surgery and radiation oncologists recommend radiation. So, I believe I made the right choice. I was confident I was making the right decision. Note respondents were able to choose more than one reason. I have selected Focal Laser Ablation as my future (soon) treatment. Cancer patients are encouraged to obtain second opinions before starting treatment. Hillen MA, Medendorp NM, Daams JG, Smets EMA. We specialize in minimally invasive treatments for prostate cancer such as: We place a high priority on sparing the nerves and tissue around the prostate whenever possible. I officially joined the club with diagnosis on March 21: three small lesions with a GS 6 on one side and both a GS 6 and a GS (3+4) 7 on the other side. I frequently make a 2 hour car ride and I have to stop about 25% of the time and when I don't, the urgency is a bit more evident and with the urgency come some hesitancy, but not terrible. Im also wondering why no one has scheduled me for MRI to see what biopsy missed. My plan is to choose quality of treatment over cost of the treatment. You can call and speak with his assistant at: (410) 614-6330. Please enable it to take advantage of the complete set of features! Dont Miss: Is Coffee Bad For Your Prostate. She put me in the hospital. But, after 4 drinks or if I'm tired/jet lagged I find that sleep is more appealing than sex. Two from one lesion were positive as was one of the two from the other. 5. - Johns Hopkins Medicine -- Get a Second Opinion -------------------------------------------------------- The biopsy disclosed I had some abnormal cells resembling cancer known as PINS, short for prostatic intraepithelial neoplasia. Ramsey SD, Zeliadt SB, Fedorenko CR, Blough DK, Moinpour CM, Hall IJ, Smith JL, Ekwueme DU, Fairweather ME, Thompson IM, Keane TE, Penson DF. So, I go one better, I call up Johns Hopkins and find a Dr who does DaVinci Prostate Surgery. I had a telemed session with Dr. Chang, and it sounds like a pretty simple procedure, with urinary side effects that resolve pretty quickly. Our gynecologic pathology team can also help determine if the tumor is localized or has metastasized from another region of the body. Of course, my old school Urologist recommended surgeryHe, of course, knew the best robotic surgeons around.Anyway. radiation, active surveillance, surgery, hormone therapy, and more. My Oncotype rating was GPS 54, with a 26% chance of metastisis within 10 years. There is no extraprostatic extension. Cleveland Clinics Virtual Second Opinions program connects you to an expert physician who specializes in your specific health needs. not hear all the viable treatment options or receive the most up to date 1. In adjusted analyses, however, only age and education were significantly associated with obtaining second opinions from urologists. According to the study, one in every 600 diagnoses showed mistakes.This study only addressed major changes in diagnoses, such as a diagnosis of cancer being reversed to no cancer, says Johns Hopkins pathologist George Netto, M.D. Both Drs and nurses knew what they were doing and had lots of experience. I'm going to reach out to UCLA to see what they can do. I'm currently in the process of getting an appointment set up with a Dr. Wang at UCLA. Learn MoreFor more information about pathology second opinions, visit pathology.jhu.edu or call 877-546-1872. Adenocarcinoma: Our collaborative processes also extend to our colleagues at Johns Hopkins Medicine, a world-wide leader in cancer research. Prostate, right medial apex: The urologist offered surgery and radiation as options on 3/10 when we met. Johns Hopkins Medicine A commercially available genomic test may help oncologists better determine which patients with recurrent prostate cancer may benefit from hormone therapy, according to new research from the Johns Hopkins Kimmel Cancer Centerand 15 other medical centers. So, I made an appointment at Emory Proton Center (Atlanta, GA) and got their opinion. My most recent biopsy resulted in two cores with Gleason 4+3=7 and one with 3+3=6. (TZ) One suspicious area - lesion size: 2cm x 1.4 cm Video consultation and written report from your expert. * IF ANYONE reading this doesn't believe in the value of MRI first and targeted biopsy next then take note that my systematic biopsy cores showed 0 positive in 8 cores and my MRI guided core samples were 6 for 6 being positive! Not all cancers are the same and not all treatment plans are absolutely clear. (The pathology report from Cedars-Sinai kept my diagnosis at 3+4, but a second opinion at Johns Hopkins upgraded me to 4+3.) Have been told a health condition is not treatable. IMPRESSION: I worked out every day and it wasn't until the last week did I feel a bit fatiguedand experience a bit of urgency and hesitation having to peeflowmax fixed that right up!90 days after treatment my PSA came in at .56. Remember if you ship them include the following information: You May Like: Blood In Urine After Prostate Biopsy. This doctor or team of doctors will review the following: The doctor then communicate their opinion regarding treatment to both the patient and the primary physician. 2: Prostate, right lateral base In terms of cancer, changes can be from cancer to benign (or vice versa) or from one type of cancer to another, which could have a significant impact on treatment and prognosis. If these do not work, your symptoms could progress and become chronic. Any input on this would really be appreciated. Because physicians may differ in their approach to treating breast cancer, its very important to check with a breast cancer expert to know youre receiving the best treatment for you. 2. That is literally the first time I heard that term other than seeing it in my pathology report. I'm 58 yrs old and had a TRUS random biopsy October 2020 after my PSA continually stayed between 4.4 and 8, and PHI score was 126. Two weeks later I meet with my Johns Hopkins Dr. * Prostate size: 3.9 x 2.8 x 3. cm The best protection for cancer patients who are Health Maintenance Organization members is to seek a second opinion even if she or he has to pay for it. It was easy. I'll post the whole thing, my doc and my own comments, and then cut/paste all my MRI results in case anyone REALLY liked data. 1: Prostate, right lateral apex But, after 4 drinks or if I'm tired/jet lagged I find that sleep is more appealing than sex. This is the most common urinary tract problem in men under 50, and the third most common in men over 65. Prostatic Adenocarcinoma A second review of Pathology more frequently also brings changes to the cancer grade or stage, which can affect prognosis as well as therapy. Many men name the diagnosing urologist as their treating doctor and do not seek other opinions. This doctor or team of doctors will review the following: The doctor then communicate their opinion regarding treatment to both the patient and the primary physician. From what I've learned from Dr. Scholz videos at PCRI, and from posts on this site it would lead me to believe the DX test is fairly common knowledge. When people recommend going to a Center of Excellence, believe them. The total number of cores identified is 3 I have posted here before, now with an update. the transition zone. Dr also stated he was able to totally spare one of my nerves, but to get margin may have damaged one. Even at the age of 48, he thought I would be a good candidate for AS. The issues in my prostate from the first procedure onward have all been in the same area and the rest of my prostate from the first biopsy and subsequent MRIs onward have never shown any indications of cancer in other areas. DIAGNOSIS: Greatest dimension 2cm. Good Day Everyone. My PSA over time has been creeping up over time (1.8 - 5/16, 1.0 8/17, 2.68 8/18, 2.9 12/18, 3.28 2/19, 3.01 8/19, 3.65 2/20, 3.31 6/20, 3.88 12/20) but I was frankly a bit shocked when I received word that I have cancer. Bring All Labs/Notes to Each Appointment. Get a Second Opinion The out-of-pocket cost may be in the $300 range (insurance may not cover it), and it is a simple matter to call your urologist to forward the slides to them. I find that when I'm trapped in the cockpit not able to use the bathroom for a long time is when I experience that most. Also, their protocol would be another biopsy, but he was comfortable with the image and velocity of PSA that he didn't have to have one to start treatmentand I was pretty hesitant (given the image and PSA) to take ADT, and didn't see a biopsy changing my mind regarding treatment and/or ADT.Oh. Surabhi Dangi-Garimella, PhD. A few weeks later and just before my meeting with my new Johns Hopkins Dr I get the second opinion results from both biopsy and MRI. They hesitated calling it a TARGET LESION, but scored it PIRADS 4. Unfortunately, what you do not realize may harm you! Johns Hopkins is home to many of the world's leaders in Pathology. 8: Prostate, left lateral base Your current doctor will frequently suggest a second opinion, if only to confirm the recommended course of action. Because every patient is different, there are several ways to approach prostate cancer treatment. Transition Zone: In the left base, mid and apical transition zone there is a large mass measuring 2 cm in size which has Patient preferences and urologist recommendations among local-stage prostate cancer patients who present for initial consultation and second opinions. Also indicated everything else was "organ confined." If I don't meter fluids before bed, I can expect to get up 3-4 times in the night.At this point, I am convinced I made the right treatment choiceOHFOR THOSE THAT DON'T KNOW, THE VA HAS MADE REPRODUCTIVE CANCERS A PRESUMPTIVE CONDITION FOR THOSE THAT SERVED IN MOST OF THE WAR ON TERROR LOCATIONS.Good luck fellas and my prayers are with all of you having to contend with this disease. My urologist suggested a couple more PSA tests followed by an MRI. I also changed my diet to plant based food, started juicing, and started taking supplements (think Turmeric, Green Tea, etc.). 2.Tammy Jiang, Christian H. Stillson, Craig Evan Pollack, Linda Crossette, Miupdachelle Ross, Archana Radhakrishnan, and David Grande, How Men with Prostate Cancer Choose Specialists: A Qualitative Study, Journal of the American Board of Family Medicine: JABFM, 30(2), (2017): 220229. I then had the PHI test which showed PSA 8.70 and overall PHI 125.9. However, learning more about prostate cancer and prostate-related health issues can help optimize health. If its a common cancer with a well-established standard of care, they can offer insight into clinical trials or novel treatments that may be better than the standard. My first PSA was 8.03. Be sure to ask about and research the skills and experience a doctor has with treating prostate cancer. peripheral zone signal intensity on T2-weighted images. I didn't study for the test and it's possible some morning activities might have affected my test score :) A new study by researchers at the Johns Hopkins University has found that . During your visit, our specialists will review your medical records, diagnostic tests and other information provided by you or your current physician. I did genetic testing and there were no mutations of concern, and everyone agreed that there probably wasn't "enough meat on the bone" to get a good genomic test from the biopsy.After seeing Dr Joe Busch, he said he didn't see any target lesions (PIRADS2), nor did he think I was in any danger. Move ahead to Dec 2020. If you choose to be treated at Johns Hopkins, you may be able to begin treatment immediately. Seminal vesicles are normal. Race and ethnicity. :) The total number of cores with carcinoma is 3 In the mean time my PSA was movingno longer static, but never back up to 6. Younger men also sought the 'best' doctor. Radhakrishnan A, Grande D, Ross M, Mitra N, Bekelman J, Stillson C, Pollack CE. They did 9 patients in Phase I and there have been 12 so far in Phase II. Benign Processes: Allow yourself the time to seek multiple opinions. Usually, patients obtain a second opinion after being referred to a second physician or to a special team of experts in a cancer center, called a multidisciplinary team. Metastasis. The results of Oncotype came back and it was a bad report. We will then prepare a written recommendation regarding your treatment plans or options. However, he also said it's treatable even at a 2cm size and the transition zone is a favorable spot. Also Check: Prostate Cancer Stage 7 Treatment. Symptoms include leaking and discomfort. Fear, confusion and uncertainty set in. Be well. While the size of an enlarged prostate will influence the extent of urinary symptoms, men may experience a range of urinary symptoms. Your email address will not be published. The biopsy took 12 cores, two from each lesion area and 8 randomly. Immediate means 6 weeks just to see his NP. If the enlarged prostate is not completely removed, it will shrink. 2019 Jan;69(1):7-34. doi: 10.3322/caac.21551. Now, though, encouraging animal data and preliminary studies in human patients are making some doctors feel optimistic. Asking for your comments: Sought Johns Hopkins second opinion of pathology slides. Get a Second Opinion What can a second opinion tell me? Dr. Erick Walser at University of Texas Medical Center. Cancer ABCs recommends: Johns Hopkins Hospital in Baltimore, Maryland, specifically Dr. Jonathan Epstein. Different institutions have different levels of experience when it comes to analyzing prostate biopsy samples and interpreting imaging results. Prostate, right lateral base: The percentage of tissue with carcinoma is 70% Following his residency in anatomic pathology at The Johns Hopkins Hospital in Baltimore, Maryland, and a fellowship in oncologic pathology at Memorial Sloan Kettering Cancer Center in New York., he then joined the staff at The Johns Hopkins Hospital and has been there his entire career. Thanks for considering. A report with the diagnosis will be faxed to your doctor. FAX 310-574-4002 The majority had lower risk tumors and clinical staging of 1 40% sought second opinions with about half having more than one reason Men seeking second opinions tended to be younger and better educated citing the need for more information as their reason. Instead, I did my homework. Some specialize in reading only slides that come from a specific organ while others are generalists who read many different pathology slides from many different organ systems. Not all cancers are the same and not all treatment plans are absolutely clear. Getting a Second Opinion The best time to seek a second opinion is before you start treatment. Hope to hear from a bunch of people. He adds that second opinions also can provide insight into topics like clinical genetics and family risk or issues related to complementary or integrative medicine approaches to manage symptoms. Required fields are marked *, PHONE 310-827-7707 If youve received a new cancer diagnosis or arent seeing results from your current treatment plan, an expert second opinion can help you move forward with confidence. restricted diffusion. Extraprostatic extension: negative In unadjusted analyses, younger men , men with college-level education , and privately insured men and Medicare ) were more likely to obtain second opinions . It is not uncommon that two different pathologists looking at the same slide come to a different interpretation and opinion about what is in their microscope! And just this week, 1 YEAR post treatment, it is .46. Epub 2017 Jun 12. Prostate, left medial base: Metastatic disease considered less likely for this pattern. * Gleason Score: 3+3, Slide 1 (vs. Sloan's 3+4) 1. ORIGINAL MRI REPORT (local radiology group): Reasons for getting a second opinion include: You want to be sure you have explored all options. sharing sensitive information, make sure youre on a federal BJU Int. 8600 Rockville Pike Either the patient or the primary physician can initiate the process of getting a second opinion. Wow, I sound like a snob now! I was offered to have my first biopsy sent to Johns Hopkins for second opinion and said why not? which came back with Gleason 9 three weeks after having the what we thought was G-7 ablated. MRI RE-READ #3 (National Cancer Center of Excellence): Consultation with your nurse care manager. Based on the results, our experts can provide you with an individualized treatment plan before you leave. Anyhow, as for treatment, yesterday I met with a Dr. William Wong at Mayo Phoenix. - DCE = (+) So the pathologist suggested a second opinion. Steve, Groucho was wrong when he said "i don't want to belong to any club that would have me as a member." With The Clinic by Cleveland Clinic, patients have access to Cleveland Clinics 3500 specialists. At this point Im still ignorant about what I ought to be doing (MRI guided biopsy is what I should have gotten).
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