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Old 07-21-2012, 09:28 AM   #1
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Trus biopsy versus mri-ultrasound fusion

I have not yet been diagnosed with prostate cancer. My last 2 out of 3 urologists have suggested a biopsy for my rising PSA currently at 4.2 on July 3rd, 2012. My previous readings have been 3.3 on 01/12 and 3.9 on 04/12. My free psa has been 18%, 18%, and 17%. 2 urologists have told me that there will be a 1 out of 5 chance that anything positive will be found. Of course they are offering the standard Trus biopsy and when I asked about an MRI guided or MRI ultrasound fusion biopsy, they informed me that they don't use it. I've found a place at UCLA that uses the fusion method with supposely greater success at finding prostate cancer in suspicious areas. There is also an option for an MRI(non fusion targeted biopsy) in NY. A urologist performs the fusion biopsy while a radiologist does the MRI targeted one. My question is this. If all my urologists at this point are telling me that I have close to a 70% chance of coming up with a negative biopsy, wouldn't it be advisable to go where some statistics are showing better results at targeting Prostate cancer? If they don't find anything the first time with the Trus, I still have to wait 6 months for another biopsy anyway. Secondly, while using the Trus method, even if they do find anything, how confident should I be with the accuracy of the gleason score if they happened to miss a more aggressive area in their biopsy? Has anyone had any experience with these newer supposely somewhat more acurate biopsy methods? I know they are far from 100% in targeting areas, but since biopsies are so invasive why not go the best possible route in finding Prostate cancer? One last question. Would it be advisable or would it be useful at this time to have an MRI spectroscopy and a PCA3 test prior to any biopsies? I have gotten neither so far. I'm extremely anxious, frustrated and scared. Thanks for any and all feedback.

Last edited by Infinity29; 07-21-2012 at 09:33 AM.

 
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Old 07-21-2012, 12:20 PM   #2
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Re: Trus biopsy versus mri-ultrasound fusion

Your fears, anxiety and frustration are all too common and are completely understandable emotional reactions. Hearing anecdotes on boards like this, from well-meaning friends, and on various internet sites about cases of lethal PC may distort your perspective about what the disease typically means. You should understand, however, that PC is most often a non-progressing or slowly progressing disease. It is vastly over-diagnosed and over-treated, and the cures are often much worse than the disease. I hope that will allay some of your anxiety, and help you to slow down and realistically assess your situation.

Your PSA velocity is 1.8 ng/ml/yr which is under the 2.0 ng/ml/yr cut-off that is associated with progression of PC. The other parameter you should look at is PSA density -- your PSA divided by the size of your prostate. Ideally, it should be less than .15 ng/ml/cc.

You didn't mention your age or the size of your prostate, but your PSA and % freePSA are probably only borderline and are affected by BPH. Has your doctor ruled out that your PSA may be due to BPH? That would be my first step. There is a new test called the Prostate Health Index (PHI) based on measuring the relative amount of a PSA precursor called [-2]Pro-PSA that only shows up with prostate cancer. It is very good at distinguishing the PSA due to BPH from the PSA due to PC. It was just FDA-approved this month, so it will take a little while before it is widely available. It may be worth waiting for and may avert an unnecessary biopsy.

With slowly rising PSA only around 4 and nothing palpable on DRE, it is not likely that any of those MRIs or fused MRIs will tell you anything useful. They are only good at detecting cm-sized lesions, whereas if you have any, they are most likely to be on the order of a few mms.

If and when you decide to have a biopsy, there are certain ultrasound-guided biopsies (e.g., color doppler, direct contrast enhanced, shear wave elastography) that in the right hands may locate small suspicious lesions for biopsy. It is highly specialized and not many doctors do them. They may help eliminate false negatives that are common with a 12-core biopsy.

- Allen

 
Old 07-21-2012, 01:07 PM   #3
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Re: Trus biopsy versus mri-ultrasound fusion

Good question. I was in your situation not too long ago. I decided to go the conventional route because MRI targeting was not available unless I flew somewhere. I figure that if the initial TRUS biopsy was negative (which it was), and I needed another biopsy in the future, i would get an MRI. 12 core TRUS guided biopsy is currently the standard of care. MRI guidance will likely become much more common. If you have a negative 12 core biopsy, this substantially lowers your risk of having prostate cancer, especially, a higer grade and volume.

However, i had a nagging question about getting an MRI guided biopsy....was it more likely to find a "clinically insignificant" cancer than TRUS guided biopsy?
As I understand it there are two types of MRI guided biopsy. One occurs during the MRI scan with special equipment. The other actually uses an US machine that has special software that fuses the images of an mri you had previously with the real time US scan during the biopsy. Keep us posted.

Last edited by starr15; 07-21-2012 at 01:09 PM.

 
Old 07-22-2012, 11:23 AM   #4
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Re: Trus biopsy versus mri-ultrasound fusion

Quote:
Originally Posted by Tall Allen View Post
Your fears, anxiety and frustration are all too common and are completely understandable emotional reactions. Hearing anecdotes on boards like this, from well-meaning friends, and on various internet sites about cases of lethal PC may distort your perspective about what the disease typically means. You should understand, however, that PC is most often a non-progressing or slowly progressing disease. It is vastly over-diagnosed and over-treated, and the cures are often much worse than the disease. I hope that will allay some of your anxiety, and help you to slow down and realistically assess your situation.

Your PSA velocity is 1.8 ng/ml/yr which is under the 2.0 ng/ml/yr cut-off that is associated with progression of PC. The other parameter you should look at is PSA density -- your PSA divided by the size of your prostate. Ideally, it should be less than .15 ng/ml/cc.

You didn't mention your age or the size of your prostate, but your PSA and % freePSA are probably only borderline and are affected by BPH. Has your doctor ruled out that your PSA may be due to BPH? That would be my first step. There is a new test called the Prostate Health Index (PHI) based on measuring the relative amount of a PSA precursor called [-2]Pro-PSA that only shows up with prostate cancer. It is very good at distinguishing the PSA due to BPH from the PSA due to PC. It was just FDA-approved this month, so it will take a little while before it is widely available. It may be worth waiting for and may avert an unnecessary biopsy.

With slowly rising PSA only around 4 and nothing palpable on DRE, it is not likely that any of those MRIs or fused MRIs will tell you anything useful. They are only good at detecting cm-sized lesions, whereas if you have any, they are most likely to be on the order of a few mms.

If and when you decide to have a biopsy, there are certain ultrasound-guided biopsies (e.g., color doppler, direct contrast enhanced, shear wave elastography) that in the right hands may locate small suspicious lesions for biopsy. It is highly specialized and not many doctors do them. They may help eliminate false negatives that are common with a 12-core biopsy.

- Allen
Thanks Tall Allen for your encouragement which is always welcome and useful in these stressful times. My age is 62 and my prostate size has only been estimated digitally at 40cc. One urologist thinks it's smaller than that. I did not include the actual day of the month for my previous PSA readings on my initial post, but when I calculated my PSA doubling time, I came up with 2.14 ng/ml/yr. Yes I have been told by almost all urologists that I have BPH and by my GP as well many years ago. My biggest concern is that my PSA continues to rise in one direction since 04/30/09 when it was stable at 1.5,then the rise began on 09/15/10 2.1 11/17/11 3.6...After 30 days on Levequin, Starting on 01/30/12 the Beckman Coulter method was used and my readings were 3.3, 04/26/12 3.9, 07/03/12 4.2 Once 4.2 was reach, Medical protocol kicked in and a biopsy was recommended by 2 out of 3 urologists. I am seeing a 4th urologist is a few weeks who supposely is the Guru of Prostate disease in Florida. Everyone seems to know this guy, except me! With regards to the MRI/fusion biopsy, I would have to fly to California (3,000 miles) and they could schedule me for late August. The frustrating thing (among many) is that in order to find the disease in it's early stages during biopsy it needs to be either aggressive or large enough to be picked up and of course we as patients don't want any more growth. I also wanted to know if at this time, taking anything to lower my PSA(and possibly slow any growth) would be wise or would just make the urolgist's job that much harder? I like to be proactive. The only thing I'm taking now in addition to all my supplements is pomegranate extract and lycopene and have changed my diet completely eliminating meats, and dairy. I've always been on low carb. I guess this won't do much, but at least I feel I'm trying.

Last edited by Infinity29; 07-22-2012 at 11:29 AM.

 
Old 07-22-2012, 11:48 AM   #5
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Re: Trus biopsy versus mri-ultrasound fusion

Quote:
Originally Posted by starr15 View Post
Good question. I was in your situation not too long ago. I decided to go the conventional route because MRI targeting was not available unless I flew somewhere. I figure that if the initial TRUS biopsy was negative (which it was), and I needed another biopsy in the future, i would get an MRI. 12 core TRUS guided biopsy is currently the standard of care. MRI guidance will likely become much more common. If you have a negative 12 core biopsy, this substantially lowers your risk of having prostate cancer, especially, a higer grade and volume.

However, i had a nagging question about getting an MRI guided biopsy....was it more likely to find a "clinically insignificant" cancer than TRUS guided biopsy?
As I understand it there are two types of MRI guided biopsy. One occurs during the MRI scan with special equipment. The other actually uses an US machine that has special software that fuses the images of an mri you had previously with the real time US scan during the biopsy. Keep us posted.
Starr15, I believe between the 2 types of MRI guided biopsy, the MRI fused with ultrasound is more precise than the MRI alone. The machine at UCLA is called the Artemis. It uses a disc which combines the MRI taken prior to the biopsy with the real time ultrasound (trus) and thus the fusion. My thoughts are that even if this method does not find anything, at least I know I would be giving it my best possible shot. A biopsy is still invasive with possible side effects, why not try to get what might be the best technology available today? I've heard way too many stories of numerous biopsies before anything is found. Each biopsy cannot be a good thing for the prostate. With regards to your question about finding an insignificant cancer with the MRI/guided biopsy over the standard Trus.......remember that the MRI/fusion still uses the 12 core method but focuses on suspicious areas and can do more cores (up to 16) if necessary.

Last edited by Infinity29; 07-22-2012 at 11:57 AM.

 
Old 07-22-2012, 02:44 PM   #6
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Re: Trus biopsy versus mri-ultrasound fusion

You seem to be under a misperception that I may be able to clear up for you. You said:
Quote:
The frustrating thing (among many) is that in order to find the disease in it's early stages during biopsy it needs to be either aggressive or large enough to be picked up
That is not the case. If your biopsy samples from a cancerous lesion and you have it read by an experienced pathologist, he will be able to tell you even if the cancer picked up is small, insignificant, and indolent. In fact, most positive biopsies are for low risk disease, neither aggressive nor large. There is a chance, however, that your biopsy may not sample the right spots, and there may be some cancer elsewhere, indolent or aggressive (unlikely with your numbers and especially with your BPH).

If you don't want to wait for PHI, and you seem to know you have BPH, another option is take Proscar or Avodart for several months, along with an alpha-blocker. This will re-set your PSA to a "truer" value which will enable you to make a better decision about whether to proceed with a biopsy. While Proscar or Avodart increases the diagnostic accuracy of the PSA test, there are some sexual risks associated with them that have recently come to light.

Usually sophisticated guidance biopsies are reserved for men who have had negative US-guided biopsies but in whom there is still suspicion of cancer. I know that Dr Ukimura at USC has developed a fused MRI/US using the Koelis Urostation Platform.

 
Old 07-22-2012, 03:24 PM   #7
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Re: Trus biopsy versus mri-ultrasound fusion

Quote:
Originally Posted by Infinity29 View Post
Starr15, I believe between the 2 types of MRI guided biopsy, the MRI fused with ultrasound is more precise than the MRI alone. The machine at UCLA is called the Artemis. It uses a disc which combines the MRI taken prior to the biopsy with the real time ultrasound (trus) and thus the fusion. My thoughts are that even if this method does not find anything, at least I know I would be giving it my best possible shot. A biopsy is still invasive with possible side effects, why not try to get what might be the best technology available today? I've heard way too many stories of numerous biopsies before anything is found. Each biopsy cannot be a good thing for the prostate. With regards to your question about finding an insignificant cancer with the MRI/guided biopsy over the standard Trus.......remember that the MRI/fusion still uses the 12 core method but focuses on suspicious areas and can do more cores (up to 16) if necessary.

I dont know wich is more accurate at targeting an MRI visible lesion. Dont know of any data that compares targeting accuracy between MRI/US fusion and direct biopsy wiyh MRI. And i dont know any studies comparing the detection of clinically insignificant cancer of regular 12 core TRUS guided versus 12+ MRI guided biopsy.

I really did not want to travel far for the biopsy. Plus' the false negative rate of 12 core is not nearly as high as the old six core biopsies. Still, i think getting an MRI prior to first biopsy is reasonable. Its just not commonly done in the USA yet..i suspect prostate MRI will be much common in the future here in the US.

I also dived into the supplement world. I did not want to take anything that wouls alter my PSA significantly and mask a cancer or confuse things. All the data on supplements is either in vitro or phase 1 or 2 trials....none of it solid. Analyzing the data and hype is frustrating. No clear answers. I looked at lycopene, POMX, EGCG, vitamin d, Zyflamend.

Last edited by starr15; 07-22-2012 at 03:39 PM.

 
Old 07-22-2012, 03:36 PM   #8
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Re: Trus biopsy versus mri-ultrasound fusion

"That is not the case. If your biopsy samples from a cancerous lesion and you have it read by an experienced pathologist, he will be able to tell you even if the cancer picked up is small, insignificant, and indolent"

Its complicated. There is no way to know with certainty whether or not low grade , low volume cancers detected by biopsy will sit there and do nothing for years or will grow enough to cause problems. That is why active surveillance exists.

 
Old 07-22-2012, 04:15 PM   #9
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Re: Trus biopsy versus mri-ultrasound fusion

As to your other question:
Quote:
I also wanted to know if at this time, taking anything to lower my PSA(and possibly slow any growth) would be wise or would just make the urolgist's job that much harder? I like to be proactive. The only thing I'm taking now in addition to all my supplements is pomegranate extract and lycopene and have changed my diet completely eliminating meats, and dairy. I've always been on low carb. I guess this won't do much, but at least I feel I'm trying.
Increasing the diagnostic accuracy of your PSA is certainly a good idea. You can do that by eliminating the sources of error due to BPH and prostatitis. You already took an antibiotic for any prostatitis.

The evidence for dietary interventions is weak. PSA velocity slowed in men with recurrent PC who took Pomegranate - what would have happened if they didn't? We'll never know, because the test was uncontrolled. Lycopene has consistently failed to show any benefit in controlled tests. Heavy consumption of dairy was associated with higher incidence in epidemiological studies and two cohort studies. A coincidence? Did the calcium deplete Vitamin D as some suppose? Was it the butterfat as others suppose? Moderate amounts especially of low fat dairy don't seem to be associated with any problems. The dietary intervention du jour is broccoli. All kinds of highly colored fruits and veggies are looking good so far (e.g. black grapes and raspberries, blueberries, beets, cranberries, pomegranate), as do extracts of turmeric/curcumin, soy isoflavones, quercetin, omega-3s and garlic. Out for now are Vitamin E, Selenium and folates. I agree with you that the biggest benefit is providing a feeling that we are taking control.

- Allen

 
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Old 07-22-2012, 04:22 PM   #10
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Re: Trus biopsy versus mri-ultrasound fusion

"Usually sophisticated guidance biopsies are reserved for men who have had negative US-guided biopsies but in whom there is still suspicion of cancer. I know that Dr Ukimura at USC has developed a fused MRI/US using the Koelis Urostation Platform."

Thanks again Tall Allen for your positive feedback. I'm trying hard to avoid that multiple negative byopsy route. Although I wish these centers were more convenient, I am willing to travel. A forum member mentioned he had an appt with USC for this very type of biopsy. While reading up on the USC targeted procedure, they mention that for non residents, they can schedule the MRI and Biopsy on the same day while understanding your treatment might be with your local urologist. Followups are recomended at their center as they have the equipment. Tall Allen.......Before you mentioned Dr Ukimura, I was only aware of UCLA using the targeted fusion biopsy using the Artemis machine. Still, there are very few locations doing these more precise biopsies. I've also heard of the Sperling Center that uses a real time MRI targeting method located in Florida. There is so much information to digest out there, from books, forums, and urologists. Ultimately though, we must be our own advocates and make all the decisions.

Last edited by Infinity29; 07-22-2012 at 04:26 PM.

 
Old 07-22-2012, 05:16 PM   #11
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Re: Trus biopsy versus mri-ultrasound fusion

"With slowly rising PSA only around 4 and nothing palpable on DRE, it is not likely that any of those MRIs or fused MRIs will tell you anything useful. They are only good at detecting cm-sized lesions, whereas if you have any, they are most likely to be on the order of a few mms."

Therein lies the crux of my frustration. How are we supposed to succeed in very early detection, if while my PSA is rising, (my velocity is 2.14 ng/ml/yr) the diagnostic tools available might not definitively find anything until it continues to grow to a detectable size? I understand that my PSA is rising as I am writing this and yet I cannot be treated even if I wanted to until a doctor has a diagnosis by finding a possible cancer that now is too small to detect! I hope I will not have to wait until my PSA is over 10 or higher before I can do anything. I apologize if I am overeacting, but I think today's medicine(although making headway) may still may be somewhat in "Frontierland" with prostate cancer diagnosis and treatment. Yet I can only use what is available to me. Thank goodness for these platforms for getting great information from caring individuals.

Last edited by Infinity29; 07-22-2012 at 05:37 PM.

 
Old 07-22-2012, 09:05 PM   #12
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Re: Trus biopsy versus mri-ultrasound fusion

Quote:
How are we supposed to succeed in very early detection,if while my PSA is rising, (my velocity is 2.14 ng/ml/yr) the diagnostic tools available might not definitively find anything until it continues to grow to a detectable size?
What do you imagine is the benefit of succeeding in "very early detection"? You may be reacting to things you've heard about other kinds of cancers that are not true about prostate cancer. Prostate cancer and, I think, testicular cancer are unique in that earlier detection is of no proven benefit.

In the Roteberg Trial, it took 14 years from the point of screening for any survival benefit at all to show up. In the PIVOT trial there was no benefit to biopsy-proven detection after ten years, except in some high risk/high PSA men.

Quote:
I understand that my PSA is rising as I am writing this and yet I cannot be treated even if I wanted to until a doctor has a diagnosis by finding a possible cancer that now is too small to detect! I hope I will not have to wait until my PSA is over 10 or higher before I can do anything. I apologize if I am overeacting
Your rising PSA is most likely due to BPH, and you would be hard-pressed to find a doctor that would treat you for prostate cancer without a biopsy-confirmed diagnosis. I am not sure why you seem to be panicking over this, before you even have a diagnosis, but your anxiety may be more deleterious to your health than any disease you may or may not have. You have plenty of time to investigate. I found Mindfulness helped me.

- Allen

 
Old 07-23-2012, 05:38 AM   #13
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Re: Trus biopsy versus mri-ultrasound fusion

"your anxiety may be more deleterious to your health than any disease you may or may not have."

I will have to agree with you here. I guess my biggest concern on early detection is the "what if I'm harboring the aggressive type"? I'm sure that puts a different light on any prostate cancer being slow growing. I would like to nip it in the bud. Thanks again Tall Allen......I can't thank you enough for how calming your positive support has been.

 
Old 07-23-2012, 07:24 AM   #14
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Re: Trus biopsy versus mri-ultrasound fusion

I’ve read your questions and concerns with great interest; I’m with you in that I’m struggling with similar concerns. (I’m 72 – PSA in the last year, 4.2 – 2.9 – 11 – 6.9). My urologist suggested a biopsy and I declined (I’m very leery of a biopsy for all its proven downsides, and in my mind, all the other possible problems it could cause that the medical community denies).

To my thinking it would seem some modern imaging technologies should be used prior to having a biopsy. For example, Mp-MRI (Multi-Parametric MRI) claims “a negative Mp-MRI can rule out up to 97% of clinically significant prostate cancers”. (Not sure about the “up to” fudge words), but anyway I’m thinking I should have this done first, prior to even thinking about a biopsy.

But then things get difficult. Apparently there are very few places where one can have this done, and how do you know whom to trust? And who pays? And what do you then do with the results? So probably it is so much easier to accept the “assembly line” standard steps most urologist’s follow. (Biopsy).

For now I’m waiting another 2 months to see what my PSA does. This PSA thing is confusing beyond belief. Many books I’ve read (and many sources) state that for a guy my age, 0 – 6.5 is “normal”…(The charts say 3.6 / 4.5 for men in their 60’s (like you) is normal). When one considers that a given PSA test can vary by up to 20%-30%, it is very difficult to know how accurate any single PSA test is.

My current thinking (that keeps me relatively calm) goes like this – (after reading 12 or so “cancer” books by doctors). Cancer as we grow old is an unfortunate fact of life we need to get used to and learn to live with. (I already have learned to live with skin cancers). Some in the medical community think that as we age, we acquire small indolent cancers in many areas of our bodies that mostly are kept in check by our immune system. Some believe we are much better off not knowing about their existence.

In my mind, I’m 72, of course by now I have some prostate cancer. (Some studies say that by 80 – a man has an 80% chance of having it). The only unresolved question is how aggressive my cancer is. This is where my logic says to me (logic I really don’t want to accept – but may eventually have to), that if my PSA continues to trend higher, I guess I will have no choice but to get that dreaded biopsy.

Sorry for rambling on – (probably I use these message boards to convince myself of what I need to do by writing and publishing it!). But Tall Allen really seems a level head in all this – I’d say his advice is right on. (Remember – when they started this whole PSA stuff – anything under 10 was OK). As long as you’re down in the 3s and 4s, seems you have plenty of time to learn and reflect on all the possibilities.

Anyway, I’m curious, who is the Florida Guru of Prostate Disease? (We have many of them here in Sarasota)!

 
Old 07-23-2012, 02:24 PM   #15
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Re: Trus biopsy versus mri-ultrasound fusion

Infinity, I am the person who posted about my upcoming 3D MRI Fusion Color Doppler Elastrography US biopsy, my appointment is Aug 3rd. because it is the earliest appointment I can get. At this point I do not have anything to report. My insurance (PPO) would not cover the 3D Color Doppler Elastrography US claiming that it is experimental and no envidence of benefits above and beyond the traditional US. It is amazing, my appeal produced the same denial. At this point I have told the doctor's office to bill me for the extra. It has been difficulat to communicate with my doctor as I have to either go through his nurse or through USC business office people.

I too did not want to do biopsy unless I have to. I had a Free PSA test, PCA3 test, and MRI. The first two were inclusive, the MRI shows a suspicious spot of 8mm. At this point, my only logical next step is a biopsy. I intentionally chose this type of biopsy because I believe it to be the best chance of catching cancer if it is there (perhaps saturated bx may be better). In addition, the fact that the whole thing will be recorded and can be used in the future to monitor the status of my prostate is a plus.

Before the MRI results, I wanted just to do the Color Doppler - Elastrography US, but the 8mm suspicious lesion changed the whole story.

Will report back.

Akai

 
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