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Preparing for 1st biopsy. Advice welcomed.


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Old 01-13-2018, 04:29 AM   #1
JimNYC
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Preparing for 1st biopsy. Advice welcomed.

I’m going for my 1st biopsy in 1 weeks and reading up on PCa (Scardino, Walsh, etc.) in preparation for likely bad news. Here’s my situation so far. For the past decade my PSA remained in the range of 3-5. Nothing was detected by DRE by 4 different urologists. I had laser TURP in 7/11 and 3/15 for BPH. This past Oct ’17 my PSA jumped to 6.2 and I consulted (Dec ’17) an urological oncologist with 35 yrs experience with prostate cancer. He found a PSA of 7, free PSA of 19%, and a 4Kscore that reads a 28% chance of Gleason 7 (if I remember his words accurately). A MRI (multi-parametric 3T with contrasts) shows an enlarged prostate (81mL) a peripheral zone lesion (PI-RADS 5 “circumscribed homogeneous moderate hypointense mass confined to the prostate”) in the base. A “mild invasion into the base of the seminal vesicle” on the left. The transitional zone is consistent with BPH. In two weeks he’ll perform a transrectal ultrasound (Fusion) prostate biopsy.

Am I going about this correctly? What more should I be asking? What more should I read? Regardless of outcome, I’ll seek a 2nd opinion.

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Old 01-13-2018, 06:14 AM   #2
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Re: Preparing for 1st biopsy. Advice welcomed.

Hi Jim,

Welcome to this board!

Your diligence in PSA testing over the years is now paying off, but in an odd way. Your enlarged prostate, 81 mL, which is the same as 81 cc - the measure more commonly used, would "explain a PSA of about 8 from healthy prostate cells. However, that PI-RADS of 5 pretty much trumps the PSA and the other tests, suggesting a cancer of at least Gleason 7.

I suspect that, because the vast majority of that PSA looks like it comes from healthy albeit enlarged prostate cells, there isn't much more cancer except for the suspicious sites.

I'm confident you will get fine guidance for preparing for the biopsy. The team will use a prophylactic(s) drug to minimize risk of infection (which is low anyway), perhaps do a rectal swab to make sure any resistant bacteria are accounted for and handled (depends on the geographic area for the degree of risk from these bacteria), numbing agents to minimize pain and discomfort, and advice to you about what to expect and report if unusual.

For most of us, especially in the hands of a good team, a biopsy is not such a big deal. On the other hand, as with so many things, a very few of us draw the short straws and have difficulties; most of the difficulties are now anticipated in advance with the rectal swab and prevented. In the rare event a problem occurs, your team would know what to do to get you back to good health rapidly.

Good luck!

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Old 01-13-2018, 07:55 AM   #3
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Re: Preparing for 1st biopsy. Advice welcomed.

Thanks for your thoughts and advice. I especially appreciate your comments on the biopsy as I brace myself. I believe I'm in good hands. We'll see how it goes.

Your recent 18th anniversary review is appreciated.

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Old 01-13-2018, 09:22 AM   #4
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Re: Preparing for 1st biopsy. Advice welcomed.

Regarding your fusion biopsy:

Jim - Would you mind telling us how your biopsy will be/was done? Fusion biopsies that guide the doctor in real time with advanced imagery, as I understand it, are becoming more common, especially at major centers. Some are done "in bore," meaning the biopsy is actually performed inside the bore (tunnel, space for the patient) of the imaging device; other fusion biopsies are not done in bore, and I'm curious how that works too. Will yours will be done in bore? I'm curious where and how the doctor literally "fits in" to all this, and, if the imaging is an MRI machine, what his biopsy instruments are made of, steel obviously not being a good choice in a powerful magnetic field. I'm thinking you may not know this until the biopsy has been performed.

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Old 01-22-2018, 01:54 PM   #5
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Re: Preparing for 1st biopsy. Advice welcomed.

I had the biopsy today (1/22).

In my case the "fusion biopsy" is what's called a "cognitive fusion" meaning little more than the doctor using the MRI by looking at it while doing TRUS. A "software fusion" takes the result of the MRI and superimposes it on the TRUS screen in realtime. I understand they even take into account the deformity of prostate by the ultrasound probe. The ads for the fusion software boast of achieving 1mm accuracy of hitting a target.

My doc took over 20 cores (don't remember the exact number 20-24) which I understand is a saturation biopsy but remember the size of my prostate (81cc). I should have the pathology report by Friday.

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Old 02-02-2018, 08:06 PM   #6
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Re: Preparing for 1st biopsy. Advice welcomed.

I was surprised and overjoyed that my pathology report showed no cancer. There is, however, high grade PIN in the left mid region. Seeing that my mpMRI showed the highest level (PI-RADS 5) for a "suspicion" of cancer, I find it surprising that none was found. I know that biopsies fail to find existing cancer in 30% of cases (if I remember the percentage correctly) although my biopsy had 20 cores and was guided by the MRI to sample the suspicious area.

At this point I have several options to consider. (1) Get another pathologist to look at the slides. (2) Wait until the next biopsy. Is another pathologist likely to come to a different conclusion?

 
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Old 02-03-2018, 08:43 AM   #7
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Re: Preparing for 1st biopsy. Advice welcomed.

Congratulations on what looks to me like great good news!

If the pathologist is not an expert in prostate cancer, it would be wise to get an expert reading, and there is a substantial likelihood of a different conclusion, though probably not much different in view of your overall information.

That percentage for biopsies that are false negatives - those failing to find real cancer - is likely based on many biopsies done in the past without the guidance of mpMRI, and without so many cores taken.

As for the PI-RADS 5, while it is highly suggestive of cancer, there is still a chance that something else is causing the image that suggests cancer. It seems wise to keep up very active surveillance because of this result and the other suggestive data, but my feeling is that you are in that area where the PI-RADS 5 was a false positive for cancer. (Please keep in mind that I have had no enrolled medical education.) The imaging result is kind of like that 4Kscore that reads a 28% chance of Gleason 7; when you think about it, that means a 72% that there is no Gleason 7.

Good luck!

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Old 02-03-2018, 09:45 AM   #8
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Re: Preparing for 1st biopsy. Advice welcomed.

praying for ya

 
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Old 02-03-2018, 11:11 AM   #9
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Re: Preparing for 1st biopsy. Advice welcomed.

Thanks for thoughtful and common sense response.

My surgeon is quite renowned both in research and practice.
Apparently he is using the pathologist recently hired at the regional branch who appears to have previously worked at a hospital best know for heart surgery, although he has over 30 years experience.

I might have another pathologist look at the slides. I'm not too worried but why not have another's opinion?

Thanks again. I hope others are reading our conversation and getting encouragement.

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Old 04-01-2018, 07:25 AM   #10
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Re: Preparing for 1st biopsy. Advice welcomed.

I finally got the second opinion pathology report. The 2nd pathologist agreed with the 1st that there is PIN on the left mid but also found intraductal carcinoma (IDC-P) and an atypical small acinar proliferation (ASAP) that "is suspicious for carcinoma."

The IDC finding was surprising as I had never heard of it. I read it is almost always found accompanying cancer but in rare cases it is found in isolation. Most of the research suggests that if it is found in isolation, a second biopsy is warranted immediately. But these cases seem to be when a standard 12 core biopsy was done and I had a 20 core biopsy (MRI guided).

I might get a 2nd opinion from another surgeon/institution. My surgeon/urologist increased the frequency of testing and examinations because of the 2nd pathology report but he wasn't worried that he missed any cancer. I see him in a month and might wait before consulting a 2nd surgeon/institution.

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