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  • PSA at 5.3, then dropping

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    Old 08-22-2019, 06:57 PM   #1
    ocman
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    PSA at 5.3, then dropping

    Sorry for the long post!

    My 3rd Urologist (first 2 wanted to do a TRUS biopsy) is recommending the Fusion Biopsy. I got the results of the MRI today but failed to ask the size of the concerned area of the prostate in the MRI. (sent message w/question)

    My question is, should I get the Targeted Fusion Biopsy?

    PSA chronology:

    7-22-16 - 1.2
    8-10-18 - 3.6
    4-23-19 - 5.3
    6-27-19 - 3.5
    7-25-19 - 4.8
    8-06-19 - 4.2

    Digital Rectal Exam (DRE) Normal

    Select MDX Test:
    40% Likelihood of prostate cancer upon biopsy
    14% Likelihood of detecting Gleason score of equal or >7 cancer

    mpMRI - PI-RADS 4/5

    Here's the test results of the MRI:

    Study Result
    Impression
    IMPRESSION:


    1. Focal findings suspicious for neoplasia, PI-RADS 4 lesion in the right posterior lateral peripheral mid gland.

    2. Capsular margin: intact -unlikely extracapsular extension.

    Overall PI-RADS Category: 4/5

    Standardized reporting guidelines follow recommendations by ACR-ESUR PI-RADS v2.1

    (The doctor reviewed this radiological study personally and is in full agreement with the findings of the report presented here.)

    Appendix (based on UCLA data/publications)

    Overall MRI sensitivity for prostate cancer detection = 47%
    Sensitivity for tumors > 1 cm or for Gleason > 3 + 4 = 72%

    Biopsy yield for prostate cancer based on overall level of suspicion:
    3/5 = 16 - 24%
    4/5 = 37 - 78%
    5/5 = 80 - 96%

    1. Eur Urol 2019;75(5):712-720
    2. Radiology 2017;283(1):130-139
    3. Cancer 2016;122(6):884-892
    4. Abdom Radiol 2016;41:954-962
    5. Eur Urol 2015;67(3):569-576
    6. Am J Roentgenol 2015;1:W87-92


    Dictated 8/16/2019 2:58 PM
    Narrative
    3T MRI OF THE PROSTATE WITH AND WITHOUT CONTRAST and with 3D post-processing

    CLINICAL HISTORY: Elevated PSA
    PSA 4.8 ng/mL 7/25/2019

    COMPARISON: None.

    TECHNIQUE: MRI of the pelvis was performed on a 3 Tesla Siemens Skyra scanner. A transabdominal phased array was used. Small field of view sagittal, axial oblique and coronal oblique T2W TSE high resolution images and diffusion weighted images with
    apparent diffusion coefficient map were obtained. Pre- and post-contrast axial dynamic view-sharing time-resolved gradient recalled echo T1-weighted images are acquired with intravenous administration of gadolinium contrast. Offline post-processing on a
    dedicated InVivo DynaCAD 3 workstation was performed for generation of time-intensity curves and pharmacokinetic maps and 3D contouring of the prostate gland and any target lesions using combined automated and manual segmentation techniques.

    CONTRAST: gadobutrol (Gadavist) 1 mmol/mL inj 10 mL.

    GLUCAGON: No

    FINDINGS:

    Quality: Excellent

    The prostate measures 31 g based on contour, (4.0 cm x 3.8 cm x 4.4 cm).
    PSA Density0.15 ng/mL/cc

    The background transition zone is heterogeneous. The background peripheral zone is heterogeneous.

    The following appears suspicious (>= PI-RADS 3):

    Target #1 / ROI #14 (3D T2 slice #30)
    Location: right posterolateral peripheral midgland
    Clock-face axial location: 8 o'clock
    Cranio-caudal location: 15% of distance from apex to base
    Longest diameter: 0.7 cm
    Capsular involvement: may abut the capsule
    T2 signal: round circumscribed moderately T2 hypointense, 4/5 suspicion
    Diffusion-weighted imaging: focal moderately hyperintense high B-value DWI and moderately hypointense ADC, 1169 square microns/second, 3/5 suspicion
    Dynamic contrast-enhanced perfusion: early intense with mild early washout (< 20% by 40 seconds) positive
    Enhancement kinetics: Ktrans 0.37, Kep 3.53, iAUC 5.44
    Suspicion for extracapsular extension: 2 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
    Suspicion for neurovascular bundle involvement: 1 (1 = none, 2 = possible, 3 = highly likely)
    Suspicion for seminal vesicle invasion: 1 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
    Overall PI-RADSv2.1 Score: 4/5 (1=very low suspicion, 5=very highly suspicious).
    Overall UCLA Score: 4/5 (1 = very low suspicion, 5 = very highly suspicious).

    Limited views of the pelvis reveal no enlarged lymph nodes. Small volume free fluid in the pelvis.
    Component Results
    There is no component information for this result.

    Last edited by Administrator; 08-22-2019 at 09:36 PM.

     
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    Old 08-25-2019, 11:15 AM   #2
    ocman
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    Re: PSA at 5.3, then dropping

    Yes, I've decided to get the Fusion Biopsy done.

    Last edited by Administrator; 08-25-2019 at 02:28 PM.

     
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    Old 08-25-2019, 02:02 PM   #3
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    Re: PSA at 5.3, then dropping

    Hi ocman and welcome to the Board!

    I am a now savvy layman and therefore lack medical authority, but I would definitely go with the urologist who would do the targeted fusion biopsy. To me the case for fusion looks clear because you probably have a pretty mild situation if indeed you do have cancer at all, and that means a standard biopsy could easily miss the one small spot noted in the MRI report. By the way, the report actually does tell you the size of the concerned area: “Longest diameter: 0.7 cm”, which means it is a pretty small target to hit with an unguided biopsy.

    It is reasonable for the other two urologists to just do a regular biopsy, but “reasonable” does not mean “best”. mpMRI is still not widely used in many areas, and many urologists have just not yet appreciated it’s value or know how to put it to use. They probably will learn in the near future, but it is fortunate that you have found a doctor who is up to speed with this fairly recent advance in technology.

    Hopefully no cancer will be found by the biopsy. (Indeed, your PSA pattern is consistent with an infection that is causing the ups and downs in PSA results. That said, you do have enough concerning information to warrant a biopsy in my layman’s opinion.) But if cancer is found, and deemed “low-risk”, be sure to learn about “active surveillance” and also why that is often a superior approach to treatment for appropriately lower risk patients. Don’t let yourself be rushed into surgery or radiation if you don’t need it at this time. If you have cancer that does warrant treatment, there are many excellent treatments now available and ways to decide which one you like best.

    That’s all I’ll write for now, unless you have questions. Thanks for providing that highly detailed PI-RADS report; it’s interesting and informative to see how mpMRI results are being reported.

    Good luck!

    Jim

     
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    Old 08-28-2019, 05:47 PM   #4
    ocman
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    Re: PSA at 5.3, then dropping

    Thanks for the reply, I appreciate it!

    My biopsy is scheduled for 10-3-19.

    I do have one question, can you recommend any over the counter supplements that might help my situation?

     
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    Old 09-01-2019, 02:04 PM   #5
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    Re: PSA at 5.3, then dropping

    Regarding supplements, at one time in the 2000s I was a big believer, as were many of us, and there was intriguing but preliminary supportive research evidence that some nutrients were helpful against prostate cancer. Now, with more, larger, and actual “Phase III” type clinical trial results, enthusiasm for many supplements has dimmed. The list includes in particular some formerly high flyers such as Vitamin E, selenium, and pomegranate supplements and juice. Vitamin D3, in contrast, continues to look like a good choice. Multi-vitamins, especially those containing a lot of Vitamin A, do not look like a good bet.

    On the other hand, a number of foods have continued to enjoy good reputations, with some other foods with a growing bad reputation. On the good side are the Mediterranean (lots of plant foot with little processing other than cooking, nuts, olive oil, very low or no red meat, fish, some red wine), vegan, and some other diets. Cruciferous vegetables (broccoli, cauliflower, etc.) and processed tomatoes have particularly good reputations. In a nutshell, a heart healthy diet is going to be good for the prostate. On the bad side is the typical Western diet, especially with a lot of red meat and processed food. I switched to a Mediterranean diet, which I like, shortly after my diagnosis and have followed it now for the past two decades. There are a lot of false, poorly based claims out there on the web.

    You can research any particular item or diet yourself by going to www.pubmed.gov and putting in a search string such as: prostate cancer AND Mediterranean diet . I just did that and got a list of 82 medical research papers. Most have brief summaries, called abstracts, and you can view them for free by clicking on the blue hypertext for a paper. Some have links for free copies of the complete paper.

    I hope this helps.

     
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    Old 09-09-2019, 12:58 PM   #6
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    Re: PSA at 5.3, then dropping

    Ok great, thanks for the info!

     
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    Old 09-10-2019, 05:20 AM   #7
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    Re: PSA at 5.3, then dropping

    Green Tea (which I forgot to mention)

    You're welcome! I'm glad to be able to help.

    I also continue to drink a lot of green tea, made from about 6 bags a day (now down from 14 bags a day during my first year after diagnosis in 1999). There is a lot of encouraging medical research about the benefits of green tea for cancer, including prostate cancer specifically. Green tea is more potent when you add a few drops of an acid, like lemon juice, which prevents oxidation. It should also be stirred a bit while brewing. While much of the benefit is obtained after a few minutes of brewing, longer brewing helps up to ten minutes.

    I just searched www.pubmed.gov for medical research on green tea; I used this search string - prostate cancer AND green tea - and activated the filter for titles. The result was a list of 71 papers that have both "prostate cancer" and "green tea" in the title. You can read brief descriptions of key points in each paper by clicking the blue hypertext. You can also do your own search, and you will get a much longer list if you do not set the filter for titles.

    (TITLES filter in PubMed

    In just a few steps you can filter your search so that only articles that have each of the key terms of your search in the paper’s title will appear. It’s quicker to do it than describe it, but it’s not completely intuitive, so here’s how it’s done: on the left side of the home page where the filters are, click on “Show additional filters,” then click on “Search Fields” when the “Additional filters” menu pops up, then click “Show” in the box, move up to “Search Fields,” which now appears, and click “Choose”, and when the box appears, to the right of “Affiliation”, scroll down to “Title” and click “Apply”. Of course you can also select any of the other filters that you want, such as papers that have all your key search terms in either the title or the abstract (“Title/Abstract”). If there is no abstract, sometimes clicking on the “Full Text Link” in the upper right corner will show the article, especially if it is short. Sometimes there is a link to a free copy of the complete paper, and there’s also a filter for that.)

     
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    Old 09-16-2019, 06:04 PM   #8
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    Re: PSA at 5.3, then dropping

    Great, again thanks for the info!!!

     
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    Old 10-03-2019, 01:17 PM   #9
    ocman
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    Re: PSA at 5.3, then dropping

    Had the Fusion guided biopsy today should hear back by Oct 10th...

     
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    Old 10-12-2019, 11:06 AM   #10
    ocman
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    Re: PSA at 5.3, then dropping

    Ok, I got the results and they did find Cancer with a Gleason score of 4+3.

    6 of the 15 cores were positive.

    4 cores = 3+3

    The 4 cores were located:
    1 was systematic biopsy in the left lateral mid
    1 was systematic biopsy in the left base
    1 was systematic biopsy in the right lateral apex
    1 was targeted biopsy in the Target Right posterolateral peripheral midgland

    2 cores = 4+3

    The 2 cores were located:
    1 was systematic biopsy in the lower lateral apex
    1 was targeted biopsy in the Target Right posterolateral peripheral midgland

    I see the Urologist on Tuesday 10-15-19.

    I appreciate any input!

    Last edited by Administrator; 10-12-2019 at 03:02 PM.

     
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    Old 10-12-2019, 02:27 PM   #11
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    Re: PSA at 5.3, then dropping

    Hello again,

    Of course this is not the news you wanted to hear. I’m sorry you have officially joined the club.

    Overall, the biopsy report indicates that your case should respond very well to treatment, with radiation and surgery being the main contenders. With that 4+3 in two cores and six overall positive cores, my layman’s impression is that there would be few if any doctors who would recommend active surveillance. Your case does not look highly aggressive, but it does look aggressive enough to warrant treatment rather than surveillance.

    These days both radiation and surgery will do an equally good job of knocking out cancer in the prostate. (Many years ago, surgery was better, but no longer due to improvement in radiation, and that goes for both effectiveness and minimizing side effects.) Because of this equality, for a case like yours, the choice of treatment mainly comes down to risks of side effects. Personally, I feel radiation gives you a better set of potential risks and very low odds of each, but it gets down to a personal choice. Spend some time looking into side effects. The main ones that bother people are sexual and continence side effects. Surgery patients have a fairly strong likelihood of urinary incontinence, but it is often quite mild, and there are therapies that can help. Radiation, with modern equipment and a good doctor and team, has a very low profile of most side effects. Sexual side effects, mainly ED, affect quite a few patients to at least some extent for both surgery and radiation, but there are steps you can take to prevent or at least minimize the impact. It would be wise to talk to the doctor about these, and, if the doctor does not seem helpful, find someone else who can advise you.

    If you choose radiation, you will probably be given a short course of hormonal therapy (for an intermediate risk case). While there are some side effects, you can use countermeasures to prevent or limit them, and they should disappear within months of stopping hormonal therapy. Also, the old and cheap diabetes drug metformin appears to both boost radiation effectiveness and reduce side effects of hormonal therapy.

    Good luck.

    Last edited by IADT3since2000; 10-12-2019 at 02:28 PM. Reason: Typo.

     
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    Old 10-12-2019, 03:59 PM   #12
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    Re: PSA at 5.3, then dropping

    Thanks for the quick reply!

    Is HIFU an option?

    When you say surgery, do you mean removing the prostate?

    Got more research to do.

    Thanks again!

     
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    Old 10-14-2019, 01:21 PM   #13
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    Re: PSA at 5.3, then dropping

    Hi again,

    Yes, surgery is removing the prostate.

    I have a mixed opinion of HIFU, which I have not had, but I am well aware of key research, at least some of it. The key is whether the situation requires “whole gland” treatment – in other words, treating the whole prostate, or is suitable for what is known as “focal therapy”, where just the area of the prostate is treated where the tumor(s) is located, which obviously requires excellent imaging, now fairly widely available. In other words, if there was just one or a small number of tumors and they were all on one side or in a small area, you could treat that focally with HIFU or one of the other focal treatment technologies, with cryosurgery being the best known. As focal therapy, my impression is that HIFU can eliminate pockets of cancer and do so with a very low burden of side effects on the patient. Preliminary research has supported that, and more research is in process.

    However, your case involves a fair number of tumors, and they are spread around the prostate, including on both sides. I doubt that doctors who are good at focal therapy would want to do that for you as they would have to treat so much of the prostate that it wouldn’t really be “focal” treatment.

    So what about HIFU as whole gland treatment? Years ago, a lot of us, including me, were excited about that, especially claims that the side effect burden should be lower than with radiation and surgery. (The burden with radiation has decreased and is now remarkably low for most types of patients, chronic prostatitis patient being a major exception.) A number of major centers began treating patients with whole gland HIFU and researching their outcomes around the world. At first, based on a year or two of averaged follow-up of effectiveness against cancer (non-recurrence), HIFU looked like it was succeeding. It was hyped heavily on internet sites sponsored by the HIFU industry. However, as years of follow-up accumulated, a pattern began to emerge at many sites: patients who looked like they had been cured were developing recurrences in large numbers by the third, fourth and fifth year, with an ever increasing proportion year-by-year. By the fifth year, it was clear that HIFU was nowhere near as effective as surgery and radiation at curing cancer.

    Also, some of the leading, highly respected doctors doing the research were growing worried about side effects, the very area where HIFU was supposed to have an advantage. One of these leaders, who still believes in HIFU for focal therapy, stopped doing whole gland HIFU about ten years ago. Here is what he said about it at a major conference for patients a few years ago: “I think if you’re going to treat at the whole gland level, you might as well have surgery or ratdiotherapy. Why, because HIFU creates a lot of scar tissue. And provided you are away from the key structures, that scar tissue isn’t a problem [such as with focal therapy]. But if you’re trying to turn a 40 cc gland into a 4 cc gland, that’s a lot of tissue the body has to absorb and turn into scar tissue, and that does have effects on strictures, on erectile function, and on , indeed, continence. So I wouldn’t use HIFU for whole gland.”

    On the other hand, despite many centers having poor success with HIFU, here is one study that gives encouraging results at five years of average follow-up. https://www.ncbi.nlm.nih.gov/pubmed/25079940 The key seems to be use of a suite of special advanced technologies to support the HIFU treatments, especially “tissue change monitoring”. Note that this center’s previous HIFU treatments were not impressive. Here is a key sentence from the study: “The 5-year biochemical disease-free survival rate [means non-recurrence based on PSA testing] in the SB200/500, SB500 version 4 and SB500 tissue change monitor group was 48.3% , 62.3% and 82.0%, respectively (p < 0.0001).” Now it’s important that there are a lot of intermediate- and high-risk patients in studies, as any therapy should work well with the kind of low-risk patients who should probably not be treated but rather managed with active surveillance. This said, I am impressed with the Japanese study. I would like to know more about the side effects that the patients experienced, but their summary statement about that is ambiguous as it relates to the tissue-change monitor group. I may have the complete paper in my files but have not checked.

    Good luck!

     
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    Old 10-14-2019, 03:05 PM   #14
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    Re: PSA at 5.3, then dropping

    Thanks again for the quick reply, I have the consultation tomorrow morning.

    Hoping for the best!

     
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    Old 10-16-2019, 04:47 PM   #15
    ocman
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    Re: PSA at 5.3, then dropping

    Ok, saw the Urologist yesterday and he recommended Surgery or Radiation. He said I have months not weeks to make a decision.

    We talked about the HIFU and he said I would be a primed candidate if I only had 1 of the 4+3 lesions and not 2.

    However, he did say he was open to doing HIFU on the (2) 4+3 lesions, even though they're on opposite sides of the prostate.

    I have Anthem Blue Cross EPO and he said they don't pay for HIFU, but of course, they would submit the order. They said UCLA would charge $25,000.00 for the procedure of both of the 4+3 lesions. This would of course leave the other (4) 3+3 lesions in the prostate. I'm entertaining this option (all comments welcome).

    I talk to both the Surgeon and Radiation Oncologist on Monday 10-21-19.

     
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