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  • PSA at 5.3, then dropping

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    Old 08-22-2019, 06:57 PM   #1
    ocman1
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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
    ocman1
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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
    IADT3since2000
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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
    ocman1
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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
    ocman1
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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
    ocman1
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    Re: PSA at 5.3, then dropping

    Great, again thanks for the info!!!

     
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