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  • New Guy - Had MRI - Next up biopsy

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    Old 12-19-2021, 01:49 PM   #1
    CentralPaDude
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    New Guy - Had MRI - Next up biopsy

    Hola Amigos,

    Had elevated PSA, went from 4.3 to 5.7 in a year and a half, with an intermediate reading at the intermediate point. I went to the doc for issues with urination (to include an episode of urine retention (could not go!) one night) and potentially blood in urine (red sediment) and had an ultrasound to look at the kidneys and bladder first. Ultrasound tech noted a *large* prostate, bladder showing signs of having had a backed up flow, but that was it.

    The MRI showed:
    Lesion 1:
    Left posterior peripheral zone of the mid gland-apex; 6.2 x 10.6 mm; axial small field-of-view T2 sequence image 22/35, ADC map and DWI image 17/25

    On T2-weighted MR imaging, the lesion is seen as a well-defined focus of low signal intensity (T2 score = 4/5).

    The lesion demonstrates marked restricted diffusion (DWI score = 4/5).

    No suspicious enhancement identified (DCE negative).

    and

    Overall PI-RADS v2 score = 4
    Capsular margin and neurovascular bundle: No evidence of macroscopic extracapsular extension.
    Seminal vesicles: No evidence of seminal vesicle invasion.
    Lymph nodes: No lymphadenopathy in the field of view.
    Bones: No suspicious lesions in the field of view.
    IMPRESSION:
    - PI-RADS v2 score 4: clinically significant cancer is likely to be present.
    - No evidence of extracapsular extension. No evidence of seminal vesicle invasion.
    - No lymphadenopathy. No suspicious bone lesions.

    Which seems to point to some cancer in there, but localized. I've got a fusion MRI biopsy in my near future. I have some antibiotic-resistant flora in the rectum, of course. Wouldn't it have to be that way.

    Looking downstream, assuming for a second it will need to be treated, I also have from the MRI

    Prostate Volume: 140.7 cc
    Heterogeneous appearance of the central gland is consistent with benign prostatic hyperplasia.

    I appear to have a HUGE prostate, which maybe I can be proud of?

    Anyway, I am furiously doing all of the reading in going from zero to educated potential cancer patient. I will share my journey as I go, curious as to the impacts of prostate size on typical treatment modalities.

    Also, anyone else use Hershey Medical Center? They are in the top 10% for urology stuff in the country, so seems like it's not a fly by night outfit.

    Cheers!

    EDIT: left off my age…just turned 61

    Last edited by CentralPaDude; 12-19-2021 at 09:48 PM.

     
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    Old 12-19-2021, 06:49 PM   #2
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    Re: New Guy - Had MRI - Next up biopsy

    Sounds like you are not dealing with prostate cancer, which is very good. But you would appear to have a VERY serious case of BPH.

    I had severe BPH also and, when I was later dx'd with prosate cancer I chose surgery to eliminate both the cancer and the BPH & its severe urination problems.

    My prostate was 4x normal size at almost 100 gms. The doctor said that prostates like that can begin to twist & deform, encroach into the urethrea, etc.

    Now, without the prostate, I only urinate once (often not at all) during the night. Urine flow is like a firehose even 10 years after my surgery.

    Good luck to you!

     
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    Old 12-19-2021, 08:14 PM   #3
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    Re: New Guy - Had MRI - Next up biopsy

    Highlander, you might want to read his MRI impression again.
    IMPRESSION:
    - PI-RADS v2 score 4: clinically significant cancer is likely to be present.

    Also if you get a chance check in with some of the old gang.

     
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    Old 12-19-2021, 10:30 PM   #4
    HighlanderCFH
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    Re: New Guy - Had MRI - Next up biopsy

    Howdy. A biopsy certainly should be performed very soon. That's the only way to determine for certain if PC is present.

    Is the old gang on the other board after our old one closed?

     
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    Old 12-20-2021, 05:56 AM   #5
    CentralPaDude
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    Re: New Guy - Had MRI - Next up biopsy

    Quote:
    Originally Posted by HighlanderCFH View Post
    I had severe BPH also and, when I was later dx'd with prosate cancer I chose surgery to eliminate both the cancer and the BPH & its severe urination problems.
    I know I’m counting my cancer chickens before the biopsy results are in, but the BPH raises the desirability of surgery over radiation in my mind. I really don’t want to increase any urinary issues, and it’d be nice to urinate like a normal person again, assuming I can be continent. But I’m also not a big fan of surgeries. There’s a reason we have skin to keep our innards in and other things out. Sigh.

    Thanks for the replies, gents.

     
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    Old 12-20-2021, 08:01 AM   #6
    Terry G
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    Re: New Guy - Had MRI - Next up biopsy

    Dude, I’m a radiation guy and feel most recently diagnosed guys will do very well with radiation. I make an exception for guy’s suffering from both PCa and BPH. When the size of your prostate is ruining your quality of life it may be time to consider getting rid of it. A two for one not to be taken lightly. Although you live in a beautiful part of the world; the skill of the medical team can make a big regarding undesirable side effects. I always recommend seeking out the best team you can find even if it involves traveling to get it. Best wishes. Terry
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    Old 12-20-2021, 08:23 AM   #7
    CentralPaDude
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    Re: New Guy - Had MRI - Next up biopsy

    Quote:
    Originally Posted by Terry G View Post
    Dude, I’m a radiation guy...
    I'd be one too in general.

    Some years back I worked on a research project involving cyclotrons to generate streams of protons, and where I first learned about how proton beams behave in the body, not interacting much until their energy drops to a certain level and then boom, dumping all of their energy into a localized spot. No doubt it will be an incredible tool as the availability rises and the price comes down, and I've looked around for who has that capability. I know U Penn and Hopkins does, neither too far away. Probably insurance cost and coverage issues.

    Hershey now has the MRIdian system that real time continuously takes MRI images while simultaneously delivering the radiation, to keep the focus on the prostate as movement goes on in the body. An obvious step forward.

    But again, the BPH and urinary tract issues.

    Thanks for the post.

     
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    Old 12-20-2021, 10:20 PM   #8
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    Re: New Guy - Had MRI - Next up biopsy

    You need to have the MRI targeted biopsy to know if you actually have cancer.

    If you do, and it is Gleason 7 or higher, then you have a choice of (1) radical prostatectomy, or (2) a "simple prostatectomy" surgery or Aquablation to core out and reduce the prostate volume, followed by any non-surgical treatment of your choice.

    If the biopsy only shows Gleason 6, the (2) options to reduce prostate volume are still needed to be chosen to deal with the huge BPH problem.
    __________________
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    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 12-20-2021, 11:37 PM   #9
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    Re: New Guy - Had MRI - Next up biopsy

    I am a classic example of this. I was dx'd with a case of Gleason 6 after going a number of years with a very weak urination stream, a fine spray that had my garden hose nozzel frustrated with envy.

    I once mused to myself that it would be a blessing if/when I got prostate cancer (strong family history) that was a non-life threatening form.

    2-3 years later I got my wish -- a non-lethal case of prostate cancer that was ideal for surgery to remove both the cancer AND the BPH ridden prostate.

    Before my surgery with the wonderful Dr Matthew Tollefson (Mayo Clinic, Rochester), I also consulted with a Mayo radiation oncologist who explained to me that radiation could cure me as easily as a prostatectomy.

    But he also noted that radiation CANNOT cure the urination woes of BPH. So the RO recommended that I go with the surgery.

    The day prior to the surgery, Dr Tollefson performed a cystocopy to get a preview of what he would be dealing with. Afterward, he said "you have a whopper of a prostate."

    And he went on to explain how huge prostates like mine (almost 100 gm) will sprawl out in every direction to find room to grow. He added that eventually it would begin deforming & twisting/encroaching into the urethra.

    He then said that there really was no choice but do the surgery. And he assured that he expected to cure me with the surgery.

    And he did. It has now been 10 years and my PSA remains at zero. And my urination stream continues to be at firehose levels.

    So I would recommend surgery -- with a TOP surgeon -- to any many with BPH and a cancerous prostate. Surgery is the way to go in these cases and I am a living testament to how wonderful the results can be.

     
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    Old 12-21-2021, 07:20 AM   #10
    CentralPaDude
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    Re: New Guy - Had MRI - Next up biopsy

    Quote:
    Originally Posted by ASAdvocate View Post
    You need to have the MRI targeted biopsy to know if you actually have cancer.
    Just got the call, scheduled 3 January. A fusion MRI biopsy.

    “huge prostates like mine (almost 100 gm)”

    That would be about 100cc volume?

     
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    Old 12-21-2021, 07:24 AM   #11
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    Re: New Guy - Had MRI - Next up biopsy

    Sorry you are part of this group. Biopsy will give you more information. Everything else at this point is speculation. One thing to be mentally prepared for is post biopsy problems. They are infrequent but they happen. If possible, get a transperineal biopsy to reduce risk of infection and access more of the prostate. Also, I had blood clots post biopsy which is not uncommon but mine stopped all urination and I had to be catheterized for one night. Not a big deal but I ddi not know that was possible. I wish you well. Denis
    __________________
    65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 All cores less than 30% 8/17 - second opinion Yale (3+4) in one core, < 5%, decipher test shows intermediate risks. HDR BT completed 2/6/18. 5/3/18 3 month Post HDR BT PSA 1.3, 6 mo PSA 1.2. 1-year PSA 1.0, testosterone 475, 18 month PSA 0.4 Testosterone 524, 24 month PSA 0.4, 32 month PSA 0.4 Testosterone 391, 40 months PSA 0.3, Testosterone 630.

     
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    Old 12-22-2021, 09:48 AM   #12
    Terry G
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    Re: New Guy - Had MRI - Next up biopsy

    @Dude…Thanks for the heads up on the MRIdian system. Although I was aware that SBRT could go by different names I was not up on what distinguishes them. The MRI guided systems certainly appear to have advantages and the results are impressive. My treatment was CT guided using gold markers.

    I know of at least one guy who had his prostate volume trimmed down to a manageable size before having SBRT. Possibly that’s an option you may wish to consider. Terry
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
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    Old 12-24-2021, 01:29 PM   #13
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    Re: New Guy - Had MRI - Next up biopsy

    Hi CentralPaDude,

    Will your biopsy be transperineal? That looks like the best approach in view of the resistant bacteria that you mentioned. If transrectal, you need to be sure the team will be giving you an antibiotic that is appropriate for your situation.

    I like radiation generally for prostate cancer, but in a case like yours, with an extremely large prostate, I'm agreeing with others that surgery looks like your best option if the biopsy shows a cancer that has a Gleason score of 7 or higher.

    A great book for getting oriented is "The Key to Prostate Cancer," 2018, by main author Mark Scholz, MD, a prominent medical oncologist with a practice dedicated to prostate cancer, as well as 29 others who contributed chapters. Hopefully your biopsy result will show that you have no need for the book.

    Good luck!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    22 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA, for some reason based on a less sensitive test on 7/20/2021 was <0.05, still apparently cured in my ninth year since radiation (PSA as of 12/2/2020 was <0.01). (T 93 as of 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. I have also had 225 undergraduate classroom hours just in statistics and experimental design, plus more in graduate school, which dwarfs what most doctors have, and that has made my “hard knocks” experience more meaningful. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 12-24-2021, 02:43 PM   #14
    CentralPaDude
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    Re: New Guy - Had MRI - Next up biopsy

    Quote:
    Originally Posted by IADT3since2000 View Post
    Hi
    A great book for getting oriented is "The Key to Prostate Cancer," 2018, by main author Mark Scholz, MD,
    Got it and already read it. Fantastic must-read, thanks for the tipper! Clarifying particularly in surgery versus everything else. That's without the new tech emerging even in the last the years since the book came out

    They prescribed a different antibiotic than the standard, picked up the prescription the other day.

    Looking forward to getting some truth in my life regarding this stuff. Bring on the biopsy.

     
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    Old 01-03-2022, 12:56 PM   #15
    CentralPaDude
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    Re: New Guy - Had MRI - Next up biopsy

    Well, I had the biopsy today. What a joy that was. MRI fusion guided TRUS. The doc said he would do the broad sampling, then try to get after the lesion identified in the MRI with two or three targeted jabs.

    It was at Hershey, and they put me out using the same stuff used for colonoscopies (propofol) plus some versad and a couple of dribs of fentanyl. Sweet dreams.

    Due to having floraquine (spelling?) resistance in my flora, they also prescribed Bactrim pills, one before and the second today, and dripped in through the IV some sort of antibiotic, name forgotten.

    Lots of freaky looking blood in the urine post+procedure, and it feels like I have a small sea urchin tucked up in the nethers, but otherwise no problems. Fingers crossed on no infection, and the waiting begins for a pathology report.

    Cheers!

     
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