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Cancer: Prostate Message Board

  • Prebiopsy MRI

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    Old 08-01-2018, 11:03 AM   #1
    My7
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    Prebiopsy MRI

    I'm in my 60's with no history of diagnosed cancer. My PSA went up 5x in a row dating back to early 2017 ( psa numbers were in the mid 3 range in early 2017, gradually increased, and most recently jumped from mid to high 4 to 9.

    My urologist recently recommended a Trus biopsy which would be my first prostate biopsy ever. This Urologist seems to be discounting the value of doing a pre biopsy MRI (says pre biopsy MRI does not increase trus biopsy accuracy)

    I'm going to do a prebiopsy prostate MRI with/wo contrast on a 3T machine. Then, my next decision will be should I folllow advice of my urologist and proceed to do the Trus biopsy (strongly recommended by this urologist irregardless of upcoming MRI results). Urinary symptoms are not that bad

    A recent in office DRE was said to find no abnormalities. Otherwise , I've been on daily Tamsulosin for around 2.5 years (unclear if I definitely have BPH). And I have a long history of inflammation in upper---lower GI and URL tract. a recent cystoscopy test result was ok

    Wondering if I should proceed
    To do the Trus biopsy vs other options

     
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    Old 08-01-2018, 12:29 PM   #2
    jerseyguy
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    Re: Prebiopsy MRI

    My7, I have been on Active Surveillance for over 6 years. Had 4 biopsies. the last 2 were MRI guided biopsies at Memorial Sloan Kettering. I am due for another biopsy in September at a different facility (new urologist) who also does MRI guided biopsies. Does your urologist use the MRI to guide him towards any suspicious areas on your prostate?

     
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    Old 08-02-2018, 12:31 PM   #3
    IADT3since2000
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    Re: Prebiopsy MRI

    Hi My7,

    I'll join in with concern about your urologist. My impression, based on no hard data, is that multiparametric MRI prior to a biopsy is not yet the standard of care but that many urologists are now using it.

    The reason it is rapidly gaining traction is that there have been good studies published about it. It is evident that your urologist is not familiar with these studies, and that suggests that he or she is not keeping up with the field. As was intimated, it seems as though he or she will not be making use of the results of your upcoming scan, and that is unfortunate.

    Here is a link to one of the most prominent mpMRI studies, known as PROMIS: https://www.ncbi.nlm.nih.gov/pubmed/30040065 , and a link to a free version of the complete paper, which is highly detailed, is included. In essence, mpMRI proved far superior to standard TRUS biopsy in detecting clinically significant prostate cancer (93% versus 48% sensitivity, nearly double!!!), and 27% had results that were negative for cancer (although 11% of that 27% were found to have clinically significant cancer when a special biopsy was done that was far more thorough than the standard TRUS biopsy.

    Moreover, this work was all done with mpMRI machines with a 1.5 Tesla magnetic field, instead of 3 Tesla, the latter providing considerably higher resolution, and it seems very likely that accuracy would have been enhanced if 3 Tesla machines had been used in the study. You can find other studies about mpMRI in the PROMIS study by searching PubMed www.pubmed.gov with a search string like - multiparametric mri prostate AND PROMIS - which resulted in 5 hits.

    Using the following string - multiparametric mri AND prostate cancer - gives you 1,390 hits, which demonstrates that A LOT of research is being published on this. You can narrow that down to 1,172 by using the filters on the left side for Abstract, and published in the last 5 years; if you go to Show Additional Filters, and then add Title under search fields to get only papers that have the elements in your search in the title of thee paper, you can narrow down the results to 134.

    The mpMRI result should give you excellent clues about whether to proceed with a biopsy. I'm thinking your PSA pattern may have resulted from infection/inflammation rather than cancer, as often happens, but a gradual climb does make it look more suspicious. That mpMRI result will also give you an accurate result for the size of your prostate, and that, combined with your PSA, will give you your PSA density (PSAD), both valuable clues.

    Good luck!

    Last edited by Administrator; 08-02-2018 at 09:39 PM.

     
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    Old 08-02-2018, 07:57 PM   #4
    My7
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    Re: Prebiopsy MRI

    Thx JG. I'm not sure about this urologist (or should I say I'm not sure about this health insurance). Good luck with your situation.

     
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    Old 08-07-2018, 10:27 PM   #5
    My7
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    Re: Prebiopsy MRI

    Fyi- MRI results reveal I have a PI-RADS 3 tumor in the prostate according to my urologist (MRI results went to him; I will pick up a copy of MRI results tomorrow). Urologist considers me at medium risk for cancer and continues to recommend standard TRUS biopsy using ultrasound.

     
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    Old 08-08-2018, 09:03 AM   #6
    IADT3since2000
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    Re: Prebiopsy MRI

    Hi again My7,

    If I had your history and a PIRADS 3 report from the MRI, I would want a biopsy performed. However, I would not be comfortable with a urologist who did not seem eager to use the MRI results in his thinking or biopsy planning. It's fortunate that you are in an area with a wealth of resources for assessing and dealing with prostate cancer.

    Did the doctor tell you the size of your prostate, which should be in the MRI report. This will enable you to calculate your PSA density (PSAD - PSA/size of prostate in cc), which is an important clue. It's good to have the PSAD at 0.15 or lower. (This is an important indicator of how much BPH is contributing to the PSA level.)

    Good luck!

    Last edited by IADT3since2000; 08-08-2018 at 09:08 AM. Reason: Added question about size right after initial posting.

     
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    Old 08-08-2018, 01:15 PM   #7
    My7
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    Re: Prebiopsy MRI

    Thx IADT.

    Today I obtained copy of my 3TMRI results report (my urologist also has it). I'm also reading up on PI-RADS 3 (including ASCO). MRI report says my prostate measures 6.3x6.2x4.0cm yielding a volume of 81 mL. Report also mentions BPH modules projecting into posterior neck (i don't recall any clear cut official BPH diagnosis from any of my urologists over the years although it was suggested to me that BPH was likely circa 3-4 years ago by my previous urologist (I since changed insurance). Report also says location of the lesion is left body/apex (and linear T2 hyperintense bands throughout the peripheral zone)

    Next step = prostate biopsy (standard 12 needle TRUS w/Sonogram to be performed by my current urologist-oncology doc who has reasonably good bio although only 4 years practice experience. My thought is he is capable given he's the only urologist with oncology/surgical experience in my region under my current insurance. My backup thought for any 2nd opinion is Gtown Hospital/Dept of Urology

     
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    Old 08-09-2018, 04:32 AM   #8
    IADT3since2000
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    Re: Prebiopsy MRI

    That written report has a significant clue about size: 81 mL, which is the same as 81 cc, indicates a very large prostate. The rule of thumb is that regular or benign enlarged prostate cells will produce about 1 unit of PSA for every 10 cc of volume; basically, just divide the 81 by 10 to get what you would expect from non-cancerous cells, in your case about 8. That means, after subtracting 8.1 from 9 and getting .9, that there is very little PSA remaining to be accounted for by cancer, infection, or other cause. This isn't exact science, but it does have a basis in research; indeed, a prostate of 81 cc (or mL) might well cover a PSA of 9 due to BPH alone.

    On the other hand, my understanding is that BPH is not usually (ever?) a rapid process and therefore does not cause a rapid increase in PSA, and my impression is that your PSA climbed rapidly, which seems, to my layman's eyes, not exactly consistent with the BPH explanation. (You posted earlier: "back to early 2017 ( psa numbers were in the mid 3 range in early 2017, gradually increased, and most recently jumped from mid to high 4 to 9.")) This is where a urologist experienced in prostate cancer, BPH and prostatitis could help sort things out.

    Getting a second opinion (or more, I had at least 9 before deciding on my strategy during the first year, but I had a challenging case) is par for the course with prostate cancer. I still think, from my layman's viewpoint, that the PI-RADS result of 3, in the context of a rapid increase in PSA (in fact a doubling to a significantly elevated level) warrants a biopsy, but this size clue, and your history of infection, calls for a little more head scratching and possibly some other tactics before doing the biopsy.

    Last edited by IADT3since2000; 08-09-2018 at 04:44 AM. Reason: Added point about rapid PSA increase.

     
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