New MRI Results
I have been on active surveillance for five years and just completed a fusion mri. My Dr is out of town and I would like to know the meaning of some of the results in terms of how serious they are.
Anatomic findings: There is a small focus of altered signal typical of tumor in
the left posterior lateral peripheral zone in the lower one third of the gland.
This has an approximate volume of 0.7 cc with a maximum in plane measurement of
1.3 x 0.8 cm. It is clearly low signal on T2 and ADC sequences and very high
signal on the diffusion sequence. It abuts the posterior capsule where there is
a mild bulge, and the capsular margin is indistinct. No gross spread of tumor
into the periprostatic fat is shown.
A second area of potential tumor is in the midline of the peripheral zone at the
base. It has approximate measurements of 0.5 cc with a maximum in plane
measurement of 1.3 x 0.6 cm. It has high diffusion signal and low ADC and T2
signal. It is relatively sharply defined. The adjacent capsule appears normal.
IMPRESSION:
1. Left lateral inferior abnormality consistent with tumor, possibly with focal
capsular disruption. PI-RADS 5.
2. Midline peripheral zone base abnormality with signal characteristics of
tumor but morphologically equivocal. PI-RADS 3.
3. No evidence for extraprostatic tumor.
PI-RADS Assessment Categories (ver. 2):
PI-RADS 1: Clinically significant cancer highly unlikely.
PI-RADS 2: Clinically significant cancer unlikely.
PI-RADS 3: Clinically significant cancer risk equivocal.
PI-RADS 4: Clinically significant cancer likely.
PI-RADs 5: Clinically significant cancer highly likely.
Comments
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biopsy
An image defined as Pi Rad 2 means that the likelihood of finding a significant cancer with a targeted biopsy , that is 3+4 or greater in unlikely.
The left lateral , where there is a pi-rad 5 indicates a high likelihood of finding a significant cancer with a targeted biopsy.
....
Everything is based on the biopsy......at this point they are only talking about "likelihood" . The tumors can be in truth be cancerous or not.
Additionally, evrn if a significant cancer is found, ie a 3+4, the volume may be small enough for you to continue in the Active Surveillance program............this it true in my case where I have a small volume of 3+4............(that area need to be monitored)
................
A targeted biopsy is indicated in your case...does your doc have a three dimensional biopsy machine, such as an Artemis at his disposal?
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Thank you for responding.hopeful and optimistic said:biopsy
An image defined as Pi Rad 2 means that the likelihood of finding a significant cancer with a targeted biopsy , that is 3+4 or greater in unlikely.
The left lateral , where there is a pi-rad 5 indicates a high likelihood of finding a significant cancer with a targeted biopsy.
....
Everything is based on the biopsy......at this point they are only talking about "likelihood" . The tumors can be in truth be cancerous or not.
Additionally, evrn if a significant cancer is found, ie a 3+4, the volume may be small enough for you to continue in the Active Surveillance program............this it true in my case where I have a small volume of 3+4............(that area need to be monitored)
................
A targeted biopsy is indicated in your case...does your doc have a three dimensional biopsy machine, such as an Artemis at his disposal?
Thank you for responding. Yes, I believe that the Dr does have a three dimensional machine. Even if I am still a candidate for active surveiliance I may opt for the latest lazer ablation treatment which is an outpatient procedure and simply kills the cancer in the area it is located. Have you given much research into this?
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.
You might want to call your doctors office to check what biopsy machine is used. When I receive a biopsy, there is a screen that I can view. It shows locking into the MRI when the biopsy cores are taken. I am treated at a center of excellence. These machines are very expensive. These three dimensional machines are only available at limited facilities. The Artemis machine is used at well machines by other manufacturers
As far as zapping the canceous cores, I looked into this type procedure...in my opinion, and this is only my laymans opinion, therorectically this makes sense, however I feel that the current technology is not advanced enough at this time for "best"results. I strongly suggest that you do your own research to determine if this will be best for you. Several months ago I followed a thread at USTOO discussion site, where you can get input...several of these men did this procedure and were happy with the results......anyway you need to research......I hope that you or others will be able to share the results of your research investigation at this thread.
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Not what I hoped for and
I am back from a fusion biopsy that occurred about two hours ago. Brutal! - 19 samples.
From the MRI I had, Dr said two lesions, each about the size of a sugar cube,,,1 centimeter. What ever happened to inches?
When the Dr was prepariing for the biopsy, I mentioned just as I did two weeks ago when when met, that I was interested in
targeted treatment - thermal or cryoablation. He acted surprised and was not anticipating that he would have to take so many samples. The Dr either does not take good notes or failed to read them. When I was in his office and told him what I wanted he suggested the biopsy I just had. Should I look elsewhere for another Doctor. When I told him that I was surprised about the new findings from the MRI, his response was, "well previous MRI technology wasn't that good". Hello? We are talking about my life here. I have been on active survailance and he did not suggest prior to now another biopsy???? There is a very good chance that I should not have been on active survailance. Would you change doctors?
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Fusion biopsy
As I understand the purpose of this visit was to have a fusion biopsy, which you did. You need to wait for the results of this biopsy before determining the best treatment for you.
I hope that your recovery from the biopsy goes well, without complications.
I was not aware that cryoablation can provide refined targeting. Cryoablation is not generally used for those having first treatment. Generally there is 100 ED among those who have cryoablation of the prostate.
https://www.cancer.org/cancer/prostate-cancer/treating/cryosurgery.html
To be honest I believe that it is best to discuss potential treatment after the biopsy, not before. You need to wait for the results before deciding on what to do.
I know exactly what you are going through now...I had a biopsy on Friday, and am also waiting for my results. At that time I will decide what active treatment I might do, , or continue with Active Surveillance.
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A fusion biopsy is the bestmcin777 said:Thank you SubDenis and
Thank you SubDenis and Hopeful. Worst thiing from the biopsy is the bleeding now. Have a call into the Dr. Will let you know outcome.
A fusion biopsy is the best way to go at this point and that information is needed before any treatment options are decided. Depending on the reults you may also have some more scans in your future and/or some blood test trends to be monitored.
If your doctor id not being serious enough about your case then by all means find a better one but he will not be able to have a productive conversation about treatment until you both have more information.
All the best.
George
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What is your clinical stage?
Jim,
From you comment in the initial post I think that you have decided not to treat 5 years ago and instead gave preferences for AS. Your initial diagnosis indicated two positive cores (Gs 6. The last MRI identified again two regions that may be cancerous. These occupy a vast area so that the affected number of cores taken from the zones may be more numerous than the one from 5 years ago.
I wonder why you have decided this time to treat instead of continuing with AS. Surely, a treatment may provide you peace of mind but it could go the other way and leave you with a nasty quality of life. You should discuss the matter with several doctor and know details of the risks each treatment involves before deciding.
Your initial thread is here;
https://csn.cancer.org/node/255309
Hope for the best,
VG
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VascodaGama said:
What is your clinical stage?
Jim,
From you comment in the initial post I think that you have decided not to treat 5 years ago and instead gave preferences for AS. Your initial diagnosis indicated two positive cores (Gs 6. The last MRI identified again two regions that may be cancerous. These occupy a vast area so that the affected number of cores taken from the zones may be more numerous than the one from 5 years ago.
I wonder why you have decided this time to treat instead of continuing with AS. Surely, a treatment may provide you peace of mind but it could go the other way and leave you with a nasty quality of life. You should discuss the matter with several doctor and know details of the risks each treatment involves before deciding.
Your initial thread is here;
https://csn.cancer.org/node/255309
Hope for the best,
VG
Hi VascidaGama
I don't know what my clinical stage is. I had a biopsy last week and should hear the results in a few days. Once I find the results of the biopsy where they took 19 snips, I will make a decision as to what I will do. Before the biopsy, I discovered that there is a treatment called MRI-Guided Focal Laser Ablation. It is an outpatient treatment that lasts for a short period of time. They fry the cancerous portion of the prostrate. No collateral damage. I thought it best to proceed instead of risking that the cancer has left the prostate.
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Focal Ablation
Prostate cancer tends to be a multifocal disease (occuring at multiple sites in the gland), as shown in your own clinical course. Although it has been a little while since I reviewed information on focal ablation, I am not aware that there is good information on long term control of prostate cancer with this modality. The way your post reads, I get the impression you believe that your prostate cancer will be eradicated by the ablation procedure. I would spend some time researching this option carefully and get opinions from people who don't have a vested interest in focal ablation.
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Thank you CowboyBobCowboyBob said:Focal Ablation
Prostate cancer tends to be a multifocal disease (occuring at multiple sites in the gland), as shown in your own clinical course. Although it has been a little while since I reviewed information on focal ablation, I am not aware that there is good information on long term control of prostate cancer with this modality. The way your post reads, I get the impression you believe that your prostate cancer will be eradicated by the ablation procedure. I would spend some time researching this option carefully and get opinions from people who don't have a vested interest in focal ablation.
Thank you Cowboy Bob. Yes, I will do more research especially in light of my new biopsy results.
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New Biopsy - Not Great But......now what to do?
My most recent biopsy leads me perhaps in new a direction of treatment, all of which are undesirable to me but necessary if I want to live into my 90s and beyond. :0)
Diagnosis After Microscopic Examination:
1. Prostate right lateral base, biopsy:
- Benign prostate tissue.
2. Prostate right medial base, biopsy:
- Benign prostate tissue.
3. Prostate left medial base, biopsy:
- Benign prostate tissue.
4. Prostate left lateral base, biopsy:
- Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),
involving 75% of tissue (1 of 1 cores; 3 mm of 4 mm total).
- Perineural invasion not identified.
- See comments.
5. Prostate right lateral middle, biopsy:
- Benign prostate tissue.
6. Prostate right medial middle, biopsy:
- Benign prostate tissue.
7. Prostate left medial middle, biopsy:
- Benign prostate tissue.
8. Prostate left lateral middle, biopsy:
- Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),
involving 25% of tissue (1
of 2 cores; 2 mm of 8 mm total).
- Perineural invasion not identified.
- See comments.
9. Prostate right lateral apex, biopsy:
- Benign prostate tissue.
10. Prostate right medial apex, biopsy:
- Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),
involving 45% of tissue (2
of 3 cores; 7 mm of 16 mm total).
- Perineural invasion not identified.
- See comments.
11. Prostate left medial apex, biopsy:
- Benign prostate tissue.
12. Prostate left lateral apex, biopsy:
- Benign prostate tissue.
13. Prostate target No. 1, ultrasound-guided fusion biopsy:
- Benign prostate tissue.
14. Prostate target No. 2, ultrasound-guided fusion biopsy:
- Benign prostate tissue.
Microscopic
Sections from the left and right side of the prostate gland show prostatic
adenocarcinoma, Gleason
score 3+3=6, (grade group 1). The neoplastic glands are small, back-to-back
with an infiltrative pattern. The nuclei are enlarged with prominent nucleoli. No evidence of perineural invasion seen.
Prognostic/Outcome
Prostate Cancer: Pre-Radical Prostatectomy Prediction Nomograms
Gleason Score: 3+3=6
Clinical Stage: T1c
PSA: 6.7 ng/mL
Extent Of Disease Probability %
Organ confined Disease 72
Extracapsular Extension 27
Lymph Node Involvement 1
Seminal Vesicle Invasion 1
Primary Treatment Outcomes
10 year(%) 15 year(%)
Probability of Cancer-Specific 99 99
Survival after Radical Prostatectomy
5 year(%) 10 year(%)
Progression-Free Probability 96 93
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More info needed?
Hi,
I think if it was me I would talk with the doctor(s) and find out how close the Pca is to the outer wall of your prostate. If it's close you might want to do something soon(radiation or surgery), if not then you could still do AS for a while longer. 3+3 is not not agressive but it's still cancer. Extracapsular Extension 27% probability is something to look into.
Dave 3+4
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.
mcin777
Another, probably better way of reading the results of the cores are to look at the actual size of the core tht is positive.....
core #4, 3mm (left lateral base)......(75% of the tissue)
core #8, 2mm (left lateral middle)......(25% of the tissue)
core #10, 7mm(right medial apex)......(45% of the tissue).....if I understand correctly, two of three cores have this this number
As I understand, the targeted cores (#'s 13 & 14) were not positive, but the random ones above were positive)
I am not knowledgeable, so I cannot make a comment on this statement, "The neoplastic glands are small, back-to-back with an infiltrative pattern. The nuclei are enlarged with prominent nucleoli"
There were 17 cores taken, so if I understand right 4 out of 17 were positive)...(24%)
There was no perineural invasion identified in your pathology.
...............................................
So what are the next steps in figuring out what is going on?
What is your age? The criteria for AS is relaxed among those who are older.
First, I would consider a second opinion on your pathology. I think that you used Johhs Hopkins in the past.
I would also ask your doctor about having a gene test. I had an genomic health oncotype dx. There are other ones, prolaris, decipher, etc. At this time, if you are of medicare age, these tests are free....medicare wants these companies to do a bunch of them before they are approved.
I would consult with your doctor for his input.....I would also consider having a second opinion by another doctor who specializes in active surveillance........(I wonder, where do you live...we at this forum might recommend an expert in your area).
It is very possible that you can continue with active surveillance, however I feel that a medical professional that you have confidence in is best to provide guidance.
Best
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New Biopsy - Not Great But......now what to do?hopeful and optimistic said:.
mcin777
Another, probably better way of reading the results of the cores are to look at the actual size of the core tht is positive.....
core #4, 3mm (left lateral base)......(75% of the tissue)
core #8, 2mm (left lateral middle)......(25% of the tissue)
core #10, 7mm(right medial apex)......(45% of the tissue).....if I understand correctly, two of three cores have this this number
As I understand, the targeted cores (#'s 13 & 14) were not positive, but the random ones above were positive)
I am not knowledgeable, so I cannot make a comment on this statement, "The neoplastic glands are small, back-to-back with an infiltrative pattern. The nuclei are enlarged with prominent nucleoli"
There were 17 cores taken, so if I understand right 4 out of 17 were positive)...(24%)
There was no perineural invasion identified in your pathology.
...............................................
So what are the next steps in figuring out what is going on?
What is your age? The criteria for AS is relaxed among those who are older.
First, I would consider a second opinion on your pathology. I think that you used Johhs Hopkins in the past.
I would also ask your doctor about having a gene test. I had an genomic health oncotype dx. There are other ones, prolaris, decipher, etc. At this time, if you are of medicare age, these tests are free....medicare wants these companies to do a bunch of them before they are approved.
I would consult with your doctor for his input.....I would also consider having a second opinion by another doctor who specializes in active surveillance........(I wonder, where do you live...we at this forum might recommend an expert in your area).
It is very possible that you can continue with active surveillance, however I feel that a medical professional that you have confidence in is best to provide guidance.
Best
Thank you hopeful. I am 74 and live in Portland, OR. I will take your advice and seek other opinions. I sure hope there is a safe (?) way around not haviing invasve treatment. I appreciate yours and others responses. My bleeding still has not stopped completely from the Biopsy. My Urologist says it is normal. 10 days have gone by. Four or five times a day I urinate a little blood at the beginning of a stream. It is usually the color of tomato soup.
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Bleeding...mcin777 said:New Biopsy - Not Great But......now what to do?
Thank you hopeful. I am 74 and live in Portland, OR. I will take your advice and seek other opinions. I sure hope there is a safe (?) way around not haviing invasve treatment. I appreciate yours and others responses. My bleeding still has not stopped completely from the Biopsy. My Urologist says it is normal. 10 days have gone by. Four or five times a day I urinate a little blood at the beginning of a stream. It is usually the color of tomato soup.
You're not on blood thinning medication or aspirin therapy are you? Just checking.
I was dealing with a lot of clotting after the biopsy... That creates its own problems.
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.
I'm the same age as you.
John Hopkins relaxed the requirements for patients over 70, I think allowing amounts of 3+4.
I list the following contacts, where there can be doctors expert in recommending a course of action based on your numbers.
The Artemis machine is used at several teaching hospitals. You may wish to contact Eigen, the manufacturer of this equipment to find out which facilities use the Artemis machine, that you may wish to visit..
If you are so inclined, UCSF has fusion biopsy equipment since 2014. They are a high volume centerYou may wish to check other centers of excellence closer to your home.US News and World report ranks hospitals by speciality.0 -
blood from biopsy
In my last biopsy I had blood for about 6 or seven days....there was less each day.....the first day , I also had clots, which stiopped my stream..I drank extra water to eliminate these clots......Mine was the color of borsht.......Jim, ...is this what we have come to at age 74; can't wait until we get a little older (lol)
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Quantity is good but Quality is better
I also counted only 17 cores not the 19 number you commented above but if those exist and were misreported they may have been negative. The findings correlate to the above MRI report and with your initial JH findings on 2013. It seems to be a contained case (negative PIN) with cancer found in 4 cores, on both lobes, classifying a clinical stage of T2c.
My lay opinion is equal to Hopeful's above. You may try getting a second opinion from a specialist on AS but I believe that at your age and with the status verified this time that you could continue with AS and avoid the risks of a radical treatment. You indicate to be interested in a less invasive therapy like thermal or cryoablation, or laser treatment, but these all are associated with risks and side effects apart from less than optimal outcomes.
Another 5 years on AS will turn you into the 80th which time would narrow the options on a radical but these years would be spent with quality of life. At that time if treatment becomes inevitable then you could opt for radiation or a palliative hormonal therapy (ADT) that is typical in aged patients. ADT has a wide range of interchangeable drugs that can be used together or solo in sequential and intermittently, providing many years of life to the patient. Statistics confirm that low Gleason rates (3) cancers provide more than 15 years of survival since diagnosis. For the moment, the only way to avoid the risks, like urine or stool incontinence, damage to local nerve bundles, colitis and proctitis, etc, is to follow AS.
Best,
VGama
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