My MRI/Ultrasound Fusion Targeted Biopsy Experience

Sw1218 said:

Stress

thank you, so much. i've been stressing prtty bad. one guy said he think i may have a gleason 6 or 7. i only pray that it's not cancer

I can sympathize with the stress.  I had a single PIRADS 4 lesion found on an mpMRI recently and it was 3 long weeks for the results of the biopsy.  I had a 12 core sextant biopsy plus two additional UroNav fusion directed cores targeting the lesion from different angles.  Thankfully, no cancer was found, only some abnormal gland cells like I had in my first fusion biopsy 10 years ago.  Of course, there is always the risk of a false negative.  Wishing you the best for diagnosis and if treatment is necessary.

SW,

You have created a newer thread but I drop my opinion in here as it contains more details of your story, therefore better to understand your situation.

You wrote;

"My PSA Is 18.67, Deciding Treatment ...  ...  is the cancer getting worse, because of no treatment just yet? i have no idea what to think. what R your thoughts? i'm scared U guys... "

We all have confronted similar situation when the need in making a decision approaches and we are afraid of choosing something that may not be the best we could have. This is a nerve breaking situation because we are dealing with the unknown and the doctors do not substitute us in the decision process. They always suggest and ask us to provide a final answer. This is scaring.

In my case I took two months of researches before deciding on a therapy. My wife and I worked as a team and we devoured the information that was available to us at the time (articles on treatments, test and exams' results, stories of identical cases, etc, etc), and did get second opinions from three specialists (another urologist, one radiotherapist and one HDR Brachy). I choose surgery and was quite comfortable with such option. Surely my wife and I knew then the possibility of fathering kids was over and sex would be on hold for many years. This occurred in 2000 (19 years ago) when imagenology for cancer was much limited than what is available today, and radiotherapy was linked to nasty outcomes. Surgery was at the time the gold standard in PCa treatment. Today much has changed. Equipments and modalities have improved significantly and radiotherapy reached similar status levels as that of surgery.

In fact, the principals in treating PCa seem to me to continuously being the same. Either, you look for a treatment to deal with a contained case or to deal with extraprostatic extensions case (localized but not contained). This is where radiation manages to be better as it can be focus for both cases at once; contained and spread. In contained cases, with surgery one knows that cancer is gone because it dissects the whole infected gland. With (all modalities of) radiation one knows that the gland is the target but the radiation doesn't fry the whole gland equally. There are regions where radiation is delivered with limits because it would affect close organs or facilities (for instance the sphincter area that stands at the base of the prostate) in the path of the rays. This limitation could jeopardy the outcome so that one should be assured that cancer is assumed to exist at other areas.

Accordingly, ide4ntifying and locating the cancer is essential to decide on a therapy and to assure the killing. In such respect, one needs to trust the facilities where the nuclear test was done, including the radiologist that provided the results. Our doctor depends much on such results to provide a reliable clinical stage from which one can gain more confidence when choosing a therapy. What is your clinical stage?

I assume that you have been attended by a radiotherapist. I wonder why you have to trust his opinion alone. Why is he consulting an urologist? Surely it is good to listen to added opinions but it should be you in doing such a step, visiting a doctor from a separate circle. You can then verify if his comments on " unfavorable intermediate risk category " is proper.
In any case, his proposed protocol involving ADT (Eligard) plus a combination of Radiation (external beam and brachy) is feasible for a patient with the status you have shared in your past threads. Gleason rate 4 is aggressive and many times linked to extraprostatic extensions. Have you done a DRE?

I recommend you to do more researches before deciding, getting additional consultations. You do not need to give a definite answer on your next visit (Wednesday). Just get notes on what he says, make some questions and request for more time to powder on the situation at home. Cancer doesn't spread that fast to become fatal. The increase on the PSA shows a similar curve since 2014. It tells you that you need to treat. Now you need to find that option that provides you comfort. There are always those things that we would not want to lose at such a young age.

Whatever you decide is good. Cancer is not going to kill you today but you will need to learn in living with the side effects caused by a therapy. Your wife and family are the best sources from where to get support in this difficult moment of a final decision.

Here are ideas for your List of Question to the doctor for your next meeting;

http://csn.cancer.org/node/224280

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

Best wishes and luck in this journey.

VGama

SW,

I would suggest you to share with us the details and results of the biopsy. How many cores were driven and what were the contents (%) in each one. In your shoes I wouldn't draw any conclusion if the biopsy has not investigated all traditional zones of the prostate. Analyzing the lesions identified in your previous MRI (Aug 2018) alone is not enough for a good judgment. I wonder what your meaning of "stage 1 grade 3" is. The only comment from you on grading was " ... john epstein downgraded my PSA to low grade G6 ... " which has no meaning. Does "G6" refer to Gleason score 6?
Please read this link and provide details for us to specify opinions;

https://www.cancer.net/cancer-types/prostate-cancer/stages-and-grades

Best,

VG

Hi,

The info you share above is for 5 cores taken from:

1) one core from left Apex

2) three cores from right mid

3) one core from left mid

It seems that the base area of the prostate was not included in the biopsy. I wonder why they didn't check the whole gland.

JH second opinion may be more reliable than the one from the pathologist at your radiologist office. However did they checked all 5 cores?

The procedure doesn't follow the traditional biopsy investigation. You may accept this way of investigation but in your shoes I would not choose radiation without checking the base of the prostate.

Best

VG

SW

I am not a doctor to give you advice on the pathologist's report. You can check yourself the details or if in doubt you can call your doctor and inquire on the details of the biopsy. Ask him if the whole areas of the prostate were exam and on the total number of needles/cores taken, and what was found.

The typical and recommended biopsy by the NCCN and urological associations is a template of 12 needles covering the two lobes (right and left) at the apex, mid and lateral zone and the base (the area just below the bladder). If lumps are detected then urologists take two extra needles directional to those places, completing a 14 needle biopsy. Some still go further and direct extra needles to the seminal vesicles and nerve bundle.

In rereading your past posts it seems that you or your doctors are following a different standard regarding the way to evaluate your case status. It is true that since the introduction of the Pi-rads several doctors use today the simple results of a multiparametric MRI to decipher a clinical stage. This is a newer practice but is not yet in full swing around the world. I have my doubts on the matter but as I said, I am a simple PCa patient, not a doctor, and you are not me.
The end goal would be to get to a conclusion in choosing the best therapy, which surely would follow the NCCN guidelines. I wonder if such newer ways of judgment with basis on MRI images alone got any newer interpretation when deciding on a treatment. At blindfold, radiotherapy is the only one to fit all stages. It could cover the all localized areas zipping out any bandit hidden around. In such a case not even a clinical stage would be required. One may take just one core to detect cancer and follow straight with a combination treatment of radiation that covers the prostate plus the surrounding areas and lymph nodes. Why bodder with more and more analysis.

Well, my opinion is that this way would just lead to unnecessary risks and side effects. In the end it may as well work beautifully. The patient will have to learn to accept the fate alone. Before starting a therapy, the patient will be requested to sign an agreement relieving the doctor and the clinic from any responsibility on the chosen treatment and its outcome.
I would not like to be put in such situation unless I am full confident that the matter works in my favor. I wuld need to be full confident on the doctors caring my case. But, we know too that other established ways also fail even if these are based on years of experience all over the world.

In regards to Epstein's second opinion on the cores I wonder if your clinic has sent all samples for examination. Typically they send one from each zone just to certify the classification of the cells (Gleason pattern). Again, if Gleason 6 is in fact the true classification and one can trust the radiologist report (negative extraprostatic extensions) then surgery could fit well as a choice. Another blindfold interpretation.

One note on the MRI/Ultrasound fusion targeted biopsy looks at the basic reason for its practice. This sort of biopsy is usually done when one sees his PSA increasing constantly after a negative 12/14 needle plate biopsy. The main intent is to get a reason for the PSA behavior so that the urologist tries finding cancer in between the areas of the template with the help of an image. In your case, it seems that it was done to substitute the tradition biopsy. Those areas away from the boring have not been analyzed but they could have cancer of sizes under the limits of a MRI detection (4 to 7 mm).

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

Best wishes,

VGama

SW,

I do not want to confuse you or displace you from your believes but in your shoes I would get second opinions from doctors away from the circle of your present doctor. Get copies of all exams and tests and consult another specialist before proceeding with something. You need to create confidence in the option you are choosing.

Please read this link on second opinions;

https://csn.cancer.org/comment/1290680#comment-1290680

Best

VG