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Can someone please help us understand our results

Loveofmylife2007
Posts: 4
Joined: May 2018

My husband got a call yesterday from a urology PA and she made his 3mpPri sound dire. We are waiting for an appointment with a urologist oncologist but it may take a couple weeks which has us in knots over here:( hopefully some of u who have more knowledge on this can help me better understand the reading of the mri and what this means.

background:

husband 45yrs old, Jewish  (no breast or prostate cancer in his family)

Symptoms: for the past 6 yrs he's had problems emptying completely, night sweats, weak stream, getting up 3-4 times at night, urge to urinate (in the course of a meal at a restaurant he will go to the bathroom 4times on average) nawing pelvic pain at times but goes away after a couple days

We've been telling multiple docs about his problems for years but since his psa is low and he has no family history they never took us seriously. Finally i insisted on a 3tmpmri of the area because my gut just felt something was off. We didn’t do the invasive elorectal coil in the rectum instead my husband wanted the weighted diaper thing around the pelvis which the ordering physician said produced comparable results

psa: Nov 16 .72, dec 17 .6, Jan 18 1.0

mri results:

MR Prostate WO+W/CST AZ MR Prostate WO+W/CST AZ

CONCLUSION: Small area of abnormal signal within the left lobe of the prostate, peripheral zone, base. PIRADS 4.

HISTORY: No Family history of prostate cancer, PSA 1.0 COMPARISON: None

FINDINGS:

Image quality is good.

Prostate: Size 3.7 x 3.6 x 3.6 cm, 24.3 mL. Central gland: Negative

Peripheral gland: 1.1 cm region of abnormal signal within the left peripheral zone at the base of the prostate. This abnormal signal is in the area of known pseudolesion, but it does extend to the left of midline and cannot be totally discounted. Minimum ADC value 755.

Seminal vesicles: Negative Extracapsular extension: None

Bladder: Normal. Bladder invasion: None.

Lymph nodes: Normal

Bones: No focal suspicious osseous lesion.

PROSTATE MRI TECHNIQUE: Multiparametric MRI of the prostate was performed at 3 Tesla with an endorectal coil using axial, coronal, and sagittal T2 weighted

series, axial diffusion weighted series, and axial dynamic IV contrast

enhanced T1 weighted and delayed T1 weighted fast gradient-echo series. Gadolinium-based contrast media was administered intravenously; see PowerChart

for the amount and type of contrast media administered and wasted.

 

from what I’ve been reading in my research the low ADC value isn’t a good sign. And the fact that he has this leission and a low psa can indicate the very aggressive type of cancer.

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Prostate cancer can only be diagnosed by a biopsy....an MRI does not diagnose.

PIrad scores range from 1 to 5; and indicate how likely the tumor that is found is cancerous. Pirad of one is least likely, while a five is most likely. Your husband's Pirad is a four, so having a biopsy is indicated. A urologist is the one who does this.

There is no extracapsular extension, that is, if there is a cancer, it is not outside the capsule.....a good thing.

I do not know what an "ADC value" rmeans.

 

There are various types of biopsies that are available. Most urologists do a random 12 core biopsy. Now there are new three dimension biopsy machines that are available in that can target the results found in the MRI, that one can place greater confidence in. Major centers of excellence have such three dimensional biopsy machines. My biopsies are done with an Artemis machine.

I wonder, your husbands race; African American males are more likely to be diagnosed and is reoommemded to be monitored at a younger age, 40 yo

lighterwood67's picture
lighterwood67
Posts: 152
Joined: Feb 2018

In my journey, the 3T MRI showed 2 lesions, graded at Pirad 5 and a Pirad 4.  The biopsy took 22 samples using the MRI to assist in targeting those areas. The biopsy showed the Pirad 4 was benign.  The Pirad 5 was adenocarinoma (cancer).  In my opinion, the best thing is to get the biopsy done.  My wife and I were afraid and scared, based on the MRI results.  Just have to put that in perspective.  The definitive test for prostate cancer is the biopsy.  I am around 7 weeks post prostate removal; bladder neck reconstruction, and 8 pelvic lymph nodes removed.  My wife and I are going camping this Thursday at the beach for a week.  I feel good and I am in good spirits.  But more importantly, I am still here.

Clevelandguy
Posts: 385
Joined: Jun 2015

Hi,

Yes he will need a biopsy hopefully guided by the MRI study to determine if he has cancer.  They will rate it as 3+3 or 3+4, ect. where the first number is the majority of the cells in the sample and the second number is the minority of the cells.  A 3 is less agressive than a 4 or a 5, a 4 is less agressive than a 5.  Of course you want the first number to be a 3. 3+3 is usually the mildest form of cancer where a 4+5 would be an agressive form of cancer.   Let us know what the results are.

Dave 3+4

VascodaGama's picture
VascodaGama
Posts: 2911
Joined: Nov 2010

Pi-rads 4 (in a scale from 1 to 5) is the level in probabilities in detecting cancer at the area identified by the MRI. The MRI is not specific enough to diagnose cancer but its computer software uses a series of coefficients (ADC) to calculate the risks. Detection in a low ADC would turn the results more realistic then if using a higher ADC. In other words, it turns the result of 4 more trustful. In any case, as above survivors comment, your husband needs to get a biopsy to certify if cancer exists. The symptoms you describe above are not typical causes from cancer. They are more typical when UTI exist, bladder or kidney infections, or due to hyperplasia. However, the later seems not to be the case because of the normal size of the prostate and the low PSA. The use of sex pills (Viagra and similar) may also cause similar symptoms including pain due to blood pressure at local tinny veins, dissipating with time.

Waiting two weeks for the consultation is proper. Your husband is young (no PCa in family) but he doesn't lose nothing if he does a 12/14 needle biopsy, directing some to the area(s) identified in the image exam at the base of the prostate (just under the bladder). The level and slight increase of the PSA (0.72 to 1.0 ng/ml in three months) is proper in a 45 yo male but this marker doesn't also diagnose cancer as it may relate to other issues and can be influenced by external occurrences such as sex or riding a bike before drawing blood for the test.

Best wishes and hope for a negative-to-cancer result.

VG

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3156
Joined: May 2012

Love of,

With all of the other guys above, the main takeaway from what you write is that the only fact highly suggestive of PCa is the Pirad.  As all have mentioned, neither this nor the T3 MRI confirms the disease.  With all, I say that a biopsy is very much necessary at this point.  Virtually all biopsies today are ultrasound guided, but the Artemis system is probably best. Ask the urologust specifically about Artemis.

His case does warrant investigation.  As Vasco noted, many of his symptoms are factors not ordinarily caused by per se PCa.  Most are also associated with BPH/BEP, but his gland is relatively normal in size, not enlarged in the range that commonly causes BPH.  ADC is not regarded as very accurate regarding PCa.  Its importance is usually limited to brain cancers a a few others.

His Jewish ancestry is likely not of significance.  If Ashkenazi (Central European strain; Poland, Hungary, and adjacent nations), it will increase the likelihood of positive BRCA 1 or BRCA 2 genes, but that is more relevant of BCa (Breast cancer) than prostate.  Ethnically, the rates for PCa fall highest on (1) blacks, (2) whites, and (3) Asians.  Sephardic Jews (Spain, Morocco, Northern Africa, most of the Middle East) are no more likely to have BRCA than any other population.

One thing in the list of symptoms that caught my attention was night sweats. As a Lymphoma survivor I know that night sweats have few causes. The two causes that are related to over 95% of cases are lymphoma and menopause.  'Menopause' is broadened to include most hormonal and histimine abnormalities generally (in both men and women).  As his doctor reviews his blood panels, ask him about what might be causing the night sweats; it is not ordinarily associated with PCa, except in cases of men who are on or who have received hormonal therapy (HT) or therapeudic castration.

And finally with everyone, I would say that a two week wait is meaningless. You are probably lucky to get in even that quickly, but PCa is virtually never a cause to rush anything.  Go on a minivacation during the wait and have some fun. Sitting and worrying is counterproductive in every way.  I would say finally that in the unlikely case that his urologiost does not see fit to order a biopsy, I would ask him to order it anyway, or go to another doctor. Biopsy of the prostate is overwhelmingly safe, and by medical testing standards, easy and inexpensive.

max

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Just noticed that you wrote that your husband is Jewish...... I am an Ashkenazi Jew.

About 9 or 10 years ago, there was a study done at Albert Einstein in NYC among Ashkenazi Jews....a correlation was shown between breast and prostate cancers. 

 

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3156
Joined: May 2012

h & o,

My father's ancesteral line comes from Prague, where many still live today. My surname is one of the most common in the Czech Republic.  There is a significant Jewish element in my ancestry, but for the last 200 years or so most have been R.C. in religion.  Because of the Jewish element, my female cousins have been testing for the BRCA 1 and BRCA2 gene mutations, linked to BCa; this is the so-called "Angelina Jolie gene."  To my knowledge, all have tested positive.  This gives an astonishing 87% liklihood of developing highly aggressive BCa, and removal of both breasts is recommended, which some have done as a precautionalry, like Angelina.

I have not yet studied any possible links to PCa, but it is an interesting topic.

max

Grinder
Posts: 428
Joined: Mar 2017

Has he had a urine culture yet?

on what was said above...

The symptoms are typical of an infection, although, as was pointed out, there should have been a corresponding rise in the PSA if the prostate was infected.

Does he have pain when urinating in his urethra? I was surprised that was not listed in the symptoms involving urination. It does not have to be intense pain, just a sharp pain as urine flows through the urethra. If there were, then like tth guys are saying, the symptoms are typical of a Urinary Tract Infection, or cystitis, a bladder infection.

Infection can be various pathogens but usually bacterial. E coli, Staphyllococcus, etc. can infect the bladder... In my case, I battled a Staph infection in my prostate off and on for 10 years, and my symptoms were very similar to your husband's but for my higher PSA levels every time the Staph infection flared up again. I did sweat as my immune system battled the infection, but not just at night.

Has anyone done a urine culture yet? Your husband could be dealing with both prostate cancer and an infection. I was dealing with all three... recurring staph infection, benign hyperplasia, and prostate cancer.

The infection would respond to antibiotics, but not eradicated totally. At first I figured I had just "caught it" again, but after the fifth prostatitis attack, it was apparent the antibios could not eradicate the infection... possibly because the prostate is much harder to treat with antibios than a UTI or bladder. 

I was experimenting with many antibios... I was so desperate to get my prostate size down. Ciprofloxacin was the least effective p, but most prescribed. Bactrium, Levaquin, et al. finally got it down to 250cc at the time of my biopsy.

I finally gave up and had a prostatectomy to kill three birds with one stone. So like the guys said above... the symptoms are not typical of pristate cancer, but it sounds like both an infection somewhere plus prostate cancer. The PC is not an immediate danger if caught early, though the  symptoms of the infection may seem scary and related.

Thats only a guess, however.

Loveofmylife2007
Posts: 4
Joined: May 2018

Hi All

First, thank you all so so much for your time and care in helping us understand all of this. To answer a few questions: he hasn’t had any pain in urination, about 3 months ago he did have a little bit of an orange tinge to his semen (which im guessing could be blood) but it only happened that one time. We just had our apt with the urologist oncologist and the first thing he seemed to focus on was how surprised he was that we were pushing for the mpmri given the low psa. He said he would have never ordered the mri but because he now has the results from it he cannot ignore it. (Not quite sure where he was going with that or if he was annoyed that we pushed for it) anyhow he said he was gonna send the images to another guy he likes to get a re read. He called us yesterday and said his guy said it might just be a pseudo lesion. So the doc suggested we wait 5-6 mnths and then repeat the  3tmpmri but instead of using the exterior diaper thing around the pelvis he wants to use the erecto coil to get a better image. I asked him again why we had to wait being that my husband and i would Rather not spend the next 5-6 mnths anxious. (As I’m 35 and we are in the middle of trying to conceive for the first time). He said if we insist he can do a biopsy but he is highly against it and because my husband is only 45 he doesn’t see why he would risk the side effects of a biopsy and the pain associated with it. However this confused me because when we first went to him with the original report (before his guy re read it) he was telling us the that biopsy isn’t a big deal and the risk of side effects are sub 1%. So now the risks outweigh us finding out if it is nothing or something? i did ask him if we hypothetically consider it is a real leision with a PIRADS 4 and a history of low PSA wouldn’t this be a high likelihood of it being the highly aggressive type? And he said yes. So now I’m having a hard time understanding 1. Why he doesn’t order to colorectal coil 3tmpmri now 2. Why he is choosing to wait and gambling with the 50/50 chance it’s real and aggressive? 

maybe i am not understanding things correctly and letting my skeptism of doctors interfer with logic?

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3156
Joined: May 2012

Loveof,

You are learning something all cancer patients learn:  You have to drive your own care (or that of a relative).  Me, I take a more aggressive approach, not letting things idle. But that is me and my personality; a worrier.  

It is impossible to know for certain what an incidental comment that a doctor makes really means, so it is probably best to ignore it and just focus on known facts.

As I stated in my last post, if it were me, I would call and tell him to schedule the biopsy.  The biopsy is more fundamental than another MRI.

He may comment about "recovery" or "side effects," but so what.  Except for  a rare infection, side-effects are extremely rare from prostate biopsy. Some men report them, but it is not the norm.

 

Your next-to-last sentence is not exactly statistically accurate, when you say that there is "a 50/50 chance he has PCa and it is aggressive."  It is 50/50 in the sense that only two results are possible: PCa or no PCa.  A 'yes or no,' 'heads or tails.'  But the liklihood that he has a rare, aggessive substrain, if he has PCa at all, is undoubtely much lower than 50%.

Tech70
Posts: 46
Joined: Nov 2017

In my opinion, if someone is having significant pain during a biopsy, they need to find a more talented urologist.  I have had two, and both were painless, including the Lidocaine injection prior to taking the samples.  Afterward I experienced a "pins and needles" feeling in my perineal area for about two hours. 

 

ASAdvocate
Posts: 106
Joined: Apr 2017

Most biopsies are no problem, but two of mine were awful. Pain and tripled PSA for six months afterwards. These were by a professor of urology at Johns Hopkins. Nothing helped except time and sitz baths. Three of every 100 biopsies results in hospitalization for sepsis, and one of every 1400 is fatal. Also, an endorectal coil is extremely painful, and there is no need for them with 3T machines. Also, I have had a PIRADS 4 lesion hit with multiple biopsies and nothing found. It was downgraded to PIRADS 3 when version 2 came out.

So, be careful what you ask for. Has he had a PHI, 4K Score, or PCA3 test?  I would recommend them as a next step.

 

 

Old Salt
Posts: 721
Joined: Aug 2014

It seems to me that the two of you and the urologist have a 'failure to understand' one another. Well, that's a bit harsh, but the communication is less than perfect. How about finding another urologist; one that is hightly rated by medical professionals. Or one that is associated with a med school?

 

Grinder
Posts: 428
Joined: Mar 2017

I was thinking the same thing as Old Salt... dont be afraid to find another urologist... preferably one that is not associated with your present urologist's clinic/organization. 

I went through 5 different guys at different times... any time I felt I was being manipulated or talked down to, I bailed by cancelling the next appointment and not rescheduling. The last guy gave me a complete picture of my particular situation, and a complete overview of treatment options, and the side effects possible as well.

But this is a big city, where the university has clinics, and they compete with Urology clinics, so I had the luxury of finding the urologist I was most comfortable with. This is another reason I am dead set against socialized medicine... not that free enterprise doesn't have flaws, but I have freedom to explore the marketplace. I would check the competing organizations and if at ALL possible, get a referral from a friend or family or even your GP, somebody so it doesnt have to be a crap shoot when choosing a urologist. 

And I would still have a culture done just to rule out infection as a cause of his symptoms. After all its easy and there are no side effects... you just pee in a cup. That's all. Then the lab tests it for pathogens. It will probably be negative, but at  least you will have ruled that out. But that's just me.

Loveofmylife2007
Posts: 4
Joined: May 2018

Thanks everyone!! So he has had a urinalist, bladder emtying test and all came back normal. This doc we went to (head of the dept at the mayo)said he sent the mri to be re read from a guy who is considered the best in the country. We are working on an apt with a urologist oncologist that came recommended by a friend that had this at Sloan Kettering and also probably going to the cleavland clinic as well for a third opinion. 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

There is a difference among radiologists in the ability to read the T3 MRI report, so I believe that your urologist sending the MRI results to an expert was a good call.

I wonder where you live?; I'm guessing that you are in the nyC area?...if so, NYU would be a great place to go since they have sophisticated three dimensional biopsy equipment......at this point it is not necessary to go to Texas..

 

 

VascodaGama's picture
VascodaGama
Posts: 2911
Joined: Nov 2010

In my lay opinion, no one knows if cancer exists without analyzing a sample of it under the microscope.

Guessing a diagnosis of prostate cancer via a MRI or PSA and follow it with again another guess on a clinical stage (quite common) is like playing Russian roulette. The lucky ones survive.

Your doctor is simply giving his opinion based on the experience he has had along his professional life. You may think his behavior ambiguous but that is what urologists do. They rarely contest the report/opinion of another physician from a different specialty so that the tendency is to stick with answers following their guide lines. I believe that your doctor doesn’t trust the Pi-rads system but he cannot deny it, however he is giving you his opinion based on the low PSA, the age of your husband and his family history (NCCN guidelines), in which cases the probability of having PCa is rather low. The same guidelines also don’t recommend MRI exams in cases of low PSA.

Pi-rads classification in a MRI exam is a recent tool used in the PCa screening process.  In the 1990th PCa screening via a PSA test was not credible by many doctors too.  My GP used to screen PCa via the Prostate Acid Phosphate (PAP) which he did in my case annually since I become 45 yo. It was by chance that in 2000 a different doctor substituting him in my annual checkup conducted a PSA that started my history with the bandit. I see your husband’s case similar to mine as he started the screening via means not yet recognized worldwide.

Your suggestion on the probability of a cancer being aggressive if diagnosed in a case of low PSA histology is correct. The doctor confirmed your opinion but a Pi-rads 4 doesn’t diagnose cancer. It all becomes true if in a biopsy a pathologist identifies the existing bandit. Another MRI (no matter how sophisticated it could be) wouldn’t give you peace of mind if done today or in six months time.

In any case, I do understand your worries in regards to your wishes in having a child and the influence cancer could have in the process, in particular if a radical treatment is to be performed. Surgery would eliminate a natural conceiving process. Radiation would also limit possibilities or even prohibit it to happen during a long time. Even a biopsy could be prejudicial if that would include cores at the seminal vesicles. Probably your doctor is thinking on this too and trying to delay any action that directly or indirectly could harm your dreams. In your shoes I would follow the case only with periodical PSA tests (every 3 to 4 months) and take action if the PSA increases to levels above the normal to his age (PSA=2.6). Meanwhile try enjoying life fully or look for artificial insemination...

Hope your dreams become real.

Best wishes,

VG 

Loveofmylife2007
Posts: 4
Joined: May 2018

Thank u so much!!!! All your answers have been so helpful i cannot even thank all of u enough!!

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