I had two MRI scans recently and both times PIRADS 5 lesion with extracapsular extension and probable invasion of the right seminal vesicle have been reported.
After that I had Transperineal prostate biopsy and Histopathology reported no malignancy.
I am totally confused and I am worried that I would lose more time if biopsy was false negative, because I can’t start any treatment.
I would be very grateful if somebody with more experience and knowledge than me, could give me some advice or opinion about my results and some idea what I should do next.
I attached both MRI reports, 5 years PSA history and Biopsy report:
MRI 1:
I had Multiparametric MRI Prostate (3 Tesla scanner, intravenous gadolinium) on May 27, and radiologists reported the following:
The prostate measures 4.8x3.8x3.8 cm giving a volume of 36 cc.
1 - Location: right mid-gland to base, posteromedial to posterolateral PZ posterolateral PZ PIRADS 5 lesion, broad capsular contact is at high risk for ECE and with suspicion of invasion into right seminal vesicle. Seminal vesicles are otherwise unremarkable.
There are no abnormal lymph nodes identified. The bones of the pelvis are normal.
Size: 20 mm
T2: circumscribed hypointense rounded nodule
DWI: severe diffusion restriction (AAV 530)
DCE: +ave
PI-RADS rating: 5
2 - Location: left mid-gland posterolateral PZ
Size: 5 mm
T2: circumscribed hypointense rounded nodule
DWI: severe diffusion restriction (AAV 589)
DCE: +ave
PI-RADS rating: 4
ECE: low risk
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MRI 2:
On June 25, 2019 I had second Multiparametric MRI Prostate (3 Tesla scanner, intravenous gadolinium) in different hospital and I got the following report:
Prostate measures: 4.1x3.3x4.8. Volume 32.5 cc.
Peripheral gland:
In the right postero-lateral mid gland to base is a 1.8 x 1.9 x 1.0 cm low T2 area with marked restricted diffusion ADC 574 with extracapsular extension and abutment to right neurovascular bundle and probable infiltration to inferior aspect of the right seminal vesicle. This has the features of a high grade prostate cancer. Features are those of PI-RADS 5.
Central Gland:
Moderate features of PBH without obvious tumour.
T1 imaging of pelvis: No haemorrhagic change shown within prostate. No discrete bone lesion.
No pelvic lymphadenopathy.
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PSA:
August 8, 2019: PSA 5.7, Free to Total PSA ratio 12 %.
May 30, 2019: PSA 6, Free to Total PSA ratio 9 %.
August 22, 2018: PSA 5.7
June 22, 2018: PSA 5.3
February 03, 2017: PSA 4.56
November 04, 2016: PSA 4.64
February 18, 2016: PSA 4.14
September 24, 2014: PSA 2.85
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Biopsy:
On August 27, 2019 I had Biopsy and I got the following Histopathology report:
1. Right anterior - Four tan discrete cores 2, 2, 3, 4mm in length and multiple fragments less than 1mm. A1. - Sections show benign prostatic tissue.
2. Right mid - Six tan cores 2, 2, 3, 4, 4, 10mm in length and multiple fragments less than 2mm. A2.
- Sections show benign prostatic tissue.
3. Right posterior Lesion - Four tan cores 9, 13, 14, 15mm in length and multiple fragments less than 2mm. A2. - Sections show benign prostatic tissue.
4. Left anterior - Two tan wispy cores 3, 4mm in length and one fragment less than 2mm. A1.
- Sections show benign fibroadipose tissue.
5. Left mid - One tan core 4mm in length and multiple fragments less than 2mm. A1.
- Sections show benign fibromuscular tissue.
6. Left posterior - Three tan wispy cores 2, 3, 5mm in length and multiple fragments less than 2mm. A1. - Sections show benign prostatic tissue.
Diagnosis: 1-6. Transperineal prostate biopsies, sites as specified above - No malignancy identified.
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Vlad55
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It seems like you have a weird prostate - infiltration of fat deposits with scar tissue and muscle with scar tissue in your prostate. It may be these benign features that were picked up by the MRI. They certainly looked hard in the suspicious areas for cancer and could not find any.
To be close to 100% certain, there is a test they can do on the biopsy tissue called Confirm MDx.
I would be suspect of steadily rising PSA and falling f-PCA below 10%. A f-PSA of <10% at 64yo indicates a 67.5% percent probability of finding prostate cancer on a needle biopsy per this article:
Just for reference, leading up to a Gl-7 biopsy, I had PSA: 33, f-PSA: 2.7%, and 4KScore: 77%
There's another imaging you may consider-- color doppler ultrasound, which identifies high bloodflow rates at tumor sites. I had this with Dr Bahn in Ventura, CA, and it accurately identified the primary tumor and SV involvement sites from which he took a targeted 9 core biopsy, confirming Gl-7.
I am not sure if my PSA history tells anything about the probability that I have a cancer?
For example, from 2014 - 2018 my PSA was steadily rising and doubled in 4 years (from 2.85 to 5.7).
And after that, from August 2018 till August 2019, in one year did not increase at all (stayed at 5.7).
It looks to me that 4 years doubling time increases the probability that I have a cancer, but after that, one year staying the same, decreases it. I am not sure if I am right? And I don’t know if we can get anything from my PSA history?
You should be vlad you came to the right place for help, information and camaraderie. If I were you I'd take Tall_Allen's advice and get a ConfirmMDx test of your biopsy tissue asap.
Thank you for sharing your experiences and your knowledge. Thank you for all your advices and your unselfish hep.
I had an appointment with my new urologist (3rd in the last 3 months) yesterday.
He done DRE and found a lump and he thinks that it is prostate cancer.
In his opinion my transperineal biopsy missed lesion, because of posterolateral mid gland to base location it was difficult to reach it by transperineal biopsy. He recommended a new biopsy, as he said sooner rather than later (because of possible ECE and seminal vehicle invasion).
He wouldn’t do MRI guided or MRI/US Fusion biopsy (so far I didn’t find an urologist who use guided biopsy, it looks that here in Australia guided biopsies are still not common practise). This time he will do, as he said “old fashion finger guided TRUS biopsy”. He would find the lump with his finger and guide the biopsy, he said that he done that many times and he is confident that he will find the tumour and he needs only 4 cores.
After long waiting I got the report from my second Biopsy today. Also, I got my PET/CT PSMA scan about two weeks ago.
My Biopsy report shows that Adenocarcinoma was found in 16 cores at five sites. It looks that I have a lot of cancer in my prostate, so I even don’t know how many tumours I have. Plus I have Extracapsular extension at two sites.
Obviously my biopsy from less than 2 months ago was false negative.
I have appointment tomorrow with my urologist (he done my last biopsy) and I would be grateful if somebody give me some idea what to ask him.
Also I do not know what my options for the treatment, with this results, are.
5.Repeat right base: Adenocarcinoma Gleason score 4(80%)+3=7 (Grade Group 3) involving 13, 11, 11, 11, 10, 10 mm of six cores (from 7 cores: 3, 19, 11, 13, 14, 15, 18 mm), with Extraprostatic Extension.
6.Left base: Adenocarcinoma Gleason score 3+3=6 (Grade Group 1) involving 1 and 1 mm of 2 cores (from 2 cores: 17, 20 mm).
7.Target - Right: Adenocarcinoma Gleason score 3+4(40%)=7 (Grade Group 2) involving 6, 5, 3, 2, 2, 1, 1 mm of 7 cores (from 11 cores: 3, 4, 4, 5, 7, 8, 8, 10, 15, 16, 18 mm), with Extraprostatic Extension and Perineural Invasion.
8.Finger guided biopsy: Adenocarcinoma Gleason score 3+3=6 (Grade Group 1) involving 0.8 mm of one core (from 5 cores: 3, 9, 11, 12, 17 mm).
Conclusion:
Prostate adenocarcinoma, involving five sites (16 cores, including template and target), highest Gleason score 4(80%)+3=7 (Grade Group 3), with Extraprostatic Extension.
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PET/CT REPORT:
Radiotracer: F18 PSMA (DCFPyL), Uptake time 104 minutes.
Findings - Primary tumour:
There is low to moderate increased PSMA uptake (SUVmax 6.1) in the right posterolateral mid to base of the prostate. This appears to correspond to the site described on the MRI from May 27, 2019 on Verd.
Nodal metastases: None.
Distant metastases: None
Further findings: The distribution of radiotracer elsewhere is physiologic.
Conclusion:
Only low to moderate increased PSMA expression in the right posterolateral mid to base of the prostate.
No evidence of PSMA avid nodal or distant metastasis.
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