Prostate is mildly enlarged measuring 4.6 x 6.2 x 6.0 cm 84 cc.
Peripheral lobe prostate has ill-defined patchy T2-weighted signal without discrete lesion restricted diffusion. Posterior right peripheral lobe has a posterior linear focus of increased signal on the value DWI that is indeterminate for an artifact on image 35/11. PIRADS 2.
Within the superior right transition zone 1.3 x 1.1 cm T2-weighted hyperintense nodule that is incompletely circumscribed, has somewhat ill-defined margins and moderately hypointense on ADC map without significant hyperintensity on high B value DWI. This has early asymmetric intense arterial enhancement (image 138/13). Underlying mild nodular central gland hypertrophy mildly indents the base of urinary bladder.
Seminal vesicles are symmetric.
Mild bladder wall circumferential thickening and trabeculation for degree of distention compatible with hypertrophy. This suggest a component of chronic bladder outlet obstruction.
No lymphadenopathy. Right external iliac 6 mm lymph node noted. No aortoiliac lymphadenopathy.
IMPRESSION:
1. Prostatic right transition zone 1.3 cm PIRADS 3 lesion.
The prostate measures 6 CM transverse by 4.7 CM anteroposterior by 6.5 CM craniocaudal, giving a gland volume of 95 mL . Severe BPH with intravesical prostatic protrusion.
A dominant tumor focus is identified in the right anterior transition zone at the apex, measuring 1.3 CM transverse by 1.5 CM anteroposterior by 1.6 CM craniocaudal, giving a tumor volume of 1.6 mL. The tumor demonstrates:
Low T2 signal: Yes. With obscured nonencapsulated borders
Restricted diffusion: Yes.
Early enhancement: Yes.
Delayed washout: Yes.
Overall Pi-RADS classification: 5
With respect to tumor stage:
Likelihood of right-sided extracapsular extension: Absent (0-20%).
Likelihood of left-sided extracapsular extension: Absent (0-20%).
Likelihood of right-sided seminal vesicle invasion: Absent (0-20%).
Likelihood of left-sided seminal vesicle invasion: Absent (0-20%).
No lymphadenopathy, suspicious bone lesions, or other abnormality identified.
IMPRESSION:
PI-RADS 5 right anterior transition zone lesion.
OHSU reviewed the MRI prior to scheduling fusion biopsy there. I didn't learn of their evaluation until 4 months after evaluation done.....at consult last week. Needless to say.....shocked! My Kaiser Doc and I had been proceeding with PIRADS 3 evaluation from Kaiser as informative . Had he and I been discussing my situation based on PIRADS 5 , we would have had different conversations and different urgency. Some part of 6.6 PSA at age 70 thought to be from BPH....84-94 CC prostate volume.
In addition to my frustration with the conflicting interpretations, I also face this decision:
Kaiser: Will do cognitive targetted biopsy with additional 12 -20 cores standard TRUS....larger number of samples to reflect large prostate. Kaiser will also do sedation in an operatory for the procedure, and at my request, use povidone iodine to help reduce infection risk.
OHSU: Will do fusion biopsy plus I think 1 sample from each region.....fewer samples than Kaiser would do. OHSU would not agree to sedation , and not agree to prepping me with the iodine solution. Sounded like sedation would only be offered if I screamed and stopped biopsy because of pain...then start over another day in OHSU hospital.
Very unhappy that OHSU evaluated my MRI at beginning of June, yet I was not informed of more concerning result until 4 months later, at pre-biopsy consult!
Thanks for any thoughts on all this !
Written by
maley2711
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All I can say is you need an MRI guided biopsy. I did a random 14 needle biopsy and found nothing. Then I did research and ended up doing a 4 needle MRI guided biopsy. 4-4 positive vs 0-14. That says it all. Random biopsies are dark ages.
I agree on superiority of combined standard TRUS biopsy plus guided biopsy if MRI indicates a suspicious target. i composed a 100 page appeal inorder to have this combined fusion biopsy covered by insurance. The average on studies of biopsy accuracy was combined biopsy finds 25% more significant cancers than does that standard TRUS "random" biopsy. However, cancer centers advise the combined biopsy, not just MRI-guided. MRI actually misses 10-15% of significant cancer that is found only by the standard TRUS biopsy. Also, significant number of men whose MRI shows no target are found to have significant cancer when standard TRUS is done.....MRI is ineffective below a certain size lesion.
What was your Gleason score after they did the MRI-guided? Was the lesion in the anterior/transition zone?
Well that’s an interesting question in and of itself. Two different psychologists disagreed on the Gleason. I ended up sending it to Dr Epstein at John Hopkins. All cores were Gleason 8. I highly suggest you send any positive results to Epstein. Only a couple of hundred dollars. One of the few things almost everyone in this field agree upon he’s the best. TA is right about Margolis. He was at ucla when I had my MRI. He too is considered one of he best at reading MRIs. Not sure what he’d charge for a second opinion
No one can judge PIRADS scores by reading a report. It takes a LOT of experience to do it well. If you don't have a top radiologist, you shouldn't bother with an mpMRI. You have to evaluate the credentials of the radiologists. Or you can pay for an expert opinion from someone like Daniel Margolis at Weill Cornell.
I suppose it doesn't matter at this point...water over the dam as far as correct Grade..there is a target, unfortunately. In one way , it does matter...in unlikely event nothing is found in this biopsy, or only a 3+3 is found, a correct Pirads gives a probability range that there is actually missed significant cancer...back for 2nd biopsy?
Re expert, I guess a patient would need to know ......if radiologist historical patient PIRAD grades and subsequent biopsies have resulted in a concordance with expected probabilities of significant cancers found at biopsy of patients with different grades. I have seen discussions of the need of certification for this skill , but not aware that any country id doing that as of now. I/most of us are biased toward med school institutions and their diagnoses, but is that always justified? Doubt I'll get anywhere, but I'll try to have Kaiser radiology review the OHSU analysis, perhaps Kaiser talk to OHSU radiology, and see if they can reach a consensus on my MRI.
Confused about fusion biopsy with no sedation at OHSU vs sedation at Kaiser, more samples, but only cognitive biopsy. The lesion is large size and perhaps cognitive is equal to fusion in that scenario. Anterior transition a challenge, I guess more so for TRUS than transperineal. Noted OHSU's comment about severe BPH...hoping that condition somehow was a factor in overgrading by OHSU..small possibility I guess.
BTW, I've been told I have a needle phobia....wanted one and done biopsy!
• How many years of experience does each radiologist have at reading mpMRIs? You can ask.
• If you have suspicion in the anterior, you should demand transperineal.
• I agree that as long as the sites identified are the same, it no longer matters that the PIRADS scores differ - they will be biopsied anyway.
• Cognitive makes no sense to me when there is fusion or in-bore possible. They have to take at least 4 cores from each suspicious site. If 4 cores doesn't find it, remember that PIRADS is only a suspicion. (BTW - UCLA, which is one of the sites where PIRADS was established, now uses their own ranking system that they find correlates better with pathology.)
Thank you Allen. Yes, I just lst nite read something re UCLA's more accurate grading system. I guess they give each patient both a PIRADS grade and a UCLA grade. If PIRADS 5 is correct, seems like I'm in the ballpark of 80% probability of significant cancer...sigh. OHSU was , IMHO, negligent in not informing my Kaiser urologist back on June 6 re the upgrade from 3 to 5.......or my Kaiser Doc negligent for not informing me after OHSU had informed him? I'm just hoping that somehow my "severe" BPH 95 cc prostate is influencing the MRI read ...in my favor re cancer? Without MRI, 80% probability anteriore/transition zone cancer would have been missed on standard TRUS....so feel good about asking for MRI before any biopsy....that is still not SOC with most insurers...credit to Kaiser to at least covering the 1.5T at Kaiser.
The OHSU Doc stated that because of the size of the concerning area, a cognitive would probably provide a good result...OHSU just completed their own comparison of the 2 methods.....of course study maybe done with more highly skilled OHSU Docs = have done more . Also, i read that for cognitive, it's advised to have a radiologist assist the urologist in correctly targeting. A number of studies besides OHSU have shown comparable result for cognitive and fusion targeting..for me, in-bore off the table because have had no prior TRUS 12 core.
FOR THE RECORD, all treatments for advanced prostate cancer are in some senses, a turkey shoot, as one CANNOT see micro-matastic disease. Also, some labs, like everything else in life, are not perfect, i.e. again we are still very EARLY in terms of diagnosis and treatment.
The key here is to get going on some treatment protocol ASAP!!!!! and then live LARGE, make up a bucket list and get to it!!!!!
What did Kaiser Wilhelm ever do to you? There are many turkeys running around amuck. A turkey shoot is not politically correct. I am building a guillotine.
Well he joined forces with a guy named Frazer and you couldn't tell whether they were coming or going.... and as far as turkeys are concerned, I married one.... and would love for you to hunt her down and you have my permission to test your guillotine on her. Drop the blade slowly.........
Sorry. I am definitely not an expert. Sadly tossing dwarfs in no longer an option. Excuse me, tossing little people is no longer an option. Tossing turkeys and guillotines. I almost have this, patent pending.
Sorry, maley. Lots of wise guys on this site. Lots of wisdom here. And me? I'm in the peanut gallery, also known as the marble gallery. After my 14 core prostate biopsy I vote sedation.
What you learned? In spite of the fancy new fangled views, you really won’t know until you lay on a table and have an Urologist biopsy your prostate. Mine was 80 cc, so I had 16 sticks...... that was in 2003. Gleason 7 (4+3). Oh yeah PSA at the time was 6.2...... I had already developed micro-metastasis, so my primary treatment failed inside of a year.
If I had to do it over, I would have had the sedation. Half way through the Doc, said that I should have gone that route......
Thanks Gourd,,,,I guess the good news is that you have now made it 17 years after initial treatment!! Did you start/stop that cursed ADT treatment after initial surgery or radiation?
My wonderful Kaiser urologist called me today...more than 30 minutes discussion about my situation. Deep sedation not GA would be used. Without sedation, nerve block is used at Kaiser and he thought also the medical school. With my little more than 1/2" diameter lesion in anterior transition zone, he said that hitting lesion will be a slam dunk if he is able to see on ultrasound image, but no guarantee he'll be able to see with low resolution US. If not visible, confidence level would be lower.
Dr. J surprisingly stated that he too has needle phobia.....even avoiding the dentist office!! He started business at Kaiser in 1999, when only pain control was the lidocaine gel ......around 2001-2003, they started doing nerve block, with MUCH higher patient satisfaction. When I asked what he would advise his Dad to do, Dr. J replied that he would advise his Dad to have the fusion biopsy at medical school...for greater confidence in results in case of negative biopsy or Gleason 3+3 or 3+4. Also I suppose if only cancerous cores are found in lesion and no other areas, leaves open option of focal therapy?
One thing we didn't discuss is the fact that Dr. J would take more more samples if sedation were used, versus fewer samples at med school without sedation. So, it really helped to talk to my bedside manner Doc, versus lesser so female at OHSU. Expect females to be , if anything, more empathetic?
Also discussed Dr. J's willingness to use povidone iodine for additional infection control...OHSU not cooperative on that matter..I guess I could push some more on that.
Even with PIRADS 5, Dr. J not convinced. I have serious cancer...that gave me some hope!!
Sounds good maley. I didn’t start ADT until I showed mets to my spine. As my Urologist said that I was one in a thousand when 24 hours after the procedure, I was admitted to the hospital with an infection. Six days IV alternating two different antibiotics was not fun......
Thanks Gourd. Sorry you ha to endure that horrible experience. Yes, these Docs minimize infection risk... "only" 2-4%...to you and me, that 2-4% is not a small risk! If something can be done to reduce to 1% or lower, and at minimal extra cost, why not!! Best wishes in your fight against this nemesis!!
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