Question on MP MRI and Pirads score along with PSA

[DRKC81]

Hello All, thanks for so much valuable information. My father is 74 and he has been on Dutasteride and Tamsulosin for elevated PSA (6) for the past two years. His PSA jumped to 8 this year and then 11. The PSA never went down with Ditasteride. The urologist has ordered for biopsy but before that we got an MP MRI done with Pirads 4, the MP MRI had the same conclusions as the one which was done two years back and it had a score of Pirads 2, don’t know what made them change it to 4, the lesion volume is .4cc in the peripheral zone and there is a high intensity at high B value and low ADC. The report also says that transition zone is normal and there is heterogenity in PZ which can be prostatis . I am sure the urologist will ask for a biopsy , which one would be the best for a diabetic? Is it possible for a Pirads 4 to be benign? He has no other symptoms and can you suggest radiologists for second opinion? Thanks a lot

[Tall_Allen]

Transperineal is best. The increasing PSA with dutasteride and the increased PIRADS score are important indications for a biopsy. He should have 4 cores from the PIRADS 4 area and 2 cores from each of the other 5 areas. Maybe 2 more cores from the TZ because it's easy to access.

[DRKC81 in reply to Tall_Allen]

Thanks Tall_allen for your quick reply. I will request it tomorrow. We had the Exodx done as well and the doctor will let us know of the result tomorrow. Are there any reasons why PSA wouldn’t go down with distaste ride in the first place ?

[Tall_Allen in reply to DRKC81]

Yes - dutasteride ONLY lowers PSA from BPH - it doesn't touch PSA from PCa or from prostatitis.

[DRKC81 in reply to Tall_Allen]

Thank you again. Can you suggest doctors in New Jersey for prostate biopsy? Hoping it is prostatis and not PCa 🤞

[Tall_Allen in reply to DRKC81]

Sorry- I don't know any NJ uros.

[DRKC81 in reply to Tall_Allen]

@Tall_Allen, I took my father to the urologist and asked for transperineal biopsy and he said he doesn't do it but is experienced in TRUS usint MRI fusion Uro NAV. The Exodx was slightly above the threshold, 16 , it was at 30. Is transrectal OK? Thank you so much again

[Tall_Allen in reply to DRKC81]

No, it is not OK. The larger centers do it. Maybe try Rutgers. Or any of the major hospitals in NYC. They all do US/MRI fusion.

[DRKC81 in reply to Tall_Allen]

Thanks Tall_Allen, we can't go to NY unfortunately his insurance is valid only in NJ. Is there a reason why you dont prefer TRUS? I've searched extensively on google for a doctor in NJ who is experienced to do transperineal (haven't seen one in any major hospitals, which is a shame).

[Tall_Allen in reply to DRKC81]

The move from transrectal to transperineal was driven by the higher infection rate and the increase in resistant infections from transrectal. It injects shit into the prostate. I also think (without evidence) it causes prostatitis. Transperineal can be done without antibiotics and it can reach parts of the prostate (anterior) inaccessible from the rectum. Doesn't MSK now have a NJ facility? Maybe transfer to a different insurance during open enrollment.

Here are a good reference:

urologytimes.com/view/case-...

[Tall_Allen in reply to Tall_Allen]

I'm surprised Rutgers doesn't do it. Have you tried any of these?

• Robert Wood Johnson University Hospital/CINJ at Hamilton

Hamilton, New Jersey,

• Carol G. Simon Cancer Center at Morristown Memorial Hospital

Morristown, New Jersey, United States, 07962

• Cooper University Hospital Cancer Institute

Voorhees, New Jersey, United States, 08043

MSK has these NJ branches:

• Memorial Sloan Kettering Basking Ridge

Basking Ridge, New Jersey, United States, 07920

• Memoral Sloan Kettering Monmouth

Middletown, New Jersey, United States, 07748

• Memorial Sloan Kettering Bergen

Montvale, New Jersey, United States, 07645

[DRKC81 in reply to Tall_Allen]

Tall_Allen I finally took my father to MSKCC to meet with the uro-oncologist that does transperineal and wasn't impressed one bit. He went on to say though he does transperineal it is still experimental and he would do TRUS because it is easier to get to the area of interest. I liked the urologist more than him, firstly he was late by 2 hours and then didn't go over the questions / results and just went on to say TRUS is better and it shouldn't cause any problems. I am back to square one now. If TRUS is my only choice I don't know what antibiotic to ask for based on Fluoroquinones and their side effects.

[Tall_Allen in reply to DRKC81]

I'm surprised, and it is certainly not true what he said- there is better access with transperineal. I suspect he has no experience doing it and was just making excuses.

If your only option is TRUS, they can culture the rectum and look for resistant bacteria.

[Justfor_]

Does the report include the ADC specifics (mean, max, min values). There are a couple of papers that examine the correlation of ADC with Gleason Score. Google it.

[DRKC81 in reply to Justfor_]

Justfor_ The report says ADC is 950 , nodule 0.9*0.4*1.3cm with a volume of 0.4 cc, DWI : Restricted diffusion with high signal on high B value DWI and low signal on ADC. Rated Pi-Rads 4.

[Justfor_ in reply to DRKC81]

Not very illuminating as the nature of the 950 is not specified (min, mean or max).

To give you something to compare to (never mind the x100 multiplier - different units used).

In my case, two lesions - PIRADS 5, the relative ADC values were:

min=0.52, mean=0,74, max=1.12

min=0.46, mean=0,70, max=0.86

I hoped for GS 7a or 7b (4+3), biopsy said 4+4=8, RP pathology upstaged to 4+5=9.

Wish you the 950 (or 0.95) reflects the min value.

[DRKC81 in reply to Justfor_]

Thanks Justfor, we got the exodx values as well and it is 30. slight above their 15.6 cut off. May be the radiologist didn't do a good job, is there any place you suggest I can get the second radiologist opinion from?

[Justfor_ in reply to DRKC81]

I have used an online site for my MRI one year post RP. The cost was about 250 USD, but I was not that satisfied as to recommend them. Main reason was that, in theory, you could select the radiologist from a list of about 50 of them. There was hardly a handful of them that, from their short résumés, prostate cancer specialization was evident. Many breast cancer specialists though, mostly women. I selected two or three that seemed the closest match. The site assigned my case, without prior consultation with me, to some third radiologist. Internet search regarding his credentials didn't reveal any prostate cancer experience. 10 years of general radiologic work or there about.

[Tony666]

My brother had pirads4 and then did a biopsy which didn’t show cancer

[DRKC81 in reply to Tony666]

This gives me hope Tony. Thanks

[j-o-h-n]

New Jersey?

A

Memorial Sloan Kettering Cancer Center

Cancer treatment center

Middletown Township, NJ · [phone]

B

Memorial Sloan Kettering Cancer Center

Cancer treatment center

Montvale, NJ · [phone]

C

Memorial Sloan Kettering Cancer Center

Cancer treatment center

Basking Ridge, NJ · [phone]

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 09/21/2021 6:57 PM DST