Step 2 - mpMRI done, results not good, I'm scared now

Hi all,

I've been enjoying following many of your stories and it has helped me prepare for this journey. Thanks to everyone who graciously shares and responds here.

My original post and bio tell my story, but I have to add this new information from my mpMRI this morning. Here it is:

IMPRESSION:

1. Lesion #1: PI-RADS v2.1 score 5 lesion measuring 13 mm in the transition zone mid gland at 11 o'clock. Suspicious for extraprostatic extension.

2. Lesion #2: PI-RADS v2.1 score 5 lesion measuring 29 mm in the peripheral zone mid gland to apex at 1-5 o'clock. Suspicious for extraprostatic extension and left neurovascular bundle involvement

3. No suspicious lymph nodes or osseous lesions.

PROSTATE

Size: 4.4 x 4.0 x 3.7 cm

Volume: 33.8 mL

PSA Density: 0.9 ng/mL^2

A little more detail on the 2 lesions but I think this group is savvy enough to get it.

Got a prompt call from my provider with results and asking about scheduling a biopsy. My response was to ask if it will be a fusion biopsy and if it will be transperineal. From the sounds of it, may be fusion, but this urology dept generally still does all transrectal. The PA told me they are not set up with the equipment for transperineal.

This is the University of Wisconsin medical group in Madison, WI so we are a pretty advanced system. I am also investigating Mayo Clinic in Rochester because I know they do a lot more prostate surgery and do mostly transperineal biopsies.

And so I'm leaving this note here to generate a little discussion. I'll be curious to hear from folks about how this preliminary result may lead to treatment options. Is it too late for RP? How much will a biopsy actually guide treatment now? Etc.

[NanoMRI]

I had two transrectal biopsies - no issues. IMO not as challenging as child birth (I was present for both my children's births). I learned after my second one mpMRI can indicate which approach will provide the better means to target the worst bits of the lesion(s).

My two mpMRIs made it clear to docs (and me) that my tumor location provided insufficient margins for all radiation/focal treatment methods. So I chose surgery and nearly nine years later believe it was the best treatment method for me. If I had a do-over I would include my third treatment, extended pelvic lymph node dissection surgery with frozen section pathology method with RP. It is my understanding from other patients and their web site the Mayo Clinic Rochester offers this procedure. Hope this helps. All the best!

[maley2711 in reply to NanoMRI]

RRely on your top Docs at those institutions to provide the best guidance on what the position of those lesions means as to best teatment option! A thing to remember...studies have shown that the lesions can actually be up to 50% "larger" than appears with MRI. I'd say, let your Docs know that you have seen studies about that fact!!!

I hada PIRADS 5 , aaaaaaand my fusion biopsy found only benign in the lesion, but one core 4+5 near but not in the lesion. Whether TRUS or transperineal, demand they take plenty of sample......maybe 3 minimum from each lesion, and another 12 "randomly" and vicinity of those lesions. I'd ask for Propofol sedation so no pain issues during the 10-15 minute biopsy.

Good luck!!! Obvious you are a good researcher!!

[j-o-h-n]

Get the best team you can handle..... and keep posting here. We have all been through what you're going through....and we're still around....

Good Luck, Good Health and Good Humor.

j-o-h-n

[Hidden]

Glad to hear from folks already. I've had some time to research and settle down. I'm hoping to have a better dialog with medical personnel soon. I want to discuss options. Today my conclusion is that a prostate biopsy is not even necessary. I can skip that and proceed directly to RARP. What NanoMRI says below about the pelvic lymph node dissection being done at same time makes sense to me. And I know that when the prostate is removed they have plenty of tissue to look at so pathology can make a pretty good determination from that.

I recognize that the 'cytoreduction' pathway is not for everyone, but I'm in great health for my age and think I'll sail through the surgery. Damn the SEs (torpedos) to stay within the maritime phrasing. I know that this is not a 'cure' and that BCR (biochemical recurrence) is still likely.

Comments?

[Mgtd]

My MP MRI showed two Pi-Rad 5 areas and one PI-RAD 3. I had radiation to prostrate and pelvic area. I also had 6 months of Lupron. Two months prior and 4 months post radiation.

It has been 15 months since radiation and so far so good. PSA is steady at 0.05. I now have been moved to getting PSA every 6 months by my MO and yearly by the RO. They share the results with each other. Makes it easy.

PSA is critical so do biopsy. My PSA was 4.8. Gleason score was 4+3.

The pelvic radiation was elective in case there was some unseen cancer. One other issue is I am almost 80 and in tremendous physical health other then prostrate issue.

Good luck.

[Hidden in reply to Mgtd]

I finally spoke to a urologic surgeon who is scheduled to do my biopsy in two weeks. He painted a bleak picture. Had to be fast as he was between seeing patients.

He said I better get a move on it. That more than likely I’ve got more metastasis than the MRI can show, and that I’m not a candidate for RP. And that the UW does not embrace transperineal biopsy for several reasons. That my disease is probably aggressive and will need to be treated aggressively. ADT + chemo. Once I'm referred to oncology.

He told me to lookup the Partin Tables to get an idea of my stage of cancer.

Ruh Roh. I guess I’m pretty sick.

Still, I’m questioning the doctor telling me I’m not a candidate for RP.

And if the MRI is not enough to show escape and metastasis, how does the biopsy help that much. Besides pathology and Gleason grade I guess. Genetics?

[Mgtd in reply to Hidden]

After the biopsy the next step is a PSMA scan to see if there is any visible spread. After that you will transition to a MO and perhaps a radiation oncologist.

I know this is hard but we have perhaps a 1000 or more guys on here just like you. It is going to be OK! Others will add to my input and most of them much smarter then me.

Keep the group informed and update your bio as you get new info. ASK Questions!

[Justfor_ in reply to Hidden]

"... how does the biopsy help that much".

In the above sentence (structurally) biopsy is the subject, help is the verb, yet, the object is undefined. In case it is the "patient", it doesn't help at all. But, if it is the "urologist", then it makes a loooot of help. Biopsies constitute a prime income for them and they wouldn't surrender this exclusive moneymaking domain of theirs to the radiologists. The implication of this is that you will not find any urological surgeon to operate on you without producing a biopsy. See it like driving a car without being able to produce a driving license at a police check.

[Hidden in reply to Justfor_]

Aw thank you so much for that information. And yes I do need to reread the book"Eats, shoots, and leaves" I fully intend to ask for a cut of my surgeon's salary.

BTW, I learned that at Mayo clinic they have a program now where a bunch of advanced practice people actually do the perineal biopsies. So it may not be a urologist income domain anymore.

[allie2020]

I had a successful RP six years ago and am doing very well today. But, one of my most basic beliefs about treating PCa is that if it is likely to have escaped the capsule, surgery is not a great option. Both of your lesions are suspicious for EPE and the 29mm one may have invaded a neurovascular bundle, I'm impressed that your surgeon told you surgery is not a good option. I think you should get the biopsy. I had two TRUS biopsies and the one under anesthesia was SO much less painful. Get with the very best MO's and RO's that you possibly can. You're going to be OK and live for many, many, many quality years. Go Badgers.

[Justfor_]

In the mpMRI report any mention of lesions' ADC (Apparent Diffusion Coefficient)?

[Hidden in reply to Justfor_]

The most details I have in the report for the lesions follows:

Lesion # 1

Location: transition zone mid gland 11 o'clock

Size: 13 mm, series 3 # 22

T2 score/characteristics: 4

DWI score/characteristics: 4

Dynamic contrast enhancement: ( +)

Prostate margin: Suspicious for extraprostatic extension

Local invasion: None.

PI-RADS category: 5 - Very High (clinically significant cancer is highly likely to be present)

Lesion # 2

Location: peripheral zone mid gland to apex left aspect of the hemigland extending from 1-5 o'clock o'clock

Size: 29 mm, series 450 # 11

T2 score/characteristics: 5

DWI score/characteristics: 5

Dynamic contrast enhancement: ( +)

Prostate margin: Involvement on the left

Local invasion: Tumor involves the left neurovascular bundle.

PI-RADS category: 5 - Very High (clinically significant cancer is highly likely to be present)

[Justfor_ in reply to Hidden]

Nothing like this, right? (served it's purpose and deleted by poster)

[Don_1213 in reply to Hidden]

I think the lawyers are responsible for this "Prostate margin: Suspicious for extraprostatic extension" I can't recall seeing a study where that isn't said. It means "well - we told'ya it might be worse than we thought..."

Kick back a bit. You've had doctors telling you things they shouldn't have. The one telling you gotta get moving on it - so he could operate? I think he's got a Porsche payment due..

I think TA will agree with me—your horse has left the barn. You need to get a good medical oncologist on your team and leave it to him to guide the treatment. The only use you have for the urologist is the biopsy if you decide on one and for the in-office Lupron shots (which make it an office procedure—and Medicare covers it).

The MO should know a good RO that he's worked with, and it's good if they're used to working together.

I'm older than you by a few decades - I had 45 radiation treatments (83Gy total) - which covered not only the prostate (singled out for special attention) but also the "prostate bed" for any lymph nodes that might be harboring nasty things and 18 months of ADT. I was just reading a thread with a posting I made that someone "liked" recently. I looked at it - it was 5 years ago... and I'm still here, and no sign of recurrence yet. My PSA number has been low, and consistently getting lower as time goes by.

You can see my full treatment story in my bio.. I should get in there and update it. Now on Repatha for cholesterol (mine was BAD BAD for 45+ years - now it's perfect) and Wegovy (Oxempic) for weight and some other side benefits that are being found out about it... but this isn't the place for that since it probably doesn't have anything to do with PCa.

Every day I wake up above ground is a gift - and I try to treat them like that (not entirely successful, but I try..) Someday 5-6 years in the future you'll be helping a newly diagnosed guy here with the knowledge you gain here and elsewhere.. and look back and think "What was I panicked about?"

[Hidden]

GAWD!That looks awful. I'd be afraid to show my prostate in public if I had a picture like that.

Nah, mine are much more elegant. It's almost like abstract art.

[Hidden]

Thanks everyone for your comments, insights, and humor. You guys are great.

[Derf4223]

@razorsaw You are blessed to have APCa in a time when you are a candidate for likely-to-cure treatment -- see triplet therapy. Doctors and trials have worked out the best sequences of various treatments. Many HU posters have thought differently -- the acid test is to go back 4-5-6 years and see if the different thinkers are still around. I fond quite few deleted 5-6-7 year old accounts and asked Darryl (HU admin contact) what it means if an account has been deleted. He said most likely deceased.

You should get familiar with trials like LATITUDE, CHARTED, PEACE-1, etc.

As for fretting about biopsy type -- the most important thing is to get it out of the way from a doctor who is highly experienced. Forget about worrying about TRUS vs perineal vs yadda yadda. I can understand that having hemmorhoids makes the thought of a biopsy difficult, but a biopsy will most likely not aggravate those.

As for the pace for treatments to go at, the big thing is to get started on firmagon. This will slow the heck out of any PCa activity -- to be followed by (in my case) RT and 21 months of ADT + generic abiraterone + prednisone. Your body _will_ undergo changes due to this which cannot be avoided. You'll need to fit in resistance exercise -- ~350 minutes/week. You will need to get a bone density DEXA scan.

Welcome to the Hydra club we have not chosen to belong to. She offers hard decisions with risks and unknowns, all the time. You'll get more of those as your treatment arc progresses.