Hope for a scared daughter after MRI results - spread to seminal vesicle?

[hopefulpigeon]

Hello all this is my first time posting. Thank you for taking the time to read my post. I just received my dad's MRI results and I'm very concerned. He only began going to the doctor again about 2 1/2 years ago after not going to the doctor for about 10 years. His PCP did some bloodwork and he had a 7.16 ng/dL PSA result August 2022 and then 9.34 ng/dL November 2022. Since then he has been seeing a urologist and has had the following varying PSA numbers:

02-15-23: 7.86 ng/mL

05-26-23 6.13 ng/mL

10-13-23 6.77 ng/mL

03-29-24 8.0 ng/mL

09-27-24 9.4 ng/mL

This first Urologist suggested we keep monitoring PSA as he stated that his prostate felt fine and my dad doesn't have symptoms. He also stated that even if he does have cancer it might not be fast progressing nor need treatment.

However at this point since this last test resulted in a 9 PSA like he had about 2 years prior, I decided to seek a second opinion. He had a visit with Dr. Reiter at UCLA in December 2024. He ordered an MRI. I've included the MRI results I received yesterday below.

He has a follow up appointment with Dr. Reiter in the middle of March. Should this length of wait be fine? I added my dad to a waitlist for a sooner appointment because my dad and I are anxious to see the Doctor. The Doctor told us he would call or message us when he got the result so I'm wondering if I should ask if we should move forward with the biopsy before my dad's schedule appointment? I'm scared of the cancer spreading or spreading more.

I'm concerned because it seems it has spread outside the prostate and into the seminal vesicle. I'm assuming Stage IIIb? I told my dad this can be cured and I'm trying to be very positive. but I'm learning as I go. I feel sad, I feel guilty. I wish I would have been more proactive and sought out a second opinion sooner but he seemed to be doing well that I could not have expected this. He is of normal weight, doesn't drink/smoke, eats healthy, and has a joyful, extroverted, positive personality. Not a day goes by that he doesn't make me laugh. I'm his only daughter, in my 30's without any kids of my own. My dad is my whole world. His father died a long time ago from an accident and didn't have medical access so we don't know if he had prostate cancer. His mother lived to 98 years old and passed in her sleep a few months ago.

Can someone please give me some hope...your insight is very appreciated.

Age: 68

“3T MRI OF THE PROSTATE WITH AND WITHOUT CONTRAST and with 3D post-processing

CLINICAL HISTORY: Prostate Cancer

PSA 9.4 ng/mL (9/27/2024)

COMPARISON: None.

TECHNIQUE: MRI of the pelvis was performed on a 3 Tesla MAGNETOM Vida scanner. A transabdominal phased array was used. Small field of view sagittal, axial oblique and coronal oblique T2W TSE high resolution images and diffusion weighted images with

apparent diffusion coefficient map were obtained. Pre- and post-contrast axial dynamic view-sharing time-resolved gradient recalled echo T1-weighted images are acquired with intravenous administration of gadolinium contrast. Offline post-processing on a

dedicated InVivo DynaCAD 3 workstation was performed for generation of time-intensity curves and pharmacokinetic maps and 3D contouring of the prostate gland and any target lesions using combined automated and manual segmentation techniques.

CONTRAST: gadobutrol (Gadavist) 1 mmol/mL inj 7.5 mL.

FINDINGS:

Quality: Excellent

The prostate measures 31 g based on contour, (4.3 cm x 3.6 cm x 3.8 cm).

PSA Density 0.30 ng/mL/cc

The background transition zone is enlarged and heterogeneous. The background peripheral zone is heterogeneous with linear and wedge-shaped foci of T2 hypointensity, consistent with sequela of prior prostatitis.

The following appears suspicious (PI-RADS 3, 4, or 5):

Target #1/ ROI #1 (3D T2 slice #22)

Location: right posterolateral peripheral midgland to base.

Clock-face axial location: 6-9 o'clock.

Cranio-caudal location: 35-85% of distance from apex to base.

Longest diameter: 2.4 cm.

Capsular involvement: minimal extracapsular extension that approaches and likely involves the neurovascular bundle, particularly at the apical midgland (8-31).

T2 signal: irregular markedly hypointense signal with irregular margins, 5/5 suspicion.

Diffusion-weighted imaging: focal markedly hyperintense high B-value DWI and markedly hypointense ADC, 650 square microns/second, 5/5 suspicion.

Dynamic contrast-enhanced perfusion: early, intense with plateau positive.*

Enhancement kinetics: Ktrans 0.107, Kep 0.655, iAUC 2.850.

Suspicion for extracapsular extension: 5 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite).

Suspicion for neurovascular bundle involvement: 3 (1 = none, 2 = possible, 3 = highly likely).

Suspicion for seminal vesicle invasion: 4 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite).

Overall PI-RADSv2.1 Score: 5/5 (1=very low suspicion, 5=very highly suspicious).

Overall UCLA Score: 5/5 (1 = very low suspicion, 5 = very highly suspicious).

Limited views of the pelvis reveal no enlarged lymph nodes. No focal bone lesions are present.

IMPRESSION:

1. Focal findings suspicious for neoplasia with a PI-RADS 5 lesion in the right posterolateral peripheral midgland to base.

2. Capsular margin: suggestion of capsular, neurovascular bundle, and seminal vesicle involvement as described above.

Overall PI-RADS Category: 5/5

*Standardized reporting guidelines follow recommendations by ACR-ESUR PI-RADS v2.1

SB1419

*Modified PI-RADSv2.1 Scoring for Dynamic Contrast-Enhanced Imaging is utilized at UCLA as follows: a peripheral zone lesion will only be considered positive if it corresponds to a focal abnormality on T2-weighted and diffusion-weighted imaging and

enhances earlier than (not contemporaneously with) surrounding normal peripheral zone tissue.

Appendix (based on UCLA data/publications)

Overall MRI sensitivity for prostate cancer detection = 47%

Sensitivity for tumors > 1 cm or for Gleason > 3 + 4 = 72%

In-Bore MR-Guided Biopsy CDR MR/US Fusion Biopsy CDR

PI-RADS 2: 7% PI-RADS 1/2: 15%

PI-RADS 3: 44% PI-RADS 3: 23%

PI-RADS 4: 63% PI-RADS 4: 64%

PI-RADS 5: 94% PI-RADS 5: 80%

1. Eur Urol 2019;75(5):712-720

2. Radiology 2017;283(1):130-139

3. Cancer 2016;122(6):884-892

4. Abdom Radiol 2016;41:954-962

5. Eur Urol 2015;67(3):569-576

6. Am J Roentgenol 2015;1:W87-92"

[GP24]

The cancer had plenty of time to spread since August 2022, therefore you can wait for your appointment. PIRADS 5 means he almost certainly has prostate cancer. He has to get a biopsy now. Should he decide to get surgery, they will remove the seminal vesicles. Otherwise they can be radiated.

[Justfor_]

Close match to my own case where the mpMRI didn't detect any seminal vesicle invasion (SVI) yet the post prostatectomy pathology revealed a unilateral one. Hence, I don't put much trust on mpMRI findings re SVI. On the "bright" side my ADC was lower (higher is better). Please don't get alarmed, it isn't as serious as you envisage it to be. Check my bio, 6 years later I am doing fine. He will need treatment no doubt but before anything else have him taken a PSMA PET/CT scan.

[VictoryPC]

You can control this.

[Tall_Allen]

You know nothing until he has a biopsy. So far, there is suspicion, but he needs confirmation from a biopsy.

He also needs a PSMA PET/CT to rule out distant metastases. If the MRI is showing extension into the seminal vesicles, and they can feel that it has penetrated the prostate capsule, he is stage T3b, which will qualify him for a PSMA PET/CT.

While you are waiting for your next appointment with Dr.Reiter, I suggest you also make an appointment with Dr. Amar Kishan, a radiation oncologist.

[TylexGP]

Hi Hopeful, Please look at my bio I am younger then your Dad but I had a similar MRI and PSA at diagnosis. I am Almost 4years since initial diagnosis. I would personally want a biopsy done. Please feel free to reachout.

[Manilo]

You can do a PSMA PET CT scan while you wait for the biopsy. And try to have the biopsy sooner. Ask for a transperineal guided biopsy. Avoid transrectal biopsy. The guided biopsy will take some random samples but will aim to get the suspicion locations.

If the PSA is rising and with Pirads 5 and very suspicious MRI, I would start ADT to halt progression and shrink the tumor for better radio therapy or proatatectomy with davinci robot, but that's just my non medical opinion.

After the biopsy, the prostatectomy needs to wait some weeks to clear the edema. Meanwhile ADT can halt and shrink the tumor.

A PET PSMA CT will discard mets and also assign a very accurate diagnosis in the prostate.

[Darryl Partner]

Welcome

[Hailwood]

Get the biopsy done and then the PSMA PET scan as per Tall Allen. I had the biopsy prior which showed all areas cancerous and after surgery to remove the PSA kept going up and they found cancer in the abdomen lymph nodes….its not the end of his world, I ve been on Apalutamide/Lupron for 4.5 years and still work full time with some of the usual side effects but still enjoying life. Get the info on where it is and where it has gone to and then begin treatment. Good luck on your Dads journey, he is lucky to have your support

[Newtonmore]

Hi

I'm from UK. Protocols here must be different.

Initial PSA 55. This indicates probable presence of PrCa.

Immediate follow up with CT scan, bone scan and biopsy.

The biopsy is important as it tells you how aggressive the cancer is. My Gleeson score was 4 + 5, which is very aggressive- therefore "watch & wait" wouldn't be an option even if my tumour had been confined to the prostrate.

I was immediately put on Bicalutimide for 6 weeks. Prostap (ADT) injection started at diagnosis (full report) and is given every 3 months. I had an MRI scan prior to starting radiotherapy (20 days) to prostate, seminal vessicle and pelvic lymph nodes. Radiotherapy started 3 months after initial start of treatment to allow androgen depletion to shrink tumour.

Because of high Gleeson Score I was advised to take Abiraterone 1000mg daily, which I did for 3 months but I am on-off because it plays havoc with my liver (ALT levels increase).

IMO (and I'm not a Dr), without biopsy you do not get full diagnosis as to the "aggressiveness" of the tumour

[j-o-h-n]

Greetings hopefulpigeon,

Remember Pca is a slow growing disease... He'll be around to make you laugh for at least another 25 years. Keep posting and keep his bio up to date.,,,,,

Good Luck, Good Health and Good Humor.

j-o-h-n

[SteveTheJ]

;tldr ... from the diagnosis to first MD Anderson appointment was almost two months for me and I'm doing fine today. Also, I never had any symptoms but still have stage 4.

Don't fear; instead, focus on options. Get a good doctor, one who talks to you (and listens) in your language. If you don't find one the first time, talk to others. Oncologists are everywhere.

[CRPCMan]

Mine has seminal vesicle involvement and diffusion in the entire gland so inoperable. 15 years later I'm stable. UCLA is a great place . I know because I had my radiation there.

[petabyte]

As some others have mentioned, the wait time for a biopsy and PET/PSMA can be long, so I suggest you find out how long and try to book them already if possible.

[timotur]

Very similar to my pathology six years ago, see my bio, and consult with Dr Chang at UCLA.