I noticed my PSA was increasing slightly over the past few years. Nothing major, but the Doctor was watching it and when it creeped to 4.4, requested that I go and get it checked. No history of prostate cancer in the family at all.
I saw a specialist who found nothing during the physical examination, but suggested I get an MRI just to be certain. Turns out it was lucky that I did, because the results are not very positive. I am booked in for a biopsy in two weeks, but have so many questions before it that I didn't ask the specialist. I wasn't expecting anything to be found, so I think I went into shock when I got told it didn't look good and I couldn't regather my thoughts.
My MRI results are below, but it would be great to get some preliminary feedback on what peoples views are and what other things I should be asking my specialist before the biopsy. Seeing a PI-RADS 5 is honestly that scary.
PROSTATE SIZE.
Estimated prostate size = 51 cc. (PSA density = 0.09 ng/ml.)
PROSTATE FINDINGS.
There are no suspicious findings within the anterior fibromuscular stroma.
Abnormality No. 1 located at the mid gland to gland base, right transition zone extending into the
right anterior transition zone at the gland base, 22 x 15 x 22 mm homogenous T2 hypointensity
with markedly restricted diffusion. Suspicious of intermediate/high-grade neoplasia.
Score T2W: 5
Score DCE: Non-diagnostic
Score DWI: 5, minimal ADC value = 624
This fits best with: Intermediate/high-grade neoplasia and a PI-RADS 5 lesion.
EPE: Negative.
LYMPH NODES AND BONES.
There are no suspicious pelvic lymph nodes or focal bony lesions within the imaged volume.
OTHER FINDINGS.
The seminal vesicles outline normally.
Written by
Fabio_08
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Most of us have been struck dumb after hearing the word "cancer."
Keep in mind that the MRI only tells you that the lesion is highly suspicious for cancer, but it doesn't tell you if you do, in fact, have prostate cancer.
The way the biopsy usually works is they stick an ultrasound probe up your ass (it's small and sounds worse than it is). You will be told to do a Fleet enema before. They usually fuse the real-time ultrasound image with the previous MRI image (more rarely, this is done inside an MRI machine "in-bore" without the ultrasound). You can ask if it's "fused image" or "in-bore," and whether an interventional radiologist will be there.
They might give you an antibiotic injection. (see below)
They numb the area, and slowly inject lidocaine as the needle approaches the right nerve. They inject more lidocaine into that nerve. After that (and they should wait a few minutes), you won't feel anything. Some prefer to give general anesthesia (hopefully, with propofol). You can ask in advance which they do. Ask if your urologist has experience doing nerve blocks (don't use the term "local" which can mean a lot of different things).
They then pull out at least 16 cores (in your case) of tissue with an 18 gauge needle. 18 gauge is about the size that they use when they give a penicillin injection. It sounds like a rubber band snapping each time. If the nerve block worked, you won't feel a thing. They should take 4 cores from the area identified by your MRI.
The top hospitals are changing their biopsy procedures. They used to stick the needle through the rectum (transrectal), but this injected fecal matter into the prostate, and with resistant e coli becoming more prevalent, the antibiotics no longer worked. So they are changing to inserting the biopsy needles through the perineum (taint). This is particularly important for you because your suspicious area is much more accessible going in trans-perineally. The infection rate is minimal, and they only need to clean the area - antibiotics are unnecessary.
A pathologist will look at the cores under a microscope and grade them. If you are in the US, also ask that your cores be sent to Epstein's Lab at Johns Hopkins for a second opinion. It may cost $300. Epstein is THE world expert on grading prostate biopsies - his opinion is definitive.
In 1-2 weeks, your urologist will meet with you to go over the results. Make no decisions at that time - especially if he pressures you to. Here are questions to ask him at that meeting:
I will comment on your ADC value. You wrote: "minimal ADC value = 624". You either missed the decimal separator (i.e. 0.624) or your lab is not using the x10^-3 normalizer.
The essence of this number is that the smaller found, the higher the Gleason Score (GS), although it only has a good discrimination power between GS 6 and 7-8-9. Personally, with a 0.46 min ADC I was found with GS 8 at biopsy and upgraded to GS 4+5=9 post RP pathology.
According to the following figure, if you are -in your life a lucky individual- it can settle down to GS 6. Your most probable score will be somewhere between 7 and 8, say 7b or 4+3=7.
I understand that it will be difficult for you to see it via my own eyes, but the fact is that you got it earlier than I. Also, if this is of any consolation to you, I believe that you are in good medical hands. I know many urologists that with a PSA of 4.4 and a negative digital examination would have told you to come back next year.
This is wanted my UR wanted to do with me on AS for a year with very small volume 3+3, PSA of 4.7 and normal DRE. I insisted we not wait - did mpMRI, fusion biopsy, and now starting SBRT.
Just a follow up question on this table. Does this refer tothe ADC (min) or the ADC (mean)? My understanding is that these are both different measurements.
Well that’s good to hear, I didn’t know what I was looking for. The specialist didn’t say too much, just said that we would need to do a biopsy and see where it goes from there. He did mention it being in the TPZ which from what I can tell is the best of two evils 🤨
The latest trend in your case, trialed in Australia, is PSMA PET CT for high risk cases ( with PIRADS 5 you are high risk no sugar coating here) before treatment decision. Two and a half years ago when I was diagnosed I asked my urologist about it, but he thought it was useless. I am certain that 5 years from now it will be the standard protocol to proccede. For the time being is a very exotic thing to ask your doc and of course you will have to pay out of pocket. Remember me in 2026.
The latter. Now regarding the lesion's position mid gland to base. It would be better if it were mid gland to apex. The reason for this is that the base, oppositely to the connotation it brings to lay people is the top part of the prostate adjacent to the bladder. We don't want it to be there for various reasons. On the bottom side, the apex, the surgeon can ressect all the tissue deemed necessary at no risk.
Sorry to keep probing, but does 'bad' mean bad prognosis or just an aggressive form of cancer? I thought the position it was in was good, turns out I got that wrong!
High risk is identical to high grade like your report states intermediate/high grade. It means that it is not a cancer in its infancy. Most people would believe that this means more aggressiveness hence worse prognosis. I DO NOT. I am a retired engineer and know that you can't assess the velocity of a vehicle via a single point in time. Aggressiveness and prognosis is a dynamic variable. To get the most elementary estimate of it you must have at least 2 points and a head scratch of the law it follows. In your case we only have a snapshot of the present. We do not know if it started a couple of years or a couple of decades ago. We also do not know if it proccedes linearly, exponentially or whatever. We only have a single snapshot. The rest is medical bs because docs like to utter some difficult but vague scientificish jargon when the accurate answer is: I can't tell.
Yes and biopsy will not tell you that in a 100% certain way. Not even surgery can do that. PSMA PET CT is the best non invasive tool there is but you can't time travel to 2026 and Australia is in Covid isolation for the time.
Lost you here. Where this T3 came from? Your report translates to T2a -T2b, not even T2c if I read it correctly. Is it possible that you are confusing it with the machines 3T which stands for the magnets rating in Teslas?
Right, but the clinical staging uses also the T scale from 1 to 5 (actually to 4 as T5 is final), The T scale is for the clinicians to use. Radiologists use the PIRADS scale as there is no 1:1 equivalency. Take my word you are FAR better than you think you are. You are fortunate to have found it as early as practically feasible.
I was told that the T3 machine was more accurate than a T2 and I had to go to a specific place (not many in NSW) to have it done. I am hopeful that it is more accurate, just not too sure.
Thank you so much, honestly. Does so much being able to talk to somoene about it.
You are most welcome. Please use the right abreviations so you don't confuse people: 3T for the machine. After you get your biopsy that hopefully will be guided, also called fusion, your docs will prescribe a CT and a bone scan (totally useless and vastly inferior to a PSMA PET CT but the protocol dictates so) and finally they will assign a T2 stage to your case. It is a shorthand for your current situation. Nothing concrete as a re-stagimg can move you a couple of slots up of down. Better than nothing though. There is a parallel thread here where the poster, also a PIRADS 5, had the fusion biopsy revealing two lesions in the suspected areas that would otherwise had been missed under a if blind biopy. Check it you haven't done already so.
T_A gave some excellent advice and what you can expect.
I would advise as he, a trans-perineal biopsy if possible. As he said, the trans-perineal will allow better access to the area to be biopsied--and the fecal issues with sepsis. An in bore biopsy, real time, with a mp 3.0T MRI taking as few cores as necessary should be thoroughly discussed prior to the biopsy. Biopsies can cause damage even when done by experienced doctors.
I have irreversible damage from the drugs Cipro and Levaquin used in biopsies and treatments. Cefdinir or Rocephin are drugs that can be used rather than drugs from the fluoroquinolone family. Insist that Cefdinir or Rocephin be used. If you do your due diligence with your keyboard you will soon understand why I tell you to avoid these drugs.
If you are fortunate you will have at worst a Gleason 6 which most men live with for their entire lives. Some lifestyle changes can help keep cancer suppressed.
Good advice here. I was on AS for two years before deciding on SBRT. There’s a very interesting article in the recent Prostate Cancer Foundation’s website on the link between sugar and (Prostate) cancer. In retrospect, I wish I had been much more aggressive in controlling glucose intake during the time by PSA was rising. So while you are in the midst of making your own decision, consider the “lifestyle change” that is directly tied to diet.
It is scary to be sure and lots of info coming at you is both good and bad. Take a look at the Prostate cancer foundation website. It is comforting and informative. The bottom line on this is that you are more than likely going to die of something else in your old age. Unless you have very advanced. PCa, the disease is treatable. Not that you want to have it, but the science of treatment gets better year by year.
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