PSA & 4K Score Concerns

[AnotherOldWhiteGuy]

Hello Group: I’m a 66 year old male, in above-average shape (until now). My PSA was 6.8 in December. I visited a Urologist last month for the first time, and he had me take a follow up PSA test, along with the 4K test. Here are the numbers I received a few days ago: 6.7 PSA with 4K Score of 24 and Free PSA of 14%. DRE revealed normal size, smooth prostate, with no nodules. I have a follow-up consultation next week. What I believe I’ve learned from this community forum, relative to next steps, is that, following my consultation, I should immediately have a 3T-MRI, with a likely Trans-perennial follow-up biopsy. Am I on the right course? Thanks!

[Tall_Allen]

An mpMRI is a controversial step - if your insurance will cover it on a first biopsy and you have an experienced radiologist, why not? If you can't get it, don't sweat it. Also 3T or 1.5T matters less than most patients think. Again, if you can't get 3T, don't sweat it.

If you can get a transperineal biopsy, it has lower sepsis rates. Not every place is capable of doing them. If your choice is between a urologist who doesn't know how to locate the right nerves on a TP biopsy and he has a lot of experience doing TRUS, go for the experience. Just make sure he does a rectal culture for resistant bacteria first.

[AnotherOldWhiteGuy in reply to Tall_Allen]

Great advice. Thanks. I’ll incorporate it into my questions for my urologist next week.

[AnotherOldWhiteGuy in reply to Tall_Allen]

Hello Tall_Allen: Well, I just got the results today from the Imaging Center, regarding my 3T MRI. The Radiologist’s report concluded “Slight BPH is present, with suspicious lesion in right mid gland peripheral zone”. He assigned me a PIRADS score of 4, with a notation that “clinically significant cancer is likely to be present”. I have a consultation with my Urologist this Wednesday, March 23, to discuss next steps. He informed me, prior to my MRI, that given my high PSA of 6.7, my 4K score of 24 and my Free PSA of 14%, he will likely recommend a TRUS Biopsy, with local anesthesia, capturing between 12 and 18 samples. Given todays results, I wonder if this approach will change when I meet with him Wednesday. I indicated I would want general anesthesia and would prefer the Transperineal approach, but he said he only performs the TRUS procedure and it will be done in his office - with no anesthesiologist available. He said he could give me a Valium if I’d like to minimize the pain from the local pain management injection.

The report further stated “The prostate measured 5.0 x5.0 x 3.9 cm. The volume is 51 cc. There is a vague T2 hypo-intense nodular area of interest in the right mid gland peripheral zone measuring approximately 9x6 mm at the 7:00 position. This demonstrates restricted diffusion and decreased signal on ADC map with enhancement concerning for neoplasm. No additional suspicious area observed. Mild BPH. No extracapsular disease.”

I’m not sure of the approach I should take with my Urologist, and once again, welcome any and all thoughts from you and the more experienced Prostate Health Nation.

Thanks again Gents!

[Tall_Allen in reply to AnotherOldWhiteGuy]

Ask for 4 cores from the PIRADS 4 area, 2 cores from each of the others. Make sure he knows how to give a periprostatic nerve block. If he doesn't find a new urologist.

[climb4blue]

You are on the right track. The 3T-MRI may show no lesions so you can avoid the biopsy trauma altogether. I am a proponent of general anesthesia for biopsies, because they can be painful.

If a lesion does show on the scan, then the same MRI images can be used to target the lesions. A fusion guided transperineal biopsy will give you the best chance for an accurate clinical diagnosis; otherwise, biopsies are just random samples and may not hit some or any of the lesions.

BTW: I had to go thru 3-levels of Cigna appeals, but eventually, was reimbursed for my pre-biopsy 3T-MRI. The NCCN mentioned MRI as part of clinical diagnosis and this is what got my appeal to be overturned and reverse the insurance denial.

You'll save costs and headache if you have the same doctor order the MRI that likely will perform the fusion guided transperineal biopsy if it is warranted.

[AnotherOldWhiteGuy in reply to climb4blue]

Met with the Urologist yesterday. Moving forward with the 3T MRI, with contrast agent, on 3/14. Good news is the Radiologist is not requiring fasting or an enema. Medicare is covering the costs. Urologist said if there is anything suspicious, he will only usethe Transrectal approach and take 12 random samples - regardless of the location of any specific lesions found. He does not use the Transperineal technique and said the risk of sepsis is less than 1%.

[climb4blue in reply to AnotherOldWhiteGuy]

Good news!Getting support both insurance-wise and doctor-wise is great progress.

Please consider an approach "beginning with the end in mind". There really are only about three main phases in your PCa journey, call it project PCa.

Although you may not need treatment, still, better to build a project plan that assumes you do and you can always end the project early if you learn you do not have PCa.

Phase I: Accurate clinical diagnosis.

Phase II: Based on clinical diagnosis, exploring standard of care options that most align with clinical diagnosis and side effects you feel you can tolerate.

Phase III: Based on your treatment choice, select the best care team. There is also a trade-off between choosing to be treated locally or choosing to travel for your care team.

Looking at these phases above, the clinical diagnosis becomes the pivot in regards to treatment, side effects, and the treatment care team choices. To me, the trust in clinical diagnosis accuracy for making treatment decisions is a critical step, much more than just a PCa presence test to determine if you have PCa or not.

If you click on my profile and look at my prior postings posted during my phases, then you will see there is a significant chance of clinical misdiagnosis.

"Beginning with the end in mind".

I was not comfortable with a random biopsy prior to an MRI. A random biopsy may hit one lesion, but it may not be the dominant lesion needed for the optimal treatment choice. In my case, my MRI showed lesions in my anterior portion of my prostate, so a transrectal random biopsy likely would have completed missed those because of the entry point of the needle biopsy in relation to the lesion locations.

Good luck in what ever choices you make. We are all here to help and support your decision, whatever it is.

[AnotherOldWhiteGuy in reply to climb4blue]

Very insightful comments. Thanks!

[timotur]

The 4K Score of 24 means you have 24% chance of a Gleason 7 or greater tumor. The free-PSA test of 14% is near the usual cutoff for a biopsy of 10%. So these numbers are suggestive of getting a biopsy. You may consider getting a CDUS biopsy (color-doppler ultrasound)-- with it the Uro can see areas of concern in real-time and target those spots for biopsy. CDUS shows increased blood flow around cancerous cells. On the West coast, Dr Scholz in Marina Del Ray does CDUS. I had mine done by Dr Bahn in Ventura, but he has since retired.

[London441]

I was given a transperineal biopsy. My urologist accurately predicted my insurance wouldn’t pay for the MRI and strongly suggested I pay for it out of pocket if I could so I did.

I have read many accounts of pain accompanying the biopsy, but that was not my experience.

You say you were in above average shape ‘until now’. That hasn’t changed. At worst you may now be in above average shape with prostate cancer.

Keep that up no matter what! It will mean everything going forward.

[bobdc6]

After my initial consult, I avoided urologists (surgeons) in favor of radiologists, in the form of a MP 3T MRI and in-bore biopsy (Busch). The doc was able to hit a very small G 4=5 (Epstein), which was later radiated (proton), plus 18 months ADT. This was all in 2017, so there may be more alternatives by now., this is a fast moving field. My last PSA was undetectable, so far, so good.Take your time, do your homework.