I decided to get a PSMA PET in lieu of a biopsy and, now that I have the report, I'm not sure I totally understand it.
First of all, there is no mets anywhere and all that is good. As for the prostate itself, the report really said 2 things:
1.). mi-T-stage: T0 (I'm pretty sure that means no detectable tumor in prostate)
2.). Then it says the following things about the prostate: "low level heterogeneous glandular uptake but possible focality in the left hemigland.
There are no SUV scores in the report and all the mi scores are 0. Is the report saying "I don't see a tumor but maybe I see something after all..." I think the "low level heterogeneous uptake" is common in benign prostates that have been beat up like mine by prostatitis, bph, etc. Is the Radiologist doing a CYA but saying "I kind of maybe possibly see something even though I see no tumors so if you don't do anything about this don't blame me because I said maybe I see something" Any thoughts?
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"The sensitivities of different prostate cancer detection methods vary depending on the imaging technique, the stage of the cancer, and the tumor’s characteristics. Here's an overview:
1. Random TRUS Biopsy (Transrectal Ultrasound-Guided Biopsy)
Sensitivity: ~50–70%
Random TRUS biopsy involves taking systematic samples of the prostate, typically 12 cores, guided by ultrasound.
Strengths:
Standard and widely available.
Useful for diagnosing prostate cancer in patients with elevated PSA levels.
Limitations:
Relatively low sensitivity, especially for small or anterior tumors.
High false-negative rates because it samples only a fraction of the prostate.
Cannot reliably differentiate between clinically significant and insignificant cancers.
2. mpMRI (Multiparametric MRI)
Sensitivity: ~85–95% for clinically significant prostate cancer (Gleason score ≥7).
mpMRI combines T2-weighted imaging, diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) imaging to evaluate prostate lesions.
Strengths:
High sensitivity for detecting clinically significant cancers.
Allows targeted biopsies (MRI-TRUS fusion or in-bore MRI-guided biopsy).
Can identify anterior and small lesions missed by TRUS biopsy.
Limitations:
Limited availability and high cost.
Requires specialized expertise for interpretation.
May miss small, low-grade (clinically insignificant) cancers.
3. PSMA PET Scan (Prostate-Specific Membrane Antigen PET Imaging)
Sensitivity: ~90–95% for detecting clinically significant prostate cancer and metastatic disease.
PSMA PET scans use radiotracers that bind to the PSMA protein, which is highly expressed in prostate cancer cells.
Strengths:
Exceptional sensitivity for detecting both primary prostate cancer and metastases.
Superior for staging, especially in detecting lymph node and bone metastases.
Useful in biochemical recurrence with low PSA levels.
Limitations:
Limited availability and high cost.
Less effective for detecting very low-grade or PSMA-negative tumors.
mpMRI ~85–95% High sensitivity, detects anterior lesions Expensive, requires expertise.
PSMA PET Scan ~90–95% High sensitivity, detects metastases Expensive, limited availability.
Clinical Implications:
mpMRI is preferred for initial imaging in patients with elevated PSA or suspicion of prostate cancer due to its high sensitivity for clinically significant disease.
PSMA PET scans are primarily used for staging and detecting metastatic disease, especially in high-risk or recurrent cases.
TRUS biopsy remains a standard diagnostic tool but is often combined with mpMRI for targeted biopsy to improve diagnostic yield.
For personalized detection strategies, patient risk factors, PSA levels, and clinical presentation guide the choice of diagnostic modality."
Tall Alan reports that sensitivities of MRI and PSMA-PET scans are less than 40-50%, but you're reporting numbers that are 90-95%.
I wonder why there is such a discrepancy?
The reference that TA cited is from 9 years ago (2016). Perhaps the MRI and PSMA-PET scans have improved since then (e.g., higher strength magnets, better software)?
I was diagnosed with a simple ultrasound guided biopsy and when I said that it is painful now a doctor said that she just punched through the cancer. I wish to say that you don't always need mpMRI or PSMA pet scan in order to diagnose prostate cancer.
One more thing. A simple CT scan before that already diagnosed me as de Novo polymetastatic prostate cancer in my bones with distant spread.
And if neither the MRI nor the PSMA pet scan will not show anything you should be happy because you may don't have high grade prostate cancer.
It doesn't work the way like why would you have PSMA pet scan and mpMRI when they are not accurate.
In my hospital a British nurse who was assisting the prostate MRI said to me that in UK every one is getting the prostate MRI first before the biopsy and that makes sense because they could have some idea where is the cancer.
and today maybe radiologists (everywhere) are more experienced with their findings/opinions? Had my first PSMA in Europe seven years ago while limited trials were underway here in US. I have had three subsequent PSMAs here in US and IMHO US still lags behind - especially on tougher cases.
UCLA is an established 2nd opinion center - they report more than 50% significant differences in opinions.
Nine years ago had an mpMRI in US and second (better one) in London, England. Again, over there, far more experienced.
oh "don't get me started on how Docteur Jehanne CALVES, Chirurgien Urologue, Le Mans, France outperformed multiple US urologists with my (tiny) kidney stone trapped by RT related ureter strictures.
If you are looking for a second opinion I use EXCEL DIAGNOSTICS & NUCLEAR ONCOLOGY CENTER Houston, TX (for first and 2nd opinions, depending). They did my first US based PSMA PET CT.
This is still reassuring that they didn't find anything. How your PSA is changing? Did you try Bactrim to see if it will stabilise the PSA?; could you get a mpMRI in order to determine the PIRADS score of the prostate?
Thanks for your reply! My psa has fluctuated for years from 8-12. My psa density has never been above .14. My prostate is 70ccs, I have had at least 3 bouts of bacterial prostatitis - the most recent being a year ago when my psa went to 18. I did take bactrim for that and it came back down to 9. I also have chronic prostatitis and bph confirmed from MRI's and symptoms. I've had 5 MRI's with both Pirads 3 & 4 lesions (and one Pirads 5 that was a confirmed error on the part of the radiologist). One MRI was completely clean. Some of those lesions have disappeared, another grew 1mm but is less conspicuous, and the other shrunk 2mm and has not increased in being conspicuous. The plan for years has been to watch things closely and not to biopsy until there is more suspicion that what we are seeing is not background noise from a prostate that has been beat up from benign causes. But, my doctor suggested a month ago that I get a biopsy or PSMA within 6 months. I think we both felt that it was time to see for sure. So, I did the PSMA. If the doctor thinks it's suspicious, I would obviously then move to a targeted biopsy.
PSMA PET scans and Biopsies are two parts of the diagnostic process. One is not done in lieu of the other; they are additive. The biopsy results let you know whether there is cancer present in your prostate and provides a general idea of its level of aggressiveness. The PSMA scan lets you know if the cancer has spread outside of the prostate and, if so, where it has spread.
First I recommend that you find an NCI Certified Comprehensive Care Center in your area. Get an appointment with a urologist there and let them get you the answers that will help guide you through the diagnostics correctly. You don't mention your PSA or Age. You also didn't say anything about an MRI. An MRI will be your first step. It will pinpoint any lesions that you might have in your prostate. The lesions will be graded on a scale of 1-5 (least likely to be cancerous to most likely). A urologist then conducts a biopsy; using the MRI as a MAP to determine where to take samples from (lesions). Once you get the results from the pathologist, you'll have a clearer picture of what you're dealing with.
Looking ahead, then you can decide on Decipher scores, etc. Generally PSMA comes after the Biopsy.
Thanks. I do know that a PSMA isn't done completely "in lieu" of a biopsy so poor choice of words on my part. I've had MRIs and my doctor believes they are likely to be reflecting background noise from a benign, beat-up, prostate. But, he wanted a biopsy anyway. But, he said that I could do a PSMA and, if nothing lit up, we would be within a reasonable confidence interval to say that I currently don't have a significant cancer to biopsy and then we would just continue to watch everything closely. So, hence my question above: I'm looking to see if someone has enough experience with PSMA to interpret the language in my report that I outlined in my question.
I have had four PSMAs, Ferrotran nano MRI, multiple mpMRIs, and now multiple imaging with my recent metastatic melanoma finding. I have the privilege of going over all imaging results with an independent radiologist. As a patient I am comfortable interpreting them.
No, I do not think your radiologist is doing a CYA. IMHO typical of challenging finding - there are features to notice but uncertainty. Your prostate bed is a bit of a mess. I offer following comparitive understanding and as reason why I do get second radiology opinions.
The Ferrotran nanoparticle MRI I share about , which correctly identified multiple cancerous pelvic lymph nodes, was no more definitive than "There are 3 suspicious nodes (Level of Suspicion (LOS) on a 5-point scale); 4's. There are two equivocal nodes (LOS 3). There a no sign for bone marrow metastases. IMPRESSION - 5 potential positive nodes, not positive on the PSMA-scan due to small size."
This past July a PSMA that identified what was determine by biopsy to be metastatic melanoma in my liver had this second opinion reading - "There is no evidence of PSMA avid lymphadenopathy or osseous metastases. There is a suspicious new non avid 2cm hypoattenuating lesion near the hepatic dome which can be further characterized with an MRI as tumor involvement cannot entirely be excluded". The primary report reading is "A new 2.3cm hypotenuse lesion in hepatic segment 8. Mild PSMA uptake is lower than surrounding background liver activity. Findings are concerning of metastatic disease of uncertain origin." Biopsy confirmed metastatic melanoma and I was on to doublet immunotherapy.
I rarely suggest - but - I suggest a second radiology opinion. I also suggest a liquid blood biopsy - I find these very helpful (others speak against but this does not deter me). As for a biopsy, IMHO the challenge is the doc hitting the most critical/important bits. My PCa Dx biopsy indeed missed the worst bits of my tumor. When I had the liver biopsy I was all focused and demanding on hitting the right spots. After multiple discussions with doc looking at my MRI and ultrasound we proceeded, and I intently observed, until I passed out Hope this helps. All the best!
I don't know how could they biopsy you if nothing is certain on the MRI and there is no definite finding on the PSMA pet scan? Maybe blindly? Because looks like that MRI guided biopsy would not be helpful?
I am not a doctor but had a PSA of 50 and the doctors still thought that I have an infection and wanted to put me on Bactrim. I already had neurological symptoms but nobody cared. They just said that it will go away in six months just do walk down the hill and they didn't care that beside a PSA 50 i also developed painful sciatica I had to sit down the wall and the floor in order to get some relief until my GP finally sent me to do a CT of my spine and the next day at 8.0 am I was doing a nuclear medicine bone scan on the recommendation of the radiologist who interpreted my CT of my spine and I was diagnosed as polymetastatic prostate cancer in my bones with distant spread in my neck etc.
Again if nothing show up on the mpMRI and the PSMA pet scan with investigational CT with contrast than you should celebrate because you most probably don't have any significant high grade prostate cancer. Ok, because a more than 100 years old biopsy is a gold standard they could try to perform an ultrasound guided biopsy most probably blindly because well nothing show up on the MRI and the PSMA pet scan with investigational CT scan with contrast.
I forgot to say again about the already mentioned decider genetic testing which could further reassure you that hopefully your cancer will not metastasize.
Ok, all these diagnostics methods are just scams.
My old GP said. It is medicine we don't know everything.
And my first medical oncologist professor Richard Epstein said very often when I asked him something: we don't know.
It sounds like you're reflecting on the challenges and uncertainties of medical diagnostics, especially regarding prostate cancer. While imaging and genetic testing have advanced significantly, they aren't perfect, and sometimes traditional methods like biopsies remain the "gold standard" due to their long history and proven utility, despite their limitations.
Your GP and oncologist's acknowledgment of uncertainty is actually a hallmark of good medicine. Medicine is a science, but also an art—it evolves, and there are always unknowns. Their honesty shows that they're not overpromising outcomes or definitive answers where they don't exist, which can be comforting in its transparency.
If you're feeling frustrated or skeptical about the diagnostic process, that's understandable. But remember, while no system is perfect, the tools and techniques available today are designed to minimize risks and provide the best care possible based on current knowledge. It’s always okay to seek a second opinion or discuss your concerns with your healthcare provider—they're there to guide and support you.
If there is a process they will probably pick it up at some point in time if you are persistent going to the doctors. I did go persistently for 5 months with high rapidly rising PSA, with neurological symptoms escalating on sciatica and they still believe that I most probably have only have an infection and the sciatica will go away in six months because I am just plain old. They had a consultation and it was paid by the Medicare and I will come again and they will charge again. But I was persistent going to them. I had a feeling that the doctors think that I am just a hypochondriac. Doctors like to use that word if you are visiting them often. My sister is a doctor and she said that despite my visits and complains they overlooked a terminal illness.
A doctor tells us you probably have an infection and gives you bactrim so of course that’s what we do. That happened to me last year so that’s what i did. In my case, it was actually an infection. It’s hard to hear the current difficulties you’re having but we all know enough to know how many effective weapons you have at your disposal! Thank you for taking the time to help me and I wish you better than well!!
I am on degarelix and Bicalutamide now more than six years after my diagnosis as de Novo polymetastatic prostate cancer in my bones with distant spread in my neck. My PSA is stable at 2.5 and I avoided two clinical trials until now proposed by my medical oncologist. The first one because the clinical trial finished before I become eligible for it. It was testing abiraterone plus prednisolone plus olaparib. The second clinical trial what I avoided was an Astra zeneca phase I clinical trial, a toxicity study of the new less toxic Astra zeneca parp inhibitor plus darolutamide first in human toxicity study.
I said to them that I am planning to move to Melbourne do they stopped recruiting me here in Sydney. Otherwise I would not have an easy ride like now. I had a PSMA pet scan with investigational CT scan with contrast and the nuclear medicine bone scan a year ago and the cancer was only visible in my prostate but the results were not conclusive mainly because the last year scans were only a year after my prostate SBRT irradiation with the MRI Linac Elekta Unity machine.
My last year PSA was 1.1 and the prostate PSMA SUV max value was 6.5.
I was waiting until a year ago only on degarelix ADT injections until my PSA jumped to almost 2 and then I added Bicalutamide.
I was thinking about a biopsy and maybe either a focal treatment like Nano knife or even radical prostatectomy but because my lungs arterial blood pressure was measured like 4 times higher than usual I decided not to do even a biopsy because my PSA is stable at 2.5 on bicalutamide alone.
I have people in my family who recently had operations (surgery) and ended up on blood thinners for life. I really don't want that at this time and I continued to have an easy ride.
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Intermediate favorable vs. unfavorable Gleason 7 acc.to 2 doctors + CLEAN PSMA, do we need third opinion +where? (Green Bay/Milwaukee areas)
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PSA continues rise...PSMA remains good
