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MRI/ultrasound fusion biopsy as a first biopsy?

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Posted 1/27/2016 9:22 PM (GMT 0)
New here, 52 and just referred by my primary to a local urologist due to rising PSA over three years: 3.2/4.0/5.1, plus some reduction in urine stream - but not at the point I need to get up in the middle of the night. Otherwise in perfect health. The data geek in me has been going a bit overboard on research already, but trying not to get too far ahead of myself.

From what I've read here I'm fairly confident that the urologist will recommend a biopsy due to PSA level and velocity. Question: would it be a good idea for a first biopsy to get a fusion MRI/ultrasound guided biopsy at a known top PC hospital? Seems they are more accurate. I am on the CA central coast, about a 3 hour drive from UCLA, Stanford, and UCSF - all of which are in my insurance network and offer fusion. Or should I just let the local guy do a standard one first?

I've been trolling here for the past couple weeks, so thanks to all the incredible info, especially the stories from Halbert and others! The journey begins...
Posted 1/27/2016 10:12 PM (GMT 0)
Typically, the first one is a TRUS-guided systematic biopsy, and if there is suspicion remaining (rising PSA) they may want mpMRI targeting. Typically, insurance will not cover advanced imaging on a first biopsy. Just because they cover fusion, doesn't necessarily mean they cover fusion for men in your situation. Get pre-authorization first.

In Ventura, you have Duke Bahn who is one of the masters of a technique called Color Doppler Ultrasound. He doesn't take insurance, but I think he charges $700 for the imaging study, and you can take it to your local Uro for the biopsy.

I think it's important to eliminate the more likely sources of PSA increase, especially BPH in your case, before biopsy. Ask your Uro how large your prostate is. It is the most likely reason for the small progressive PSA increases and the reduction of the urine stream. Two drugs, Proscar and Avodart, shrink the prostate, and if they reduce your PSA to a low and stable level, there is really no reason to explore further. You can also get a PHI blood test. (see this other current thread for details)

- Allen
Posted 1/28/2016 4:48 PM (GMT 0)
Hi Calkid. You got some great advice from TA, I would find out if you have BPH first before the biopsy. However if you go down the targeted biopsy road, I went to Dr Bahn, in the end, and it was money well spent for me. His imaging is about $700 but if he sees a lesion, he will ask you if you want a biopsy at that time. It cost about $250 more and he only puts the needle where he sees the problem instead of randomly like a standard uro biopsy. The other cost is the pathology but my insurance picked up that bill from the hospital. Good luck on your journey, I hope its just something else and you don't have join this club. Take care. -JR
Posted 1/28/2016 6:36 PM (GMT 0)
The reason why the volume (Allen asked about volume) of your prostate is interesting is because there is a strong correlation between the volume of a benign enlarged prostate (BPH) and the PSA value. PSA density is the PSA value divided prostate volume in cubic centimeters. PSAD < 0.1 ng/ml/cm3 strongly suggests that it is a benign prostate enlargement that cause an elevated PSA value, especially if the f/tPSA is high. PSAD > 0.2 ng/ml/cm3 speak however for a treat demanding prostate cancer.
Posted 1/28/2016 8:47 PM (GMT 0)
In my opinion, once you have the BPH possiblity out of the picture I would go straight for the MRI screening/ guided biopsy. I personally had the MRI guided biopsy (4 needles) followed straight away by a 12 needle Trus biopsy, this was part of a clinical trial. Only the MRI biopsy found PCa and all of the 12 random jags were negative. So if the TRUS biopsy was my first biopsy I would probably have then wondered off for 6 or 12 months happily thinking I was clear, potentially worsening my outcome.

I believe Trus must be gradually fazed out, its just too hit and miss!
Posted 1/29/2016 8:27 PM (GMT 0)
Thanks for the great responses and information. Just came from the urologist. DRE shows enlarged both sides, but no nodules. He wants to go ahead and do a Trus biopsy, so I think I'll contact Stanford and UCLA about an MRI/fusion biopsy - and see if insurance will cover.
Posted 1/30/2016 4:33 AM (GMT 0)

calkid said...
I think I'll contact Stanford and UCLA about an MRI/fusion biopsy - and see if insurance will cover.

If the insurance will cover the only reason to not do a fusion is if there is nothing found in the MRI to target. If there is nothing to target, you are just looking basically at a blind.

If that turned out to be the case (nothing to target for fusion,) and I was within driving distance of Duke Bahn I would seriously consider seeing Duke Bahn if my PSA continued to be concerning.

www.ncbi.nlm.nih.gov/pmc/articles/PMC4495493/

If I'm reading that correctly, down at the bottom it says that 3T mp MRI has a negative predictive value of 89.6 at five years.

MRI imaging is not perfect but that is one of the highest % of accuracy that we see in PCa, outside of pathology on removed prostates.
Posted 1/30/2016 1:29 PM (GMT 0)
Thanks, Ken. When I talked to them they said that if nothing interesting was found on the MRI, they wouldn't do the follow-on fusion with US and biopsy, and would instead recommend a regular MRI and PSA to monitor. They are pushing this as a way to get insurance to pay as in aggregate MRI alone is less than a traditional TRUS biopsy, and if it reduces the number of TRUS biopsies (with 40% false negative) with the small percentage of hospitalizations due to infection, or gives earlier heads up to true PC allowing less expensive long-term treatment. Sort of what Aussie above mentioned.
Posted 3/19/2016 3:13 PM (GMT 0)
Well to follow up, I went straight to a 3T MRI at Stanford. Yesterday I got the results with them saying it's a good thing I did as it as I probably would have had a couple more years of false negatives with regular biopsies. This Friday there will be a targeted biopsy to confirm. Then I guess the fun starts. BTW, UHC PPO covered the MRI with no hassle, even though I hadn't had a previous false negative.

1. PI-RADS v1 category 4 (clinically significant cancer is likely to
be present) and PI-RADS v2 category 4 (clinically significant cancer
is likely to be present) lesion measuring 8 x 7 mm in the left base
in the peripheral zone of the prostate gland.

2. No MR evidence of extracapsular extension, involvement of the
neurovascular bundles, or seminal vesicle invasion.

3. No MR evidence of lymphadenopathy or focal suspicious osseous
lesions in the pelvis.

4. The prostate is enlarged measuring 5.4 x 4.2 x 5.2 cm, TR x AP x CC
(volume 62 mL).
Posted 3/19/2016 4:13 PM (GMT 0)
Glad you were able to get the 3T first. If I knew what I know now, I would've certainly investigated that. While a biopsy isn't exactly the definition of a 'good time' it isn't all that bad--but who wants to get them any more than they have to?! Looks like we're about the same age, so yep--let the fun start! Keep in mind that you may very well get the standard 12-core blind biopsy in addition the the targeted area needles. Not a big deal, but I wasn't expecting it. Also, for my second biopsy I got prepped with some numbing gel prior to the numbing needle. This _did_ seem to make it a bit more comfortable than the first biopsy where the doc didn't use any gel. It may be worth asking about.

Good luck!
Posted 3/20/2016 7:27 PM (GMT 0)

calkid said...
Well to follow up, I went straight to a 3T MRI at Stanford. Yesterday I got the results with them saying it's a good thing I did as it as I probably would have had a couple more years of false negatives with regular biopsies. This Friday there will be a targeted biopsy to confirm. Then I guess the fun starts. BTW, UHC PPO covered the MRI with no hassle, even though I hadn't had a previous false negative.

1. PI-RADS v1 category 4 (clinically significant cancer is likely to
be present) and PI-RADS v2 category 4 (clinically significant cancer
is likely to be present) lesion measuring 8 x 7 mm in the left base
in the peripheral zone of the prostate gland.

2. No MR evidence of extracapsular extension, involvement of the
neurovascular bundles, or seminal vesicle invasion.

3. No MR evidence of lymphadenopathy or focal suspicious osseous
lesions in the pelvis.

4. The prostate is enlarged measuring 5.4 x 4.2 x 5.2 cm, TR x AP x CC
(volume 62 mL).

Calkid, glad to hear you went the 3T MPMRI route. I'm a big fan having undergone a fusion biopsy based upon 3T MRI findings. It really helped me to get more specific data as to the extent of my cancer. The fusion biopsies are really the best of both worlds IME. It combines targeted computer assisted biopsies of suspicious areas from the MPMRI scans, and also includes a random 12 core biopsy to ensure other areas of the prostate are checked since PCa is known to be a multi-focal cancer. I had an 18 core fusion biopsy at the NIH last year - six targeted cores based upon MPMRI results and the usual 12 standard cores.

Good luck with your next steps! :-)
Posted 3/20/2016 8:42 PM (GMT 0)
Why do you say you would have 2 years of false negatives with TRUS biopsies?
Posted 4/1/2016 8:44 PM (GMT 0)
Well to wrap this up, I had a 15 core fusion biopsy at Stanford last week. I have to recommend Dr. Sonn's group there - it was less eventful and far less painful than getting a dental filling. They are real pros. UHC (PPO) insurance didn't question a thing, from consult to the 3T mpMRI to the biopsy, even though it was my first biopsy.

The good news is that I just found out that even with a PI-RADS 4 lesion (with 3 of 15 needles targeted at it), everything came back benign. So I guess the lesson is to still have hope even after that mpMRI result. And I need to be rechecked in a year or so.

Thanks to all of you for being an incredible source of information. I've learned so much, which will probably become useful again some day.
Posted 4/1/2016 9:17 PM (GMT 0)
Hmmm...would this count as the two years of false biopsies that you were afraid of?
Posted 4/1/2016 10:19 PM (GMT 0)
Really glad you are looking so good on your pathology.

This thread is an excellent example of why this forum is such a great resource.
Posted 4/2/2016 12:10 AM (GMT 0)
You realize,of course , that a second opinion on reading of the MRI is paramount. As in reading prostate pathological histology there must be only 1 or 2 doctors in the country that can read an MRI correctly a la Epstein and and Bostwick..apparently now anyone trained under Bostwick counts since he no longer is at the company. If anything it must be even more subjective. We've had guys here who also found a negative result on an MRI only to have a second opinion that the biopsied area via MRI was not only NOT negative,but Gleason 8 or worse.
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