mri guided biopsy

I am new to this forum and am impressed by the knowledge and experience of members here. I am a 66 year old man with a chronic neuromuscular illness likely caused by a virus (or combination of viruses) that was triggered by Lyme disease. I've been dealing with this situation over the past 11 years. During that time, my PSA has slowly been increasing and latest blood work came in at 6.1. My PCP referred me to a urologist who of course immediately wanted me to have a needle biopsy, which I refused. At my request, he referred me for a 1.5T MRI, (at the time I didn't know enough to make sure it would be a 3T MRI), which showed two areas of concern, with PI-RAD of 4 in both areas. I don't believe the MRI showed any indication of metastasis.

I submitted these results to a heavily internet advertised prostate center located in 3 different cities on both coasts. I was told that I should schedule a MRI guided biopsy and that if results reveal cancer that I am a candidate for focal laser ablation treatment, at the cost of $30K. Of course, this particular clinic has opted out of Medicare (which is my insurance), with the result that I likely would have to pay $2500 for the biopsy, with the hope that Medicare and my supplemental plan would reimburse me for part of the cost. I also learned that many of the patients who underwent the MRI guided biopsy at this clinic ended up with a catheter for at least part of their recovery time.

At this point, I am uncertain what to do next. I do not want the biopsy and I do have concerns that that procedure may not be entirely safe for a number of reasons. At the same time, if it is absolutely necessary to deal with a more aggressive cancer then I am beginning to reconcile myself to having it done. I wonder what thoughts those of you with a lot more experience might have.

barbling4:

You are correct that the typical prostate biopsy procedure is not "entirely safe".

I declined to undergo biopsy without prior expert imaging and analysis (3T multiparametric MRI).

If your MRI and analysis were done by true experts, the assignment of PIRADS 4 calls for biopsy.

The fact that your MRI was 1.5T leaves open the question whether your MRI qualifies as expert imaging and analysis. Will you say where and by whom the process was carried out?

As Tall Allen has pointed out, the selection process for treatment begins only after diagnosis is complete.

Additionally, I am puzzled by your reference to "catheter" and "recovery time" in connection with biopsies performed at the clinic you contacted.

I consider the MRI, the analysis of the MRI, and the MRI-guided biopsy to be a package deal, meaning that they should all be done at the same facility under the control of the same expert practitioner. The same expertise that was used in reading the images to establish suspicious areas and assign PIRADS scores is needed to insure correct biopsy needle placement during the MRI-guided biopsy.

You may find that the expert doctor to perform the MRI-guided biopsy wants to work the whole process from beginning to end rather than working from MRI outputs produced at another facility.

I know from my own case that MEDICARE + MEDICARE SUPPLEMENT PLAN F will pay 100% of the charges for MRI, analysis, and MRI-guided biopsy at a facility that accepts MEDICARE assignment for medically indicated actions. I don't know how they might react if asked to pay for a second occurrence of MRI and analysis right after the first. Was your first MRI paid for by MEDICARE?

More perhaps after hearing the answers to the questions.

Thank you Tall Allen, Bob 46 and Subdenis for your replies. I first went to a local urologist (I live near the seacoast of NH in the southeastern part of the state about 75 minutes from Boston). He sent me to Lahey Clinic in MA for the biopsy. When I returned to the urologist he quickly determined I should go back to Lahey for the biopsy. At that appointment, there was very little time to ask him questions, but one thing he mentioned was the need for more needle extractions than is typically the case because they would want to use the MRI results to target some of their extractions. I do have concerns about SE of this procedure, especially given the "hit and miss" aspect of the approach. The Sperling Center grabbed my attention with their emphasis on MRI guided approach, which seemed to me would limit the number of extractions needed. Then I read that many who've had biopsies with them had to have a catheter during recovery and that concerned me. The head of that center reviewed my MRI findings and mentioned the possibility of FLA if cancer is found on biopsy. I agree this seems like putting the cart before the horse.

In terms of insurance, I do have Medicare and Plan F, covering 100% of everything. I don't know if they would allow a second MRI so soon after my June 1.5T. I would like to think I'm not locked in to using Lahey for the next step, especially if I can find a doctor whom I can work with who can guide me through the entire process

You don't need another MRI - the one you had identified suspicious areas - that's all you need. They merge the image from the MRI with a real-time ultrasound to target the suspicious areas. They take extra cores from those areas but others from around the prostate.

"I was told that I should schedule a MRI guided biopsy"

I am uncertain of current usage of the term "MRI guided biopsy."

"MRI guided biopsy" from my limited experiences is the same as a "targeted biopsy" where an MRI is used to target areas and an ultrasound is used by the URO surgeon to biopsy the target area in such a manner that the ultrasound is combined with the MRI in a manner which leads to the name (one brand) Fusion Biopsy.

While it may be that in fact that particular term is coming into usage by some when they mean "MRI combined with Ultrasound, there is a particular process done by a radiologist without the use of ultrasound that the Schedule Nurse for Radiology at Emory in Atlanta called an MRI guided biopsy.

In an "MRI guided biopsy" the process is done by a radiologist and the radiologist is in the act of using an MRI machine to target and determine where the biopsy is being taken from and in the radiologist is usually the one that takes the biopsy. There are only eight or ten places in the country that do a truly "MRI guided biopsy" while there are many more places in the US that do a combined MRI/ultrasound "fusion" Biopsy. URO NAV is another brand, in addition to "Fusion," I believe there are other brands also.

3T is not nearly as important as 3D, you cannot target from an MRI that is not multi-parametric, multi-planar. As I found out. Thought I had what I needed with a 3T MRI, nope. Not enough.

Sorry, didn't mean to get so technical but in fact if you want to ensure that you properly direct your care you will find that there is a tremendous amount to learn about the various aspects of the path you are headed down.

Fortunately, you are at one of the best places to find out more. There is a tremendous amount of knowledge and experience on this forum, and a great group of guys and gals. Some of the ladies have wonderful input and basically take charge of directing their husbands care.

Hopefully things will work out well for you
1

barbling4:

There has been no mention of any symptoms of, or investigation for, BPH or prostatitis. You should be satisfied that neither is the cause of your elevated PSA. A more detailed history of PSA scores might be informative. The MRI report may offer an estimate of prostate size.

As always, a prediction of life expectancy based on individual health situation plays into strategy.

Having done much prior research myself, I do not see anything to suggest the Lahey Clinic as a place to seek a prostate diagnostic MRI or a follow-on MRI-targeted biopsy. Consider the PIRADS 4 score in that light.

Your hope to find one doctor "who can guide me through the entire process" is very unlikely to be fulfilled.

Your goal to avoid undergoing the mainstream blind TRUS biopsy is rational and justified. The percentage of men suffering significant negative effects of blind TRUS biopsy is small. But for the unlucky few, the negative effects can be severe, up to and including death.

Avoiding the mainstream blind TRUS biopsy is also achievable. That is not to say it will be easy.

For decades, there were no imaging techniques that were good enough to be the basis for targeted prostate biopsy. During this time period, the blind TRUS biopsy became entrenched as the "normal" method. Now there is an imaging method (3T multi-parametric MRI) that makes possible a better approach. But the blind TRUS biopsy is still the most common method offered, simply because of the vast number of veteran urologists who have invested large amounts of time and money into the method.

Your original urologist and Tall Allen have described a concept under which a urologist uses the output of an MRI to identify ADDITIONAL locations to take biopsy cores beyond the 12 or more cores that would comprise their standard blind TRUS biopsy. This is because they do not trust the MRI analysis to accurately identify all suspicious areas. This concept defeats one of the main reasons for seeking out the 3T MP-MRI, which is to MINIMIZE the number of cores required to achieve an accurate indication of cancer risk, and, correspondingly, the overall risk of the biopsy procedure.

Because of the expense of MRI machines, and the extensive training and experience required to make them useful for prostate cancer diagnosis, the implementation has been slow. The number of locations where you can obtain truly expert imaging and analysis resulting in a trustworthy report is still quite small. So perhaps there is good reason for the urologist to be cautious when using imaging and analysis provided by others when doing a biopsy.

Ken seems to describe a case where MEDICARE paid for a second MRI after a first one that was not useful.

I suggest the following.

First, decide how much energy, time, and money you are willing to spend to avoid the blind TRUS biopsy approach, which is no longer the best approach, but may be the most pragmatic, depending on other circumstances in your life.

If you decide to pursue the 3T MP-MRI with follow-on biopsy (if indicated), among others, check out Dr. Joseph Busch in Chattanooga, Tennessee. When comparing, note the following significant differences:
1. use of endorectal coil, or not
2. number of cores to be taken per suspicious area, and overall
3. biopsy performed using real-time imaging in the MRI machine (in-bore),
or
performed elsewhere by a urologist using the MRI output images (FUSION or cognitive)

Ten years ago, it took my urologist 3 tries to find my PC..2.5 years passed before "The Problem" was found. There is no doubt in my mind that if my cancer was found sooner that my treatment would have been more successful...The standard 12 core TRUS biopsy has trouble sampling the "apex" area of the prostate gland and that's where a lot of cancer likes to hide. With better tools to work with, Urologists are able to detect PC more reliably and get treatment started sooner when it's likely to be more effective..

Fairwind said...
Ten years ago, it took my urologist 3 tries to find my PC..2.5 years passed before "The Problem" was found. There is no doubt in my mind that if my cancer was found sooner that my treatment would have been more successful...The standard 12 core TRUS biopsy has trouble sampling the "apex" area of the prostate gland and that's where a lot of cancer likes to hide. With better tools to work with, Urologists are able to detect PC more reliably and get treatment started sooner when it's likely to be more effective..

WOW,, entirely possible the out come could have been different for you.. stay strong man.. Ed

Not understanding all this mri guided biopsy ..to me the mri was way worse than the biopsy ..1 hour in that god awful tube .......anyway u r right about the biopsy ..I had 2 before the third was found ...PSA was 5.2 fir about 6 years then went to 8.1 third was done by another urologist and found 3 cores .hmmm 3 cores can grow that fast with just a 3 point rise why can’t they do a sonogram guided mri ...darn sonogram only takes a minute and is painless and showed clearly where the tumor was ...now I’m pissed as well I bet that first urologist missed it twice ...I mean if we could see it clearly on the sonogram at 8.1 why wouldn’t you at 5.3 ...
And at 8.1 I had 3 cores 2 of them 3-4 with 4 10 % and it was cribifirm .. if I found out 5 years earlier may have been all 3-3 no cribifirm yet ...
Anyway Biopsy was painless as long as they use s numbing agent ...don’t know why it isn’t safe they say

Post Edited (Stan1961) : 8/13/2018 9:10:24 PM (GMT-6)

RobLee said...
Stan - it is the way that it is because it is complicated. I don't for a minute believe that they are making biopsies more complicated than is necessary. Our bodies are very complex and even though the prostate is small, it is deep inside and surrounded by a lot of various tissues. And prostate cancer comes in so many forms that a simple ultrasound or sonogram just doesn't provide enough information.

Believe me, I am MAD AS "HECK" that my original Uro totally missed the giant tumor under my bladder. Furthermore he only told me that the biopsy was negative and he repeatedly told me that my prostate was normal. My PSA was 12 at the time. This bugs me ALL THE TIME. I obsess over it all day and in bed at at night.

But it happened, and I can't change that. And I'm getting better at accepting that. My biggest gripe is that this process is mandated by the insurance companies. They won't pay for an MRI unless there was a negative TRUS biopsy followed by rising PSA. When my wife had persistent spinal pain we paid cash for an MRI that fortunately located her bone cancer.

Over the past decade, the hysteria regarding overtreatment and the USPSTF's role in downplaying PSA screening had put many of us at risk of going untreated. Some ended up like Fairwind, or Mattamx. Others have been more fortunate. We never know which way the dice will land.

Thoughtful post Man.. Ed