MRI and 12 Core Biopsy

I'm having a prostate MRI at Duke next week, and I was told if the MRI indicates cancer, they still do a 12 core biopsy. I was surprised and asked why and was told that they didn't consider the MRI to be accurate enough on its own. Makes me wonder if they will still want to do a biopsy even if MRI is negative. Anyone else have a 12 core biopsy after MRI?

I think my current PSA was 7.1, but the % free PSA indicated a likelihood of less than 20% of cancer. I have about 15 years of PSA jumping around from a little over 5 to as high as 16. It tends to cluster around 6 - 6.5. The one consistency is that my free PSA always indicates about 20% probability of cancer regardless of how high or how low PSA is. The other thing I have going for me is current urologist did a very aggressive dre and couldn't find anything that indicated cancer. Five years ago, a urologist and pc doc both said they felt a firm spot on prostate. The current urologist did his best to find it and said he didn't feel any firm spot.

As Froggy says, the MRI does not give you a definitive diagnosis. Also, it can't give you a Gleason score, which is crucial for deciding on a treatment plan, should the biopsy be positive for PCa.

MRI's can only show areas that are suspect. These areas can be targeted in the next biopsy. Only a biopsy can confirm the presence of cancer.

DREs are subjective and results vary over time and between doctors.

Andrew

richh said...
Makes me wonder if they will still want to do a biopsy even if MRI is negative. Anyone else have a 12 core biopsy after MRI?

richh, your very important point seems to have been overlooked by other responders.

You are absolutely right! One of the benefits of an mp-MRI prior to biopsy is to reduce the number of patients undergoing biopsy (which carries it's own set of risks to the patient). Prebiopsy MRI might lead to a refined diagnostic pathway differentiating those having significant disease, which warrants treatment, from those who have insignificant or no cancer, which does not require detection (ie. does not require biopsy).

As was said before MRI by itself is not conclusive. It is capable of detecting what they call clinically significant disease G7 or better. There is a grading system they use indicating the probability of disease present. But biopsy can only tell for sure. And the only way to grade aggressiveness with gleason score.

Problem with biopsy it can easily miss. This is where MRI helps cause you have an image of the whole prostate and can target suspicious spots.

G6 is not likely to be detected. I had a biopsy without MRI and 1 core was G6(5%). Did MRI later and did not detect any lesion but did indicate BPH. the score was Pi-rads 2 (clinically significant cancer unlikely). By the way if you do biopsy first you need to wait 6 week before and MRI can be done. The prostate must heal from biopsy

So looks like you are on the right course

Just one inexperienced guys opinion

richh:

The 12+ core transrectal ultrasound biopsy was adopted as the standard approach during a time when there was no effective imaging method for the detection of probable prostate cancer targets for biopsy.

Now, there is an effective imaging method, the multiparametric 3T MRI (requiring analysis by a truly expert practitioner).

From a purely technical viewpoint, the 12+ core biopsy is a seriously deficient method whose time has passed. The risk of infection and the negative effects of many needle punctures are real. The percentage of men experiencing serious side effects is not large, but for the unlucky few they can range from troublesome to life-threatening.

But, as with all things medical, money matters. MRI machines are expensive. The training to achieve true expertise in analyzing MRI images for prostate cancer diagnosis is very time consuming, and therefore expensive. And legions of veteran urologists have invested a massive amount of time and money in the deficient method. Adoption of the new, better method is slow.

I read an earlier post of yours that said you have BPH and prostatitis, and that your PSA had been as high as 30. You also inquired about coverage by MEDICARE for certain tests.

In my opinion, if you have concluded that MRI is the proper next step, you should be seeking out one of the very few centers nationwide where biopsies are performed in-bore of the MRI by the same expert practitioner who does the analysis of the MRI images and assigns the PI-RADS scores. Such a practitioner will see the needles entering the identified target areas in live images, and will have the confidence to take cores only from identified suspicious areas.

When I was seeking that (November, 2017), I traveled from Oregon to Chattanooga, TN, to be diagnosed by Dr. Joseph Busch at the CHATTANOOGA OUTPATIENT CENTER. He did the MRI in the morning of day 1, followed by a face-to-face analysis session in the afternoon of day 1. The biopsy was done the morning of day 2. The pathology report was available on day 3.

All medical charges were paid by traditional MEDICARE. You should verify that such an mp-MRI is "medically indicated" based on your previous history.

What you are hearing from DUKE is that between the person analyzing the images and the second person performing the biopsy, there is not the confidence in their joint expertise to target only the identified suspicious areas.

Mayo Clinic released a study last year reporting that “approximately 17 percent of [prostate] biopsies resulted in complications, the most common of which included infections, bleeding and urinary retention.” An alarming number of men who undergo the procedure are getting infections that are resistant to antibiotics.

Mayo also reported that there was a marked decrease in the number of biopsies being performed recently. This is primarily due to the fact that rushing to biopsy for a high PSA is exactly what urologists were doing as “step-1” 10-years ago before the prostate cancer overtreatment balloon busted, but today doctors have more modern tools at their disposal and have recognized the risks inherent in the biopsy process.

From the Mayo summary: “Our findings indicate that we should focus further efforts on improving (i) how we select patients to undergo a biopsy, (ii) how we prep them and, perhaps, even (iii) how we perform biopsies to reduce the complications associated with the procedure." Multiparametric-MRI is one of those tools to address (i) “how we select patients to undergo a biopsy.”

https://www.mayo.edu/research/forefront/prostate-biopsies-complications


The prostate biopsy absolutely IS an important tool in the urologist’s toolbox, but has been widely misused in the period that many of the men here at this site were diagnosed…so it’s what they know to do. But it’s not what the most up-to-date urologists will rush you into any more…

Your advice from Duke is spot on; you wrote: "I'm having a prostate MRI at Duke next week, and I was told if the MRI indicates cancer, they still do a 12 core biopsy." Absolutely.

But, "Makes me wonder if they will still want to do a biopsy even if MRI is negative." Probably not, at least not now and not with the info you've presented here. But you will now be regularly monitoring. Prostate cancer is a natural phenomenon of aging, but most cases don't even need treatment. The PC overtreatment era bubble has busted, but patient knowledge, awareness & empowerment is still the best personal protection against an over-zealous laggard of the era.

Post Edited (Normal59) : 10/5/2018 8:29:57 AM (GMT-6)

Had my MRI this morning. Just received a message from Duke saying no cancer indicated by MRI. Follow up appointment not needed. Just continue to test PSA every 6 months.

So Duke's policy appears to be if MRI doesn't indicate cancer, then no biopsy. But if the MRI does indicate cancer, they do a 12 core biopsy. I don't know if it is 12 plus more for the MRI indicated areas or just 12 total. Since I don't have to have a biopsy, I didn't ask.

Just to put all the info in one place, my PSA varied from a little over 5 to over 20. In the past I took antibiotics to bring PSA down, but now I take a product that includes oregano, olive leaf extract, curcumin, and a couple other things, so I'm not killing off good bacteria. Even when my PSA was high, my % free PSA was around 30% which indicated a rather low likelihood of cancer.