The search for the best diagnostic

I do not much about the PHI test but I guess it improves the accuracy of standard PSA tests. But, unfortunately, still with false positive, falase negatives.
The mpMRI tests give a good clue if there is significant PCa (it means, not a small spot of less-aggresive G6). They are accurate in many cases. But PCa is not officially diagnosed without a positive biopsy. And there is not a certain way to know the grade if the cells are not analysed.

Welcome to HW.

You're describing the protocol I'd normally suggest: PSA, PHI, DRE, MRI and if all that doesn't show why the PSA is high, then a biopsy is needed. TRUS (Transrectal, ultrasound) biopsy is the standard of care. There are other biopsy methods that can be used, there is an MRI guided, saturation (more than the standard 12 core).

Part of the problem you'll run into is what can you afford, will your insurance pay for and what is the doctor willing to do. There is also the question of doing more than is needed. While you have a number of red flags, you don't need to call in the air tankers when a garden hose will put out the fire just as effectively.

If I was in your place, I'd proceed with the MRI and if that shows anything suspicious, then I'd do the TRUS and see what that finds.

Andrew

Thanks all. 60 seems to be the expiration date for prostates in my family - grandfather, father, and me. At least I have better options available to me. I was hoping the mpMRI would be the 'tricorder' of prostate scans and if clean, eliminate the biopsy altogether. Sounds like we are not quite there yet. Its just that the PSA and random needle biopsy seems like such poor diagnostics, even if they are the standard of care. Has anyone seen side-by-side images of standard MRI vs 3T mpMRI? No problem paying for the upgrade even though my insurance covers the standard version.

Had a 1.5T mpMRI with contrast, and my insurance covered the 1k cost. The tech said the quality of the images was good, and that my impersonation of a corpse was just fine. Funny that they ask what kind of music you want to listen to, since I couldn't hear it over all the weird sci-fi noises from the machine.

I asked for and received a CD with the slice pics and a tool to display them on any computer. Viewing them I see grey-scale images, some pretty sharp but others not so much. The tool links the front and side views, so if you 'push' thru the slices from a front view, you will also see how 'deep' this is from the side view. Some will have no interest in looking at this stuff, but I'm the guy who asks to be awake during surgery so I can watch.

One thing I learned quickly is that the human body is not an anatomical drawing, and even comparing against other MRIs online only proves that every person is unique. It took awhile, but I can at least identify which organ is which. I can safely say my prostate is bigger than a walnut, but it takes a professional to say much more.

Good news is the doc called and says he (or probably the radiologist) sees nothing of concern in that MRI, but was quick to add there is a lot he can't see. I believe this means the biopsy will be random unless the ultrasound spots something.

Post Edited (mathias81) : 8/19/2019 8:13:02 AM (GMT-6)

I'd say that 4 positive cores, and one a 3+4 albeit it small, would certainly warrant staying alert. I'll leave it to the handsomer and more knowledgeable gents here to parse this further. However I do want to add one caveat based on personal experience.

No matter the strength of the machine and skill of the technician, MRI reading is an art. In my case, as my signature shows, I was examined by artists of varying ability. I'm very glad I paid 150 bucks to have mine read by the locally best team. Going forward I'll never take a single radiologist's reading for granted again. That said, perhaps yours was a Michelangelo and I hope he/she was!

Anywho, food for thought.

Do get a second read on the slides. You can contact their offices directly to find out about cost. Reading the slides is a bit of an art so you want more than one pair of eyes on them.

Likely you're okay to wait for that to happen. Depending on the re-read, you'll want to think about your plan. I find it odd that your PSA dropped. PSA due to PC rarely drops without treatment. You might want to monitor that a bit more closely.

A grade 4 cell is one that might generate mets, so even though you don't have many, it still could be a problem and why most docs will recommend treatment at this point.

All you options are open at this point - AS, surgery, radiation (beam, seeds). You might want to consider making the rounds of surgeons, and ROs just to explore your options. SBRT or LDR Brachy might be interesting options for you to consider.

Andrew

My take on the MRI is that it is a scene photographed from a moving train on a hazy day. There are points of clarity with unknowns between them. Now I have only seen the raw images from the MRI without the software enhancement supposedly available to the radiologist, or his training. Without those I'd expect more definitive statements about what it does and does not mean.

JohnT: I'd tolerate an a** probe all day long if it meant an accurate, definitive reading. As it was I had the 1.5T Siemens with a torso coil. Next time a 3T for sure. Ventura is just a couple of hours away, but there are imaging centers nearby in San Diego. Also, I have not heard how CDU compares with 3T mpMRI.

Since the majority of my biopsy is pattern 3, I'd like to better understand that first. I certainly have not read every post about it, but I gather that pattern 3 typically:
Grows slowly,
Does not evolve to pattern 4 or higher,
Does not metastasize (escape the prostate),
May eventually be a nuisance such as creating pressure on surroundings, reducing urine flow, raising PSA.
Those last reasons may require surgery, but typically it is not life threatening by itself.

Is pattern 3 one specific cancer, or are there multiple pattern 3 cancers?
Edit: Based on one Dr's opinion and my readings, pattern 3 (G3) is all the same class of abnormality (cancer), but it is as unique as your DNA

Since all cancers begin with just a few undetectable cells, it seems possible that an area showing just pattern 3 may later show pattern 4 as well, and being more aggressive the 4 may later become the predominant cancer. It may appear that the 3 has mutated into 4, but really it has just lost to the competition.

Comments?

I've started Active Surveillance. As a G3+4 low-intermediate, this paper confirms that for the short term this is a reasonable path:

https://prostatecancerinfolink.net/2018/04/19/active-surveillance-in-men-with-gleason-3-4-7-prostate-cancer-at-diagnosis

I received the 2nd opinion on the biopsy (Epstein). An additional core was seen with G 3+3 (so now 5 pos out of 12). The previous Gleason pattern 4 was downgraded to pattern 3.

Before I celebrate, the report also found perineural invasion in one of the other G 3+3 cores (right medial base). I know what the thoughts are on PNI from 10,20 years ago (all over the map). Are there more recent stats?

I believe the std template biopsy only samples tissue inside the prostate, but the needles do enter from the outside. The Dr said it is not possible to locate the needle/tissue core with any accuracy, so there is no way to say if the cancer areas are nearer the capsule or the interior. Disappointing.

Also has anyone found a diagram that shows the placement of needles in a std template with the labels A thru K? Knowing where the cancer was found and the proximity to nerves & capsule seems important.