Oh brother! (hood?) (potential new dx)

Hi, been lurking the last few weeks getting sadly up to speed.

Me: age 53, good general health with no family history of PC. Grandparents all lived into 90s and, until recently, I've always assumed myself to be holding relatively lucky genetic cards.

My first-ever PSA test conducted this fall came back at 12.3. After 10 minutes on google, I realized this was a shot across the mortality bow, even though my GP thought it unlikely to be anything as the DE was unremarkable. Still, he referred me to a urologist, with almost a 2 month wait for an appt. Met the uro just before Christmas; he seemed surprised to hear of my PSA number but we were both relieved his DE also found nothing remarkable. He suggested a new PSA test and if it returned a similar value, that an MRI would be the next step, likely on the way to a biopsy.

Second PSA test returned a value of 13.3 (so a 1.0 climb in two months; great), so the mpMRI was done last Friday. I have a follow up appt to discuss with the uro later this week -- but I've just read the radiologist's report online. If I'm reading this right, it found a 23 cc prostate with minimal BPH and one suspicious lesion (9x9x10mm) scored at PI_Rads 4--no other apparent lesions or involvement. Pretty much what I've been steeling myself for, and though I'm unhappy for the apparent result, I am pleased it's not showing worse.

Do you guys think I'm safe in assuming that I have a happy biopsy in my near future? (I stumbled on IntheShop's poem and am looking forward to singing my own verses. Not) I know only a biosopy can furnish a definitive diagnosis, but are there any inferences/assumptions I might safely draw from the facts known now?

Thanks guys, trying to laugh nonetheless

Hi Will. Welcome. Having an MRI first is a smart way to go -- but as you said, only a biopsy can diagnose prostate cancer (PCa). The future may bring changes, but that's the current situation.

A PIRADS 4 lesion may well turn out to be cancer -- however, sometimes even suspicious lesions (4's and 5's) turn out not to be cancer. The biopsy could also turn up PCa lesions missed by the MRI. You should be prepared psychologically for a diagnosis of cancer, and, of course, pleased if the biopsy is negative.

As you may know, PCa ranges in severity -- at the low-risk end, men are candidates for on active surveillance (AS). Some AS men never need treatment, while other will. While PSA can rise for many causes, PCa included, if your PSA increase to > 10 is all attributable to PCA, coupled with the PIRADS 4 lesions, you shouldn't be shocked if the biopsy finds PCa that needs treatment. This is why I suggest you be psychologically prepared.

A biopsy can hold surprises -- my uro found a new nodule on the DRE. My biopsy foudn that the nodule wans't cancer turned, but found a Gleason 9 and G 10 lesion in different locations. (about 50% of DRE nodules turn out to be PCa). Be aware that should everything come back negative, it's likely that there are repeat biopsies and MRIs in your future, especially if your PSA continues to rise.

Keep us posted! All the best,

Djin

Thanks guys. Going back over the report, I'm admittedly more concerned about the following part of the radio's report: "DWI: Markedly ADC dark". That adverb, along with the Pirads score lead me (not quite an MD but an educated layperson who's spent 1.5 hours on Google, so I'm pretty much like a PhD in this area) (that was a joke) to suspect I may end up with a potentially higher Jackie Gleason score than I'd been hoping for.

Needless to say, my productivity at work this afternoon has been nil. Curse you, Google!!

Thanks again guys; will update if/when I have news. Breathing in the meantime. Thanks

Many thanks BB!

Thanks Leah!!

I would agree with you. First, your uro can still use the MRI to sample the target area (its dimensions aren't that small). This ties in with my second point. A TRUS "random" biopsy isn't exactly random. Within each zone the uro looks for areas that appear suspicious on the ultrasound. Abnormal tissue, including PCa, reflects the US differently than normal tissue (lesions appear darker, I believe). These hypoechoic areas may not be cancer, of course, but the more experience a uro had, the better his eye and intuition/expertise. But yes, it is reading shadows a bit. So both your PIRADS 4 lesions and any other lesions may well be discernable on the US screen.

I would just make sure your uro plans on taking the usual cores in all the standard biopsy zones in addition to extra cores in the area flagged in the MRI reading, so perhaps 14 instead of the usual 12 cores, which is what my uro did at my request.

The not-so-good news about a good-news negative biopsy is that, if your docs have continuing suspicion for PCa, say because of a still rising PSA, there are probably repeat biopsies in your future ;)

Djin

Post Edited (DjinTonic) : 1/10/2020 2:48:44 PM (GMT-7)

Thanks very much guys. I think he said he’d numb me up with lidocaine (?) but I believe he said he’d just take samples from the left target area. How important do you think the full sampling is (or why?)?

I do plan to seek a second pathology opinion from Dr. Epstien at JHU if PCa is found—would that be reason enough to get the 12+ samples?

I am wondering if I should try to look for a real fusion biopsy in Boston instead..

Again, thank you.

During a visit last year with Bal Carter of Johns Hopkins, he stated adamantly that a targeted-only biopsy was inferior to one that did systemic sampling PLUS some extra cores from the target areas.

Dr. Carter, who recently retired, was a highly regarded expert in prostate cancer. He had 30 years of biopsy data to research, and knew his stuff.

The take-way? Don't have a targeted only biopsy, they can miss significant cancer that was not seen on the MRI.

ps: A nerve block is injecting a numbing agent into the nerve bundles outside the prostate as opposed to numbing the prostate itself like you might think of when numbing a lip for stitches. Suppose to be the best way although I had some pain for a couple of the cores, the rest were easy.

I kind of remember my doc saying he was going to apply a topical numbing but was still freaked out from him shoving that probe thing up my butt so don't know for sure if that's what he said but I had absolutely no feeling at all when he took the 12 samples, just heard the clicking sound. He asked me I I wanted him to tell me before he took each sample and I said.....no, just take the darn things.....but, again, never felt anything.

Freewill,

OK, welcome to the club. It's not a bad club--actually a lot of really caring open folks here. If you're at Dana Farber, that's a good place to be..def a world-class institution. You probably don't need a MO (yet), but consults with both RO and Uro is advisable. They will probably send you for full body, with contrast, CT and bone scans, just to confirm that it's all still local.

We usually suggest sending your slides to Johns Hopkins for the final opinion--they are arguably the best in the business.

After that, you'll want to ask about surgery and all possible flavors of radiation treatment. Don't be disenheartend--cure is actually in your vocabulary. With the 4+3 as opposed to 3+4, I'd be leaning more towards radiation--SBRT is an awesome choice if they do it there.

Sorry to hear you joined the brotherhood. No matter how many knowledgeable brothers you have joined, it is your cancer and unique to you so take all the recommendations and opinions in stride. You will have your own feelings about things and will come to your own conclusions eventually.

Your pathology review can go either way or stay the same so don’t worry about it until it happens. Biopsy samples are really small and not always representative of the entire prostate. Your decisions will be riding on that be accurately assessed so make sure you are comfortable with the opinions. Get an opinion from Dr. Epstein’s group to be sure if need be.

Was there any indication in your MRI of the lesion being at the edge of the prostate or past it (EPE)? You may want to ask about genomic testing of the cancer cells to see where it fits in the risk profile also.

I trust you will do well with this, you sound like you have a good attitude which goes a long way in dealing with your new life.