Pre Biopsy Strategy?

User

Posted 11 Dec 2015 at 13:29

Hello Everyone,
First post for me after already gleaning some useful information from this community - thanks already!

My dad was diagnosed with Prostate Cancer at 62 in the USA. He had IG IMRT and brachytherapy treatment at the Dattoli Centre in Florida and 10 years on now he's still in the clear :)

When he was diagnosed, he was told that if he had any sons, they should start to have PSA monitored from the age of 40 to establish an early baseline.

So as the only son and at 40, I did as I was told (much to the initial amusement of my GP) and booked a PSA test at the end of October. Unfortunately the amusement quickly passed :( My first reading came back at 4.1. I was given a urine analysis and put on antibiotics whilst waiting for the analysis. That came back all normal so PSA was retested a couple of weeks later. Second reading came back at 3.3

Now I'm at the point where I've been referred to a Consultant Urologist who I asked (after reading some info on here) to do an MRI prior to any biopsy. I got my MRI results earlier this week and have been told that my Prostate has multiple 'suspicious' areas of change all over with the biggest area of concern measuring in at approx 8mm.

The Urologist told me that it's now time for a TRUS biopsy given (a) family history, (b) PSA and (c) MRI. I can't fault that logic and I'm booked in for early Jan but I do have some concerns which perhaps someone here has some advice on!

The concerns really stem from the fact that the Urologist indicated that should the biopsy come back positive (which I think looks likely), that because of my 'tender years', a radical prostectomy, in his opinion would be the only way forward.

Gulp! I'll be honest, at 41 (my birthday's been and gone during this initial process!) and with a younger wife and a 4 year old son, that kind of scares the living bejeezers out of me!

Presuming for now that is how this will play out, I'm wondering whether I should do anything else pre biopsy to give my future, as yet undetermined surgeon, the best possible information about my condition?

I asked the consultant whether a more detailed MRI (parametric style on a 3T scanner) rather than the 'basic' MRI I've had so far on a 1.5T scanner would be worthwhile. He said, 'No'.

I asked whether having a PCA3 test would be worthwhile. He said, 'Pfff £350, waste of money.'

I asked whether given the family history and for the benefit of both my current diagnosis and perhaps my son in the future, whether there was worthwhile genetic testing that might help understand the nature of my condition. He said 'Biopsy first, then you can sign up for ongoing genetic studies if you want - it's only blood tests'

By this stage I was getting the impression he wanted me to have a biopsy....!! Nevertheless, I asked whether there was any other testing or whether given his description of the 'multiple areas of concern and 8mm mass(?)' there was any benefit in a targeted biopsy rather than TRUS. He said 'no'.

I also wished I'd asked whether he could tell from the MRI whether the areas of concern where limited only to the prostate gland or showed any signs of spreading but I don't know if that's possible to determine anyway at this point?

I'd be more than grateful to hear from anyone who's got an opinion on this. Am I making a mountain out of a molehill by being unable to shake the feeling that more can be done diagnostically/imaging wise prior to traumatising the gland through biopsy?

So far everything has been handled through the NHS and I appreciate it's resources may be limited but I also have a comprehensive private health policy through work which I believe would cover any further 'necessary' diagnostics.

Apologies for the length of my first post - I'm not usually so self absorbed!

Cheers
Paul ('Big_Stan' to my 4 year old!)

User

Posted 11 Dec 2015 at 19:06

Hi Big Stan,
I don't think there is any point in delaying with any of the alternatives you suggest - the only way to diagnose prostate cancer is with a biopsy (except in cases where the PSA is up in the thousands and scanning shows that there is already extensive spread)

The MRI scan will have given them an idea already of whether it is contained or has escaped the prostate wall. Not foolproof; my husband's scan was completely clear so it was a shock to all concerned when the surgery showed that every section of the gland was cancerous and it was already into the bottom of his bladder.

Once you are diagnosed - and if it does indeed turn out to be cancer rather than deep seated infection or PIN - then you can talk to urologists and oncologists about the different treatment options. Of course a surgeon will recommend surgery as that is his or her specialism. Likewise, an oncologist is likely to recommend radiotherapy. At such a young age, you may wish to seek a second opinion from a brachytherapy specialist as brachy seems to have just as good results without quite as much risk of side effects. This depends on certain criteria - our hospital will not give brachy to younger men, and generally it is only suitable for men with a smallish prostate, low PSA, no pre-existing urinary problems and low grade cancer.

IF you are diagnosed, you might want to wait a little while before deciding on treatment anyway, particularly to discuss with your wife whether or not you should bank some sperm. Treatment for PCa will leave you infertile and too late is too late if you subsequently wish you had had a second child.

It may turn out to be simply that you need to be monitored carefully in the future so no point p a icing yet but get the biopsy.

One last thought about genetic testing. Again, this is not straightforward. Although there is a clear familial link for men diagnosed young, less than 10% of prostate cancers are thought to be genetic - research suggests that it is more often an environmental link rather than plain old genes. Before you have genetic testing, there is usually some counselling and I was talked out of testing when it was explained to me that if I had a faulty gene (different kind of cancer obviously) then I would no longer be able to get a mortgage, life insurance, etc and nor would my children. Having no wish to prevent my kids fom buying their own homes as they got older, I decided not to bother :-)

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 11 Dec 2015 at 19:56

I would get on and have the biopsy and find out for certain one way or the other , then you will be able to plan ahead, Andy

User

Posted 11 Dec 2015 at 20:11

Hi Paul, I think finding out if, where and what is the first thing to do then you will know how to deal with it.

Fingers crossed eh?

Regards Chris/Woody

Life seems different upside down, take another viewpoint

User

Posted 11 Dec 2015 at 22:26

Hi Paul

Try to look on it this way.

You are fortunate. Should you be diagnosed with Pca, like my OH, your early diagnosis will have been pure fluke. But you have options.

In two or three or five years time when you were getting symptoms, it may have been too late for a cure. At the moment, it doesn't appear to be.

Try to think about what's most important. Being alive is first on the list. One hurdle at a time. Have the biopsy. Prepare for bad news- if it's good news, rejoice. If it's not, move on to the next step. Try not to worry about things that may not happen or to overcome steps which are too far in the future

Louise x

User

Posted 12 Dec 2015 at 11:44

Hi
It seems to me that your consultant is suggesting you have your Prostate removed if the biopsy shows cancer and the majority of young men who are recommended treatment do have surgery.

However, in your shoes and having medical cover I would first opt for a template Transperenial biopsy for the following reasons:-

1. It is more likely to find any areas of cancer so that these can be assessed in the lab and positions plotted. This could also be helpful in deciding whether any cancer should be dealt soon and with what options or whether it could be just monitored for a time.

2. There is a greater risk of infection with the TRUS biopsy.

Barry

User

Posted 12 Dec 2015 at 12:25

My guess is that with a number of grey areas and a single mass of 8mm to aim at, the NHS consultant said no to the targeted biopsy because he already knows where he is aiming and what he is expecting to find? No harm taking the scans to a private urologist for a conversation about targeted v TRUS but personally I would rather tiny risk of infection than slightly bigger risk of general anaesthetic if the result is nearly a foregone conclusion anyway

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 12 Dec 2015 at 12:54

Hello Paul and welcome

Good luck with your choice.

It seems to me that in order to make an informed decision you need to have the information on which to base it and so a biopsy would be the obvious route.

I know that the consultant says there is a 8mm area of concern and I don't know enough about the various treatments to comment on any of them and their possible effects given your young age, but I assume he wouldn't consider you suitable for Active Surveillance?

We can't control the winds - but we can adjust our sails

User

Posted 12 Dec 2015 at 20:40

Paul I had a template bi-opsy and did not have a general anaesthetic, all I was given was a "relaxation" injection which did not hurt and there was no discomfort.

There were no problems after with any infection or blood in my stools etc, although I was told that it may have happened.

If you go down this route I hope you end up unaffected by the procedure like I was.

Best wishes, Chris /Woody

Life seems different upside down, take another viewpoint

User

Posted 13 Dec 2015 at 02:00

Big Stan, a normal size prostate is about 4cm long and 2cm wide so your surgeon would have about a quarter of the gland to aim at - it would be pretty hard to miss now he knows where to aim for!

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 13 Dec 2015 at 17:13

Hi Paul,

I was 58 when I was diagnosed. As with you my father had PC but unfortunately he was diagnosed far too late and the cancer had spread to his lungs and bones. With my maternal grandfather also dying of PC I was keen to monitor my spa. When the test came back at 7 last year I was referred to a urologist. After listening to my family history and getting quite intimate with my nether region he recommended a biopsy and said I could have it there and then. I was a bit reluctant but my good lady took over and because I was a little in shock she just told me to go for it. I did and a fortnight later received the diagnosis and, although shocking to hear, allowed me to start researching the treatment options available to me. After an MRI scan and bone scan I was told all treatment except Bracci therapy were open to me.

So I was not in the position you are in where I had time to contemplate the biopsy. I will just concur with the advice already proffered up to now in as much as the biopsy is a key piece of diagnostic kit to allow the clinicians and you to form a treatment plan.

Good luck.

Paul

THE CHILD HAS GROWN, THE DREAM HAS GONE

User

Posted 13 Dec 2015 at 20:00

Hi Big Stan

Welcome to the forum although you would rather be somewhere else.

I have recently undergone RP (open surgery) last Monday with the almost guarantee of RT next July.

When I was diagnosed last August I joined this forum for advice just as you have, all I can say is that the people on here have been very supportive and very informative.

Not much to add though on what has been said before, all I will say is that the biopsy is a must to determine where you go from here

Best wishes on getting results that you wish for.

Also speak to the nurses via the phone line,they are a tower of strength and full of knowledge.

Hope for a good outcome.

User

Posted 14 Dec 2015 at 00:53

Different Urologists have their own reasons for suggesting a TRUS or Transperineal Biopsy. The former is is quicker and a cheaper procedure but is more prone to infection and does not locate tumours so well and sometimes means this is then followed by a Transperineal biopsy.

In my case first MRI was done on a 3 Tesla MRI scanner which suggested to the reviewers that there was an 8mm tumour. My pathology report stated 51 prostatic biopsies from 21 sites and even then only found one 2mm tumour. (The number of cores taken varies from person to person). With a TRUS biopsy the usual number of cores taken is 12 but can be rather more or as little as 8.

The reason why the Transperineal Biopsy is usually done under anesthesia is because it is imperative that the patient remains absolutely still. Histology and preop test are done to ensure the patient is a good candidate for the procedure. Take a look at these vids :-

https://www.youtube.com/watch?v=2ymlnjraXOc

http://www.nuadamedical.co.uk/prostatecancer/film-precision-prostate-diagnostics.htm

If you do need treatment soon, you might like to ascertain whether HIFU (High Intensity Focal Ultrasound) might be an option. This is not widely adopted in the UK, particularly within the NHS. Maybe worth checking it out as a possibility. It can be repeated if necessary. I had it as a salvage treatment for failed RT but it can also be given as a primary treatment in cases where it is a suitable option.

Edited by moderator 19 Oct 2023 at 15:36 | Reason: Not specified

Barry

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User

Posted 11 Dec 2015 at 19:06

It may turn out to be simply that you need to be monitored carefully in the future so no point p a icing yet but get the biopsy.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 11 Dec 2015 at 19:56

I would get on and have the biopsy and find out for certain one way or the other , then you will be able to plan ahead, Andy

User

Posted 11 Dec 2015 at 20:11

Hi Paul, I think finding out if, where and what is the first thing to do then you will know how to deal with it.

Fingers crossed eh?

Regards Chris/Woody

Life seems different upside down, take another viewpoint

User

Posted 11 Dec 2015 at 22:26

Hi Paul

Try to look on it this way.

You are fortunate. Should you be diagnosed with Pca, like my OH, your early diagnosis will have been pure fluke. But you have options.

In two or three or five years time when you were getting symptoms, it may have been too late for a cure. At the moment, it doesn't appear to be.

Louise x

User

Posted 12 Dec 2015 at 11:44

Hi
It seems to me that your consultant is suggesting you have your Prostate removed if the biopsy shows cancer and the majority of young men who are recommended treatment do have surgery.

However, in your shoes and having medical cover I would first opt for a template Transperenial biopsy for the following reasons:-

2. There is a greater risk of infection with the TRUS biopsy.

Barry

User

Posted 12 Dec 2015 at 12:25

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 12 Dec 2015 at 12:54

Hello Paul and welcome

Good luck with your choice.

It seems to me that in order to make an informed decision you need to have the information on which to base it and so a biopsy would be the obvious route.

We can't control the winds - but we can adjust our sails

User

Posted 12 Dec 2015 at 20:05

Wow, thanks everyone for your input, I really appreciate it (although I think I need to re-read and assimilate it again!)

It does seem like you're all telling me exactly what the Consultant said....'Get on with Biopsy!'. Fair enough!

The NHS Urologist is also the one and the same Urologist I would have seen privately anyway - hence why I haven't opted to go privately yet. He appears to be the head honcho of the local hospital Urology Dept but I'm unsure as to his credentials specifically in regard to PC.

On a first read, I'm slightly confused about the advice re Template vs Trus biopsy. Is an 8mm mass big enough for him to get a chunk of without template? I don't even know if 8mm is considered 'big' (apparently my prostate according to the DRE was 'normal sized').

So, yes, I understand template requires a GA (with the associated risks) but is it more or less likely to result in infection? Less I presume?

Thanks again for your support and advice, it was a lovely and welcome surprise to find your comments after a day of 'trying to behave normally' with the family!

Cheers

Paul

User

Posted 12 Dec 2015 at 20:40

Paul I had a template bi-opsy and did not have a general anaesthetic, all I was given was a "relaxation" injection which did not hurt and there was no discomfort.

There were no problems after with any infection or blood in my stools etc, although I was told that it may have happened.

If you go down this route I hope you end up unaffected by the procedure like I was.

Best wishes, Chris /Woody

Life seems different upside down, take another viewpoint

User

Posted 13 Dec 2015 at 01:56

I think a few do template biopsy under local anaesthetic but the vast majority knock you out.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 13 Dec 2015 at 02:00

Big Stan, a normal size prostate is about 4cm long and 2cm wide so your surgeon would have about a quarter of the gland to aim at - it would be pretty hard to miss now he knows where to aim for!

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 13 Dec 2015 at 17:13

Hi Paul,

Good luck.

Paul

THE CHILD HAS GROWN, THE DREAM HAS GONE

User

Posted 13 Dec 2015 at 20:00

Hi Big Stan

Welcome to the forum although you would rather be somewhere else.

I have recently undergone RP (open surgery) last Monday with the almost guarantee of RT next July.

When I was diagnosed last August I joined this forum for advice just as you have, all I can say is that the people on here have been very supportive and very informative.

Not much to add though on what has been said before, all I will say is that the biopsy is a must to determine where you go from here

Best wishes on getting results that you wish for.

Also speak to the nurses via the phone line,they are a tower of strength and full of knowledge.

Hope for a good outcome.

User

Posted 14 Dec 2015 at 00:53

https://www.youtube.com/watch?v=2ymlnjraXOc

http://www.nuadamedical.co.uk/prostatecancer/film-precision-prostate-diagnostics.htm

Edited by moderator 19 Oct 2023 at 15:36 | Reason: Not specified

Barry

User

Posted 14 Dec 2015 at 23:36

Once again, many thanks to you all for your comments, it is really, very helpful!

Pretty much from the day I found out my first PSA result was 'elevated', I knew a biopsy would almost certainly follow. That hasn't changed - I do understand the role of the biopsy (and it's certainly not something I'm looking to dodge).

It's more that I'm unsure whether despite that acceptance, there's anything more I should do *now*, (as I've said before, specifically regarding MRI imaging and biopsy procedure) so I don't regret it later - that of course is hoping I have a chance to actually make choices let alone regret them later!

I think I've convinced myself to try and have a chat with another consultant (radiologist) this week to get their take on approach pre biopsy. Obviously they'll have a radiology bias but I think I just have to do everything to satisfy myself at this stage that I haven't missed anything early doors which might haunt me later.

Thanks again for all the advice and long may it continue!

Cheers

Paul

User

Posted 04 Feb 2016 at 18:48

Thank you again for all your previous comments and advice and sorry for my lack of activity here - there wasn't much to report and I was trying to get my head round everything!

Finally though, here's my very positive update!

After last posting, I did indeed speak to another Consultant who told me that having reviewed my MRI report, a TRUS Biopsy would probably not reach the 8mm mass identified on the MRI because of it being positioned on the anterior of the prostate.

He told me that the MRI report had graded it at T2c and PIRAD 4 (PIRAD grading was not something I had heard of before) and he suggested that the best course of action now was to have a new up to date PSA test, MRI on a 3T machine with DCE (previously it had been a 1.5T scan with no DCE) and then, with the new MRI, he wanted to do an MR fusion targeted transperineal biopsy under general anaesthetic.

I had the second MRI on 26th Jan and weirdly (amazingly?), it came back showing no sign of the 8mm anterior mass/suspected tumour that the first MRI had shown. It seemed especially strange as my PSA, done at the same time, had jumped up to 4.6.

The DCE scan did show other suspicious areas however and I went ahead with the targeted biopsy on 1st Feb. Aside from some difficulty initially passing urine, recovery (so far, on day 3) has been uneventful but just a bit uncomfortable!

I had a follow up for results the following day on 2nd Feb (talk about speedy!) and to my amazement all 34 biopsy cores had come back negative :-)

I'm still in a bit of shock at my good fortune, especially as I was told by the consultant a few weeks ago (prior to the second MRI) that my chances of the biopsy coming back negative given the evidence to date was probably only a couple of percent!

I'm also still slightly in disbelief that a 41 yr old with family history, can have a small (28mls) prostate, PSA of 4.6, a probable tumour in November that disappeared before the end of January and a negative 34 core transperineal biopsy!

When I asked how all that was possible, the consultant stressed that PSA was only prostate specific and not prostate cancer specific. I get that but still....!

Right now I feel unbelievably lucky but I have to admit that I'm also a bit paranoid that it's too good to be true! I hope that's just the result of the last 3 months of stress though and I'll start to really appreciate my good fortune when my perineum stops smarting!!

So that's it from me, I'm really pleased I chose the targeted biopsy route because I think if a TRUS had come back negative I would definitely not have believed it and probably would have therefore ended up having a second targeted biopsy anyway! I also have a lot of faith in the second consultant that I saw who seemed exceptionally competent and empathetic.

Presuming they stay high (for my age), or continue to increase, I'm not quite sure how we'll be able to interpret my PSA readings in the future but on the consultant's advice, I'm going to have them every 6 months and take it from there.

Thanks again for listening and your advice, it's been a most welcome!

Cheers
Paul

User

Posted 04 Feb 2016 at 19:02

Hello Paul,
Very pleased for you with your positive update. Long may it continue.

We can't control the winds - but we can adjust our sails

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