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Biopsy clear but MRI extremely anomalous

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User
Posted 26 Mar 2024 at 16:37

Hi - I’m hoping for some advice or opinions on anything I can do or ask given I’ve today got a clear transperineal biopsy result but because my MRI in March identified  an extremely anomalous area which if cancerous would be rated T4 N1, the junior doctor I saw for my results said he was going to put my case forward for team discussion and consideration of further tests, meaning most likely repeat or more invasive biopsies, as he thought the 2 results were so hugely inconsistent. The doctor clearly expected the biopsy to be positive although the consultant who actually did the biopsy told me he thought it was unlikely cancerous not least because my prostate felt very smooth but also because I’d had a clear transrectal  biopsy of the same area in 2019.

 

It might be worth sharing some of my history. I was referred to urology by my GP in early 2019 due to a high PSA (around 7-8 I think). I had a MRI in 2019 which identified a moderately rated anomalous area which led to a transrectal biopsy which was all clear. I was put on a waiting list for urolift but due to Covid then the hospital ceasing to offer the procedure I was instead  left soldiering on with Finasteride and Tamsulisin. Over time I first dropped Tamsulsin then about 9 months ago Finasteride also (due to side effects). Last summer in consultation with my GP and on the basis that my quality of life would improve if I had treatments such as PAE or Rezum, I went back on the urology waiting list and am in fact now on 2 lists at 2 different hospitals – one for Rezum and the other for PAE. It was at my request the MRI was repeated just before I was due to have Rezum earlier this year. The highly anomalous area revealed by the recent MRA meant the Rezum procedure couldn’t go ahead and instead I was listed for transperineal biopsy. Likewise the hospital offering to consider me for PAE is waiting on the transperineal  biopsy results before seriously considering me for PAE.  I  will  postpone a CT angiogram which is part of the assessment procedure while the cancer-or-not issue remains in abeyance as it seems consultants are not keen to proceed with either PAE or Rezum unless there is confidence in a negative biopsy, which according to the doctor I saw today there isn’t – as he put it I’m still “under investigation “.

 

 

As for my PSA scores, from memory these were hovering around 7-8 before I went on Finasteride, fell to around 3-4 while on it, rose again to around 7 after I came off Finasteride, blipped at around 11 in Dec 2023 but fell to 3.3 in early 2024. I queried the3.3 score early this year but was told it is highly unlikely to be an error and more indicative of my PSA varying day to day.

 

Urinary symptoms are fairly mild but problematic at times, like when on long journeys. I have a significant but not huge volume of retention. Occasional dashes to the loo and repeat trips. I can no longer pee with the firehouse stream of a teenager. Long  drives require planning of toilet breaks. I rarely wake at night even if I drink a beer or hot drink immediately before bed. I’d say things are slowly worsening as I age but are far from dire.

 

Apparently my prostate is roughly 60cc.

 

Meds wise since coming off Finasteride I’ve found 5mg of daily cialis helpful. I buy that privately. I don’t always take it regularly. I try not to take more medication than I need, but do load up on herbals and vitamins (saw palmetto, zinc, multivitamins, etc).

 

I drink a lot of coffee and am trying not to. That certainly doesn’t help with the toilet dashes.

 

So that’s it. My 2 MRIs, 5years apart, show the same area becoming increasingly suspicious and more recently alikelihood that cancer has spread beyond my prostate. However I’ve now had 2 different biopsies, one rectal and perineal, which are completely negative. The last transperineal (20 samples plus about 6 anaesthetic injections) was incredibly painful and I don’t relish the thought of repeating that in the near future and also am concerned, what with the amount of blood afterwards, that my prostate is going to end up damaged by such butchery. So while I’m waiting on what the team review comes up with, I’d welcome any thoughts  from anyone who’s experienced similar history or such near certainly bad MRI results followed by clear biopsies.

Many thanks in advance!!

 

User
Posted 26 Mar 2024 at 20:10
An MRI is only indicative and not a cert - we have had a number of men on here in the last couple of years with a PI-RADS score of 5 who went on to get the all clear following biopsy. A suspicious area on mpMRI can be infection or inflammation and your jumping / dropping PSA also suggests inflammation. In the absence of any other evidence, I would also be more persuaded by the consultant's view than the junior doctor, especially as the consultant was in there and the junior doctor is looking at images. Can you confirm a) that the MRI was an mpMRI and b) whether the TPB was image guided or by template?

It will be interesting to see what the MDT recommends.

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

User
Posted 08 Apr 2024 at 21:43

I had a similar experience with a MRI that showed a 20cc prostate, PSAD 0.6, clinically significant disease within the right peripheral zone of mid gland PIRADS 5.  Yet, when I had the biopsy, the right lobe was clear and the left came back with a Gleason Score of 3+4.

I had a nerve sparing RP on the right side as there was apparently no cancer there but when I spoke to the consultant four weeks post-op he told me that the '...ultimate histology does show quite a large area of cancer on the right side, Gleason 4+3 with a maximum diameter of 23mm.'  Bearing in mind my prostate was on the small side he said it was disappointing it wasn't picked up!  It's likely that I'll need top-up radiotherapy (I'm just waiting on my first PSA test result post-op).  In hindsight (for whatever that's worth) I wish my consultant had thought another biopsy to double-check was worth while!

User
Posted 26 Mar 2024 at 16:37

Hi - I’m hoping for some advice or opinions on anything I can do or ask given I’ve today got a clear transperineal biopsy result but because my MRI in March identified  an extremely anomalous area which if cancerous would be rated T4 N1, the junior doctor I saw for my results said he was going to put my case forward for team discussion and consideration of further tests, meaning most likely repeat or more invasive biopsies, as he thought the 2 results were so hugely inconsistent. The doctor clearly expected the biopsy to be positive although the consultant who actually did the biopsy told me he thought it was unlikely cancerous not least because my prostate felt very smooth but also because I’d had a clear transrectal  biopsy of the same area in 2019.

 

It might be worth sharing some of my history. I was referred to urology by my GP in early 2019 due to a high PSA (around 7-8 I think). I had a MRI in 2019 which identified a moderately rated anomalous area which led to a transrectal biopsy which was all clear. I was put on a waiting list for urolift but due to Covid then the hospital ceasing to offer the procedure I was instead  left soldiering on with Finasteride and Tamsulisin. Over time I first dropped Tamsulsin then about 9 months ago Finasteride also (due to side effects). Last summer in consultation with my GP and on the basis that my quality of life would improve if I had treatments such as PAE or Rezum, I went back on the urology waiting list and am in fact now on 2 lists at 2 different hospitals – one for Rezum and the other for PAE. It was at my request the MRI was repeated just before I was due to have Rezum earlier this year. The highly anomalous area revealed by the recent MRA meant the Rezum procedure couldn’t go ahead and instead I was listed for transperineal biopsy. Likewise the hospital offering to consider me for PAE is waiting on the transperineal  biopsy results before seriously considering me for PAE.  I  will  postpone a CT angiogram which is part of the assessment procedure while the cancer-or-not issue remains in abeyance as it seems consultants are not keen to proceed with either PAE or Rezum unless there is confidence in a negative biopsy, which according to the doctor I saw today there isn’t – as he put it I’m still “under investigation “.

 

 

As for my PSA scores, from memory these were hovering around 7-8 before I went on Finasteride, fell to around 3-4 while on it, rose again to around 7 after I came off Finasteride, blipped at around 11 in Dec 2023 but fell to 3.3 in early 2024. I queried the3.3 score early this year but was told it is highly unlikely to be an error and more indicative of my PSA varying day to day.

 

Urinary symptoms are fairly mild but problematic at times, like when on long journeys. I have a significant but not huge volume of retention. Occasional dashes to the loo and repeat trips. I can no longer pee with the firehouse stream of a teenager. Long  drives require planning of toilet breaks. I rarely wake at night even if I drink a beer or hot drink immediately before bed. I’d say things are slowly worsening as I age but are far from dire.

 

Apparently my prostate is roughly 60cc.

 

Meds wise since coming off Finasteride I’ve found 5mg of daily cialis helpful. I buy that privately. I don’t always take it regularly. I try not to take more medication than I need, but do load up on herbals and vitamins (saw palmetto, zinc, multivitamins, etc).

 

I drink a lot of coffee and am trying not to. That certainly doesn’t help with the toilet dashes.

 

So that’s it. My 2 MRIs, 5years apart, show the same area becoming increasingly suspicious and more recently alikelihood that cancer has spread beyond my prostate. However I’ve now had 2 different biopsies, one rectal and perineal, which are completely negative. The last transperineal (20 samples plus about 6 anaesthetic injections) was incredibly painful and I don’t relish the thought of repeating that in the near future and also am concerned, what with the amount of blood afterwards, that my prostate is going to end up damaged by such butchery. So while I’m waiting on what the team review comes up with, I’d welcome any thoughts  from anyone who’s experienced similar history or such near certainly bad MRI results followed by clear biopsies.

Many thanks in advance!!

 

User
Posted 27 Mar 2024 at 13:53
If there was a contrast fluid, sounds like an mpMRI. This is good. In the circumstances, I doubt very much that the second biopsy was just random cores taken; they will have aimed for the suspicious areas.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Apr 2024 at 00:38
Okay - you have had an mpMRI (the contrast is one clue and the fact that you were given a PI-RADS score is the other clue) and the ultrasound with your template biopsy will have been to ensure samples were taken from the suspicious areas. So all good news! Now you need proper treatment for the prostatitis, which can be notoriously difficult to treat
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 09 Apr 2024 at 14:14

Hi, I hope your hospital visit goes well today and whatever treatment you have sorts it all out for you!

User
Posted 09 Apr 2024 at 17:39

There are many natural remedies for prostatitis 

It involves targeting DHT 

DHT is short for dihydrotestosterone the culprit responsible for male hair loss and prostate cancer 

Saw Palmetto is the most popular alternative to Finesterine which can have nasty side effects 

 

Edited by member 09 Apr 2024 at 17:42  | Reason: Not specified

User
Posted 10 Apr 2024 at 15:25

Originally Posted by: Online Community Member

Saw Palmetto is the most popular alternative to Finesterine which can have nasty side effects 

 

 

Thanks for this suggestion - ironically I’ve been taking saw palmetto for several years as a natural alternative to tamsulosin and finasteride. I took both for several years but couldn’t tolerate the side-effects, so first dropped tamsulosin then early last year finasteride. Hence my renewed interest in surgical options, which were sideswiped by the scary MRI.

 

Saw a very helpful consultant yesterday who assured the MDT were confident there was no malignancy so the options were to proceed with Rezum or likely most appropriate try to treat the prostatitis first. I was happy to treat the prostatitis not least because it’s possible that may also relieve some of my urinary symptoms without the need for surgery. So I’m on antibiotics now. I asked about the possibility of a further MRI to see if the antibiotics work, as otherwise there’s no way I can see of knowing if the prostatitis has relented or not. I’ve no pain and although likely chronic my prostatitis has no physical symptoms that don’t overlap those of BPH. So for now the plan is 6 weeks of antibiotics followed by another PSA test, some urine cultures (I gave a sample), then take stock. 

I also queried the type of biopsy I had. They took 20 samples. It wasn’t a fusion type biopsy where they overlap the MRI images with the ultrasound, but template in which the person performing the biopsy is aware of the biopsy and so targets the suspicious areas and takes some other samples also (so I understand). Again, apparently on reviewing the scans and biopsy results the MDT seemed to be in consensus about everything suggesting prostatitis.

I’ll naturally feel more confident about the prostatitis diagnosis  if the antibiotics make a difference, and it seems that may also depend on hitting upon the correct antibiotics to use. A slight difficulty there  may be that it seems there are many possible bacterial causes and the hospital does not routinely test for “everything” nor offer  some of the more esoteric tests. I’m therefore wondering about how to get a full range of bacteria tests privately or through my GP, because if I’ve got a detectable infection of bacteria that don’t respond to my antibiotics they won’t help. However, given how difficult it can be to identify causes of prostatitis I’m happy to begin with ciprofloxacin and see how things go.

 

Thanks for the helpful and supportive comments. Needless to say I’ve also found other threads and information here very useful.

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User
Posted 26 Mar 2024 at 20:10
An MRI is only indicative and not a cert - we have had a number of men on here in the last couple of years with a PI-RADS score of 5 who went on to get the all clear following biopsy. A suspicious area on mpMRI can be infection or inflammation and your jumping / dropping PSA also suggests inflammation. In the absence of any other evidence, I would also be more persuaded by the consultant's view than the junior doctor, especially as the consultant was in there and the junior doctor is looking at images. Can you confirm a) that the MRI was an mpMRI and b) whether the TPB was image guided or by template?

It will be interesting to see what the MDT recommends.

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

User
Posted 27 Mar 2024 at 00:38

Originally Posted by: Online Community Member
Can you confirm a) that the MRI was an mpMRI and b) whether the TPB was image guided or by template?

It will be interesting to see what the MDT recommends.

 

Thanks LynEyre! Unfortunately I don’t know whether my biopsy was an mpMRI or not (I was injected with a contrast fluid, if that has any relevance) or whether my biopsy was image guided or template. I will try to find out. 

User
Posted 27 Mar 2024 at 13:53
If there was a contrast fluid, sounds like an mpMRI. This is good. In the circumstances, I doubt very much that the second biopsy was just random cores taken; they will have aimed for the suspicious areas.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 04 Apr 2024 at 16:48

I have another meeting with a urologist next week at an outpatients clinic to discuss my recent MRI. The hospital’s multidisciplinary team, which I think includes urologists and radiologists,  have now considered my MRI and biopsy results and I have a preview of the radiology perspective. If anyone has some guidance on what to make of things and what it will be helpful  to ask  I’d be very grateful!

Since my original post, I’ve also found out my biopsy was template guided using ultrasound (I’m not sure if the prior MRI guided the sampling). I’m still not sure if the MRI was mpMRi but I was given a contrast injection. The hospital has also kindly sent me a copy of my MRI report with an addendum following the MDT meeting outcome.

I’ve pasted below some extracts from my MRI, including the addendum note which gives me great relief but also more questions since I was previously listed for Rezum and have also been considering the possibility of PAE (though have not yet had a CT scan) to ease my urinary symptoms. All thoughts welcome! And again, at this point I feel very relieved but appreciate no amount of sampling is 100% certain to confirm I’m  “clear” of cancer though possible prostatitis seems the lesser of two unwanted conditions by far.

“FINDINGS:

Prostate volume is 67 cc.

PSA density is 0.16 ng/ml/cc.

There is bilateral diffuse T2 hypointensity in the peripheral zones. There is uniform postcontrast enhancement noted with minimal restricted diffusion. However there is abnormal soft tissue involving both seminal vesicles with involvement of the mesorectal fascia. Multiple well-defined nodules noted in the transition zone. There is a 1 cm slightly irregular lymph node posterior to the right seminal vesical. The imaged pelvic bones are normal.

IMPRESSION:

Although appearances are not typical, the imaging findings are suggestive of PIRADS 5 abnormality in the peripheral zones involving the seminal vesicles.

If this is confirmed on biopsy, staging would be T4 NI.

ADDENDUM …….

Reviewed for Urology MDT……

Appearances most suggestive of prostatitis. Biopsies show patchy inflammation, no malignancy.

DR …… CONSULTANT RADIOLOGIST……”

 

User
Posted 07 Apr 2024 at 00:38
Okay - you have had an mpMRI (the contrast is one clue and the fact that you were given a PI-RADS score is the other clue) and the ultrasound with your template biopsy will have been to ensure samples were taken from the suspicious areas. So all good news! Now you need proper treatment for the prostatitis, which can be notoriously difficult to treat
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Apr 2024 at 02:59

Thanks Lyn. I feel very fortunate. I was told some of my MRI “scores” before the biopsy results so naturally was prepared for a diagnosis of PCa. I’m reading up now on prostatitis and think I may have the asymptomatic variety, but I know very little and am therefore on a learning curve. It does indeed sound problematic to treat…. I am actually looking forward to my next meeting with a consultant rather than dreading it. At least my situation underlines the fact that shocking MRI results don’t necessarily mean the worst. Thank you again!!

User
Posted 08 Apr 2024 at 21:43

I had a similar experience with a MRI that showed a 20cc prostate, PSAD 0.6, clinically significant disease within the right peripheral zone of mid gland PIRADS 5.  Yet, when I had the biopsy, the right lobe was clear and the left came back with a Gleason Score of 3+4.

I had a nerve sparing RP on the right side as there was apparently no cancer there but when I spoke to the consultant four weeks post-op he told me that the '...ultimate histology does show quite a large area of cancer on the right side, Gleason 4+3 with a maximum diameter of 23mm.'  Bearing in mind my prostate was on the small side he said it was disappointing it wasn't picked up!  It's likely that I'll need top-up radiotherapy (I'm just waiting on my first PSA test result post-op).  In hindsight (for whatever that's worth) I wish my consultant had thought another biopsy to double-check was worth while!

User
Posted 09 Apr 2024 at 14:05

Thanks for sharing your sobering experience. Although I don’t exactly relish the thought of a further biopsy, I’m off to the hospital today and will see what the consultant thinks. I imagine that since their current diagnosis for me is leaning towards prostatitis, a likely way forward would be to treat that then not too far into the future follow up with another MRI and if suspicious areas remain, another biopsy then. I’m no expert, but if there is a bacterial infection already I would be worried that a biopsy risks spreading/worsening that. Realistically, I’m not out of the woods yet.

User
Posted 09 Apr 2024 at 14:14

Hi, I hope your hospital visit goes well today and whatever treatment you have sorts it all out for you!

User
Posted 09 Apr 2024 at 17:39

There are many natural remedies for prostatitis 

It involves targeting DHT 

DHT is short for dihydrotestosterone the culprit responsible for male hair loss and prostate cancer 

Saw Palmetto is the most popular alternative to Finesterine which can have nasty side effects 

 

Edited by member 09 Apr 2024 at 17:42  | Reason: Not specified

User
Posted 10 Apr 2024 at 15:25

Originally Posted by: Online Community Member

Saw Palmetto is the most popular alternative to Finesterine which can have nasty side effects 

 

 

Thanks for this suggestion - ironically I’ve been taking saw palmetto for several years as a natural alternative to tamsulosin and finasteride. I took both for several years but couldn’t tolerate the side-effects, so first dropped tamsulosin then early last year finasteride. Hence my renewed interest in surgical options, which were sideswiped by the scary MRI.

 

Saw a very helpful consultant yesterday who assured the MDT were confident there was no malignancy so the options were to proceed with Rezum or likely most appropriate try to treat the prostatitis first. I was happy to treat the prostatitis not least because it’s possible that may also relieve some of my urinary symptoms without the need for surgery. So I’m on antibiotics now. I asked about the possibility of a further MRI to see if the antibiotics work, as otherwise there’s no way I can see of knowing if the prostatitis has relented or not. I’ve no pain and although likely chronic my prostatitis has no physical symptoms that don’t overlap those of BPH. So for now the plan is 6 weeks of antibiotics followed by another PSA test, some urine cultures (I gave a sample), then take stock. 

I also queried the type of biopsy I had. They took 20 samples. It wasn’t a fusion type biopsy where they overlap the MRI images with the ultrasound, but template in which the person performing the biopsy is aware of the biopsy and so targets the suspicious areas and takes some other samples also (so I understand). Again, apparently on reviewing the scans and biopsy results the MDT seemed to be in consensus about everything suggesting prostatitis.

I’ll naturally feel more confident about the prostatitis diagnosis  if the antibiotics make a difference, and it seems that may also depend on hitting upon the correct antibiotics to use. A slight difficulty there  may be that it seems there are many possible bacterial causes and the hospital does not routinely test for “everything” nor offer  some of the more esoteric tests. I’m therefore wondering about how to get a full range of bacteria tests privately or through my GP, because if I’ve got a detectable infection of bacteria that don’t respond to my antibiotics they won’t help. However, given how difficult it can be to identify causes of prostatitis I’m happy to begin with ciprofloxacin and see how things go.

 

Thanks for the helpful and supportive comments. Needless to say I’ve also found other threads and information here very useful.

User
Posted 10 Apr 2024 at 19:30

Originally Posted by: Online Community Member
  It's likely that I'll need top-up radiotherapy (I'm just waiting for my first PSA test result post-op)

Welcome to the forum Daz. Good luck mate.

Edited by member 10 Apr 2024 at 19:35  | Reason: Typo

User
Posted 11 Apr 2024 at 22:33

Hi, I think I'm in pretty much the same situation.  I had a PSA test recently and it came back as a 4.5.  Got sent to the urologist and he suspected an enlarged prostate.  From this went for an MRI scan and they found a concerning area, this I later found scored 5 on the scale.

From this went to for a TP biopsy where they took 19 samples.  The results from this all came back negative.

I was given the choice of waiting or doing a template biopsy. I chose the biopsy and an awaiting an appointment. 

User
Posted 21 Apr 2024 at 01:54

Hi Shifty, many thanks for your comments. Yes, your situation sounds very similar to mine. However, my doctors sounded very confident that the suspicious areas on my MRI were inflammation / prostatitis and the choices I was given were, essentially, to go back on the list for Rezum or have some antibiotics first. I opted for the antibiotics on the basis that if any of my BPH symptoms are due to prostatitis the antibiotics might ease things enough that I can postpone the Rezum. 

I do wonder about asking for a further biopsy. If the antibiotics don’t change anything I suppose I may be going down the route of considering whether or not to repeat the MRI and biopsy and/or proceeding with Rezum before my prostate gets too massive. It also depends on what the doctors are prepared to do. It’s all very dicey, isn’t it?

I’d be very interested to hear how your further biopsy turns out. 19 samples is a lot so if your next biopsy isn’t clear (and I hope it is clear!!) that’ll get me thinking more along your lines of getting more certainty from more samples. 

Good luck, buddy

 

 

 

 

User
Posted 24 Apr 2024 at 13:05

Hi, I'll be able to report back pretty soon.

My template biopsy is scheduled for the 1st of May, so should have the results back by the 14th of May.

Once I get them back I'll be sure to post them up here

User
Posted 24 Apr 2024 at 19:26

Thanks Shifty. Fingers crossed for you. If your result is clear you may well be in an even more similar situation to mine. All the best!!!

User
Posted 15 May 2024 at 09:54
Hi, I got my results back and they were all clear, obviously really happy with that.

It's nice to be able report something positive!!

User
Posted 15 May 2024 at 22:47

That’s great news. The consensus was that my suspicious areas were prostatitis. I was given 6 weeks of cipro which I had 2 cracks at starting but the side effects were too bad to continue (tiredness, dizziness, nightmares, tingles…). I regret ever taking it at all, having read up on how nasty it can be, a real case of the cure being worse than the disease in many cases. Now I’m on trimethoprim and so far so good.

 

I guess your journey isn’t yet over either, at the very least keeping a close eye on your PSA…

 

In my case the specialists wanted to put a name to the anomalous areas so inflammation/prostatitis fits. I read somewhere that inflammation is associated with the development of cancer so decided to agree to some antibiotics in the hope it’ll further delay PCa - I’m trying to be realistic rather than pessimistic in thinking that the oddities with my own MRI are still possibly indicative that something worth treating is going on….

Anyway, again, good news and another indication that worrying MRI results may not be so grim after all.

 

 
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