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What would you do ?

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User
Posted 11 Jun 2018 at 10:29

Please look at my profile and I would welcome any comments.

My MRI results are back which confirms that there is a benign prostatic hyper trophy volume 85ml. No significant sign of prostate cancer is indentified on T2 weighting, diffusion weighted imaging or gadolinium enhancement. The prostate capsule and seminal vesicles appear intact. There is no lymphadenopathy.

My PSA results back at 5.5, which have improved. 

I have a TRUS booked in for Friday but I am now thinking about cancelling this and would prefer watchful waiting.

what would you do ?

User
Posted 11 Jun 2018 at 14:56

Personally, I would politely decline the TRUS Biopsy, and request a Template Biopsy, even if I had to wait a few months. Far too often TRUS Biopsies have to be succeeded by Template Biopsies in a quest for more accurate results.

But please have one or other biopsy to put your mind at rest.

User
Posted 11 Jun 2018 at 15:20
Brian,

Different men would respond one way and the other in your situation but what is important is that you think it over and decide what you feel ir right for you now. The TRUS biopsy in your case would be tantamount to throwing darts at a board whilst blindfolded with a risk of infection.. Many of the men on this forum being already diagnosed with PCa might come down on that side of having the TRUS but you have a particularly large Prostate so not surprising your PSA is somewhat elevated.. In your position I would not proceed with a TRUS for the time being.unless indicators show this would be of more benefit. But this is just what I would do in your present circumstances and is not a recommendation.

Barry
User
Posted 11 Jun 2018 at 16:10

Sorry you don' say how old you are? Or family history?? Also was it an MPMRI? Assuming it was an MPMRI then to answer your question of what I would do:

If you are "old" and your urologist agrees then I would say monitor PSA every 3 months and get a consistent picture over 12 months before having any invasive tests as biopsies are not without significant risk.

If you are young, and there is family history then you probably want to be sure nothing is going on and a template biopsy would give a better chance of confirming this.

Or some path in between!! but a Trus with no target isn' going to give you a definitive all clear.

 

User
Posted 12 Jun 2018 at 07:49

sounds like it' a monitor job to me!

User
Posted 12 Jun 2018 at 08:45

In my opinion its similar to what Barry has written, depends on the individual. If you were going to have any biopsy I'd say template but my feeling is that there is a good chance it could find clinically insignificant cancer. If it was a 3t mpMRI and it showed no PIRADs 4 or 5 areas then in the last study I read showed a very low chance of finding anything significant on biopsy less than 7% of PIRADs 3 areas turned out to be cancerous and most of them were g6. That said if it was me I'd want to be as sure as possible and I'd have a template biopsy to back up the mri findings. From the study:

 

The mean age of patients in this cohort was 62.6 years. Median prostate specific antigen (PSA) was 6.5 ng/ml and median prostate size was 78.4 ml. Eightysix (93.5%) of biopsied PIRADS 3 lesions were benign and 6 (6.5%) lesions were found to be malignant. Of these 6 malignant lesions, 4 (66%) were Gleason score 6 (3 + 3) and 2 (33%) were Gleason score 7 (3 + 4). 

Edited by member 12 Jun 2018 at 08:50  | Reason: Not specified

User
Posted 16 Jun 2018 at 05:56
Largely agreeing with earlier suggestions...

'Ordinary' (non-mpMRI) MRI may not show stuff, so an appropriate mpMRI is preferable.

TRUS biopsies often miss problems (akin to stabbing a fruit-cake and hoping to spear a cherry), so template is preferable. An 'in-between' option is 'fusion' (combining MRI and TRUS).

A template biopsy should help you be better informed.

Depending on your provider, various options may not be offered - either by the hospital or the consultant - and you might be fobbed-off. But everything that's been suggested here is normal, and should be available/offered if you 'push' for it and are prepared to change providers.

Personally, if I wanted to be 'as sure as I could be', I'd request mpMRI and then template.

User
Posted 16 Jun 2018 at 08:51

Can't advise you what to do Brian for the best but can only tell you my husband's experience.

He was scheduled for a TRUS following mpMRI but after reading one too many horror  stories about the pain during the procedure he politely asked a couple of weeks before the due date if he could be lightly

 

sedated. They declined this saying this is not how we do it here. ( Local general hospital who just do the tests but not treatment if PCa is found) If they had offered him some diazepam he would have gone ahead with it.

He declined with the result that a  registrar rang him back and was sympathetic enough to offer the Template biopsy. With hindsight we are glad this happened because out of 38 samples,    9 were Gleason 3 and only one a 4.

We can't  help but wonder if he had gone ahead with the TRUS it is unlikely it would have found the 4 and he may well have been persuaded to go down the active surveillance route leaving the more dangerous 4 element to progress..

 

As it happens his post prostatectomy histopathology results were good although it did show moderate patchy lesions and  at the apex the cancer was only 0.5mm away from breaking through so he may well have missed his window of opportunity for the surgeon to achieve negative margins which are obviously better than positive ones.

Best Regards

Ann

 

User
Posted 16 Jun 2018 at 12:16

Originally Posted by: Online Community Member
Largely agreeing with earlier suggestions...

'Ordinary' (non-mpMRI) MRI may not show stuff, so an appropriate mpMRI is preferable.

TRUS biopsies often miss problems (akin to stabbing a fruit-cake and hoping to spear a cherry), so template is preferable. An 'in-between' option is 'fusion' (combining MRI and TRUS).

A template biopsy should help you be better informed.

Depending on your provider, various options may not be offered - either by the hospital or the consultant - and you might be fobbed-off. But everything that's been suggested here is normal, and should be available/offered if you 'push' for it and are prepared to change providers.

Personally, if I wanted to be 'as sure as I could be', I'd request mpMRI and then template.

 

It seems that Brian23 has already had the mpMRI which showed no areas of concern.

 

TRUS seems pointless in this situation, especially with such a large prostate and so watchful waiting (aka careful monitoring) is probably very wise for the time being.  

Edited by member 16 Jun 2018 at 12:17  | Reason: Not specified

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

User
Posted 25 Aug 2018 at 08:00

@Rich12...

Credit to you for the irony remark.

I too 'was riddled'... surgeon remarked 'with that PSA it'd be harder to miss than hit it'. When Gleason came-in at only 4+4, I quipped 'so you missed it then'.

Edited by member 25 Aug 2018 at 08:01  | Reason: Seagull flew over and distracted me.

User
Posted 06 Dec 2018 at 18:33
Make sure that your urologist is aware of what you are taking. Pygeum may falsely lower your PSA - in other words, it is possible that your true PSA may have risen significantly but is being masked by the supplements you are taking.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 06 Dec 2018 at 18:43
Hi Brian

I presume you are in England, despite you having a German doctor.

Personally, I would not set much store by these herbal remedies although a friend of mine has researched this intensively for the past four years and he feels there may be some benefit from CBD oil.

If it comes to it, do stick out for an NHS template biopsy. Unless you want to ‘enjoy’ another one a few months later.

Cheers, John

Show Most Thanked Posts
User
Posted 11 Jun 2018 at 14:56

Personally, I would politely decline the TRUS Biopsy, and request a Template Biopsy, even if I had to wait a few months. Far too often TRUS Biopsies have to be succeeded by Template Biopsies in a quest for more accurate results.

But please have one or other biopsy to put your mind at rest.

User
Posted 11 Jun 2018 at 15:20
Brian,

Different men would respond one way and the other in your situation but what is important is that you think it over and decide what you feel ir right for you now. The TRUS biopsy in your case would be tantamount to throwing darts at a board whilst blindfolded with a risk of infection.. Many of the men on this forum being already diagnosed with PCa might come down on that side of having the TRUS but you have a particularly large Prostate so not surprising your PSA is somewhat elevated.. In your position I would not proceed with a TRUS for the time being.unless indicators show this would be of more benefit. But this is just what I would do in your present circumstances and is not a recommendation.

Barry
User
Posted 11 Jun 2018 at 16:10

Sorry you don' say how old you are? Or family history?? Also was it an MPMRI? Assuming it was an MPMRI then to answer your question of what I would do:

If you are "old" and your urologist agrees then I would say monitor PSA every 3 months and get a consistent picture over 12 months before having any invasive tests as biopsies are not without significant risk.

If you are young, and there is family history then you probably want to be sure nothing is going on and a template biopsy would give a better chance of confirming this.

Or some path in between!! but a Trus with no target isn' going to give you a definitive all clear.

 

User
Posted 11 Jun 2018 at 16:41

Thanks for your comments,

 I am 67 years young this year with no family history.

The procedure MRI was a Pelvis and prostate with contrast. MRI Diffusion weighted.

conclusion was : There is BPH volume 84ml. There is no sign of significant prostate cancer.

My PSA level has improved from 7 to 5.5 over the last six week period.

User
Posted 12 Jun 2018 at 07:49

sounds like it' a monitor job to me!

User
Posted 12 Jun 2018 at 08:45

In my opinion its similar to what Barry has written, depends on the individual. If you were going to have any biopsy I'd say template but my feeling is that there is a good chance it could find clinically insignificant cancer. If it was a 3t mpMRI and it showed no PIRADs 4 or 5 areas then in the last study I read showed a very low chance of finding anything significant on biopsy less than 7% of PIRADs 3 areas turned out to be cancerous and most of them were g6. That said if it was me I'd want to be as sure as possible and I'd have a template biopsy to back up the mri findings. From the study:

 

The mean age of patients in this cohort was 62.6 years. Median prostate specific antigen (PSA) was 6.5 ng/ml and median prostate size was 78.4 ml. Eightysix (93.5%) of biopsied PIRADS 3 lesions were benign and 6 (6.5%) lesions were found to be malignant. Of these 6 malignant lesions, 4 (66%) were Gleason score 6 (3 + 3) and 2 (33%) were Gleason score 7 (3 + 4). 

Edited by member 12 Jun 2018 at 08:50  | Reason: Not specified

User
Posted 16 Jun 2018 at 05:56
Largely agreeing with earlier suggestions...

'Ordinary' (non-mpMRI) MRI may not show stuff, so an appropriate mpMRI is preferable.

TRUS biopsies often miss problems (akin to stabbing a fruit-cake and hoping to spear a cherry), so template is preferable. An 'in-between' option is 'fusion' (combining MRI and TRUS).

A template biopsy should help you be better informed.

Depending on your provider, various options may not be offered - either by the hospital or the consultant - and you might be fobbed-off. But everything that's been suggested here is normal, and should be available/offered if you 'push' for it and are prepared to change providers.

Personally, if I wanted to be 'as sure as I could be', I'd request mpMRI and then template.

User
Posted 16 Jun 2018 at 08:51

Can't advise you what to do Brian for the best but can only tell you my husband's experience.

He was scheduled for a TRUS following mpMRI but after reading one too many horror  stories about the pain during the procedure he politely asked a couple of weeks before the due date if he could be lightly

 

sedated. They declined this saying this is not how we do it here. ( Local general hospital who just do the tests but not treatment if PCa is found) If they had offered him some diazepam he would have gone ahead with it.

He declined with the result that a  registrar rang him back and was sympathetic enough to offer the Template biopsy. With hindsight we are glad this happened because out of 38 samples,    9 were Gleason 3 and only one a 4.

We can't  help but wonder if he had gone ahead with the TRUS it is unlikely it would have found the 4 and he may well have been persuaded to go down the active surveillance route leaving the more dangerous 4 element to progress..

 

As it happens his post prostatectomy histopathology results were good although it did show moderate patchy lesions and  at the apex the cancer was only 0.5mm away from breaking through so he may well have missed his window of opportunity for the surgeon to achieve negative margins which are obviously better than positive ones.

Best Regards

Ann

 

User
Posted 16 Jun 2018 at 11:47

Thank you for your post Ann,

Thankfully he had the template biopsy which showed the problem which would have probably gone un noticed with the TRUS.

I do hope your husband is on the road to recovery. 

For myself I cancelled the TRUS biopsy and because of this the follow up appointment has been cancelled by them so I am waiting for another appointment to discuss the way forward. My GP was not happy about them cancelling the appointment as I am still waiting for the Specalists take on the MRI scan. The wait is agonising ! The scan shows a BPH. 

Once again thank you for your comments.

User
Posted 16 Jun 2018 at 12:16

Originally Posted by: Online Community Member
Largely agreeing with earlier suggestions...

'Ordinary' (non-mpMRI) MRI may not show stuff, so an appropriate mpMRI is preferable.

TRUS biopsies often miss problems (akin to stabbing a fruit-cake and hoping to spear a cherry), so template is preferable. An 'in-between' option is 'fusion' (combining MRI and TRUS).

A template biopsy should help you be better informed.

Depending on your provider, various options may not be offered - either by the hospital or the consultant - and you might be fobbed-off. But everything that's been suggested here is normal, and should be available/offered if you 'push' for it and are prepared to change providers.

Personally, if I wanted to be 'as sure as I could be', I'd request mpMRI and then template.

 

It seems that Brian23 has already had the mpMRI which showed no areas of concern.

 

TRUS seems pointless in this situation, especially with such a large prostate and so watchful waiting (aka careful monitoring) is probably very wise for the time being.  

Edited by member 16 Jun 2018 at 12:17  | Reason: Not specified

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

User
Posted 24 Aug 2018 at 15:52

Hello again, I have at last got an appointment at the PSA clinic to discuss the results of the MRI scan with the consultant,In readiness for this I had a PSA blood test done at my GPs and the results have come back at 6.2 and saying "normal for this patient" My research is telling me that my PSA level is elevated due to my enlarged prostate in view of this I am hoping that my consultant agrees and I can watchfully wait with regular PSA tests.

User
Posted 24 Aug 2018 at 20:18
To help Brian (and myself!).....

is there ever a situation where you (commentors) advocate TRUS biopsy? Every post I see from you guys says TRUS is no good cf template. I had this on private treatment yet now worry what may have been missed?

From Brian's point of view is there a scenario where you would TRUS is ok?

User
Posted 24 Aug 2018 at 21:44

I'd advocate a TRUS biopsy if an MRI had been done to direct it.  Also in my case where the psa at 9 had the potential to be going into a higher risk region a faster diagnosis is welcome. They only need to find some Gleason 4 to know it needs fast treatment. 

I had the biopsy first and had the impression the MRI gave the most information for me.  If the biopsy had missed it with a psa of 9 they knew there was high probability of something there and a template biopsy would have been done along with the MRI.   I was offered a template biopsy for further definition but rejected it.

Also the pain of a TRUS is exaggerated, the vast majority have only discomfort.  There is discomfort post biopsy and having twice as many holes punched in your prostate must be more to heal with the potential to spread the disease and be susceptible to disease.

In my case the MRI after the biopsy said it was near the edge of the prostate and with the Gleason 4+3 was more reason for fast treatment.  The Gleason post op was 4+4, whether it was that all along I don't know but speed must have done some good.  In some cases PCa is slow growing and time may not be critical but with 4+4 on the edge of the prostate it was already in a high risk situation.

Edited by member 24 Aug 2018 at 21:47  | Reason: Not specified

User
Posted 24 Aug 2018 at 22:22

Originally Posted by: Online Community Member
To help Brian (and myself!).....

is there ever a situation where you (commentors) advocate TRUS biopsy? Every post I see from you guys says TRUS is no good cf template. I had this on private treatment yet now worry what may have been missed?

From Brian's point of view is there a scenario where you would TRUS is ok?

Ideally you would use TRUS if you have a target to aim at from an MRI. The danger of TRUS is the limited number of samples may mis significant cancer but having a clear target from MRI mitigates this risk. 

It is also a less invasive and less painful procedure hence it can be done with a local anesthetic.

In your case Rich you have had the kitchen sink thrown at it so there is no danger of undertreatment.

 

 

 

User
Posted 25 Aug 2018 at 01:37
The reason I eschewed the offered TRUS biopsy in the first place is that two friends had one and then they both had to undergo template biopsies subsequently.

Now on this site and others I read of men almost daily who suffered the same scenario. In fact, yesterday I read somewhere (can’t remember where) of a man who had had three TRUS biopsies over a couple of years which all came back clear, but it was only after an MRI and a template biopsy that his cancer was confirmed!

User
Posted 25 Aug 2018 at 04:44

@Rich12...

>Is there ever a situation where you (commentors) advocate TRUS biopsy?

Yep sure: if you'd rather remain relatively clueless about what's happening inside you, and are happy with an increased risk of death.

In some cases (high double-digit and greater PSA, and a prior MRI indicating 'likely riddled with it') a TRUS is acceptable. But 'advocate'? Nope.

Commonly accepted statistics suggest TRUS to be unreliable in 25-30% of cases. The similar figure for MRI is less than 10%.

(Also relevant... it's not wise to walk-away smiling after a GP has shoved a finger up yer wotsit and told you 'all ok'.)

User
Posted 25 Aug 2018 at 07:29
Mr Gulliver, or do you get "Gulls" or "Liver" (the irony....).

So for Brian's sake, I had TRUS after MRI showed ~19mm tumour on left lobe which was targeted on biopsy. Some random samples were taken and ALL found to be cancerous (i.e. "Riddled"). Therefore TRUS was appropriate for me I suppose. Not so for you Brian.

User
Posted 25 Aug 2018 at 08:00

@Rich12...

Credit to you for the irony remark.

I too 'was riddled'... surgeon remarked 'with that PSA it'd be harder to miss than hit it'. When Gleason came-in at only 4+4, I quipped 'so you missed it then'.

Edited by member 25 Aug 2018 at 08:01  | Reason: Seagull flew over and distracted me.

User
Posted 25 Aug 2018 at 21:54

According to one of the UK's leading urologists, MRI should be done before biopsy, this is what urologists prefer and is being increasingly adopted. Quite apart from the greater cost of Template over TRUS biopsy, the former takes more resources and time, something that adds to the problem of processing patients in our overstretched NHS. It is true that the Template biopsy leaves more perforations to heal but there is much less chance of infection because the needles go through the perineum rather than the rectum as in the TRUS biopsy. Also, because of the grid placement of needles with the Template, there is a much greater chance of finding significant tumours, So if a man can have the Template version, this is generally better where biopsy is deemed advisable.

Edited by member 25 Aug 2018 at 21:57  | Reason: Not specified

Barry
 
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