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Thread: In-Bore MRI Guided Prostate Biopsy

  1. #11
    Quote Originally Posted by garyi View Post
    I’m positive Dr. Sanda will know exactly what Sw1218 needs in the way of testing. So as the tatt commercial says, “stay in your own lane, bro”.

    Wifeofgolpher....hoping for the best for you two. You are very well prepared.
    Garyi, I hope that your comment was not aimed as a personal affront to me. Because, neither of us has had an in-bore biopsy. But, unlike you, I have read hundreds of posts from men who talked about their own experiences. Sharing their hero, Dr. Busch’s name, was intended to provide another point of reference for SW.

    Chill, bro
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  2. #12
    Top User garyi's Avatar
    Join Date
    Apr 2017
    Posts
    1,107
    No, ASA, nothing concerning you at all. Where you get that from, Harry?
    Last edited by garyi; 01-17-2019 at 04:56 AM.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19
    We'll see....what is not known dwarfs what is thought to be fact

  3. #13
    Top User garyi's Avatar
    Join Date
    Apr 2017
    Posts
    1,107
    What are you talking about, Harry. Nothing was ‘aimed’ at you, check the time stamps, and take your own advise and cool it.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19
    We'll see....what is not known dwarfs what is thought to be fact

  4. #14
    Garyi, I saw your reply posted right after mine. But, at only five minutes later, I can accept that it was coincidental.

    Enjoy your day, and keep making your valuable contributions to this forum.😀
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  5. #15
    Quote Originally Posted by Sw1218 View Post
    that's all right. at least you were kind enough to take the time to respond. because it took so long, i didn't think i would even get a response. anyhow, i went to visit the uro and like your husband, my uro recommends the MRI/ultrasound fusion targeted biopsy. he said it's my best option considering my situation. also, the nurse practitioner says my most MRI doesn't look as bad as i thought. still only a biopsy will dictate if i have PCa, but that's still a good sign. one more thing, my uro performed a DRE and he said it felt normal.
    So Sw1218: Re "my uro recommends the MRI/ultrasound fusion targeted biopsy. he said it's my best option considering my situation.:" For clarification:

    - Does your new URO MD plan to do this immediately?

    - Has it been scheduled?

    - I assume that the MRI will be repeated?

    - What were his thoughts about what might be going on (or not) with you?

    - Do you feel confident and comfortable with your new URO MD?

    Good job connecting with a very Top Tier URO MD. Best wishes for good results and findings!

    MF
    Last edited by Michael F; 01-17-2019 at 05:04 PM.

  6. #16
    Quote Originally Posted by ASAdvocate View Post
    There is another PCa support forum that has many, posts over the years praising Dr. Joseph Busch of Chattanooga, TN as being the ultimate expert on in-bore biopsies.

    I am a bit skeptical of the amount of deference given to him, as I don't see much mention of him on other forums. But, it won't hurt you to read up on him.
    Hi ASA! Re Dr. Joseph Busch of Chattanooga: My former next door neighbor was diagnosed with PCa (G6) around the same time as me. He is extremely smart and researched all of his options starting with a "Sarasota Quack URO MD & Book Author" who wanted $40K in cash to meet in a Latin American nation to undergo HIFU. Ultimately he opted for Cyberknife with a premier URO MD in NYC.

    During his opinion gathering, he visited one the "The Top PCa Meccas" where they did an MRI and told him that it was clean and there was not evidence of PCa and no need for treatment. Meanwhile, back in Atlanta a different URO Surgeon advised him to go to Dr Busch for evaluation. He brought a copy of his "clean" MRI (from the Mecca Institution) Dr Busch looked at it and pointed an area of PCa on the MRI and stated that it was "Gleason 7!" A subsequent Bx proved Dr Busch was 100% correct!

    Thus, even the Apex Institutions can be wrong!

    I sense that Sw1218 is in extremely good care with Dr Sanda. Dr S is at the Top of The URO MD Pyramid. He was not yet in ATL back in 2012 at the time of my diagnosis. Today I would recommend 2 surgical consultations to a newly diagnosed PCa patient in my area: Dr Tully / Birmingham & Dr Sanda / Atlanta

    MF
    Last edited by Michael F; 01-17-2019 at 05:06 PM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = Gleason 7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left Positive Margins + EPEs. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO / Prostate Size = 32 grams; Tumor = Bilateral; 20% / Perineural invasion: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  7. #17
    Senior User Sw1218's Avatar
    Join Date
    Jul 2015
    Posts
    123
    So Sw1218: Re "my uro recommends the MRI/ultrasound fusion targeted biopsy. he said it's my best option considering my situation.:" For clarification:
    - Does your new URO MD plan to do this immediately?
    no. it will be done by doctor cara cimmino. i have yet to meet/talk with her.
    what R your suggestions about this?


    - Has it been scheduled?
    monday february 25th

    - I assume that the MRI will be repeated?
    i'm not for certain.

    - What were his thoughts about what might be going on (or not) with you?
    he felt that were several lesions [3 to be exact] found on my prostate that needed to be looked at

    - Do you feel confident and comfortable with your new URO MD?
    No. I think he's a bit of an ASS When he recommended the type of biopsy, he actually didn't recommend the procedure, he told me it was the best option. 2ndly, when I asked him about the in-bore MRI targeted biopsy, he got a bit of an attitude and told me no that was an old school procedure and told me how it was going to go down, as supposed to suggesting. Based off my research, the in-bore biopsy was a better procedure and more accurate than the one he's suggestion. So, I will continue to ask around before I fully accept his plan.
    D.O.B. 1973
    07/14 PSA 5.5
    08/14 TRUS Bx Prostatitis & BPH
    07/15 PSA 5.9
    01/16 PSA 7.6
    03/16 PSA 6.2
    07/16 PSA 6.9
    10/16 PSA 6.9
    03/17 PSA 7.2
    05/17 3T MRI Good
    11/17 PSA 7.7
    11/18 PSA 10.8 Cipro for 2 wks
    07/18 PSA 11.9
    08/18 3T MRI: 3 per ZN focal ABN, 1 with a PI-RADS 4 lesion & 2 with PI-RADS 3 lesions. No extra PCa disease, pelvic LAD, or pelvic lesions
    02/19 MRI fusion biopsy
    Bx Findings
    A. PROSTATE, LESION 1, LEFT APEX, 3D MRI FUSION BIOPSIES: * BENIGN
    B. LESION 2, RIGHT MID GLAND *PCa, GS 4+3=7 (GRADE GRP 3) 3 OF 3 CORES
    (95% DISCONTINUOUS, <5%, <5%) * GS GRADE 4 60% OF THE TUMOR
    0 PERINEURAL INVASION IS PRESENT
    INFLAMMATION.
    C. LESION 3, DIFFUSE LEFT MID GLAND, 3D MRI FUSION NEEDLE CORE BX's
    PCa, GS 3+4=7 (GRADE GRP. 2) LESS THAN 5% OF THE FRAGMENTED CORES
    GS GRADE 4 INVOLVES 5% OF THE TUMOR
    2nd Bx OPINION
    A. Benign
    B. PCa, GS 3+3=6 (Grade Grp. 1) 80% of 1 core
    C. PCa, GS 3+3=6 (Grade Grp. 1) 20% of 1 core
    Considering options

  8. #18
    A critical comparison of techniques for MRI-targeted biopsy of the prostate [2017, Full Text]

    Abstract

    MRI-targeted biopsy is a promising technique that offers an improved detection of clinically significant prostate cancer over standard non-targeted biopsy. It is established that prostate MRI is of use in both the primary and repeat biopsy setting for the detection of significant prostate cancer. There are three approaches to targeting biopsies to areas of interest seen on prostate MRI. They each rely on the acquisition and reporting of a diagnostic quality multi-parametric MRI scan used to identify areas of interest, and the subsequent use of those diagnostic quality images in combination with real-time images of the prostate during the biopsy procedure. The three techniques are: visual registration of the MRI images with a real-time ultrasound image; software-assisted fusion of the MRI images and the real-time ultrasound images, and in-bore biopsy, which requires registration of a diagnostic quality MRI scan with a real time interventional MRI image. In this paper we compare the three techniques and evaluate those studies where there is a direct comparison of more than one MRI-targeting technique. PubMed was searched from inception to November 2016 using the search terms (cognitive registration OR visual registration OR fusion biopsy OR in-bore biopsy OR targeted biopsy) AND (prostate cancer OR prostate adenocarcinoma OR prostate carcinoma OR prostatic carcinoma OR prostatic adenocarcinoma) AND (MRI OR NMR OR magnetic resonance imaging OR mpMRI OR multiparametric MRI). The initial search included 731 abstracts. Eleven full text papers directly compared two or more techniques of MRI-targeting, and were selected for inclusion. The detection of clinically significant prostate cancer varied from 0% to 93.3% for visual registration, 23.2% to 100% for software-assisted registration and 29% to 80% for in-bore biopsy. Detection rates for clinically significant cancer are dependent on the prevalence of cancer within the population biopsied, which in turn is determined by the selection criteria [biopsy naïve, previous negative biopsy, prostate specific antigen (PSA) selection criteria, presence of a lesion on MRI]. Cancer detection rates varied more between study populations than between biopsy approaches. Currently there is no consensus on which type of MRI-targeted biopsy performs better in a given setting. Although there have been studies supporting each of the three techniques, substantial differences in methodology and reporting the findings make it difficult to reliably compare their outcomes.

    From the Full Text:

    Conclusions

    Ideally, the optimal biopsy technique should have the highest detection rate of clinically significant prostate cancer, while simultaneously having the lowest detection rate of clinically insignificant disease. Currently there is no consensus on which type of MRI-targeted biopsy performs better in a given setting. Although there have been studies supporting each of the three techniques, substantial differences in methodology and reporting the findings make it difficult to reliably compare their outcomes. The economic implications of using software assisted registration or in-bore registration should be borne in mind when choosing an approach.
    [Emphasis mine]

    The Full Text has a description of the three techniques.

  9. #19
    Senior User Sw1218's Avatar
    Join Date
    Jul 2015
    Posts
    123
    thank you for the report
    D.O.B. 1973
    07/14 PSA 5.5
    08/14 TRUS Bx Prostatitis & BPH
    07/15 PSA 5.9
    01/16 PSA 7.6
    03/16 PSA 6.2
    07/16 PSA 6.9
    10/16 PSA 6.9
    03/17 PSA 7.2
    05/17 3T MRI Good
    11/17 PSA 7.7
    11/18 PSA 10.8 Cipro for 2 wks
    07/18 PSA 11.9
    08/18 3T MRI: 3 per ZN focal ABN, 1 with a PI-RADS 4 lesion & 2 with PI-RADS 3 lesions. No extra PCa disease, pelvic LAD, or pelvic lesions
    02/19 MRI fusion biopsy
    Bx Findings
    A. PROSTATE, LESION 1, LEFT APEX, 3D MRI FUSION BIOPSIES: * BENIGN
    B. LESION 2, RIGHT MID GLAND *PCa, GS 4+3=7 (GRADE GRP 3) 3 OF 3 CORES
    (95% DISCONTINUOUS, <5%, <5%) * GS GRADE 4 60% OF THE TUMOR
    0 PERINEURAL INVASION IS PRESENT
    INFLAMMATION.
    C. LESION 3, DIFFUSE LEFT MID GLAND, 3D MRI FUSION NEEDLE CORE BX's
    PCa, GS 3+4=7 (GRADE GRP. 2) LESS THAN 5% OF THE FRAGMENTED CORES
    GS GRADE 4 INVOLVES 5% OF THE TUMOR
    2nd Bx OPINION
    A. Benign
    B. PCa, GS 3+3=6 (Grade Grp. 1) 80% of 1 core
    C. PCa, GS 3+3=6 (Grade Grp. 1) 20% of 1 core
    Considering options

  10. #20
    Hi Sw! My sense is the In-Bore MRI Biopsy may be a fairly labor intensive production. I suspect that the Radiologists may be bigger proponents of this technique than the Urologists. Also, I'm not sure if In-Bore MRIs are available in GA.

    - Does your new URO MD plan to do this immediately?
    no. it will be done by doctor cara cimmino. i have yet to meet/talk with her.
    what R your suggestions about this?

    Definitely set up a consultation with Dr Cimmino well in advance and discuss your issues & concerns. You will likely benefit and gain more confidence with Dr S's game plan

    - Has it been scheduled?
    monday february 25th

    - Great!

    - I assume that the MRI will be repeated?
    i'm not for certain.

    My guess is they will want a fresh MRI done with their equipment. Ask Dr Cimmino

    - What were his thoughts about what might be going on (or not) with you?
    he felt that were several lesions [3 to be exact] found on my prostate that needed to be looked at

    You have followed your instincts and now Dr S concurs that a biopsy is needed

    - Do you feel confident and comfortable with your new URO MD?
    No. I think he's a bit of an ASS When he recommended the type of biopsy, he actually didn't recommend the procedure, he told me it was the best option. 2ndly, when I asked him about the in-bore MRI targeted biopsy, he got a bit of an attitude and told me no that was an old school procedure and told me how it was going to go down, as supposed to suggesting. Based off my research, the in-bore biopsy was a better procedure and more accurate than the one he's suggestion. So, I will continue to ask around before I fully accept his plan.

    First and foremost, it is MOST important that the URO MD is a world renowned expert in treating PCa! Regardless of personality or social skills!

    Set up the consultation with Dr Cimmino. Meanwhile, if still uncertain, check with Dr Busch in Chattanooga and see whether or not he recommends and performs In-Bore MRI Guided Biopsy. His office is only about 1:45 minutes north of Atlanta so you may want to set a meeting with Dr Busch.

    Good job staying on top of your prostate health! Keep us updated on your new pathway to discovery.

    MF
    Last edited by Michael F; 01-18-2019 at 03:58 PM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = Gleason 7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left Positive Margins + EPEs. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO / Prostate Size = 32 grams; Tumor = Bilateral; 20% / Perineural invasion: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

 

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