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Thread: Is getting a Prostate MRI before doing a biopsy a good idea?

  1. #1
    Newbie New User
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    Aug 2019
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    Is getting a Prostate MRI before doing a biopsy a good idea?

    My urologist has advised a biopsy following a second psa to confirm a high reading.

    My psa went from a .5 to a 4.1 in one year

    Would it be wise to undergo a prostate MRI first before the invasive procedure which several friends have advised is an unpleasant experience

    Thanks for your help

  2. #2
    Quote Originally Posted by provlima View Post
    My urologist has advised a biopsy following a second psa to confirm a high reading.

    My psa went from a .5 to a 4.1 in one year

    Would it be wise to undergo a prostate MRI first before the invasive procedure which several friends have advised is an unpleasant experience

    Thanks for your help
    An MRI can help the doctor focus in on possible "hot spots" in the prostate.

    But I didn't have an MRI before my biopsies, and I don't think most patients do.

    It does interpose another step in the whole process, and it is pretty expensive. If your insurance will pay for it, and the doctor recommends, sure.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  3. #3
    Top User
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    A biopsy is the only the way to detect prostate cancer. Without a positive biopsy you can not begin treatment.

    Biopsies have a high false negative rate. An MRI can sometimes suggest areas to direct the biopsy. A negative MRI is not sensitive enough to rule out cancer. Same for a biopsy, a negative biopsy is not safe enough to rule out cancer in the face of a rising PSA.

    Negative biopsies and MRIs increase the risk of men to ignore the signs of prostate cancer and delay or avoid biopsies.

    Prostate cancer is slow growing and treatable in most cases. Early detection and treatment is the best strategy for "curing" prostate cancer. A persistent rising PSA is still the most reliable indicator of a prostate cancer risk.

    Advanced prostate cancer is a long and painful way to die. Much more unpleasant than a biopsy or early treatment. For those committed to early detection multiple biopsies may be required.

    A friend does not advise avoiding a biopsy because it is unpleasant. If your PSA remains elevated at or above 4.0 a biopsy is called for. Even more so the younger you are.

    Most men will develop prostate cancer at sometime in their life.
    Last edited by Another; 11-05-2019 at 09:26 AM.

  4. #4
    Regular User
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    As far as the unpleasantness of the biopsy, I was under for the procedure. I did not feel a single thing, woke up later and went home. Perhaps you can request that.
    Age 52, No symptoms, healthy, GrF had PCa at age 78
    First PSA test ever 5/2019: 7.037 (referred to urologist)
    Normal DRE
    PSA 7/2019: 5.152, Free 8%
    PSA 8/2019: 4.652, Free 7%
    Biopsy 8/16/19
    Dx PCa 8/30/19
    16 cores taken/ 5 positive for PCa
    L Apex and L Mid: (G 3+3=6) involving 2 cores, 10% of ea / Grade Group 1
    L Lat Apex: (G 3+3=6) involving 20% of 1 core/ Grade Group 1
    L Lat Mid: (G 3+3=6) involving 60% of 1 core/ Grade Group 1
    L Medial Mid: (Gleason 3+3=6) involving 70% of 1 core/ Grade Group 1

    DaVinci RP 10/10/19 Nerve Sparing
    Post RALP Path:
    G 3 + 4 = 7 (was 3 + 3 = 6 on biopsy)
    Grade Group 2
    % of prostate involved by tumor: 6%
    EPE, BNI, SVI, Lymph invasion, Margin positivity in area of EPE: All of these were not identified
    Margin involved by invasive carcinoma: Limited (<3mm), Focality: Unifocal, Location: L Mid Posterior
    PNI: Present
    Pathological Staging: T2 N0 MX

  5. #5
    Quote Originally Posted by provlima View Post
    My urologist has advised a biopsy following a second psa to confirm a high reading.

    My psa went from a .5 to a 4.1 in one year

    Would it be wise to undergo a prostate MRI first before the invasive procedure which several friends have advised is an unpleasant experience

    Thanks for your help
    Both a mpMRI and a biopsy can miss cancer, but the combination has a lower rate of false negatives. Note that when a biopsy is advised in biopsy-naive men to rule out PCa, a negative MRI does not mean the biopsy can be skipped! Areas that are judged to be suspicious on the MRI get extra cores in the biopsy, which samples zones from around the prostate. During the biopsy your uro uses the ultrasound image to target areas within each zone that look suspicious on the screen. This "semi-random" sampling often finds small lesions that were not identified in the MRI.

    Djin
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  6. #6
    Biopsies aren't fun, but they certainly aren't the worse thing you can go through and may save your live. I just had my second one in a little over a year - did I look forward to it? Not in the least, but the actual procedure is probably 20 minutes in total. In some ways I am more afraid of doing an MRI...a little claustrophobic I guess....

    In any event, best of luck to you and I would suggest that you ask your URO about doing an MRI first.
    Age 59
    PSA 09/13 - 2.6
    PSA 05/18 4.7
    DRE 05/18 Nothing of note
    MRI PROSTATE W/WO CONTRAST WITH 3D 06/18 Assessment Low (clinically significant cancer is unlikely to be present)
    Biopsy 08/18 - SMALL FOCUS OF PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+3=6 (GRADE GROUP 1), INVOLVING LESS THAN 5% OF ONE (1) CORE.
    08/18 - Joined Active Surveillance Program at JHH under Dr. Christian Pavlovich
    PHI 02/19 - PSA (Hybritech) 3.8 ng/ml, PSA % Free 5%, PHI - 31.0
    PSA 08/19 - 5.8
    Biopsy 10/19 - in

    Family history: Father diagnosed with PC at 61

  7. #7
    Senior User
    Join Date
    Feb 2017
    Posts
    128
    Quote Originally Posted by provlima View Post
    My urologist has advised a biopsy following a second psa to confirm a high reading.

    My psa went from a .5 to a 4.1 in one year

    Would it be wise to undergo a prostate MRI first before the invasive procedure which several friends have advised is an unpleasant experience

    Thanks for your help
    Short answer: Yes, the MRI would be helpful.

    The long answer is taken from personal experience, my own, where an MRI located an apparently high-risk lesion which the biopsy successfully targeted and confirmed to be Gleason-4 cancer.

    Since my prostate was very large, almost 100 cc's as found in the prostatectomy, it would have been sheer luck to have discovered that spot in a blind biopsy.

    Some important caveats: insurance may or may not cover the MRI. Luckily, mine did, but the policy of some companies is to disapprove the procedure in the absence of a positive biopsy beforehand. That's a shortsighted policy but hey, we're talking about insurance companies here.

    Also, as with most medical things, an experienced and skillful doc is a big plus, particularly in the matter of MRI-targeted biopsies.

    As others here have mentioned, neither an MRI nor a biopsy are infallible. (In my own case, after RP the lab found -- surprise, surprise! -- the Gleason 4+3 was actually Gleason 4+5.) Still, taken together, I think the combination increases the odds of an accurate diagnosis.

    Guys' experiences with biopsies are all over the lot. The procedure should not be lightly undertaken but remains the primary tool available, however imperfect, to confirm the presence of prostate cancer. For me it was a piece of cake because the doc was good, no complications were encountered either during or after, and best of all -- I was in never-never land for the whole 30 minutes or so. The sedation experience is equivalent to that of a colonoscopy. I'd recommend that route to anyone, but they will require you to have a driver on hand.
    YOB: 1954
    PSA 4.4 -- March 2016
    PSA 5.9 -- January 2017
    Cystoscopy to assess unexplained episode of severe overnight bleeding from urethra in December 2016; results normal; incident unexplained -- February 2017
    PSA 7.7 and PHI 59 -- March 2017
    3T MRI of prostate -- April 2017; prostate found to be enlarged (79cc) with two potentially cancerous lesions, one PIRADS-3 and one PIRADS-4 -- the latter in the anterior apex of organ
    Fusion biopsy -- August 2017; 14 cores taken, with two measured at Gleason 4+3, corresponding to the MRI PIRADS-4 target location
    PSA 7.0 -- November 2017
    RALP at Johns Hopkins, Dr. Allaf (highly recommend) -- February 2018
    Pathology report upgrades G4+3 tumor to 4+5. One additional cancerous nodule found, G3+4; organ-confined; margins clear, SV clear, LN clear
    Continence: One pad for two months, then dry
    ED: Resolved at one month with aid of Cialis
    PSA <0.1 -- May 2018; Aug 2018; Dec 2018; Apr 2019; Aug 2019

  8. #8
    I've had two biopsies: the first the usual TRUS and the second MRI-guided. I found neither experience terribly bad. Not that I'd sign up for fun of course, but considering all the things they can do to you (and as Frank sang, I've had a few...) it's just a bit of discomfort and over in 15 minutes. It's my understanding that some doctors are moving in the direction of MRI replacing biopsy, at least in certain cases. For now I'll take both, thank you, even with (maybe especially because) their record of possible false negatives*. Given your PSA jump, definitely.

    Good luck and keep us posted!

    * I'm sure our resident guru DjinTonic can give you the % stats. In fact I recommend you take a drive through his Sub-Forum: it is a cave of wonders.
    Born 1953. All care at Kaiser in LA.

    10/11/18: 2 positive low volume (5-20%) G6 cores out of 12. Prostate vol 33g.
    Jan-June 2019: saw several uros, only initial one recommends treatment: all others AS.
    7/15/19: Dr. Leonard Marks at UCLA: AS. UCLA radiologist finds nothing abnormal in MRI.
    Currently on AS.
    Urolift for BPH 10/21/19

    PSA
    8/2/18: 1.2
    3/26/19: 1.8
    6/14/19: 2.2
    10/18/19: 2.0

    Head and neck cancer 2009: Surgery and 31 days IMRT. NED for 10 years and counting.

  9. #9
    Just two thoughts. As a veteran of 9 biopsies over the years, I can say that none was terrible for me. I believe your level of discomfort depends on:

    1. The total number of cores. Insult to the prostate accumulates and increases slightly with each core, as does the discomfort. The core order starts away from the nerve plexuses and gradually get nearer. So you feel the later cores more. Whether the last core is n.12 or n.24 therefore makes a difference.

    2. The skill of your uro in administering the nerve block (the first couple of needle punches you feel). Some docs are better than others at delivering the anesthetic to the right points on the left and right sides. Finally, given the accumulated insult, the faster your uro works, the better.

    3. I found it helps to chat with the doc -- it takes your mind off things and makes makes the procedure seem to go faster.

    Biopsy experiences seem to range quite a bit. How much that is because of the above and how much is because of anatomical/psychological/pain-tolerance differences, I don't know.

    Djin
    Last edited by DjinTonic; 11-06-2019 at 08:36 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  10. #10
    Experienced User
    Join Date
    Oct 2019
    Posts
    82
    My husband had a little propophol nap for his. He had a tiny amount of discomfort for a few hours after. We were told to expect “a little” blood in urine, stool, and semen. He wasn’t prepared for the clots he passed in his urine. He said that felt really weird. He also wasn’t prepared for his semen to be total blood. Like bright red. We were expecting a tinge of pink. All was completely normal just wasn’t quite prepared for it.

    From my understanding most insurances won’t pay for a MRI before a biopsy. It can’t hurt to try though.

    We had a biopsy after an elevated PSA test and 4K score. It was positive and now our next step is the MRI and then likely a MRI guided biopsy.

    You should ask about a 4K score test or at the very least a PSA total and free.
    Then definitely have the biopsy!
    Wife posting
    Age 51
    PSA 9/2019 - 4.8
    fPSA - 9%
    4K score 12%
    Bx 9/2019
    Final Diagnosis - prostate carcinoma
    Highest Gleason Score - 3+3=6
    Number of cores positive - 4
    Percent of cores positive - 28.6% (4 of 14 cores - 12 samples taken. 2 broke in half)
    Maximum % of tumor in positive cores - 60%
    Overall prostatic tissue involvement - 5.8%
    Perineural invasion - present
    Lymph-vascular invasion - not identified
    Periprostatic fat invasion/extrsprostatic extension - not identified

    Left base - G3+3=6. 4% involved. Perineural invasion present.
    Right apex - G3+3=6. 40% involved.
    Right lateral mid - G3+3=6. 5% involved.
    Left lateral apex - G3+3=6. 40% involved.

    OncoDX score 23. Low Risk.
    High Grade Disease 14%
    Non Organ Confined Disease 16%

 

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