Thanks for this video. I have an elevated PSA (5.1; an increase of 2.53 in 5 months). I’m a retired scientist (hydrologist) and whenever I have a medical issue, I like to be an informed px, so I research the matter. When I raised the notion of doing an MRI biopsy before the systematic grid sampling, my urologist actually got pissed off! He said he does the 12-needle grid-based first, which only samples the posterior side of the prostate (when I said that to him, he slammed his hand down on the desk and sarcastically yelled “I DIDN’T KNOW THAT!”) I was stunned by his behavior, because up until that point, we had a very good relationship. He stated that he does systematic sampling, sees the results, further monitors PSA levels, and if indicated, then will go to the MRI biopsy methodology. He also sternly said “I’M THE CAPTAIN, I’M DRIVING THE BOAT!” Once again, I was shocked and dismayed. I’m thinking about jumping ship and finding a different boat (and captain). Thoughts?
That's a more "traditional" was of doing a biopsy. The evidence is clear, MRI up front leads to more accurate biopsies. Based on the current state of the field you would probably get the most accurate biopsy results from doing a combined MRI targeted and systematic biopsy. In other words a 12 core sampling of the prostate plus extra cores of any abnormal areas seen in the MRI.
Off topic, but maybe useful: I just went for a LATP biopsy (local anesthetic transperineal prostate biopsy) last month. I asked for half of the typical dose of local anesthesia and was granted, no relaxant either. I took one single Tylenol 500 mg right before the procedure instead of two as prescribed. I took one single dose of Keflex (cephalexin) 500 mg two hours before the procedure to reduce the chance of infection. The experience: No pain at all even when my urethral was accidentally pierced through (fresh blood coming out from the tip of my thing). Throughout the procedure, I chatted and laughed with the doctor and the nurse. At home, I touched the area where the needles went in, there was no pain either. To compare: a dental root canal is much worse, I tell you. I was back in my regular activities the next day, sans exercising.
I came across your channel today and I'm thankful to you for the work that you are doing, you're genuinely making an impact so God Bless you. I'm in really confused about my situation, I was referred for a Biopsy in 2019 for a Biopsy after a raised PSA of 15, actually I had an MRI which detected a suspicious area in my prostate, long story short, I did an MRI targeted biopsy, they took 33 or was it 35 core samples for the biopsy which came back negative. They diagnosed Chronic Prostatitis. I had a terrible outcome from the biopsy, urine retention and a catheter for 10 days. I was placed on blood PSA monitoring from then onwards and this is the full list of my PSA readings over time to date. these are the results of my PSA since then 31/08/19 15.4 13/12/19 11.9 28/07/20 14 10/09/21 11.5 10/10/22 19.1 19/01/23 31.4 16/02/23 20.6 29/09/23 25.7 27/02/24 27.3 since the biopsy I keep having burning pains in my perineum, this happens usually days after I've ejaculated, urine retention as well, some nights are worse than others. The urine issues are mainly to do with not emptying my bladder completely. I regret having the biopsy because there's a clear difference in my urinary issues before and after, in that they are worse now. With my rising PSA, I've also had 2 MRIs since which came back negative, the last one was in December last year. I've contacted Oxford Biodynamics to try their new PSA Episwitch test, I haven't filled out the consent from yet because I need a Physician's consent. My consultant has arranged for me to have a medical prostate massage in late March but I'm thinking about not going ahead with it, I don't have confidence that interfering with my prostate will not cause further problems, the prostate massage will be under GA. Any advice or tips will be highly appreciated. I'm of African origin and I'll be 54yrs old in June.
First I’m sorry to hear about your situation. It sounds very miserable. First consider talk to your doctor about an antibiotic course to see if you can treat the prostatitis. Usually this requires 6 weeks or more of antibiotics. You could also ask to see if a culture of your ejaculate is possible to see if they might find bacteria in it. If bacteria are found you will have an idea what is causing the infection. I hope this helps to find a solution.
Hi Doctor, A very informative video and clearly explained. I am a 52 year old male that has been on finesteride since my late 20s for male pattern baldness, I discussed with my GP to cease using finesteride because I had read on some medical literature that it can increase the chance of having high grade cancers. My psa was 2.6 in January (On finesteride) and has risen to 4.5 by June this year with a free psa ratio of 12.6%. I was immediately referred to a Urologist, a MRI was performed, the report came back with a PIRADs 4 (Rt mid posterior) and a 5mm lesion was identified. The rest of the peripheral zone had a PIRADs 1 (anterior, posterior) (base, mid, apex) Extraprostatic extension: none. I have just had a ultrasound guided transperineal prostate biopsy performed on Tuesday infact, (under general anaesthesia) 18 core samples were taken. I should also mention that the prostate gland is 11cc which is very small, but as previously mentioned I have been using a 5 alpha inhibitor for the past 26 + years. With everything that you have discussed in the video regarding targeted and random needle biopsies I would just like to know if 18 core samples was too many considering how very small my prostate gland actually is?
Hard to say because I’m not sure what technique he used. In my publication on the topic patients had between 14-20 biopsies so it seems to be in the ball park. That point about finasteride causing cancer is highly debated. I’m personally not a believer
@@cancerbetter MRI findings: right lateral peripheral zone mid 5mm focus of restricted diffusion Biopsy Diagnosis: R mid and target: Adenocarcinoma in 1/4 cores Gleason score 3+3=6 0.8/51 mm The 2 numbers don't correspond the Transperineal biopsy says 0.8/51mm which is 10x greater than what the MRI says 5mm (restricted diffusion)?
My husband has pretty much fallen into all the sink holes that you have mentioned. We were flabergasted after the fact to learn that he should have had an MRI first, then a targeted biopsy. But looking back we believe that his small amount of GG7 cancer would have been missed entirely on a targeted biopsy. Dr did a 24-core "random" biopsy and in retrospect, he did a good thing. mpMRI 3T PIRADS grade was a 1. Only in a second opinion from Johns Hopkins on the biopsy did we find out there is PNI, which was not found/mentioned on first biopsy read. We were hoping for AS until the point of PNI. So in his situation, the MRI seemed to not provide any further clarity, and only stated possible BPH in T. Zone. Waiting on 2nd Dr. opinion from Mayo.
Thanks for helping men make excellent Pca decisions. MRI (mp) followed by Ultrasound targeted biopsy provides many pathways to best treatment options. The pathology report contains an important comment rarely discussed.....the cancer burden...how much cancer was seen in the core samples....mine was 0.23. More burden = more Pca = more treatment. Bigger prostate glands will require MORE core samples. Finally, Pca patients post treatment should have a PENIS rehab plan.
I was the odd guy, first MRI and biopsy one mass “ the size of a dime” (Gleason 6) I decided to get HIFU, after the long drawn out process to get referred out. Six months later the new doc wanted a new MRI guided biopsy showed two masses just bigger then a nickel. And the doc said “that shouldn’t happen, you don’t have small cell carcinoma”.
Very helpful; about to get de-briefed by my urologist on my prostate MRI. This video has helped me prepare for that conversation. I find all of your videos to have been helpful from a patient preparation perspective. Clear. Concise. Informative.
Great video. With a elevated PSA of 3.97 up from the prior year and half of 2.1 I did tons of research on 3T Multiparametric MRI and originally placed high priority on it. With nothing felt on DRE (confirmed BPH in 2013 by Ultra sound and symptoms) In my first Urologist visit, the Doctor wanted to move directly to a TRUS Biopsy but I requested a 3T Multiparametric MRI. He agreed but did said the reason he does not do MRI first is due to insurance denies on most cases. I said I would pay for it if denies so I did the 3T MP MRI first. My MRI showed nothing of significant concern with a PI-RADS 1 however my Urologist recommendation was to do a TRUS biopsy next which I almost politely declined however he advise MRI can miss some PS cancers so I agreed. The 12 core TRUS Biopsy found 2 out of 12 cores 3+3=6 and other cores with HGPIN and ASAP on others. What was confusing is why MRI didn't show anything. So if the biopsy shows Gleason 6 3% and 8% on two upper and lower left peripheral cores, Does this mean the cells haven't yet formed an actual tumor yet? When I think of cancer in an organ or on a bone (other than blood born leukemia or marrow) I think of an actual physical tumor that can be seen on a 3T MP MRI with contrast. Very confusing. Now my concern is the reading radiologist was not skilled enough in prostate reading as he seems to be know for general pelvic radiology but I have little knowledge on this. Any insight would be appreciated.
MRI is very bad at detecting low grade cancer (i.e. Grade group 1 aka Gleason 6) but rather good at detecting the dangerous cancers (grade group 3-5). Remember most people with Gleason 6 do not need treatment. In fact, in most cases treatment does more harm than the Gleason 6 itself. Hope this helps. Good job educating yourself. On a separate note, as a result of my research and other in the field insurance companies no longer deny reimbursement for MRI prior to biopsy.
@@cancerbetter Thank you for answering my post and thank you for your contribution. My insurance did end up paying for the MRI all be it at a slightly higher out of network deductible. I am 55 and my real problem now is fear. Fear of not treating and missing the optimal window even though I am already scheduled for a 6 month PSA, MRI and TRUS Biopsy follow up with Active Surveillance.
A couple questions: 1 in 6 men with a Pirads 2 has a potentially risky cancer. Might this be true of the general population of older men (65+) who have never had an MRI? Has there ever been a study of Pirads 4 patients wherein they look at the detection rates of those patients with known prostatitis and bph and those patients who do not have prostatitis and bph? I ask because those conditions can sometimes mimic cancer on MRI and may be particularly tricky for less experienced readers.
That’s not how it works. A systematic biopsy samples 12 areas from the entire prostrate so the data presented doesn’t apply to doing only half the systematic biopsies.
Excellent information. I'm encouraging my dr now to do an MRI first. Psa keeps increasing then it will drop then back up. Highest has been 7.3 then drops to 6.5 6.3 back to 7.0. This has increased from 4.3 5 years ago. I'm 69 will be 70 in 2 weeks. No family history so I've refused a traditional biopsy. Probably need to have it done.
Getting the MRI is half the battle. Once you get the MRI, you need to see a physician who knows how to do MRI targeted biopsy. This is not a universal skill among urologist. Thank you for the compliment and I’m happy to see the videos are helpful
@@cancerbetter: MRI reveals- in the lower mid gland and apical region of the transitional zone representing PIRADS -3 lesion. There are PIRADS -2 nodules in the transitional zone bilaterally as described. My prostate gland is enlarged in size 43x41x34 mm and weighs about 31 gms. My total PSA is 16.57* Urine test : ph 6.0 : color - Pale Yellow : Deposit: present. X-Ray impression: C6-C-7 PIVD PET/CT scan: urinary bladder shows physiological excretion of FDG. IMPRESSION - No obvious evidence of active disease in the present study to suggest malignancy. So far I don't have any pain, discomfort, and any sickness problems except- unhappy to see the results of:- PSA, Prostate enlarged, (Bacteria, bad breath)
Dr. Ahdoot - a clarifying question please. If a patient has an MRI with contrast; then a month later has a TRUS biopsy - which category do these two procedures fall under? A systemic, an MRI-targeted, or a combined? Thanks.
All depends. If your doctor does biopsies targeted to the abnormal area of the prostate that is the targeted biopsy. If there do 12 samples then it’s a systematic. If they do both then it’s combined. While it’s not an optimal practice some people get an MRI and then fail to do targeted biopsies to that area.
Thank you for this video. MRI showed PI RADS 5 and the fusion biopsy showed inflammation and no sign of cancer cells. (Psa 5,7 and 0,09). I am confused.
This can happen. If you look at the data about 10% of people with a pirads 5 will be found to have a non cancer finding. Sometimes we will do a second biopsy to be extra sure it’s not cancer.
GG1 all cells reported were GG1. Urologist is recommending hormones and radiation. I’m looking for a 2nd opinion. I feel active surveillance is the treatment for me right now.
An ExoDX score less than 15.6 means it is very less likely. If ExoDX is between 15.6 and 19 and a PIRADS 3 or greater lesion is present, biopsy can be directed to the lesion. If ExoDX is over 19, but no lesion is seen, only then would the 12 core template systematic biopsy be indicated.
Am in the UK, my husband is just going through this. PI-RAD of 3, PSA of 10.1. He's had the MRI, 2 x DREs and now they are talking about a biopsy and will take 12 bites so my thoughts are why did they bother doing the MRI because they will revert to the grid system and just go with that anyway. Yet the MRI was sold as a tool to reduce biopsies - now it seems as though they are causing an increase in the number of bites during biopsy. Surely, if the MRIs are all they cracked up to be the biospy bites should just be in that area.
MRIs are not perfect at finding cancer. A PIRADS 3 for example means the radiologist sees something they think might be cancer but they aren’t sure. A pirads 5 however is very likely to be cancer. It’s just where we are. With time things will improve as technology evolves
Hi doctor, Thank You for these videos. You made a comment I do not understand and I need to as my MRI came back with a RAD 5 score , and my Dr is pushing for a full TR biopsy. You said for ppl with Rad5 you do not recommend traditional 12 core biopsy, which is exactly what my doctor has ordered up. So....Why do you say not to do it.....( Im with you, I just don't understand the medical reasoning ) if you could write and explain this to me it would be greatly appreciated. Thank You.
For PIRADS 5 prostate findings systematic biopsy or more likely to miss the area of cancer than the systematic 12 core. The most complete biopsy would be to do both a targeteted biopsy and a 12 core at the same time but if you wanted you’d could skip the 12 core with only a small reduction in total cancer detection rates.
@@cancerbetter Thanks for quick reply, as Im having anxiety about all this.... I think my question should have been, since the MRI shows exactly where the nodule is located, doesnt that mean the surgeon knows and can see exactly where to go, and perhaps only need a few core samples , with the MRI image it is not "random" needle pokes, we have a picture of the exact location. Also looking for the perineal version , dont like the possible infection % of rectal, I'm 72....with T2 diabetes,
Hi my psa started to rise about 5yrs ago when i was 60yrs old. My psa have risen to 14 and an mri scan was done showing i had inflammation of the prostrateand a enlarged prostrate to. My Urologist told me i had prostritis and my PRADAS was 2. I find it a little worrying as my Father passed away with Prostrate cancer. And plan on taking an MRI scan every 12 months to keep a check on it.
@cancerbetter Can you explain this to me please, our urologist never did. The 3T MRI, no contrast, was done in May. Not seen a doctor since begining of May just before this MRI. Thank-you Prostate gland measures 6.6, 5.5, 4.4 centimeters on CC, TR and AP dimensions respectively with estimated volume of 84 cc and PSA density of 0.063 ng/ml/cm3. 9.5 mm ill-defined nodule with obscured margins are noted within posterior medial aspect of left peripheral zone at mid gland which show mild hypointense signal on ADC and mild hyperintense signal on high B value DWI sequences likely representing PI-RADS 2/3 lesion. No other peripheral zone lesion is noted. PSA is 4.86.
My father's recent medical situation has left us feeling uncertain about the next steps. After his PSA level reached 13.5, an MRI showed PIRADS V, but a PET-guided biopsy came back negative. His PSA level has now decreased to 2.09, but we have received conflicting advice from doctors regarding monitoring the PSA or repeating the biopsy. We would greatly appreciate your guidance on the best way forward. Your expertise would be invaluable in helping us make an informed decision.
I can’t give medical advice about individual cases on this platform as I can’t get all the details like this but I’d start by having a second opinion on the prostate MRI. If they are sure the pirads 5 is real a RE-biopsy is reasonable. My studies and others have shown that a PIRADS 5 lesion has a 5-20% chance of no cancer detection based on where the clinical trial was performed.
That's a PIRADS 1. That means the saw nothing abnormal on the MRI and there is nothing to target with an MRI targeted biopsy. If your PSA density is high a biopsy might still be a good idea but that is the exception rather than the rule.
Short answer is for transrectal the biopsy needle goes through the rectal wall. For transperineal the needle goes through the skin below the scrotum. As you can imagine a needle passing through the rectum is a risk factor for bacterial contamination to the needle and for rectal bleeding. As a result there is a 4% chance of hospitalizations after thanks rectal biopsy due to infection and a 0.5% of death if that infection is not treated soon enough. Transperineal biopsy avoid this and has lower bleeding risk. Why the US has been slow to uptake transperineal biopsy there are many of us who do this now. I have switched to doing nearly all my biopsies transperineally for these reasons..
@@cancerbetter That’s the answer I was looking for. My urologist wanted to do a transrectal biopsy, but I have found a couple of practitioners who do the transperineal biopsy.
Very thought provoking video, In a blood test we discovered my PSA is 26.2, I have an enlarged prostate and have have had past readings up to 21 but then backs off. My GP sent me to a urologist he had me get an MRI the type where they give you intervenes solution about 2/3 then way through MRI. The Urologist reads it and called me and said it looks suspicious and he wants to do a Biopsy it's scheduled next week but after seeing the video I am not comfortable with that without a conference with the Dr. and discussing your article with him. Do you have any advice? Bob Irwin P.S. I am an 84 year old in pretty darn good shape!
As a person's PSA rises the risk of prostate cancer also rises. However PSA can be elevated due to multiple reasons including prostate enlargement, infection or cancer. It's uncommon for PSA to get into the 20s based on size or infection so your urologist is likely concerned. We use a tool called PSA Density to correct a person's PSA level for the size of the prostate. Generally if the PSA density is over 0.15 the risk of prostate cancer is pretty high and we recommend biopsy. The last thing is that usually prostate cancer is slow growing and takes 15 years or more to go from localized to death risk. For this reason we often stop checking PSA levels in men above 75.
What if you’ve had a PMSA test and based off the test, it is used to determine where to biopsy. Then would it be reasonable for forgo the random biopsy? Even if you have PIRADS4 or 5.
That’s a strategy that is being studied right now. Early data suggests that might be OK but PSA pet alone will perform alone. The real question is whether PSA pet and MRI will not perform. The data suggest it will, but there is substantial financial cost and a technology gap.
@@cancerbetter Thanks you. It’s so confusing for someone who got a C in biology in college…the second time. 555 But for those with the right aptitude, what a challenge.
Hello Dr. Ahdoot: I am PIRAD-2 with a big prostate (166 cc) and a PSA of 15 for a Prostate density less than 0.1. I will have a PAE (prostate arteries embolization), but first i will have a biopsy. I have the following questions: a. Probability of cancer? b. Probability of a significant cancer c. Is it necessary to have a biopsy before PAE? d. Is PAE a good option for me? According to this excellent video the best biopsy for me is the systematic... Is it right? Thank you in advance to your answer, I appreciate a lot you recommendations. Best regards
Hi I had an MRI MP 3T biopsy done after my uro thought he felt something on DRE. Came back PIRADS 2 "no focally suspicious prostatic lesion", only that TZ was "heterogeneous with matched areas of restricted diffusion and focally increased perfusion that are not clearly suspicious." No abnormal signal of seminal, nerves, lymph nodes. I calculated my prostate density at 0.05, with a PSA of 2.6 and volume of 52ml. I've not heard from my uro since a month after but have a follow up call soon. Thoughts? I'm 66 and my father had Pca at 74 (RP) but lived to 92.
As a rule, I can’t give direct medical advice here, but I can tell you some information that might be useful. Generally a heterogeneous appearing prostate on T2 can suggest prostatitis which can masquerade as prostate cancer and cause an elevation of PSA. A PSA density of 0.05 with a PIRADS 2 is also associated with a very low risk of prostate cancer ~5% based on data I currently have submitted for review for publication.
@@cancerbetterThanks very much. My uro got back with me and said he would keep an eye on it and we'll do another appointment in a year to assess, along with another exam and PSA, possibly repeat the MRI.
I’m a PIRADS 3 waiting for biopsy. You show a 50/50 chance of cancer in this category. My question is, if the lesion shown in the MRI is not cancer, what is it? Thanks
Yes PIRADS 3 has a 50% chance of cancer but about half of those cancers are grade group 1 which can be watched. Real chance of cancer you need to treat is about 25%. You can Google "Ahdoot euo" to look at the original paper. If no cancer is found it means most likely it was just an anatomic variation in your prostate, artifact from the scan or possibly that there was cancer but the biopsy missed it because it was a lesion to small to hit. So after a negative biopsy you should still keep following your PSA. Hope this helps
My husband is 54. His PSA was a 4.7 in Jan and was checked again in May it was a 7.4. MRI shows Pi Rad lesions score 3. Biopsy in 2 weeks. Very scared wife here.
@@luketimber4679 yes! Research research research. His general doc made him an appointment with a doctor that I did not like what I read about him. We went to a younger doctor at a hospital I hate! Best decision ever. I used to be a nurse. He came home and I cared for him. He hated the catheter as he had never had one before but he has gone back to work and goes for a follow up visit in February. I wish you all the best. I hope you have a good support system. If not find a local men's support group. Your doctor might even have one.
My MRI found 2 lesions, initially reported as both PIRADS 5, but upon review, one was downgraded to 4. I requested targeted biopsy, by my doctor was not convinced it would help. I requested he take his usual 12 cores but add some from the identified lesions. I dont know what the difference in in the biopsies would look like. How would I know if he did the traditional systemic one or the targeted one? And if he did the traditional one, what is the probability something was missed? The results came back grade group 1, cancer in one core, less than 5%.
Go to your medical records for your clinic or hospital and get a copy of your pathology report. If there are only six or 12 named biopsy samples in the report, then the doctor did only the systematic biopsies. If there were 13 or a labeled specimen that says MRI visible lesion then that would likely indicate that they did the MRI targeted biopsy as well. I think it’s very important to point out that some urologist do not have comfort with interpreting prostate MRI or have the knowledge of how to do an MRI targeted prostate biopsy. Unfortunately, as technologies evolve some doctors fail to adopt the newer technologies resulting in sub optimal care. Situations like yours are exactly the reason why I made this channel; to help people find better cancer care. While I do sincerely, hope there is no dangerous cancer. I think you doing the right thing to confirm that you did in fact have an MRI target to biopsy. If you have any doubts, I would strongly encourage you to find a provider who does offer MRI Targeted biopsy and is experienced with the technology. I hope this is helpful. - M. Ahdoot MD
4K test is a pretty good blood test for determining a person's risk of prostate cancer after an elevated PSA. The 4K test however is worse than MRI at determining risk so MRI is used far more frequently. MRI also adds the utility of localizing tumors in the prostate, defining an individual's anatomy, and helping with targeting at the time of biopsy. If you can not due an MRI due to non compatible implants or severe claustrophobia for example, a 4K score is a reason test.
I am of 67 years age.I recently approached to urologist for my complain of blood in semen. He suspected as Hematospermia and suggest me to do MRI Prostate.At present my PSA is 2.98ng/ml.In USG KUB Prostate size is 35cc.I have done Prostate MRI with 3T machine. In MRI radiologist found PIRADS-III and suggested me to do SOS TARGETED TRUS guided biopsy.Now how can I find best Urologist to do this?What sould I do now? please guide. Is it life threatening stage?
PIRADS 3 often does not necessarily mean prostate cancer. You can look at things like PSA density to further stratify your risk. Only a biopsy however will tell you for sure if you have cancer. If you are in the Los Angeles area I could see you but there are also lots of excellent doctors out there who know how to do MRI targeted biopsy.
@@cancerbetter Thanks for your instant reply. I am in India. After writing to you I recently approached to a very senior urologist Doctor here.He also postponeded my Trus biopsy of my prostate at present . He adviced me to do some PSA related test in the next month.I will consult him once again than after in next month.Thanks once again doctor with regards.
Why and in what cases is active surveillance enough? Isnt the point removing cancer as soon as possible? How can you be 100% sure that cancet is not agressive at it wont spread when you are just doing surveillance?! Do you check the whole body with CT scans before deciding for just active surveillance? How often are appointments duringn just surveillance? Thank you
I had a biopsy done first and they found that I had a Gleason 6 on 3 cores,, Then I got a second opinion and that doc took an MRI instead and found nothing in MRI ,, what should I do next or should I begin treatment
Talk with your doctor about the possibility of active surveillance. All Gleason 6 does not need to be treated. In fact, most Gleason 6 prostate cancer can be watched. I can't comments about the specifics of your situation but I'd speak with you doc about the risks and benefits for treatment vs watching it closely.
Hi Doctor, when you say MRI targeted biopsy here, is it a real-time MRI targeted biopsy or MRI fusion biopsy? My MRI result is PI-RADS 5, my doctor will do a MRI fusion biopsy. I wonder if real-time MRI targeted biopsy is better.
So when it comes to MRI targeted biopsy, it can be done in an actual MRI machine or it can be done using fusion software after the MRI to facilitate an easier biopsy. Very few people do biopies in the MRI scanner because it's more expensive, complicated due to the need for all non-magnetic tools and takes potentially much more time. However to answer your question biopsies done inside the MRI gantry have equal or slightly higher (~ 1-2%) cancer detection rates than biopsies done using fusion software. For a PIRADS 5, the lesion will be larger by definition and it won't make a difference if it's done in the MRI machine or using fusion software.
PiRad3 on MRI report Transitional lesion radiologist recommends MR perfusion guided biopsy...How do you do biopsy on ostomate with total colectomy sans rectum.?
It's possible to do a biopsy without a rectum but it's challenging. You would need to do a transrectal biopsy or a biopsy in an MRI machines. Fewer people know how to do this or have the equipment but it's possible.
Hi Doc, firstly thank you for these very informative videos, I had a pi rads 4 identified on mri and had a random plus targeted trans rectal biopsy, 16 cores were taken and thankfully all came back benign, my psa was 2.6 at the time and they also said I had an enlarged prostate 32cc for a 49 year old man, my psa increased in one year by 0.2 but they said in the context of the size of my prostate they didn't find it to concerning, I'm still being monitored but I'm just wondering would you have any advice for me and do you think I can feel reasonably assured that having had a 16 core biopsy taken that the biopsy was pretty accurate.
I can’t give medical advice on this platform. You can read my publication on this topic to get an idea of rates. Search Ahdoot NEJM. It should be the first hit. Towards the end of the publication we talk about people who undergo surgery after prostate cancer, diagnosis and the rates of upstaging, and you could use that as a surrogate test to meet the risk of a prostate biopsy missing cancer.
@@cancerbetter That's totally fine, I seen that video already and what I took from it is that you get more accuracy with both random and targeted biopsy, like I said I'm still under surveillance and my psa in proportion to the size of my prostate is actually okay, I failed to mention I had a bad bout of prostatis a couple of months before the scan and they said it was possible that it could have left a mark, it was so bad I couldn't sit down comfortably at times, anyway I'm still being monitored so thanks for getting back to me.
Hello there doc i hope you are well ..will try and shorten this as much as possible dude..am 38 i had covid brung me down badly..got afull blood test done all good outher than ..my psa level which was 4 then went up to 4.2 doctor sent me to consultant got checked he thought everthing felt soft and fine..had an mri scan just to be safe unfortunately came back pirad 5 lesion on left side prostate iam now going for a trasperineal biopsy..what do you think about this?.. and could there be any spread of cancer somewhere else in my body?..hopefully i don't have it anywere else?.. would that mri i had tell that if i did have anything anywere else?...i have my biopsy next Wednesday...and could it come back that i dont have cancer ?... iam assuming i have it with my pirad level beeing at 5..also they said on the letter they think it will be curable and treatable if it is nothing sinister...cheers mate
It's uncommon for men if your age to have prostate cancer but it's definitely possible. I have treated a few in my career. Obviously when you are this young, if cancer is found, radiation may not be an ideal choice for treatment. Yes it's possible this may be inflammation or other non cancer findings but with a PIRADS 5 prostate cancer is the most likely finding. The good news is you are likely catching this early when it's likely curable. Transperineal prostate biopsy is a great technique. I plan to make a video on that topic as well in the future.
PSMA PET is not an established means for prostate biopsy targeting. The data just isn’t mature enough yet but perhaps out will be a standard of care in the future. I do have a video on PSMA pet for metastatic work up.
It does now. All major insurance carriers cover pre-biopsy MRI now. If they don't just send them Ahdoot et al NEJM 2020 as evidence of it's medical necessity. In the last year I have not had a single insurer deny an MRI for my patients with an elevated PSA.
It sounds worse than it is. I did 2 transperineal biopsies today in clinic. Both guys were comfortable and chatting during the procedure. Key is just to give the local anesthesia time to kick in. Typical combined biopsy is 14 cores. 2 of the target and 12 from the systematic. Cores are 18 gauge as you said. This is similar to the size of an IV when people go to the hospital. I typically will make only 2 punctures in the skin with an access needle and I’m able to do all the biopsy cores through those 2 punctures.
hi I had a 12 core biopsy 11yrs ago and they didnt find anything...lss I continued getting psa checked annually and was urged to follow up again with urology. this time I had an mri and report was pirads 4. I have a targeted biopsy set in a few days. Question is the doc plans another 12 core with an additional core where the lesion was noted on mri? does that sound right? Also does the prostate get damaged with all the stabs and does that heal completely. I recall the orig biopsy I peed red for a week + and ejaculated pink for a couple weeks and ir was more uncomfortable each core taken.
Yes doing biopsies of the target plus the 12 cores would be appropriate for a PIRADS 4 lesion. The prostate usually fully heals after a biopsy but there are risks your doctor should discuss with you like infection, blood in the urine, and blood on the ejaculate.
@@cancerbetter ok that sounds like what I am getting. 12 cores and 2 in the targeted area. The last time I had a biopsy I recalled it was unfomfortable the more cores that were extracted but I dont believe I was sedated as I drove myself to and from. Another concern is there a chance the biopsy itself could transfer cancer cells to other areas during the procedure?
I don't know about biopsies, I read a comment on the internet were a fella got a 12 core and they found nothing. About a year later he goes in for a colonoscopy and they found some cancer on the core sight in his rectum...
@@cancerbetter can a mri give you a new gleason score?..pi rad 5 and pi rad 4 can you elaborate on this, and does this pi rad 5 give you a higher chance of BCR? ...Thank you in advance
Clinical staging is complicated and in my opinion out of date. A complete overhaul of the clinical staging system is needed but cT3 is most often used to state a person suspects the cancer has extended beyond the prostate. Here is a good reference for more information: amp.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html
Best predictor of your risk of prostate cancer prior to a biopsy is the MRI. If the radiologist gives you a score of 5 its very likely they will find cancer. The lower the number the lower the risk. This video provides the data.
I was recently recruited from the NIH to Cedars Sinai Hospital in Los Angeles where I practice Urologic oncology. My practice focuses on the treatments of prostate, bladder, and kidney cancers.
@@cancerbetter I’ve been scheduled for a biopsy, should I have gotten the MRI first. I have never had a problem with PSA before, it was brought to my attention this time When my PSA came in at 5.07 I was referred to a urologist. I asked for my past records to take with me. In 21 my PSA was 2.3 in 22 it was 3.2 there was nothing for 23 and in 24 it was 5.07. I’m 69 and in great shape, I workout 5 days a week and my training was going great. This is why I was taken totally by surprise. I have another blood test scheduled for Monday just to make sure my last blood test was accurate. I’m very hesitant to go through with this biopsy. It seems to me that when you start down this road there’s many risks.
I assure you I have no boat and where I practice I don’t make a dollar more or less based on how many tests I order. Only perk to my job is the satisfaction of feeling someone and an occasional gift from a happy patient.
There is a video on my channel on the meaning of PSA. I'd recommend watching that. Generally an elevated PSA can be a sign of inflammation, cancer, or enlargement of your prostate. Prostate MRI is often the first step in finding out which of these it is.
Hello doc, i ve been watching all your videos about prostate with great interest, my father is 57 year, with PSA 7,6 level result went to Urologist sent him to MRI and his result it s next can you please see it and give an onest opinion , the next step it s biopsie that will make next week with local anest. Thank you for your videos,i will continue to hear you, hope to read it. In your country we have cm not inch to measure. 2 Prostate nodules at the level of both lobes in the transitional zone of size 2.8 cm on the right and 2.4 on the left well delimited without expression in the adenomatous diffusion sequence, with peripheral gadolinophilia. And another small node at the level of the right prostatic apex in hyposignal t 2, with discrete expression in the diffusion sequence, ADC, with late wash out, with a diameter of 1.1 cm. Rectum, hairy and pararectal spaces, seminal vesicles without changes with pathological significance. No tumor subdiaphragmatic lymphadenopathy. No ascites fluid. No MRI circumscribed bone lesions
It hard to comment without seeing the scan myself. If your local doctor is recommending a biopsy I would go with it and see what the biopsy shows. That way the uncertainty will likely be resolved. Generally it's just not right to give advice unless I've had the opportunity to do a full visit and get all the records. My goal here is to help people get access to guys info so they can find the best care possible.
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Thanks for this video.
I have an elevated PSA (5.1; an increase of 2.53 in 5 months). I’m a retired scientist (hydrologist) and whenever I have a medical issue, I like to be an informed px, so I research the matter.
When I raised the notion of doing an MRI biopsy before the systematic grid sampling, my urologist actually got pissed off! He said he does the 12-needle grid-based first, which only samples the posterior side of the prostate (when I said that to him, he slammed his hand down on the desk and sarcastically yelled “I DIDN’T KNOW THAT!”) I was stunned by his behavior, because up until that point, we had a very good relationship.
He stated that he does systematic sampling, sees the results, further monitors PSA levels, and if indicated, then will go to the MRI biopsy methodology. He also sternly said “I’M THE CAPTAIN, I’M DRIVING THE BOAT!” Once again, I was shocked and dismayed. I’m thinking about jumping ship and finding a different boat (and captain).
Thoughts?
That's a more "traditional" was of doing a biopsy. The evidence is clear, MRI up front leads to more accurate biopsies. Based on the current state of the field you would probably get the most accurate biopsy results from doing a combined MRI targeted and systematic biopsy. In other words a 12 core sampling of the prostate plus extra cores of any abnormal areas seen in the MRI.
May I suggest finding another Dr. That behavior is very unprofessional
Dude, report his azz
Yes time to jump ship.
Oftentimes insurance demands a certain progression in tx so they pay for it. Otherwise, get a new doc.
Off topic, but maybe useful:
I just went for a LATP biopsy (local anesthetic transperineal prostate biopsy) last month. I asked for half of the typical dose of local anesthesia and was granted, no relaxant either. I took one single Tylenol 500 mg right before the procedure instead of two as prescribed. I took one single dose of Keflex (cephalexin) 500 mg two hours before the procedure to reduce the chance of infection.
The experience: No pain at all even when my urethral was accidentally pierced through (fresh blood coming out from the tip of my thing). Throughout the procedure, I chatted and laughed with the doctor and the nurse.
At home, I touched the area where the needles went in, there was no pain either. To compare: a dental root canal is much worse, I tell you. I was back in my regular activities the next day, sans exercising.
sir we need doctors like u benefits lot of human beings
Very kind of you. Thank you
I came across your channel today and I'm thankful to you for the work that you are doing, you're genuinely making an impact so God Bless you.
I'm in really confused about my situation, I was referred for a Biopsy in 2019 for a Biopsy after a raised PSA of 15, actually I had an MRI which detected a suspicious area in my prostate, long story short, I did an MRI targeted biopsy, they took 33 or was it 35 core samples for the biopsy which came back negative. They diagnosed Chronic Prostatitis. I had a terrible outcome from the biopsy, urine retention and a catheter for 10 days.
I was placed on blood PSA monitoring from then onwards and this is the full list of my PSA readings over time to date.
these are the results of my PSA since then
31/08/19 15.4
13/12/19 11.9
28/07/20 14
10/09/21 11.5
10/10/22 19.1
19/01/23 31.4
16/02/23 20.6
29/09/23 25.7
27/02/24 27.3
since the biopsy I keep having burning pains in my perineum, this happens usually days after I've ejaculated, urine retention as well, some nights are worse than others. The urine issues are mainly to do with not emptying my bladder completely.
I regret having the biopsy because there's a clear difference in my urinary issues before and after, in that they are worse now.
With my rising PSA, I've also had 2 MRIs since which came back negative, the last one was in December last year.
I've contacted Oxford Biodynamics to try their new PSA Episwitch test, I haven't filled out the consent from yet because I need a Physician's consent. My consultant has arranged for me to have a medical prostate massage in late March but I'm thinking about not going ahead with it, I don't have confidence that interfering with my prostate will not cause further problems, the prostate massage will be under GA.
Any advice or tips will be highly appreciated. I'm of African origin and I'll be 54yrs old in June.
First I’m sorry to hear about your situation. It sounds very miserable. First consider talk to your doctor about an antibiotic course to see if you can treat the prostatitis. Usually this requires 6 weeks or more of antibiotics.
You could also ask to see if a culture of your ejaculate is possible to see if they might find bacteria in it. If bacteria are found you will have an idea what is causing the infection. I hope this helps to find a solution.
Hi Doctor,
A very informative video and clearly explained.
I am a 52 year old male that has been on finesteride since my late 20s for male pattern baldness, I discussed with my GP to cease using finesteride because I had read on some medical literature that it can increase the chance of having high grade cancers. My psa was 2.6 in January (On finesteride) and has risen to 4.5 by June this year with a free psa ratio of 12.6%.
I was immediately referred to a Urologist, a MRI was performed, the report came back with a PIRADs 4 (Rt mid posterior) and a 5mm lesion was identified. The rest of the peripheral zone had a PIRADs 1 (anterior, posterior) (base, mid, apex)
Extraprostatic extension: none.
I have just had a ultrasound guided transperineal prostate biopsy performed on Tuesday infact, (under general anaesthesia) 18 core samples were taken. I should also mention that the prostate gland is 11cc which is very small, but as previously mentioned I have been using a 5 alpha inhibitor for the past 26 + years.
With everything that you have discussed in the video regarding targeted and random needle biopsies I would just like to know if 18 core samples was too many considering how very small my prostate gland actually is?
Hard to say because I’m not sure what technique he used. In my publication on the topic patients had between 14-20 biopsies so it seems to be in the ball park.
That point about finasteride causing cancer is highly debated. I’m personally not a believer
@@cancerbetter
MRI findings: right lateral peripheral zone mid 5mm focus of restricted diffusion
Biopsy Diagnosis: R mid and target: Adenocarcinoma in 1/4 cores
Gleason score 3+3=6
0.8/51 mm
The 2 numbers don't correspond the Transperineal biopsy says 0.8/51mm which is 10x greater than what the MRI says 5mm (restricted diffusion)?
My husband has pretty much fallen into all the sink holes that you have mentioned. We were flabergasted after the fact to learn that he should have had an MRI first, then a targeted biopsy. But looking back we believe that his small amount of GG7 cancer would have been missed entirely on a targeted biopsy. Dr did a 24-core "random" biopsy and in retrospect, he did a good thing. mpMRI 3T PIRADS grade was a 1. Only in a second opinion from Johns Hopkins on the biopsy did we find out there is PNI, which was not found/mentioned on first biopsy read. We were hoping for AS until the point of PNI. So in his situation, the MRI seemed to not provide any further clarity, and only stated possible BPH in T. Zone. Waiting on 2nd Dr. opinion from Mayo.
Sounds like you are in good hands. Lots of intelligent, evidence based doctors out there.
Thanks for helping men make excellent Pca decisions. MRI (mp) followed by Ultrasound targeted biopsy provides many pathways to best treatment options. The pathology report contains an important comment rarely discussed.....the cancer burden...how much cancer was seen in the core samples....mine was 0.23. More burden = more Pca = more treatment. Bigger prostate glands will require MORE core samples. Finally, Pca patients post treatment should have a PENIS rehab plan.
I was the odd guy, first MRI and biopsy one mass “ the size of a dime” (Gleason 6) I decided to get HIFU, after the long drawn out process to get referred out. Six months later the new doc wanted a new MRI guided biopsy showed two masses just bigger then a nickel. And the doc said “that shouldn’t happen, you don’t have small cell carcinoma”.
Very helpful; about to get de-briefed by my urologist on my prostate MRI. This video has helped me prepare for that conversation. I find all of your videos to have been helpful from a patient preparation perspective. Clear. Concise. Informative.
Awesome! Thanks for the comment!
Knowledge is power, thank you, just a sufferer!
Correct! Knowledge is power. Cancer is not something people choose but quality informs empowers you to make the best decision’s possible.
Well done video.
Thank you for the detail.
Thanks for watching!
Excellent information -- very helpful. Congratulations on the research and publication.
I really enjoy your videos, thank you!
Great video. With a elevated PSA of 3.97 up from the prior year and half of 2.1 I did tons of research on 3T Multiparametric MRI and originally placed high priority on it. With nothing felt on DRE (confirmed BPH in 2013 by Ultra sound and symptoms) In my first Urologist visit, the Doctor wanted to move directly to a TRUS Biopsy but I requested a 3T Multiparametric MRI. He agreed but did said the reason he does not do MRI first is due to insurance denies on most cases. I said I would pay for it if denies so I did the 3T MP MRI first. My MRI showed nothing of significant concern with a PI-RADS 1 however my Urologist recommendation was to do a TRUS biopsy next which I almost politely declined however he advise MRI can miss some PS cancers so I agreed. The 12 core TRUS Biopsy found 2 out of 12 cores 3+3=6 and other cores with HGPIN and ASAP on others. What was confusing is why MRI didn't show anything. So if the biopsy shows Gleason 6 3% and 8% on two upper and lower left peripheral cores, Does this mean the cells haven't yet formed an actual tumor yet? When I think of cancer in an organ or on a bone (other than blood born leukemia or marrow) I think of an actual physical tumor that can be seen on a 3T MP MRI with contrast. Very confusing. Now my concern is the reading radiologist was not skilled enough in prostate reading as he seems to be know for general pelvic radiology but I have little knowledge on this. Any insight would be appreciated.
MRI is very bad at detecting low grade cancer (i.e. Grade group 1 aka Gleason 6) but rather good at detecting the dangerous cancers (grade group 3-5). Remember most people with Gleason 6 do not need treatment. In fact, in most cases treatment does more harm than the Gleason 6 itself. Hope this helps. Good job educating yourself.
On a separate note, as a result of my research and other in the field insurance companies no longer deny reimbursement for MRI prior to biopsy.
@@cancerbetter Thank you for answering my post and thank you for your contribution. My insurance did end up paying for the MRI all be it at a slightly higher out of network deductible. I am 55 and my real problem now is fear. Fear of not treating and missing the optimal window even though I am already scheduled for a 6 month PSA, MRI and TRUS Biopsy follow up with Active Surveillance.
My husband had a pirad score of 2-3 with a lesion 1.9 mm lesion. We are on watchful waiting with no need for biopsy. Wise decision???
You can consider calculating the psa density or other blood tests (4k score, iso psa, psa3 etc) to help stratify the risk of cancer
@@janetw9430Pirads 2 or 3? Even if 3 then it’s nothing to worry about.
A couple questions: 1 in 6 men with a Pirads 2 has a potentially risky cancer. Might this be true of the general population of older men (65+) who have never had an MRI? Has there ever been a study of Pirads 4 patients wherein they look at the detection rates of those patients with known prostatitis and bph and those patients who do not have prostatitis and bph? I ask because those conditions can sometimes mimic cancer on MRI and may be particularly tricky for less experienced readers.
What is the right side is PIRADS4 and on the left side is PIRADS5. Just do target and random of the PIRADS4 and skip the random on the PIRADS 5.
That’s not how it works. A systematic biopsy samples 12 areas from the entire prostrate so the data presented doesn’t apply to doing only half the systematic biopsies.
Excellent information. I'm encouraging my dr now to do an MRI first. Psa keeps increasing then it will drop then back up. Highest has been 7.3 then drops to 6.5 6.3 back to 7.0. This has increased from 4.3 5 years ago. I'm 69 will be 70 in 2 weeks. No family history so I've refused a traditional biopsy. Probably need to have it done.
Getting the MRI is half the battle. Once you get the MRI, you need to see a physician who knows how to do MRI targeted biopsy. This is not a universal skill among urologist.
Thank you for the compliment and I’m happy to see the videos are helpful
My MRI result shows as PIRADS -2 & 3.
Is here I need to go biopsy?
@JB-be8co sometimes. Depends on your age, PSA density and other metrics
@@cancerbetter: MRI reveals- in the lower mid gland and apical region of the transitional zone representing PIRADS -3 lesion. There are PIRADS -2 nodules in the transitional zone bilaterally as described. My prostate gland is enlarged in size 43x41x34 mm and weighs about 31 gms.
My total PSA is 16.57*
Urine test : ph 6.0 : color - Pale Yellow : Deposit: present.
X-Ray impression: C6-C-7 PIVD
PET/CT scan: urinary bladder shows physiological excretion of FDG. IMPRESSION - No obvious evidence of active disease in the present study to suggest malignancy.
So far I don't have any pain, discomfort, and any sickness problems
except- unhappy to see the results of:-
PSA, Prostate enlarged, (Bacteria, bad breath)
Dr. Ahdoot - a clarifying question please. If a patient has an MRI with contrast; then a month later has a TRUS biopsy - which category do these two procedures fall under? A systemic, an MRI-targeted, or a combined? Thanks.
All depends. If your doctor does biopsies targeted to the abnormal area of the prostate that is the targeted biopsy. If there do 12 samples then it’s a systematic. If they do both then it’s combined. While it’s not an optimal practice some people get an MRI and then fail to do targeted biopsies to that area.
@@cancerbetter Thanks Dr. Ahdoot.
Thank you for a great video
Very welcome. More videos to come!
Thank you for this video. MRI showed PI RADS 5 and the fusion biopsy showed inflammation and no sign of cancer cells. (Psa 5,7 and 0,09). I am confused.
This can happen. If you look at the data about 10% of people with a pirads 5 will be found to have a non cancer finding. Sometimes we will do a second biopsy to be extra sure it’s not cancer.
@@cancerbetterthank you very much for your response.
GG1 all cells reported were GG1. Urologist is recommending hormones and radiation. I’m looking for a 2nd opinion. I feel active surveillance is the treatment for me right now.
Sounds reasonable. Get a urologist to get you on a good surveillance plan.
An ExoDX score less than 15.6 means it is very less likely. If ExoDX is between 15.6 and 19 and a PIRADS 3 or greater lesion is present, biopsy can be directed to the lesion. If ExoDX is over 19, but no lesion is seen, only then would the 12 core template systematic biopsy be indicated.
Mark do you have a reference for this by chance. I don’t think I’ve seen that study. Sounds interesting
thanks for your insight
Very welcome
Am in the UK, my husband is just going through this. PI-RAD of 3, PSA of 10.1. He's had the MRI, 2 x DREs and now they are talking about a biopsy and will take 12 bites so my thoughts are why did they bother doing the MRI because they will revert to the grid system and just go with that anyway. Yet the MRI was sold as a tool to reduce biopsies - now it seems as though they are causing an increase in the number of bites during biopsy. Surely, if the MRIs are all they cracked up to be the biospy bites should just be in that area.
MRIs are not perfect at finding cancer. A PIRADS 3 for example means the radiologist sees something they think might be cancer but they aren’t sure. A pirads 5 however is very likely to be cancer. It’s just where we are. With time things will improve as technology evolves
Hi doctor, Thank You for these videos. You made a comment I do not understand and I need to as my MRI came back with a RAD 5 score , and my Dr is pushing for a full TR biopsy. You said for ppl with Rad5 you do not recommend traditional 12 core biopsy, which is exactly what my doctor has ordered up. So....Why do you say not to do it.....( Im with you, I just don't understand the medical reasoning ) if you could write and explain this to me it would be greatly appreciated. Thank You.
For PIRADS 5 prostate findings systematic biopsy or more likely to miss the area of cancer than the systematic 12 core. The most complete biopsy would be to do both a targeteted biopsy and a 12 core at the same time but if you wanted you’d could skip the 12 core with only a small reduction in total cancer detection rates.
@@cancerbetter Thanks for quick reply, as Im having anxiety about all this.... I think my question should have been, since the MRI shows exactly where the nodule is located, doesnt that mean the surgeon knows and can see exactly where to go, and perhaps only need a few core samples , with the MRI image it is not "random" needle pokes, we have a picture of the exact location. Also looking for the perineal version , dont like the possible infection % of rectal, I'm 72....with T2 diabetes,
Short answer yes, if using targeting shortwave and if you have a pirads 5
Hi my psa started to rise about 5yrs ago when i was 60yrs old. My psa have risen to 14 and an mri scan was done showing i had inflammation of the prostrateand a enlarged prostrate to. My Urologist told me i had prostritis and my PRADAS was 2. I find it a little worrying as my Father passed away with Prostrate cancer. And plan on taking an MRI scan every 12 months to keep a check on it.
If you wanted certainty you could request an MRI. Or you could do one the many urinary tests to help further stratify your risk of prostate cancer.
@cancerbetter Can you explain this to me please, our urologist never did. The 3T MRI, no contrast, was done in May. Not seen a doctor since begining of May just before this MRI. Thank-you
Prostate gland measures 6.6, 5.5, 4.4 centimeters on CC, TR and AP dimensions respectively with
estimated volume of 84 cc and PSA density of 0.063 ng/ml/cm3.
9.5 mm ill-defined nodule with obscured margins are noted within posterior medial aspect of left
peripheral zone at mid gland which show mild hypointense signal on ADC and mild hyperintense signal
on high B value DWI sequences likely representing PI-RADS 2/3 lesion. No other peripheral zone lesion
is noted. PSA is 4.86.
My father's recent medical situation has left us feeling uncertain about the next steps. After his PSA level reached 13.5, an MRI showed PIRADS V, but a PET-guided biopsy came back negative. His PSA level has now decreased to 2.09, but we have received conflicting advice from doctors regarding monitoring the PSA or repeating the biopsy. We would greatly appreciate your guidance on the best way forward. Your expertise would be invaluable in helping us make an informed decision.
I can’t give medical advice about individual cases on this platform as I can’t get all the details like this but I’d start by having a second opinion on the prostate MRI. If they are sure the pirads 5 is real a RE-biopsy is reasonable. My studies and others have shown that a PIRADS 5 lesion has a 5-20% chance of no cancer detection based on where the clinical trial was performed.
Radiologist for my MRI provided no PIRADS number. All he wrote was “no suspicious lesions.”
That's a PIRADS 1. That means the saw nothing abnormal on the MRI and there is nothing to target with an MRI targeted biopsy. If your PSA density is high a biopsy might still be a good idea but that is the exception rather than the rule.
What’s the difference between perineal and rectal biopsy?
Short answer is for transrectal the biopsy needle goes through the rectal wall. For transperineal the needle goes through the skin below the scrotum. As you can imagine a needle passing through the rectum is a risk factor for bacterial contamination to the needle and for rectal bleeding. As a result there is a 4% chance of hospitalizations after thanks rectal biopsy due to infection and a 0.5% of death if that infection is not treated soon enough. Transperineal biopsy avoid this and has lower bleeding risk.
Why the US has been slow to uptake transperineal biopsy there are many of us who do this now. I have switched to doing nearly all my biopsies transperineally for these reasons..
@@cancerbetter That’s the answer I was looking for. My urologist wanted to do a transrectal biopsy, but I have found a couple of practitioners who do the transperineal biopsy.
Very thought provoking video, In a blood test we discovered my PSA is 26.2, I have an enlarged prostate and have have had past readings up to 21 but then backs off. My GP sent me to a urologist he had me get an MRI the type where they give you intervenes solution about 2/3 then way through MRI. The Urologist reads it and called me and said it looks suspicious and he wants to do a Biopsy it's scheduled next week but after seeing the video I am not comfortable with that without a conference with the Dr. and discussing your article with him. Do you have any advice? Bob Irwin P.S. I am an 84 year old in pretty darn good shape!
As a person's PSA rises the risk of prostate cancer also rises. However PSA can be elevated due to multiple reasons including prostate enlargement, infection or cancer. It's uncommon for PSA to get into the 20s based on size or infection so your urologist is likely concerned.
We use a tool called PSA Density to correct a person's PSA level for the size of the prostate. Generally if the PSA density is over 0.15 the risk of prostate cancer is pretty high and we recommend biopsy.
The last thing is that usually prostate cancer is slow growing and takes 15 years or more to go from localized to death risk. For this reason we often stop checking PSA levels in men above 75.
What if you’ve had a PMSA test and based off the test, it is used to determine where to biopsy. Then would it be reasonable for forgo the random biopsy? Even if you have PIRADS4 or 5.
That’s a strategy that is being studied right now. Early data suggests that might be OK but PSA pet alone will perform alone. The real question is whether PSA pet and MRI will not perform. The data suggest it will, but there is substantial financial cost and a technology gap.
@@cancerbetter Thanks you. It’s so confusing for someone who got a C in biology in college…the second time. 555 But for those with the right aptitude, what a challenge.
How do I know, I'm not a Dr. And you as a Dr. are trying to tell me who has prostate cancer that he might be doing it wrong? I've already had it done.
It’s easy to know. Did you get an MRI prior to your prostate biopsy? Did your doctor do biopsies targeted to the abnormal area found on MRI?
@@cancerbetter yes I had both
Hello Dr. Ahdoot: I am PIRAD-2 with a big prostate (166 cc) and a PSA of 15 for a Prostate density less than 0.1. I will have a PAE (prostate arteries embolization), but first i will have a biopsy. I have the following questions: a. Probability of cancer? b. Probability of a significant cancer c. Is it necessary to have a biopsy before PAE? d. Is PAE a good option for me? According to this excellent video the best biopsy for me is the systematic... Is it right? Thank you in advance to your answer, I appreciate a lot you recommendations. Best regards
Thanks for watching all the videos. I answered this comment on the other video you left the same comment.
Hi I had an MRI MP 3T biopsy done after my uro thought he felt something on DRE. Came back PIRADS 2 "no focally suspicious prostatic lesion", only that TZ was "heterogeneous with matched areas of restricted diffusion and focally increased perfusion that are not clearly suspicious." No abnormal signal of seminal, nerves, lymph nodes. I calculated my prostate density at 0.05, with a PSA of 2.6 and volume of 52ml. I've not heard from my uro since a month after but have a follow up call soon. Thoughts? I'm 66 and my father had Pca at 74 (RP) but lived to 92.
As a rule, I can’t give direct medical advice here, but I can tell you some information that might be useful. Generally a heterogeneous appearing prostate on T2 can suggest prostatitis which can masquerade as prostate cancer and cause an elevation of PSA.
A PSA density of 0.05 with a PIRADS 2 is also associated with a very low risk of prostate cancer ~5% based on data I currently have submitted for review for publication.
@@cancerbetterThanks very much. My uro got back with me and said he would keep an eye on it and we'll do another appointment in a year to assess, along with another exam and PSA, possibly repeat the MRI.
I’m a PIRADS 3 waiting for biopsy. You show a 50/50 chance of cancer in this category. My question is, if the lesion shown in the MRI is not cancer, what is it?
Thanks
Yes PIRADS 3 has a 50% chance of cancer but about half of those cancers are grade group 1 which can be watched. Real chance of cancer you need to treat is about 25%. You can Google "Ahdoot euo" to look at the original paper.
If no cancer is found it means most likely it was just an anatomic variation in your prostate, artifact from the scan or possibly that there was cancer but the biopsy missed it because it was a lesion to small to hit. So after a negative biopsy you should still keep following your PSA. Hope this helps
@@cancerbetter Thank you.
My husband is 54. His PSA was a 4.7 in Jan and was checked again in May it was a 7.4. MRI shows Pi Rad lesions score 3. Biopsy in 2 weeks. Very scared wife here.
@@AmyBethB Please tell me your husband is doing OK now. I got a PSA pf 10 and seeing a urologist today. A bit worried too.
@@luketimber4679 yes! Research research research. His general doc made him an appointment with a doctor that I did not like what I read about him. We went to a younger doctor at a hospital I hate! Best decision ever. I used to be a nurse. He came home and I cared for him. He hated the catheter as he had never had one before but he has gone back to work and goes for a follow up visit in February. I wish you all the best. I hope you have a good support system. If not find a local men's support group. Your doctor might even have one.
My MRI found 2 lesions, initially reported as both PIRADS 5, but upon review, one was downgraded to 4. I requested targeted biopsy, by my doctor was not convinced it would help. I requested he take his usual 12 cores but add some from the identified lesions. I dont know what the difference in in the biopsies would look like. How would I know if he did the traditional systemic one or the targeted one? And if he did the traditional one, what is the probability something was missed? The results came back grade group 1, cancer in one core, less than 5%.
Go to your medical records for your clinic or hospital and get a copy of your pathology report. If there are only six or 12 named biopsy samples in the report, then the doctor did only the systematic biopsies. If there were 13 or a labeled specimen that says MRI visible lesion then that would likely indicate that they did the MRI targeted biopsy as well.
I think it’s very important to point out that some urologist do not have comfort with interpreting prostate MRI or have the knowledge of how to do an MRI targeted prostate biopsy.
Unfortunately, as technologies evolve some doctors fail to adopt the newer technologies resulting in sub optimal care. Situations like yours are exactly the reason why I made this channel; to help people find better cancer care. While I do sincerely, hope there is no dangerous cancer. I think you doing the right thing to confirm that you did in fact have an MRI target to biopsy. If you have any doubts, I would strongly encourage you to find a provider who does offer MRI Targeted biopsy and is experienced with the technology.
I hope this is helpful. - M. Ahdoot MD
HELLO, DR MICHAEL, SHOULD ONE REQUEST OR CONSIDER ABOUT THE 4K BLOOD TEST, PRIOR A BIOPSY???
4K test is a pretty good blood test for determining a person's risk of prostate cancer after an elevated PSA. The 4K test however is worse than MRI at determining risk so MRI is used far more frequently. MRI also adds the utility of localizing tumors in the prostate, defining an individual's anatomy, and helping with targeting at the time of biopsy.
If you can not due an MRI due to non compatible implants or severe claustrophobia for example, a 4K score is a reason test.
I am of 67 years age.I recently approached to urologist for my complain of blood in semen. He suspected as Hematospermia and suggest me to do MRI Prostate.At present my PSA is 2.98ng/ml.In USG KUB Prostate size is 35cc.I have done Prostate MRI with 3T machine. In MRI radiologist found PIRADS-III and suggested me to do SOS TARGETED TRUS guided biopsy.Now how can I find best Urologist to do this?What sould I do now? please guide. Is it life threatening stage?
PIRADS 3 often does not necessarily mean prostate cancer. You can look at things like PSA density to further stratify your risk. Only a biopsy however will tell you for sure if you have cancer. If you are in the Los Angeles area I could see you but there are also lots of excellent doctors out there who know how to do MRI targeted biopsy.
@@cancerbetter Thanks for your instant reply. I am in India. After writing to you I recently approached to a very senior urologist Doctor here.He also postponeded my Trus biopsy of my prostate at present . He adviced me to do some PSA related test in the next month.I will consult him once again than after in next month.Thanks once again doctor with regards.
Yes density of prostate is great 5:59 5:59 5:59
Why and in what cases is active surveillance enough? Isnt the point removing cancer as soon as possible? How can you be 100% sure that cancet is not agressive at it wont spread when you are just doing surveillance?! Do you check the whole body with CT scans before deciding for just active surveillance? How often are appointments duringn just surveillance? Thank you
I'll make a video about active surveillance in the coming weels
Does Medicare pay for this procedure?
Yes it does.
Yes
I had a biopsy done first and they found that I had a Gleason 6 on 3 cores,, Then I got a second opinion and that doc took an MRI instead and found nothing in MRI ,, what should I do next or should I begin treatment
Talk with your doctor about the possibility of active surveillance. All Gleason 6 does not need to be treated. In fact, most Gleason 6 prostate cancer can be watched. I can't comments about the specifics of your situation but I'd speak with you doc about the risks and benefits for treatment vs watching it closely.
Hi Doctor, when you say MRI targeted biopsy here, is it a real-time MRI targeted biopsy or MRI fusion biopsy? My MRI result is PI-RADS 5, my doctor will do a MRI fusion biopsy. I wonder if real-time MRI targeted biopsy is better.
So when it comes to MRI targeted biopsy, it can be done in an actual MRI machine or it can be done using fusion software after the MRI to facilitate an easier biopsy. Very few people do biopies in the MRI scanner because it's more expensive, complicated due to the need for all non-magnetic tools and takes potentially much more time. However to answer your question biopsies done inside the MRI gantry have equal or slightly higher (~ 1-2%) cancer detection rates than biopsies done using fusion software.
For a PIRADS 5, the lesion will be larger by definition and it won't make a difference if it's done in the MRI machine or using fusion software.
@@cancerbetter Thanks for the detailed explanation.
PiRad3 on MRI report Transitional lesion radiologist recommends MR perfusion guided biopsy...How do you do biopsy on ostomate with total colectomy sans rectum.?
It's possible to do a biopsy without a rectum but it's challenging. You would need to do a transrectal biopsy or a biopsy in an MRI machines. Fewer people know how to do this or have the equipment but it's possible.
@@cancerbetter Thanks for the reply Doctor...with a total colectomy and a sewn up rectum...does make it a challenge indeed...
I wish I could get a urologist to at least consider an mri. I think they make more money by doing a lot of biopsies. Money first then patient care.
Look for a younger urologist.
You are welcome to come see me or a member of our team in Los Angeles. Or better yet, try a larger academic hospital in your area.
Hi Doc, firstly thank you for these very informative videos, I had a pi rads 4 identified on mri and had a random plus targeted trans rectal biopsy, 16 cores were taken and thankfully all came back benign, my psa was 2.6 at the time and they also said I had an enlarged prostate 32cc for a 49 year old man, my psa increased in one year by 0.2 but they said in the context of the size of my prostate they didn't find it to concerning, I'm still being monitored but I'm just wondering would you have any advice for me and do you think I can feel reasonably assured that having had a 16 core biopsy taken that the biopsy was pretty accurate.
I can’t give medical advice on this platform. You can read my publication on this topic to get an idea of rates. Search Ahdoot NEJM. It should be the first hit. Towards the end of the publication we talk about people who undergo surgery after prostate cancer, diagnosis and the rates of upstaging, and you could use that as a surrogate test to meet the risk of a prostate biopsy missing cancer.
@@cancerbetter That's totally fine, I seen that video already and what I took from it is that you get more accuracy with both random and targeted biopsy, like I said I'm still under surveillance and my psa in proportion to the size of my prostate is actually okay, I failed to mention I had a bad bout of prostatis a couple of months before the scan and they said it was possible that it could have left a mark, it was so bad I couldn't sit down comfortably at times, anyway I'm still being monitored so thanks for getting back to me.
I got no PIRADS score on my MRI report. All it said was “no suspicious lesions.”
Very blessed.
That’s it move on nothing their
Hello there doc i hope you are well ..will try and shorten this as much as possible dude..am 38 i had covid brung me down badly..got afull blood test done all good outher than ..my psa level which was 4 then went up to 4.2 doctor sent me to consultant got checked he thought everthing felt soft and fine..had an mri scan just to be safe unfortunately came back pirad 5 lesion on left side prostate iam now going for a trasperineal biopsy..what do you think about this?.. and could there be any spread of cancer somewhere else in my body?..hopefully i don't have it anywere else?.. would that mri i had tell that if i did have anything anywere else?...i have my biopsy next Wednesday...and could it come back that i dont have cancer ?... iam assuming i have it with my pirad level beeing at 5..also they said on the letter they think it will be curable and treatable if it is nothing sinister...cheers mate
It's uncommon for men if your age to have prostate cancer but it's definitely possible. I have treated a few in my career. Obviously when you are this young, if cancer is found, radiation may not be an ideal choice for treatment.
Yes it's possible this may be inflammation or other non cancer findings but with a PIRADS 5 prostate cancer is the most likely finding. The good news is you are likely catching this early when it's likely curable.
Transperineal prostate biopsy is a great technique. I plan to make a video on that topic as well in the future.
@@cancerbetter thankyou very much for your reply and all and the very best 👌 🙏 👍
No mention of PSMA PET SCAN why is that?
PSMA PET is not an established means for prostate biopsy targeting. The data just isn’t mature enough yet but perhaps out will be a standard of care in the future. I do have a video on PSMA pet for metastatic work up.
Not sure Medicare pays for it I ask for it to be done first and was told my insurance won’t cover it
It does now. All major insurance carriers cover pre-biopsy MRI now. If they don't just send them Ahdoot et al NEJM 2020 as evidence of it's medical necessity.
In the last year I have not had a single insurer deny an MRI for my patients with an elevated PSA.
When you say both biopsies does that mean puncturing the prostate 24 times with 18 gauge biopsy needles??? Poor guys who go through this.
It sounds worse than it is. I did 2 transperineal biopsies today in clinic. Both guys were comfortable and chatting during the procedure. Key is just to give the local anesthesia time to kick in. Typical combined biopsy is 14 cores. 2 of the target and 12 from the systematic.
Cores are 18 gauge as you said. This is similar to the size of an IV when people go to the hospital. I typically will make only 2 punctures in the skin with an access needle and I’m able to do all the biopsy cores through those 2 punctures.
hi I had a 12 core biopsy 11yrs ago and they didnt find anything...lss I continued getting psa checked annually and was urged to follow up again with urology. this time I had an mri and report was pirads 4. I have a targeted biopsy set in a few days. Question is the doc plans another 12 core with an additional core where the lesion was noted on mri? does that sound right? Also does the prostate get damaged with all the stabs and does that heal completely. I recall the orig biopsy I peed red for a week + and ejaculated pink for a couple weeks and ir was more uncomfortable each core taken.
Yes doing biopsies of the target plus the 12 cores would be appropriate for a PIRADS 4 lesion.
The prostate usually fully heals after a biopsy but there are risks your doctor should discuss with you like infection, blood in the urine, and blood on the ejaculate.
@@cancerbetter ok so just one core from where the lesion is noted and 12 random?
Usually 2 to 4 cores from the lesion and 12 from the rest of the prostate gland.
@@cancerbetter ok that sounds like what I am getting. 12 cores and 2 in the targeted area. The last time I had a biopsy I recalled it was unfomfortable the more cores that were extracted but I dont believe I was sedated as I drove myself to and from. Another concern is there a chance the biopsy itself could transfer cancer cells to other areas during the procedure?
That is a very very unlikely.
I don't know about biopsies, I read a comment on the internet were a fella got a 12 core and they found nothing. About a year later he goes in for a colonoscopy and they found some cancer on the core sight in his rectum...
Unusual situation. Would need to know more to understand how that happened.
@@cancerbetter can a mri give you a new gleason score?..pi rad 5 and pi rad 4 can you elaborate on this, and does this pi rad 5 give you a higher chance of BCR? ...Thank you in advance
what does a Clinical stage T3 mean
Clinical staging is complicated and in my opinion out of date. A complete overhaul of the clinical staging system is needed but cT3 is most often used to state a person suspects the cancer has extended beyond the prostate. Here is a good reference for more information: amp.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html
Any doctors in The Woodlands, Texas follow your system?
I'd recommend checking the big academic centers. Most academic centers are doing MRI targeted biopsies.
I am having a biopsy as well do you think I have cancer
Best predictor of your risk of prostate cancer prior to a biopsy is the MRI. If the radiologist gives you a score of 5 its very likely they will find cancer. The lower the number the lower the risk. This video provides the data.
Update?
Could you tell me where you are located. Thank you
I was recently recruited from the NIH to Cedars Sinai Hospital in Los Angeles where I practice Urologic oncology. My practice focuses on the treatments of prostate, bladder, and kidney cancers.
@@cancerbetter Can you recommend any urologist here in Las Vegas?
I live in Las Vegas, they don’t have that capability here.
They should. If they done come to Los Angeles. We definitely have it here
@@cancerbetter I’ve been scheduled for a biopsy, should I have gotten the MRI first. I have never had a problem with PSA before, it was brought to my attention this time When my PSA came in at 5.07 I was referred to a urologist. I asked for my past records to take with me. In 21 my PSA was 2.3 in 22 it was 3.2 there was nothing for 23 and in 24 it was 5.07. I’m 69 and in great shape, I workout 5 days a week and my training was going great. This is why I was taken totally by surprise. I have another blood test scheduled for Monday just to make sure my last blood test was accurate. I’m very hesitant to go through with this biopsy. It seems to me that when you start down this road there’s many risks.
And don't forget , boat and condo payments HAVE to be made. So you will see Doctors pushing test after test after test.
I assure you I have no boat and where I practice I don’t make a dollar more or less based on how many tests I order. Only perk to my job is the satisfaction of feeling someone and an occasional gift from a happy patient.
My psa level is 3.5 is that cancer
There is a video on my channel on the meaning of PSA. I'd recommend watching that. Generally an elevated PSA can be a sign of inflammation, cancer, or enlargement of your prostate. Prostate MRI is often the first step in finding out which of these it is.
Prob not but how much has it moved up is the key….for instance 3.2 to 3.5 in a year prob ok. 2.5-3.5 in a year get a mri of it
Hello doc, i ve been watching all your videos about prostate with great interest, my father is 57 year, with PSA 7,6 level result went to Urologist sent him to MRI and his result it s next can you please see it and give an onest opinion , the next step it s biopsie that will make next week with local anest. Thank you for your videos,i will continue to hear you, hope to read it. In your country we have cm not inch to measure.
2 Prostate nodules at the level of both lobes in the transitional zone of size 2.8 cm on the right and 2.4 on the left well delimited without expression in the adenomatous diffusion sequence, with peripheral gadolinophilia. And another small node at the level of the right prostatic apex in hyposignal t 2, with discrete expression in the diffusion sequence, ADC, with late wash out, with a diameter of 1.1 cm. Rectum, hairy and pararectal spaces, seminal vesicles without changes with pathological significance. No tumor subdiaphragmatic lymphadenopathy. No ascites fluid. No MRI circumscribed bone lesions
It hard to comment without seeing the scan myself. If your local doctor is recommending a biopsy I would go with it and see what the biopsy shows. That way the uncertainty will likely be resolved.
Generally it's just not right to give advice unless I've had the opportunity to do a full visit and get all the records. My goal here is to help people get access to guys info so they can find the best care possible.
How are you after one year from taking pfizer vaccine?
Alive and well! : )
@@cancerbetter thanks, I've had 2 doses and am fine.