Prostate MRI: Do You Need a Random Biopsy? | Off The Cuff with Mark Moyad, MD
HTML-код
- Опубликовано: 30 июл 2024
- PCRI’s resident moderator, Mark Moyad, MD, MPH, and radiologist Daniel Margolis, MD, discuss the current state of the 12-core prostate biopsy and whether it still has a place in the diagnosis of prostate cancer or whether it should be totally replaced by the MRI targeted biopsy.
Daniel Margolis, MD, is an Associate Professor of Radiology at the Weill Cornell Medical College and an Associate Attending Radiologist at New York-Presbyterian Hospital. He received a B.A. from UC Berkeley in 1992 and his medical degree at the Keck School of Medicine of USC in 1998. He went on to serve his community by completing an internship at the Los Angeles Department of Veterans Affairs. He then finished his residency at the UCLA Medical Center in 2003 and completed a prestigious fellowship at Stanford University sponsored by the National Cancer Institute. Dr. Margolis specializes in abdominal imaging and has co-authored nearly 100 publications, many of which focus on prostate imaging.
0:08 Dr. Moyad asks Dr. Margolis why with all of the improvements in imaging a doctor would order a biopsy without first doing an MRI. Dr. Margolis responds by describing a rigorous international study published recently in the New England Journal of Medicine by University College London. It compared two groups of men: One that used an MRI to determine whether a biopsy was necessary and where to perform it, and another group that did not use the MRI. The study found that the group who used MRI found more significant cancers in their biopsies, less insignificant cancers, and had fewer biopsies overall than the group that did not have MRI. The data was so strong that the study ended early. It is unclear if the FDA will use this study to determine protocol in the United States because they are wary of studies that do not include American patients, however, this study may be an exception because it included so many different countries.
2:25 Dr. Moyad asks Dr. Margolis if the MRI targeted biopsy will completely replace the random 12 core biopsy in the coming years given the strength of the evidence. Dr. Margolis says that this has not happened yet (apart from bureaucratic inefficiencies) because there is a small percentage of men whose cancer will be missed by an MRI. Normally cancer that is missed by an MRI is insignificant, and there is now an attempt to find signs to help predict which men would have significant cancer that does not show up on MRI, but that is still a work in progress. In England, the protocol is already moving towards the exclusive use of MRI targeted biopsies and their strategy for filling this gap is to ensure follow up MRIs. Even if the cancer is still not detectable on the follow-up MRIs, a radiologist will be able to see suspicious changes from the first MRI and can then order a targeted biopsy.
Don’t know your stage? Take the quiz: Visit www.prostatecancerstaging.org
To learn more about prostate cancer visit www.pcri.org
To download the free Staging Guide visit www.pcri.org/prostate-cancer-s...
Who we are:
The Prostate Cancer Research Institute (PCRI) is a 501(c)(3) not-for-profit organization that is dedicated to helping you research your treatment options. We understand that you have many questions, and we can help you find the answers that are specific to your case. All of our resources are designed by a multidisciplinary team of advocates and expert physicians, for patients. We believe that by educating yourself about the disease, you will have more productive interactions with your medical professionals and receive better individualized care. Feel free to explore our website or call our free helpline at 1 (800) 641-7274 with any questions that you have. Our Federal Tax ID # is 95-4617875 and qualifies for maximum charitable gift deductions by individual donors.
The information on the Prostate Cancer Research Institute's RUclips channel is provided with the understanding that the Institute is not engaged in rendering medical advice or recommendation. The information provided in these videos should not replace consultations with qualified health care professionals to meet your individual medical needs.
#ProstateCancer #Prostate #DanielMargolisMD
GREAT VIDEO GUYS!!! Yes, yes yes....by all means NO more "Poke and Hope (TRUS 12-Core Biopsies)...do an mpMRI or bpMRI. But you need to ADD a couple of things:
(1.) Make sure you're getting your initial MRI on a 3T (3-TESLA) MRI machine (not 1.5T) so you don't have to use 'contrast' or Gadolinium... NO GADOLINIUM injection at this point is necessary (bpMRI) because the 3T magnet will give you a very accurate v2 PI-RADS score without the contrast. Most MRI's done for initial diagnosis of PC are done without GAD because both mpMRI and bpMRI have similar diagnostic accuracy. If you have a suspicious area, get an "In-bore MRI-targeted Biopsy" from a facility that marries the needle to the MRI image within 1mm accuracy for a very accurate Gleason Score.
(2.) If you get a nasty Gleason score of (4-3 or 4-4 or worse and no penetration of the capsule), DON'T let your physician automatically 'arm-twist' you into a Prostatectomy... check out the high-powered seeds with external beam radiation. Check with your Doc first, but you should know this combo provides the highest cure rate today according to the LATEST clinical studies.
5 Reasons To Say GOOD-BYE forever to the 'Poke n' Hope 12-Core Random TRUS Biopsy:
(1.) It can't tell you if your cancer has become metastatic (moved outside the capsule) which is CRITICAL to know if you have advanced cancer.
(2.) Needlessly annihilates your poor prostate with several random stabs that aren't necessary and might not find anything.
(3.) You can acquire the possibility of a life-threatening serious infection that results from all those unnecessary stabs to your prostate.
(4.) Major cancers are MISSED 30%-40% of the time with just 'Poke n' Hope' random 12-cores.
(5.) If an MRI can show little need for a biopsy, you will have just saved yourself a lot pain, blood, discomfort, time, money, worry, fear and stress at having to undergo a 12-core random biopsy.
The perennial biopsy is realy a piece of cake in my experience. No blood whatsoever in urine or sperm. 12 quick pinches. But did have a mri first that showed 2 small liaisons. My small worry is subsequent biobsy was done with ultrasound. Urologist said he's sure he got the area. A second opinion said a MRI should be used during biopsy.
The big problem with biopsy without a target is the negative result. Is it the 30-40% false negative? It is most untoward for the person to find out only years later the biopsy missed the tumor. Even with the positive test, there is also the question with low grade tumor. Is it real low grade or did the needle miss the center of the tumor. How do we resolve these two questions?
@@tomslick2058 Seems you have lesions but no tumor. A tumor is a lesion but a lesion may not be a tumor. Your doctor should make it clear to you. It is very important, and any specialist can tell the difference on the MpMRI, 1.5 or 3 T does not matter. A lesion is normal cell and does not grow. An inflammed tissue such as bruise, or biopsy cut will show up as lesion.
It looks very much like you have inflammation causing elevated PSA. You should engage a good urologist and investigate that. An untreated inflammation over a long period of time can result in something very nasty. Kidney failure can kill you sooner than prostate.
You really should read about “MRI blind” clinically significant cancer. Usually they are G4 cribriform shaped, invisible on MRI and very dangerous.
Unfortunately I was only offered a 12 core biopsy. It is a horrible experience. I guess that MRIs are not as lucrative for the doctor.
I had 2 they both sucked i won't do anymore im doing an mri
You hit he nail on the head. It is all about money. Period. I had six urologist try to force a biopsy on me. I am not concerned about cancer. I am concerned about voiding. Read the "The Great Prostate Hoax" by Richard Ablin.
Your doc. isn't paid for the MRI. Almost always the equipment is owned by the hospital and the radiologists are salaried by the hospital.
When are we going to see PC diagnosis via imaging WITHOUT BIOPSY?
Hear me on this! INSIST on a MRI BEFORE any biopsy! Insist on a transperineal biopsy if MRI shows a lesion.
Also, examine RATE OF CHANGE in PSA over the years & NOT if it’s simply below 4.0 (and assuming things are just fine!).
Why would one not do that?
Age 55 with a 3.97 PSA which is up about 1.5 from three years ago and just got my 3T MP MRI results today. The report shows enlargement which was felt on the DRE and "1. no lesion of at least mild suspicion" but the Doc still wants to do a biopsy which is a bit perplexing. After doing some further research, it seems even radiologist are split on the need for follow up biopsy due to the small percentage that may be missed by the reading doctor. I looked up who did mine and he is 8 years out of med school. This is all a bit disappointing as I payed for the MRI to be done first in hopes that if negative findings were produced, it would avoid the 12 point ultrasound guided biopsy but I now get why a biopsy should still be performed.
Is there a follow up video on what has happened over the last 4 years?
Excellent video, 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
Im 51 my psa is 4.1 and i have an appointment in 2 day to see a uroligist. I bleed excessively and always have. Im worried they will want a ramdom biopsy and that because of my profuse bleeding it will lead to longer healing. Normal guys bleed up to a week and a half i read. And then only 25% of those have cancer and only 10% of those are agressive.
If your observation is accurate, prostate issues aside, you should have a thorough coagulopathy workup by a hematologist. It's very important.
Ime going for biopsy after they found a 11 mm mass on the left hand side of the prostate my main concern is infection.Even tho I've been given 4 lots of anti biotics to take 2 the night before 2 two hours before and after and another later on.My other concern is that when a biopsy is done that cancer can form from that procedure everything seems to be a risk .why can't another MRI be taken 3 months after if its slow growing.
Is it safe for MRI for patients with aortic valve and left coronary stent for the prostate
And what if PSA is slightly elevated, MRI is negative but liquid biopsy indicates the need for a biopsy (e.g. Proclarix score slightly above the cut-off value of 10)? In such a constellation, is it better to get a random biopsy, better to wait 6 months or better to get a PSMA PET/CT scan?
Hello. My husband is scheduled on Wednesday for a biopsy. He did have an MRI first...however, he had to ask for it. Yes, his PSA is crazy high @ 54. But he wanted to be certain they knew exactly where to go with those needles..or whatever they use. He is Pirad 5. I'm very worried!! 😥
Best wishes to him. If you ever have any questions, you are welcome to contact our free helpline. We have patient advocates who are trained to help patients with their questions. You can find our contact information at pcri.org/helpline.
Out of forty prostate pokes 5% of one core is still Gleason 6?
Find a urologist that does perennial biopsys. They are easy. But get a mri first.
Did you mean perineal biopsy?
@@jayv9286 yeah sorry. My phone is dumb and changes words. Not that I'm a great speller.
Yes I just had one and it’s not bad at all.
Is a randomized biopsy considered randomized if the CT probe was used to for the technician to direct the needle?
I am not sure what you mean by CT probe, but I assume you mean something with the same principle as an ultrasound-guided biopsy (without a prior MRI) in which they are only using imaging to locate the prostate gland. Once the gland visualized, the physician would then take 12-14 or more samples from different parts of the prostate to be sent to the pathologist. It is not technically random-- if it was truly random, a urologist could--potentially--take all of their samples from one small area of the right side of the gland, for example. However, it is random in the sense that they do not have a particular target within the prostate; the physician is hoping that if there is serious cancer, it will be in one of the 12+ spots from which they took their samples. Studies have not had very consistent results, but this method of biopsy does end up missing serious cancer about 30-40% of the time; each biopsy core only samples about 1/10,000 of the prostate (assuming an average-sized prostate) and so by existing between those samples, the cancer can evade detection. So, it is "random" in that sense.
The alternative method that we endorse (although it is not an option everywhere and for everyone) is to do a multiparametric MRI before the biopsy. The MRI, depending on the institution, is going to miss about 5%-10% of serious cancers, which is not perfect, but it is an improvement over not using imaging. If the MRI detects a suspicious lesion, that particular area can be targeted and the biopsy process can be done which much fewer samples taken, which also means less risk of side effects-- the most concerning of which is infection. If a targeted biopsy is performed of a suspicious area, and it is determined not to be cancer, then it becomes debatable whether or not a random biopsy should be performed. If you are ever in a situation like that, you can call our helpline, and our patient advocate can explain the different sides of the debate and help form questions for your doctor(s), etc. It's a free service and our contact information is at pcri.org/helpline.
When will we have the results from England’s switch to high PSA/negative MRI/no biopsy paradigm?
I am not knowledgable about how things are done in England, but I would be interested in reading more about that. If you have any links about it, please feel free to post them here or email me at austin@pcri.org. I am curious if they would do a follow up MRI a year or so later to see if the first negative MRI missed anything or, generally, how the follow up would be handled in the event of high PSA, no detectable lesions on MRI, and the data that they used/are using the draw their conclusions.
@@ThePCRI It’s talked about in the last minute of this video we are commenting on.
I am having a mri on a 3T machine with contrast in a few days. My psa has gone from 1.7 to 3.4 over 4 years then fom 3.4 to 6.5 in a year, retested 3 months later and my psa is now 9. Not concerned with the overall number but i am concerned with the psa velocity. I have had and xontinue to have symptoms of an enlarged prostate, more recently i have discomfort. I am banking on the mri to help tell the story and help me with my next steps.
Talk with your urologist and radiologist about also doing a PET scan of your pelvis and prostate.
I am 51, with a psa of4.1. I am worried that because i bleed excessivly that a biopsy will take s long time healing and lead to complications.only 25% have cancer and onlyb10% are agressive.
a Person I love very much has a 62 PSA is 61.1 with a % PSA of 9.1 Three years ago his PSA was 2.4 Does this not seem high and within a short time? Trying to get insurance to approve his Fusion guided Biopsy. His Dr. did a DRE and said it was Hard. Not large but Hard Should I be very concerned about him?
Hi, our prostate cancer helpline may be able to answer your questions and help you find helpful information. Please feel free to contact us here: pcri.org/helpline
@@ThePCRI v
I don't understand why biopsies are so common in prostate cancer, especially when the rich blood drainage into the spinal column from the prostatic plexus of veins occurs. Also from 2020: Tumor-Associated Release of Prostatic Cells into the Blood after Transrectal Ultrasound-Guided Biopsy in Patients with Histologically Confirmed Prostate Cancer
so i had an elevated psa yrs ago around a 4 had the biopsy was told nothing found that was 11yrs ago... ff I continued to have high PSA but aside from frequent urination no other issues then developed bowel issues after a colonosocopy so GI doc orders a liver mri aside from a somewhat fatty liver nothing seemed alaming the GI doc did order a cancer marker blood test prior which was above what was in range. my family doc said I still needed to follow up with urologist which I just did and had another mri with contrast (more worried about the gadolinium than anything) I have only seen the mri report but it stated a pirad 4 and 10mm tumor so what does this mean exactly have a follow-up appt in a couple weeks
Is there any risk of the biopsy causing the cancer to spread outside of the prostate ?
Excellent question ,I believe it's no harm, prostate cancer been around for a while and tons of men are diagnosed every year. By now the urologist would have caught on to it if it did spread. It's safe but painful.
I will tell you this, it's a money driving field like no other. Think about it, no biopsies, pathologist go hungry. I combed the streets of Phoenix looking for any urologist to give me a 3t mri..out of the 20 I called seriously, not one was willing to do mri first..I finally gave in after 2 months of searching. I hate to say it ,but if you have a aggressive cancer you only need a micro blip to get into your body ..scary stuff.
It is called track seeding (Google it). It's considered rare. It's considered rare because they can't prove without a doubt that the biopsy spread it. If a patient says "the Dr said I was all clear with clean margins when they removed my prostate" they say, "we may have missed something and track seeding is very rare." Personally I'd fall into the MRI and done group. I had an MRI about a month after I had Covid. My PSA spiked to 13. The primary care physician pushed the panic button. I went to a urologist who said my DRE was normal, followed by "I recommend MRI so we know where to target, then a TRUS biopsy." The MRI comes back clear RADS2. Why not a 1? They see a spot on my hip. Radiologist writes that is a "lesion" on my femoral head which is the ball of the hip bone. OK so I'm thinking it's the classic story. They go looking for one thing and they find something else. And how lucky it is that they found it. Or worse, it's already spread. I didn't feel good about it at all. So I go back to the radiologist to have the hip xrayed again in detail and the result comes back "no suspicious bone lesion." So I'm good again. The urologist say's "biopsy still recommended" so I go to urologist #2 who also states the DRE is normal. U2 say's OK we'll do the free PSA test. My PSA @ 13 was in January 2023. Almost three (3) months to the day in April 2023, my PSA drops to a 7 and free is 17. With a clean MRI and PSA dropping 6 points in 3 months I become optimistic. U2 would do a biopsy but I remind him of the MRI. Like in the video, I am scheduled to go back again in January 2024 for checkup which will likely entail another DRE and follow up PSA. I would be willing to be in a trial to see what happens to men like me who have clear MRI and do nothing further. Honestly, even though I had the PSA spike, I'm about ready to stop PSA testing altogether. There really is no normal level of PSA. A man can have prostate cancer with either high or low PSA. The PSA test was discovered when they were looking for a way to determine if a man had a prostate. For example after the prostate is removed, the PSA should be zero. If they saw PSA rising it meant that they had a re-occurrence of cancer because they don't have a prostate, but prostate cancer still makes PSA. They use PSA as an excuse to biopsy because men with prostate cancer often have high PSA, but a man can have prostate cancer with a PSA under 3. PSA can rise from exercise, bike riding and sex as well as covid, BPH and infection. So I had two normal DRE's, a clear MRI and PSA dropped, so I'm done. I'm not going to get 12 needles, randomly stuck through my rectal wall into my prostate unless there is compelling reason to do so. Some might argue there is a need, but even though I live in the USA, I'm going the British route. As I said if there is a study, I'll participate.
@@vimzibaiegh The blood for your PSA should be drawn before your DRE.
@@wholeNwon The 2nd PSA test where it dropped to 7 from 13 in about a month was taken a few weeks after U2 did the DRE.
I had MRI and he took 12 pops of the prostate . He said he hits the spots found on MRI and the other clear areas. He also said he’s found just as much cancer in the non MRI targeted sites.
Not fun but not bad either.
Wouldn't that be the insignificant cancers that he's detecting in the non mri targeted spots.
I'm a 43 year old man that had my first PSA exam last year which was 1.9 . Doctor did rectal examination which was normal bur the new psa test came out as 2.1. Now the doctor is recommending biopsy. Is really necessary?
Hello, our prostate cancer helpline may be able to help with your question. Please feel free to contact us here: pcri.org/helpline
I was told no. If it goes over 4. Sounds like a second opinion.
Mine was 6 when they did one
You don't need a biopsy ,unless rectal exam felt tumors or the PSA is above 4 , but a PSA of 5 or 6 can be normal over 70 yrs old !
Makes no sense to do it without the MRI. 8 out of 51 of my samples were targeted by the MRI. And they showed way more problems than the rest.
Got mri results thru nyu medical...with 5k results of probability cancer...getting a targeted biopsy next week...what choice do I have...my psa is 14 from a 3 last year...hope for best I have no enlarged prostate or major symptoms..I'm 60 years old
good luck.
Psa over 10 means 50 percent cancer
My urologist ignored the radiologist rating saying he he did not think they were cancer and said the two lesions were small. Did a perineal biopsy and said no cancer. But who's to say he did not miss them or what the future says. Did a pas a year later which dropped a half a point. Surprisingly he said see you next year. I suspect a repeated mri will eventually. Regardless of Psa
@@tomslick2058 That is the big question for biopsy. What does the negative really mean? 30-40% miss is big!
@@jackboone6794 well that's why they superimpose the mri image over the ultrasound during the biopsy. The chances of missing it are way lower. Now they can do a biopsy live via a mri. So they know for sure there getting it. Both ways are well respected. A blind biopsy without a mri image is something I would not recommend nor a transrectal biopsy. These 3tMri have only been around for a few years and limited areas. But there pretty standard the last couple years.
@@tomslick2058 Yes you can use the MRI image to mark the area. Even though not every clinic or hospital can do it. Anyway is 30-40% miss with the image?
very interesting indeed. i am having an mri later this month and the result
will determine if i then have the TRUS biopsy. i live in Australia.
ps my latest psa test result in august was 8.7
Good luck how did it go I just had biopsy after MRI found nodule on apex of the prostate .
PSA went from 4.1 to 4.5 in 8 months so had to get it checked out despite zero symptoms
@@imedi yeah mine was in the apex. Think that's the most common spot for cancer. I drove myself nuts with research.
@@tomslick2058 yep unfortunately I tested positive as well ..
G score of 7 Just have to wait now for radium treatment
@@imedi sucks sorry. See if you quality from seeding. One time procedure.
@@tomslick2058 thanks will ask about that although my cousin showed my results to a consultant urologist friend of hers and he thought my cancer wasn't evolved far enough to need seeds ..
Hopefully it works out whatever they do. .
Hope your treatment works out as well ..
Came as a bit of a stunner with the low PSA reading and no symptoms ..
Just shows people should get their blood checked regularly I would have been happily getting on with life for another few years oblivious to what was growing inside me
I’m sorry I really love Dr. Scholz but not doing systematic biopsies just seems crazy. A systematic biopsy can catch the 5-10% of clinically significant cancer that an MRI misses. For the gold standard of care, you need both.
They basically diagnosed my loved one by PSA and bone scan alone, stage 4.