Avatar universal

Prostate Biopsy or MRI

If an MRI is the be all/end all in determining prostate cancer...why do I need a biopsy...???...why cant I just have an MRI...???

My PSA was at 5.5.  I'm 67 years old.  My urologist performed a cystoscopy; & said that everything was normal, but to keep an eye on my PSA.  It went up to 8.2, so he ordered a biopsy.  He tells me that if the biopsy comes back clean, but my PSA remains high or goes up...then I will need an MRI.

So...why do I need to put myself thru such an invasive technique...if an MRI can fully determine prostate cancer.  Biopsy side effects range from blood in the urine to not being able to urinate & a bunch of other stuff.

please help...thanx,

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Avatar universal
Thanx to everyone who replied!...very much appreciated.  Fox Chase radiology team declared that 5 suspect lesions were all consistent w/ BPH (as opposed to the PIRADS score reading from my local hospital where the prostate 3T MRI was performed)...*no biopsy warranted at this time*...go back to see my Urologist in 1 month.  thanx again.
Helpful - 0
Hey, you got yourself off the conveyor :)  Congratulations and good luck with no-biopsy into the far future. Thanks for the update.
That's awesome news! I'm really happy to hear this.

Keep us posted. :)
20620809 tn?1504362969
How is it going?  Any new updates to add to this? I'm following.
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207091 tn?1337709493
How are you doing now, Mark?

What I learned from my dad's battle with prostate cancer is that everything is a "hurry up and wait" issue. It's the ultimate in frustrating.

You aren't happy with your uro - can you find another one? My dad was sick for 12 years before he died, and had 3 different urologists. It's important that you find one you can work with, and you feel is current on the treatments and testing, etc. You could be working with him for a long time.

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1081992 tn?1389903637
Mark, can you post the MRI report? There should be a sentence or two about each of the multiple 'sequences' done (which is why it is called 'multi').

Briefly, remembering from a year ago: Relative has episode of severe UTI with mild sepsis. PSA is 25 (not a typo). Uro does DRE and says, "I'm an expert, you have cancer". TRUS is scheduled to determine aggressiveness. I say, "Whoa, this could be just inflammation". I read up a little and quickly discover that the MRI + fusion biopsy is better. Uro wants TRUS biopsy done NOW, but consents to MRI, which happens in 4 weeks. By then, PSA is down to ~15.

I read the MRI report, finding various lesions, and then look up the PI-RADS V2 document from the ACR. One finding tended towards inflammation, another to inflammation or cancer. I seem to remember also that the 'ADC map' with high B-value should show high signal for cancer, but was instead low signal on the MRI report.

Here's the big kicker: the radiologist says at the end that "overall findings may be due to prostate cancer or prostatitis..." Then inexplicably rates this as PI-RADS 4.

PI-RADS™ v2 Assessment Categories

PIRADS 1 – Very low (clinically significant cancer is highly unlikely to be present)
PIRADS 2 – Low (clinically significant cancer is unlikely to be present)
PIRADS 3 – Intermediate (the presence of clinically significant cancer is equivocal)  
PIRADS 4 – High (clinically significant cancer is likely to be present)
PIRADS 5 – Very high (clinically significant cancer is highly likely to be present)

Inexplicable... since it very much seems EQUIVOCAL, therefore should be a 3.

When asked to order another PSA to see if it's fallen further, Uro says, "What for? We already know there is cancer." It takes a couple of weeks to get a new Uro, who promptly orders a PSA which comes in at 2! When asked, the new Uro says he wouldn't have rated that MRI as PI-RADS 4. Voila, it's all over. All the delays turned out to be very fortunate in this particular case.

So whatever you may have, Mark, this type of happening is something to be aware of. I've come to think of it as patients being put all on the same conveyor belt -- everybody just gets moved along, moved along. For some it's good, for some it's not - but all get moved along the same generic way.

I wouldn't be satisfied with the Uro merely saying, "suspicious lesions".

I'd also take a look at that PHI test that BonzoDog talks about, if your MRI is (or should be) a PI-RADS 3.
Helpful - 0
Avatar universal

[first of all...thanx for all the knowledgeable replies]

my prostate MP 3T MRI scan results came in; & indicate "suspicious lesions".

my frickin' (old-school) urologist seemed to be reading me the riot act over the phone, telling me "I NEED A BIOPSY!" (as if to suggest I shouldn't have messed the MP 3T MRI in the first place). He was however open minded enough to suggest another urologist, who performs an MRI guided biopsy procedure, in the hospital, under general anesthesia.

so...I'm pretty damn apprehensive at this point...the new doctor needs me to come in for an appointment/consultation first...so as to establish myself as his patient (but doesn't have an opening until the end of the month). Don't like the delay...but unless I learn something different about this entire process...I guess I'm going that route

Helpful - 0
1081992 tn?1389903637
Hi, Mark. Your thinking is pretty much spot on. I know this is a month old, so I hope it worked out for you.

But if it's not over yet, I urge you to carefully read the PI-RADS report and don't just go along with the score number. If you're still around and reply, I'll tell you a story about that from when I was helping a relative last September. He was almost pushed into a biopsy, but it was a false alarm.

Overall you are correct: you should want the 3T *multiparametric* MRI first - not last. What that uro says is  backwards.

If the MRI looks bad, then you use the MRI for an accurate fusion biopsy. Even a 1.5T (weaker magnet) MRI is better than a 'blind' TRUS biopsy, which is from the stone age. You can even get the MRI and the fusion biopsy done at different institutions, as long as you double check that they have compatible equipment.

If the MRI says benign or 'equivocal', then you probably have avoided the biopsy as you hope your PSA will go down.

"Biopsy side effects range from blood in the urine to not being able to urinate & a bunch of other stuff. "
Yep, including sepsis - which can be fatal.

"...if an MRI can fully determine prostate cancer."
Not exactly correct. It can see extremes of cancer versus not-cancer. It can see tissue that looks like inflammation.

I hope you're having good luck.

Helpful - 0
Avatar universal
Hey, before you submit to a biopsy, ask your Dr. about getting a PHI test - stands for Prostate Health Index. It’s a simple blood test & you get results in a cpl days. This test is WAY more specific for prostate cancer than PSA - it combines PSA along w/ 2 other factors & the 3 together generate a number. If it’s under 24, you have less than 10% chance it’s cancer, over 55 means >50% chance. I’m a prostate cancer patient myself, had radical prostatectomy Jul 31, 2018. I had a high PSA but digital exam didn’t find anything, 1st Uro wanted to immediately do a biopsy, but like you, I was leery of side-effects, so I asked for the PHI, he referred me to his colleague for that. Unfortunately, my number came back very high (68), which indicated virtually 100% certainty of cancer, so I went ahead w/ the biopsy, which confirmed cancer, fairly advanced in my case, unfortunately. I don’t know why more Dr’s don’t immediately order the PHI & want to proceed immediately to biopsy. The PHI is quick, non-invasive & your insurance should cover the cost, which is way less than either biopsy or MRI. If your Dr. won’t do it, tell him or her you’ll see someone who will. Put your foot down & insist on this. There are a cpl other other similar blood tests that are more accurate than PSA alone, so if they don’t offer PHI, ask for one of those. Best of luck to you...
Helpful - 0
"I don’t know why more Dr’s don’t immediately order the PHI & want to proceed immediately to biopsy."
Isn't that the truth? Some uros seem biopsy-happy.

You've got a very reasonable attitude,
BonzoDog - especially considering that your story did not end all that well.

Btw, there's also a different type of emerging blood test for PCa that looks for prostate lysosomes. I don't recall the name of it.

I hope you're doing well.
Thx, Ken. Unfortunately, not doing so well, partly my fault for not addressing it earlier. Actually, I feel just fine right now & no one would know to look at me that there’s anything wrong. I just had follow-up surgery to remove a malignant lymph node (Surgeon also took some add’l nearby nodes), but Pathology showed none of this tissue was cancer. Normally you’d think that’s good news, but in my case, we were hoping to find some of that tissue w/ cancer & then the thinking was, my PSA might drop after it was removed. Since no add’l cancer was apparently removed, there’s not much chance of a PSA drop, so the Oncologist says it’s time to start thinking about hormone therapy - that would drop my Testosterone to virtually zero & has many very unpleasant side effects - loss of strength, loss of muscle, weight gain (especially around the middle), depression, cognitive difficulties, total lack of libido & severe ED (already battling that because of nerve damage from the surgery). I’m not sure I’ll agree to do it, but if I don’t, it’s 100% sure my cancer will advance into the bones. Neither choice is a good one. I urge every guy to take this disease seriously, and if you have a male relative (father, grandfather, brother, cousin) who has or had or it, you have a considerably higher chance of getting it yourself. Much better to catch this thing early, if at all possible...
I'm sorry to hear this, Bonzo.

My dad did hormone treatment 2 or 3 times. I won't lie and say it was easy, but there are ways to manage the side effects. He did become depressed, though it's hard to say if it was the treatment, or because of his health (he had PC and quite a few other serious illnesses), but antidepressants helped. He gained a little weight, and I never noticed any cognitive issues. Remember that with all treatments, your mileage may vary.

Since my father never once discussed his actual penis with me lol, I don't know about his libido or ED. I know he had a script for meds for it, though.

His cancer did advance to the bones. Unless you are done, as in done fighting, do what you can to prevent this for as long as you can. It is PAINFUL. I believe fully in making your own life decisions, so if you are done treating, you're done. Just make sure you are.

Hugs to you.
Thx, auntiejessi, appreciate those kind words from you! I haven’t made a decision yet - I see my Uro / Surgeon on Thurs 08/22 for follow-up after this latest surgery, we’ll do a PSA & see where we’re at & then decide. One of my issues is, if mine is not curable & I’ll end up w/ progression into the bones in a few years anyway, I have to decide if gaining 3-4 add’l yrs at a markedly reduced quality of life is worth it.

In the meantime, I appreciate all the info you & Ken have provided - this disease is notoriously unpredictable & can be difficult to treat, and you’re right that ‘mileage varies’ from one patient to the next.  My own opinion is, each guy facing this has to arm himself w/ as much knowledge as he can & be his own health advocate - these important decisions should be your OWN - it’s YOUR body & YOUR life, so don’t let anyone talk you into smthg you’re not comfortable with...
That's something I struggled with for my dad. For various reasons, he tried every treatment possible, and it may have added a few years to his life, but he was miserable. Granted, he had some pretty serious illnesses going at the same time, so it wasn't just the PC, but I wonder if he'd have been happier.

Then again, it allowed him to fulfill some bucket list things, and there's that, too.

It's never easy, and no right or wrong.
Yep - exactly!
207091 tn?1337709493
The MRI allows for more targeted biopsies, meaning you may not have to have as many samples taken.


As CurfewX said, the MRI can't determine the type of cancer, or the grade. This is really important as it determines your treatment options.

I hope you get some good news. Even if it's cancer, I hope it's early stages, and a slow-growing type. Keep us posted on how you are.
Helpful - 0
great link...!!!...thanx very much
You're welcome. I hope you get good news. :)
Oh and let us know what happens.
Yep, that is quite a good overview article, auntiejessi. Well done on your part for pointing to that. This section stands out a lot:

"Considering the newest data, increasing evidence supports a possible role of upfront MRI in the biopsy-naive setting. However, since most urologic guidelines do not recommend this approach, it is still not widely adopted as the standard of care."

So it will unfortunately take time for Uros to stop recommending TRUS, as if anybody should want that.
3191940 tn?1447268717
An MRI can detect abnormal growth, but it can't detect cell abnormalities like a biopsy can.  A pathologist will examine the cells to determine if they are cancerous or not, and if cancerous, they can identify and grade the cells: https://www.mayoclinic.org/tests-procedures/prostate-biopsy/about/pac-20384734  An MRI can't determine the type or grade of cancer.

The MRI may be recommended on follow-up, particularly if the cells are determined to be cancerous, to identify additional areas where lesions may be present.  There are some additional tests that you may want to discuss with your doctor: https://www.pcf.org/c/biopsy-things-you-need-to-know/

Ultimately, the decision to undergo tests is up to you, but if you plan to treat the cancer, if present, a biopsy is a must.
Helpful - 0
I do not know that I have cancer...I may not...I may only have an enlarged prostate & a high PSA.  Having said that, a 3T MRI first seems the way to go...why put my prostate thru such an invasive procedure if I don't even know I have cancer.  If a 3T MRI determines I have abnormal growth, then of course I'll do the biopsy at that time
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