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Questions about the diagnostic process
Hello,
I'm a 63 year old male. My dad had prostate cancer at 58 years old in 1990. He had radical prostatectomy (the procedure was pretty rough back then) but he's been cancer free since. About three years ago I noticed common urinary issues that got progressively worse (reduced stream, trouble emptying, etc.). My PSA tests started rising over the past couple of years and finally got referred to urologist when it was over 4. I got put on Flomax. They ran a PHI test which was 47.9 so got sent for 3D MRI with contrast on a 3T machine. Here's the radiologist's impression: Lesion 1: At the level of the mid gland extending into the prostatic apex in the right lateral transition zone, there is a mildly T2 hypointense lesion with associated diffusion restriction measuring up to 1.7 cm with a volume of 1.28 mL (PI-RADS 4). I got scheduled for a transrectal fusion biopsy with a well known urology oncologist. My doctor/hospital is Duke University Medical Center, a national cancer center of excellence. I have several questions...
1. Is it normal to wait over two months to get scheduled for a biopsy after MRI? They said they were unusually backed up because of increased patient volume.
2. I've been immunocompromised in the past due to an autoimmune disease/medications and had numerous serious infections including bacterial meningitis. I'm not currently on immunosuppressing meds. I asked about risk of infections from transrectal procedures because I read they are fairly common. They said almost all the doctors at Duke do transrectal fusion biopsies and that prophylactic antibiotics should keep me safe. But the Nurse practitioner said she'd ask as one doc does transperineal biopsies but I never heard back . Should I press this issue more or just go along with the transrectal procedure?
3. Is a 1.7 cm/1.28 ml lesion large enough to cause the urinary symptoms? Or maybe there's also BPH?
4. I know that biopsy if the only way to officially diagnose malignancy. But with what is known so far, how prepared should I be for the biopsy to be malignant?
Thanks!
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I switched to an NCI Designation Cancer Center. It really helped. I created a simple "Notes" treatment tracking timeline on my phone to use before, during, and after my oncology sessions, helps me and oncology/cancer team with communication treatment planing/process.
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1 Reaction1. My father also had prostate cancer, and I followed PSA until it got over 4. I waited 2 months from decision for biopsy until appointment was available. I assumed I had cancer until proven otherwise (which of course was the case.) Use this time to learn about possible treatments and ways to manage side effects.
2. Since you are immuno compromised and have had infections as a result before, I would be very assertive with your desire for minimal risk, and don't rest until you can get a transperineal biopsy. I had a transrectal with no pain or complication, but in your case, caution is the best approach.
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2 ReactionsI was fearful of that procedure also.I spent 50yrs in the animal industry and watched 99.9percent of animals tha somehow got fecal material inside their body cavity die inspite of whatever antibiotic used. I was flabbergasted by the proposed procedure . Not enhanced by the death of my friend from septis from his biopsy, Urologist assured me the likelihood was only 1 in 764 that I would die from it. Changed urologists at that point and went to a nci facility took the protective antibiotic and lived to tell this tale.
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1 ReactionI would absolutely go with transperineal - totally avoids fecal contamination and possible infection - some of which can be life threatening even without immune issues.
I pressed for one, had it done with local anesthetic; no pain, blood in urine or aftereffects. Besides, many feel there is greater access to more surfaces of the prostate using the TP method. Best!
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2 ReactionsI had a 30 core transperineal MRI fusion guided biopsy because of my large 120 gram prostate at Mayo Phoenix and it was painless and much less worrying than a transrectal although I told the urologist that if I had a choice between him or going to the dentist the dentist would win every time.
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3 Reactions@happydappy, waiting for a biopsy appointment for 2 months can be anxiety inducing. It gives you time, however, to do your research and you're asking good questions. If getting an appointment at Mayo Clinic, perhaps Jacksonville, is an option to be seen sooner, here's how to submit a request. http://mayocl.in/1mtmR63
Here are a few related discussions in addition to the helpful responses you've already received to help you with your research:
- Transperineal biopsy options & location recommendations
https://connect.mayoclinic.org/discussion/transperineal-biopsy-options/
- Anyone have an Ultrasound-Guided Transperineal Prostate Biopsy?
https://connect.mayoclinic.org/discussion/anyone-have-an-ultrasound-guided-transperineal-prostate-biopsy/
- Your experience during & after Transrectal Prostate Biopsy (TRUS)
https://connect.mayoclinic.org/discussion/your-experience-during-and-after-a-trans-rectal-prostate-biopsy/
Have any additional questions?
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1 ReactionI am with heavyphil here. Certainly given your history, that seems like the only way to go.
The two month wait is no big deal in medical care today, that is how things work. But one thing that hasn't been mentioned on why you should go transperineal is the location of your lesion. You list a lesion in apex area, they can't even reach that tranrectally, they can, but not well with a good set of samples. In your case with location of the lesion, plus the past medical history, you want transperineal.
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1 ReactionThe very latest (February 1, 2024) ProBE-PC randomized clinical trial results comparing infectious complications of Transrectal prostate biopsy versus transperineal prostate biopsy produced clear results.
Results of the randomized trial:
“A composite infectious complication event occurred in 9 participants (2.6%) in the transrectal and 10 participants (2.7%) in the transperineal group (odds ratio, 1.06; 95% CI, 0.43 to 2.65; P = .99). None of the participants developed sepsis in either group. There were no between-group differences in any of the individual component infectious events.”
Conclusion from the report:
“Among men undergoing transperineal or transrectal prostate biopsy, we could not demonstrate any difference in the infectious or noninfectious complications. Both biopsy approaches remain clinically viable and safe.”
https://www.auajournals.org/doi/abs/10.1097/JU.0000000000003788
Maybe the MRI based location of your lesion would indicate a transperineal procedure is better suited…but I’d go with the recommendation of your doctor.
However, regarding the potential for infection between the two procedures…follow the data…
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5 ReactionsThanks for sharing this study.