What I Got Wrong About My MRI Fusion Biopsy

MRI scan (not mine) with possible hot spots, lesions as it would be used in an MRI fusion biopsy.

As I wrote in my post from July 1, after noting the basis for an MRI fusion guided biopsy, e.g.

https://health.clevelandclinic.org/2014/09/fusion-guided-biopsy-a-smarter-way-to-look-for-prostate-cancer/

"This will then limit the needle insertion (and extraction of tissue) to the four suspicious areas noted in the MRI as opposed to "shooting in the dark" with 12 random stabs in the standard needle biopsy. Fortunately, a phone call to the local Urological Associates has determined that they can do it."

Well, I got one part of that right, the other wrong. The part I got wrong was assuming that the needle insertions would be "limited". They were not. In the MRI fusion guided biopsy I had yesterday afternoon no fewer than 19 sticks with the needle were delivered one after the other.

When I was first notified of this after I entered the biopsy room I couldn't believe it. I sputtered: "But I thought because there were only four suspicious areas* the extractions would be limited to four maybe one or two more."  "No" was the answer, "the four suspicious regions only means we now know where to concentrate our focus so can really go in there and take up to 24 samples!"

Fortunately, it ended up being only 19 thanks to several "calcified" areas - most likely from the previous radiation (HDR)  treatment-  that they didn't want to disturb. But still, to prepare for the onslaught, I not only had to take the prescribed 750 mg  Levofloxacin antibiotic tablet but also two stabs of gentamycin in each buttock 20 minutes before the biopsy commenced (this in addition to the lidocaine needle to numb the gland, and hopefully not pass out from the pain.)

I ought to have figured something wouldn't be as I expected when we had to wait over an hour for what was supposed to be a 1:45 p.m. appointment. Then, only after entering the biopsy room did we find out the guy in before me had passed out on the table. They, of course, had to allow sufficient time for him to recover- so then all the appointments that followed were backed up.

As the needle sticks were ongoing, lasting maybe 30 minutes because each tissue extracted from the prostate had to be sample-tubed and labeled, I talked with the doctor performing the sticks about treatment alternatives. He seemed to believe the "ice ball" or cryotherapy was the best for salvage, e.g. the general procedure outlined here:

https://www.youtube.com/watch?v=-OnqA-mJDWg

And more detailed here:

 https://www.youtube.com/watch?v=Hoi0872F3Cg

I told him I was thinking instead of HIFU (high intensity focused ultrasound) which many prostate cancer survivors on various forums said worked for them. (Though they had to obtain the treatment in Mexico or Canada since at the time the FDA hadn't yet approved it here  -only some clinical trials. I have since found out that HIFU-  'Ablatherm'-  received approval since October last year but is still awaiting CPT code assignment. Until then no Medicare payments for any HIFU!)  ). His snarky reply was "I wouldn't do that to my dog".  But remember, this guy is a urologist and in their 1-dimensional universe surgery (radical prostatectomy) is the one and only solution. Never mind in 25 percent of cases cancer is left in the margins and there is biochemical recurrence. Nearly the same percentage have to get salvage therapy, though to be sure making a choice after surgery is easier than after radiation, given the damage to tissues already inflicted by the latter.

I also mentioned not doing anything, and he agreed that could be a valid option, or non-option, especially if it is found the Gleason scores are high (8, 9). Then I just accept 4 to 7 more years of life and go with it, ditching the many side effects of hormone treatment like cardiovascular issues, metabolic syndrome and cognitive decline. As I told him "we all gotta go some time".

Now, I play the waiting game and in the next week or so should receive the results of the histology-pathology analysis of the slides.

I am hoping for the best.


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* Details

Adopting the PI-RADs MRI imaging scale my original MRI report noted 4 lesions ranging in size from 7 mm to 12 mm (almost a half inch across) with a PI-RADS score of category 4.

According to the Radiopaedia site:

"PI-RADS (Prostate Imaging Reporting and Data System) refers to a structured reporting scheme for evaluating the prostate for prostate cancer. It is designed to be used in a pre-therapy patient.The original PI-RADS score was annotated, revised and published as the second version, PI-RADSv2  by a steering committee with the joint efforts of ACR, ESUR, and AdMeTech Foundation.

The score is assessed on prostate MRI. Images are obtained using a multi-parametric technique including T2 weighted images, a dynamic contrast study (DCE) and DWI. If DCE or DWI are insufficient for interpretation the newest guidelines recommend omitting them in the scoring. (DCE = dynamic contrast enhanced imaging, and DWI = diffusion weighted imaging.)
.
A score is given according to each variable. The scale is based on a score from 1 to 5 (which is given for each lesion), with 1 being most probably benign and 5 being highly suspicious of malignancy:

• PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)
• PI-RADS 2: low (clinically significant cancer is unlikely to be present)
• PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal)
• PI-RADS 4: high (clinically significant cancer is likely to be present)
• PI-RADS 5: very high (clinically significant cancer is highly likely to be present)" 

Low T Therapy For Bigger Muscles? Blame This "Remedy" For Medical Interventions You Don't Want!

Kristen was still distraught after losing her hubby Rob, a year earlier. What had been planned as a trip for two to Barbados this year ended up a trip for one. The saga isn't new and will likely unfold in many more households as low T mania continues unabated. How bad is it? According to the article, 'Low T: Real Problem or Ad-driven Fad?' in the AARP Bulletin (July-August, p. 18):

"A 2013 study in JAMA Internal Medicine found testosterone prescriptions grew more than threefold between 2001 and 2011. Data from IMS Health shows T sales rose from $324 million in 2002 to nearly $2.3 billion in 2012. Sales could hit $5 billion by 2018."


As the article also notes, most of this increase isn't based on any genuine medical issue. It is based on ads shamelessly playing to male insecurities. The loss of muscle mass , sex drive or energy -  once described as "getting older" -  suddenly was transmogrified into a condition dubbed "low T" by the Madison  Avenue Ad makers. Thus were unleashed a torrent of print and TV ads from the makers of testosterone replacement meds and gels. One ad actually advised: "Millions of men 45 or older may have low T so talk to your doctor!"

Really? Gimme a break!

In Kristen's husband's case, Rob (then 47) felt he needed an edge at work so began the low T prescription solution. He did feel his energy rebound, his muscle mass increased and his renewed sex drive pleased Kirsten. Only she worried about taking increased testosterone which as a medical person (urology RN) she already knew provided a fuel for prostate cancer.

According to Dr. Mark Scholz, in 'Invasion of the  Prostate Snatchers', p. 42:

"testosterone fuels prostate cancer growth  and prostate cancer is the only type of cancer susceptible to testosterone inactivating pharmaceuticals"

Alas, Rob dismissed all such concerns, according to Kristen, and even increased his testosterone use. If some is terrific, more got to be better, right? Not quite. Within a year Rob's PSA had doubled, and six months later tripled. Finally, under pressure from his wife he reluctantly submitted to a prostate biopsy and prostate cancer was found in five cores with Gleason scores 4 + 5, and two with 5 + 5. The urologist pronounced "advanced prostate cancer" and recommended radical prostatectomy in combination with female hormone treatments.

The next year or so was 'hell' as he descended into depression following the surgery which left him incontinent, his penis shrunken, zero sex drive and with large breasts - arising from the hormone treatments.  Kristen confided that at least he hadn't ended up like another T-using patient who - after his operation around the same time - experienced a vesicularectal fistula-   farting through his penis and saddled with other complications before having to get a colostomy.

Despite all the horrific side effects Rob had to endure, the prostate cancer spewed secondaries into bones and lungs - and he died 6 months ago.  Kristen said if she had one wish it would be to "get men to back off from this silly, idiotic non-solution".

She may well have a point. Even if by some miracle prostate cancer isn't spawned, other negative medical impacts abound. According to Dr. John La Puma, quoted in the AARP article,

"When you take testosterone your body shuts down production. As a result the testicles shrink and you could be using supplementation indefinitely."

He noted this circumstance meant "expense, inconvenience and  worst of all, possible catastrophic health consequences."

Think aggressive prostate cancer. But as the AARP article also pointed out:

"A study published last year in the Journal of the American Medical Association reported a 30 percent jump in the risk of stroke, heart attack and death among men undergoing testosterone therapy."

It would seem that any guy seriously thinking of aspiring to be muscle-bound  and energetic using T, would be advised to watch the video below first and pay close attention! Note the particulars of treating low testosterone, including the fact: a) testosterone can vary during the day so the time you get the blood test is critical, and b) the low testosterone can be due to multiple other causes than natural, including stress, fatigue, diabetes or other hormonal imbalances.


http://www.webmd.com/prostate-cancer/video/testosterone-replacement-prostate-cancer

The AARP article also adds (ibid.):

"But what is a healthy T level for an older man? Doctors can't agree. Many laboratories use wildly varying reference numbers based on the average testosterone levels of young men, anywhere from 300 to 900 nanograms per deciliter."

The Bulletin adds that,  incredibly, just about any purported "symptoms list" will ensure a low -T diagnosis.

The fact is, as Dr. La Puma observes,  most men (maybe 80%) don't need this "therapy" at all, period.  As he puts it:

"All men need to do is eat a healthier diet and be more active."

To reinforce that, "it's found that when obese men shed an average of 17 pounds,  testosterone levels climb 15 percent."

This in addition to quality sleep and regular exercise can help any guy improve his energy and muscle mass as well as sex drive.

Trouble is, too many guys want the "quick fix".  For those who want the T-quick fix to “muscle up” to look better or get more energy, I'd say just be prepared for what’s coming later. It might also help to imagine yourself long past the cancer treatment stage when your dick is U-shaped, your breasts are bigger than Mariah Carey’s (so much you want to hide from your wife) and you have to wear giant diapers just to go to the corner 7-11.