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Cancer: Prostate Message Board


Cancer: Prostate Board Index


Hi again,

This is basically good news, though you might not consider it so at this time. The bottom line is that it looks like, pending confirmation by a well-targeted biopsy, that you have a cancer that needs treatment, but that a cure is quite likely. It is still possible that this will not turn out to be cancer, and on the other hand it is still possible that it could turn out to be aggressive cancer, but the odds are fairly strongly in your favor based on the multiparametric MRI biopsy. Here are some of the details:

Regarding: "IMPRESSION:

12 x 8 mm left anterior midgland-to-apex peripheral zone lesion. PI-RADS 4, high (clinically significant cancer likely). This lesion abuts capsule without gross extraprostatic extension."

- The word “apex”, in the context of a cancer that needs treatment instead of a mild cancer, alerts the doctors to a cancer that has a fairly easy route to escape the prostate capsule if left untreated. Your mpMRI indicates that this tumor does not extend beyond the capsule, which puts it in the range of surgery as well as radiation (which is effective also beyond the capsule).

The PI-RADS grade of 4, out of 5, may seem at first glance as bad news, which in a meaningful way it is, but it is also good news, really, in that it is not a 5. PI-RADS grades essentially break into 3 meaningful groups: 3 or lower is good, probably pointing toward no cancer or active surveillance; 5 heralds a real battle, with multiple therapies probably needed; 4, while indicating cancer that likely needs treatment, is very likely a winnable battle, often with just one kind of therapy, or a one-time combination of therapies, and usually not involving the more burdensome therapies such as chemotherapy. Also, a finding of a 4 (or 5) indicates strongly that a biopsy is warranted; the mpMRI image targets an area that the doctor doing the biopsy should sample with a biopsy probe or two.

The size seems about that of a small marble – not huge, but significant.

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Regarding - "5 x 3 mm left anterior distal apex peripheral zone lesion. PI-RADS 3, intermediate (clinically significant cancer equivocal). This lesion abuts the anterior fibromuscular stroma without gross extraprostatic extension."

- This 5 X 3 tumor is between a BB and a pea, rather small, and the grade of 3 suggests this, if it is cancer, by itself would not need to be treated. Sometimes the fibromuscular stroma is confused with a lesion in interpretation of a tricky image.

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Regarding - "No seminal vesicle invasion or pelvic lymphadenopathy.
Narrative
MRI Prostate with and without intravenous contrast"

- Sometimes mpMRI is focused exclusively on the prostate, and, as a layman, I’m not sure how much beyond that the image shows. However, the mpMRI can be focused to show a great deal more. It appears that yours picked up the seminal vesicles and at least the pelvic lymph nodes that were nearby and saw no indication of cancer.

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Regarding - "TECHNIQUE: Multi-parametric 3.0 Tesla pelvic phased-array coil MRI was performed, including multiplanar T2-weighted images, diffusion-weighted images (including ultra high b-1500 images and ADC map), and dynamic contrast-enhanced images of the prostate. In-and-opposed-phase T1-weighted images and pre- and post-contrast T1-weighted images of the entire pelvis were also obtained. Dynacad software was used for image processing and analysis."

- That 3.0 Tesla magnetic field is powerful, providing excellent image resolution. The T2-weighted images give a good picture of the anatomy, and I think the T1 images support that, but I’m not sure. The diffusion images indicate whether water is moving normally or appears obstructed, such as by cancer. The contrast images indicate whether there is abnormal blood vessel growth, as is needed to support a growing tumor. All these clues are considered together to home in on likely cancer or cancer free areas.

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Regarding - "CONTRAST: 8.9 cc Gadavist.
COMPARISON: None."

- The element gadolinium is used as a standard contrast agent.

I’m not sure what “Comparison: None” means. If you find out, perhaps you could share that.

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Regarding: - "FINDINGS:

Prostate size: 4.2 [CC] x 3.3 [AP] x 4.7 [transverse] cm for an overall volume of 34 cc.
Intra-vesical protrusion: None

Peripheral zone hemorrhage: None"

- The size is pretty normal – little benign enlargement. The “none” findings are favorable. If it turns out that you have a Gleason 3+4 = 7 tumor there per the biopsy, that size could be significant in deciding whether active surveillance is possible; the PI-RADS 4 grade is on the negative side, and the location is not favorable to surveillance due to the escape potential, but, as a layman, my hunch is that active surveillance is not entirely out of the question at this point pending the biopsy.

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Regarding - "LESION: 1
PI-RADS Assessment Category: 4, High (clinically significant cancer likely)
T2-weighted images: 4 (Circumscribed homogeneous moderate hypointense mass confined to prostate; <1.5 cm)
Diffusion-weighted images: 4 (focal marked decreased ADC & marked increased ultra high b-value signal; <1.5 cm)
Dynamic post-contrast images: (+) Focal early enhancement with edges matching lesion on other sequences
Size: 12 x 8 mm as measured on image 15 of series 9 (ADC map)
Side: Left
Location within transverse plane: Anterior
Level of prostate: Midgland-to-apex
Zone: Peripheral
Extra-prostatic extension: Abuts capsule without visualized EPE"

- This is the detail of what we went over above. The radiologist explains that a hypointense (low intensity) area that suggests cancer is rather small and matched by other clues (water movement and blood flow) that suggest a cancer that likely needs treatment, pending confirmation by a biopsy, which will give a Gleason score and other clues.

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Regarding - "LESION: 2
PI-RADS Assessment Category: 3, Intermediate (presence of clinically significant cancer equivocal
T2-weighted images: 3 (Heterogeneous or non-circumscribed round moderate hypointensity)
Diffusion-weighted images: 3 (focal mild/moderate decreased ADC & normal or mild increased ultra high b-value signal)
Dynamic post-contrast images: (+) Focal early enhancement with edges matching lesion on other sequences
Size: 5 x 3 mm as measured on image 10 of series 9 (ADC map)
Side: Left
Location within transverse plane: Anterior
Level of prostate: Distal apex
Zone: Peripheral
Extra-prostatic extension: Abuts capsule without visualized EPE"

- The fact that this is an “anterior” lesion indicates it is in an area of the prostate where it would have likely been missed on the old style normal, untargeted type of biopsy.

Abutting means the lesion (tumor) lays against the prostate capsule but has not penetrated beyond it.

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Regarding: "Additional peripheral zone findings: None
Additional transition zone findings: Enlarged and heterogeneous in appearance, consistent with BPH."

- This is addressing other details in the peripheral zone as well as details in another zone of the prostate, the transition zone, where only likely BPH is noted, in other words, benign, non-cancerous, enlargement. (But that can be a separate problem in itself that impacts continence, urgency and frequency of urination.)

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Regarding - Lesion 2 generally -

- Lesion 2 is milder, as discussed above. I can go into detail if you like, but the format is similar to that in the discussion above.

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So there is a bit of BPH, which will contribute a bit to elevated PSA, along with the cancer, and any infection.

These findings indicate the cancer is likely well contained, which makes it likely that an attempt at a cure with surgery or radiation is likely to be successful, assuming use of modern technology and competence.

To me this covers the key bases, but I've been at this a long time, and when I was where you are, I knew little. Please ask if you have further questions.

Again, good luck sorting this all out.





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