MRI PI-RADS scoring
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Hi Can anyone tell me more about PI-Rads scoring after an MRI scan on the prostate. My husband has been graded a 4 and it waiting for a biopsy the one done under a general anaesthetic. I have not been able to find out much about it other than 4 means very likely that clinically significant cancer will be found. We we spoke to the specialist nurse she also said that there was some concern over pelvic lymph nodes. Not sure if she meant swollen or they thought there was cancer. Bone scan was negative. Background on my husband age 71. Hight psa's since 2002 ranging from starting point of 4 and rising over the years with scores of 7, 14,19,21 and 2016 38. He was diagnosed with enlarged benign prostate and has had 2 negative biopsies over the years and 2 negative MRI scans. The only thing found was lot of inflammation noted on biopsies. Last year when it rose to 38 he had a negative MRI scan which the team looked at and thought it was all down to the inflammation and the prostate size. We have moved house to a different area where the recent MRI has been done. I should add that he was given finasteride 2016 to reduce the size of the prostate and his last reading was 26. The consultant says that drugs reduces the psa reading by 50% which means the true reading would be 52. In the letter sent to our gp which we have a copy of it just says if psa rises 20% above presenting level of 38 to refer back. I should add that my husband has other health problems namely type 2 diabetes, asthma/copd and is overweight. Obviously we will have to wait until the biopsy is done. He is not keen as he had a reaction to the anitbiotics hence the MRI scans. He also has to have a pre assessment to see if he it fit for general or maybe an epidural. It is all very worrying and can't seem to read about any patient with a similar story. All I read is about men with psa under ten being diagnosed with advanced cancer and or those with readings in the 100s or 1000s. The nurse mentioned if it was cancer and they seem to think it is then maybe radiotherapy or hormone treatment both of which seem to have bad side effects. Not sure but think that he would not cope very well. I can't seem to find anything much about inflammation with no symptoms and high psa readings either. I should add that I have read that the drug finasteride can cause agressive cancers but protect against non agressive ones. Also he takes a spiriva inhaler for his asthma since Sept 2015 and there are reports of it causing problems with prostate and psa spikes and cancer. The consultant said it does not. I have asked the nurse to do some research for me for when we go back. This is a long and complicated post and unfortunately my husband is not type to want to find out about anything even if he is diagnosed so I try to find out and be prepared. If anyone could comment I would be grateful I did post in the Prostate problems forum about 1 year ago and just recently as well which give more details. Thanks for reading this sorry I have gone on a bit.
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libralady13
Posted
This post is for all who were good enough to reply to my original posting about PIRADS scoring. At last 4 weeks after biopsy we have a follow up appointment to see the consultant for my husbands biopsy results. I am expecting bad news, although my husband if confident it won't be. The nurse at the last clinic appointment mentioned the possibility of radiotherapy or hormone treatment. Having read up on both I am really worried about all the side effects. The hormone treatment seems to have hotflushes,tiredness,risk of Diabetes, weight gain and breast enlargment. The radiotherapy urinary and bowel problems which could be permanent. My husband of 71 is obese so needs to lose weight not gain it especially as he has type 2 diabetes and asthma/copd. At long last he is on a pulmonary rehab course which will last until around the end of September.
The course includes exercising, diet and treatment. It has taken me a long time to get him to agree to go on this course and I was glad he was finally accepted as from what I have read from other sufferers he will benefit greatly. Back to the hormone treatment would you think he would being suitable for hormone treatment given the side effects and his other health problems. Like wise the radiotheraphy side effects he already has some urininary problems although not bad from his very large prostate. I know him very well as I don't think he would be able to accept these side effects. Can you suggest what questions we should ask if he needs treatment I am so frightened of making life worse for him but realise he may need treatment. Any views would be appreciated.
Thanks.
barney34567 libralady13
Posted
Many questions come to mind.
For you:
Has your husband had any recent scans that show a metastasis?
If not, then why is anyone recommending radiotherapy?
While you mention the psa rising, you don't reveal how long it takes to rise. Does it double in a year? Two years? The rule of thumb is that there's a problem if it doubles in a year.
If the urologist believes that there are small metastasis on the skeleton, too small to image then I ageee that hormone therapy is indicated. If the psa is climbing.
Does your husband have other major illnesses?
Is he in danger of death from those illnesses? If so, in how many years?
For the urologist:
What does the urologist say would happen if your husband has no treatment for the PCa?
How long would he live?
If he agreed to hormone therapy, how long would he be on it?
What hormone therapy is proposed?
What are the expected side effects of such therapy for someone with your husband's medical profile?
How will that impact his quality of life?
Are there alternatives to hormone therapy?
Are there any medical trials he can join?
If I think of more, I will let you know.
Note, in my experience, physicians other than oncologists give the best advice as to what oncological treatment to have eg radiotherapy or hormone therapy, because they don't deliver either and are in my experience, independent and not captive to any one therapy.
libralady13 barney34567
Posted
Hello again and thanks for your reply. It was a bit of last minute panic posting as the clinic appointment is tomorrow I realise this does not give much time for replies.
To answer your questions one by one.
The MP MRI scan and bone scan were done around two months ago. If you look at my original post you will see that when we went to the clinic for the results we were told it was PIRADS 4 and they were concerned about pelvic lymph nodes. The bone scan was clear showing only normal degenerative changes. The appointment was brought forward 1 week the orginal being cancelled as circumstances beyond their control. We surprised that we did not see the urologist but a Macmillan cancer specialist nurse. She said the team had met and looked at the MRI and had advised he must have a biopsy. She mentioned that with the pirads 4 score the biopsy would just confirm that it was cancer. When my husband asked about treatment she spoke about radiotherapy, hormone treatment or no treatment at all. So from this we took it that it would be back news once the biopsy results were available.
The PSA is a bit more complicated. If you look at my first post see will see that the Urolodgy dept in our local hospital in London had been monitoring it since 2002. Durng this time he has 2 biopsies and 2 MRI scans. The only things ever found were BPH and inflammation. His PSA in 2016 was the highest then at 38 hence the MRI in 2016. I was concerned it might have been caused by the inhaler he has started using the year as it has a warning about use by men with large prostate. We were told this was fine to use although my googling has found several people on forums who think otherwise. His PSA earlier this year was 26 which because he is taking finasteride means you need to double the result to get the true reading as this drug reduces the psa by 50%. This means his psa is now 56. Once again others on forums are saying that this is just a quide some men don't respond so well so it might be from 20 to 50%. The Hospital in London obviously had been monitoring for years and were well aware of the pattern of his psa tests. The team there seemed satisfied that the MRI scan did not show any cancer and were happy just to monitor him as before. Then we moved and of course a new hospital and of course having to be thorough. I did give them copies of all correspondence and psa mri and biopsy results from London. So you can see it does not seem as simple as how often his psa is doubling. I wonder do you know how much of a psa reading is accounted for my BPH or inflammation. It does seem to that the last hospital seemed much more relaxed about his psa readings because they had been monitoring him for 14 years.
I mentioned that my husband is obese has type 2 diabetes and asthma/copd from years of smoking. Thank heavens he gave up smoking 9 years ago or it might be worse. So you can see we are concerned about making the right choices. I believe from my own experience that doctors underplay side effects.
I will certainly make a note of the questions you think we should ask. I will let you know what happens tomorrow. I do thank you for your interest and advice.
libralady13 barney34567
Posted
barney34567 libralady13
Posted
Ok. Two things come to mind. I can't help you regarding a key issue: how medications your husband takes influences his PSA. By all means ask a urologist about this, but in addition, find another physician you trust, say an endocrinologist who will be involved directly or indirectly in any hormone treatment for an opinion on the medications' influence on PSA.
Also to set your mind at rest, a PIRADS 4 MRI conclusion should be followed with a biopsy I think in all cases unless the patient is very old or is suffering greatly from other maladies. It should not be forgotten that a biopsy is an invasive procedure.
libralady13 barney34567
Posted
anne05147 barney34567
Posted
''What does the urologist say would happen if your husband has no treatment for the PCa?''
Agree, amongst other questions, think this is a most important question to always ask.
libralady13
Posted
Update on my husband. Went to see the consultant this afternoon. Good news the biospy( 24 samples taken) no cancer was found. The worrying thing is that his PSA seems to be rising. His prostate is 200cc? according to the consultant. I asked about correlation between prostate size and psa level but he said he could not really give me an answer. He suggested he see my husband in 4 months for a psa test and a urine flow test to see if he is retaining urine. It is then up to him if he has a Transperineal ultra sound guided biopsy (which I think he should have had last time but it got changed). He mentioned that the more biopsies ae taken the less chance there is of finding cancer but said that tthe type of biopsy proposed can find cancer which the ordinary ones can't. I think my husband has already decided that he would not have any more biopsies after the last one. It will be his decision but I can undertand that at 71 and with other health issues he has had enough. In the meantime I might do some research into benign causes of high psa. Anything any one can add would be appreciated.
anne05147 libralady13
Posted
Hi Carol just been reading your above post. I think it is awful to keep putting men through numerous biopsies if there is a particular biopsy that is much more definitive i.e, transperineal biopsy.
This is the biopsy that my husband is hoping to have once recovered from having his appendix removed.
I don't blame your husband for not wanting anymore biopsies and feeling he's had enough of it. My husband has also been told he has a large prostate from his previous MRI and ultrasound. Like you I am checking out rising psa due to enlarged prostate. Will share whatever I find out with you.
All best wishes
Anne.
libralady13 anne05147
Posted
barney34567 libralady13
Posted
Transperenial biopsy which is guided by ultrasound is so much more accurate than transrectal biopsies. It's a shame your husband didn't get one, which would possibly negate the need for several transrectal non ultrasound guided biopsies over the years.
The comparison on the nhs is not just the cost of a transperenial v transrectal, which I assume is far cheaper, but also the multiple times a risky transrectal procedure is performed eg risk of sepsis that is FAR lower with transperenial approach.
anne05147 libralady13
Posted
My husband only got offered the transperineal biospy as he was reluctant to have the rectal, well basically near refused, so they offered it when we said we would try to get another MRI done privately as they said he didn't need another one, the last was taken over a year ago, then the professor of urology got involved and said he could have one done as they were doing a clinical trial that involved MRI, ultrasound and transperineal biopsy. I guess cost is involved as the clinical trial is being funded by the researchers.
It really is a merrygoround trying to find out what to do for the best.
libralady13 anne05147
Posted
vincentb libralady13
Posted
J really explains it well.im 68 now
I was 66 when I had T2C Gleason 9.i had open prostactomy . Now 2 years on wear the thinnest Tena man pads one lasts all day.i had lucky escape psa ever since opp is 0.05 undetectable. I hope your husband does as well .best wishes . Vin
libralady13 vincentb
Posted
Thank you for your reply. I am so pleased you are doing well after your open prostactomy. Great news that your psa in undetectable.
My husband saw the consultant last week and had already decided to tell him that he does not want any more biopsies. Having thought about it for some time at nearly 72 with other health problems tests and procedure plus the scare of a possible mini stoke last month (which according to the stroke consultant was probably a migraine, MRI results next week) he has had enough. Having had 3 MRI's 4 biopsies over a period of over 10 years his recent psa is 21 much lower than earlier this year and although of course high is due to a very large prostate. Incidentally he had psa levels of 21 years ago. He has though agreed to see the consultant every 6 months for psa testing. I hope you continue to do well and enjoy life to the full.