Difference between mpMRI and Biopsy reports

desperate for hope

Hello everyone, 

I posted a few weeks ago about PCa found in my husband's bladder. https://csn.cancer.org/node/306036  (PSA 28, GS4+5, N0, M0)

 Since then, we've had a mpMRI (endorectal coil) and just received the results. The radiologist wrote: 

The prostate measure 4.0 x 3.8 x 3.7 cm (anterior to posterior by medial to lateral by cardiocaudal) with volume estimated in 30cc.

There is nearly T2 isointense signal involving the left tansitional zone, left base and midgland with projection into the left bladder neck with early enhancement in the dynamic series post gadolinium injection however no definite diffuse restriction. This area is poorly defined however measures approximately 3.0 x 2.3 cm in the T2- weighted axial sequence. There is an ill-defined T2 hypointense area with early enhancement however no definite diffuse restriction in the left base of the prostate which measures roughly 1.8 x 1.5 cm. There is no evidence of extracapsular extension of the disease, invovlement of the neurovascular bundle or enlarged lymph nodes. 

No free fluid in the pelvis. No suspicious lesions identified in the visualized bones. 

INTERPRETATION

The MRI findings are indeterminate (PI-RADS 3 for both the abnormal areas) however topographically concordant with the areas of disease demonstrated in the outside biopsy. There is no evidence of extracapsular disease or pelvic adenopathy. 

 

My husband has had Firmagon (240 mg + one 80mg shot) and his prostate has shrunk 40% and his PSA is down from 28 to 1.68 in 5 weeks.

I understand the MRI report to be very good, considering the values we had going into it but I'm confused. Shouldn't the PR-RADS score be higher if Glease was 4+5? 

I'm also not sure if "projection into the left bladder" confirms that there is definitely no growth in the bladder. 

If the MRI is correct (and I know the sensitivity is around 70%), then our greatest concern if he has RP would be pos surgical margins at the bladder neck.  It was the oncologist who gave us the report and he didn't seem to know much about it. 

 

I appreciate anyone's thoughts! Thank you. 

Swingshiftworker

MRSI?

Was a MRSI (magnetic resonance spectroscopic imaging) scan also done in connection w/the mpMRI?

If not, given the uncertainty associated w/the spread of the cancer at the bladder neck and base of the prostate, I suggest asking that another mpMRI with an MRSI be done to determine the exact extent of the spread of the cancer. 

An MRSI involves the injection of a contrast dye into the blood stream before the scan is done, which will highlight the presense of choline which is a marker for cancer.  I had this procedure done on me when there was worry that I may have experienced a recurrence, which the MRSI determined was NOT the case.

Here are a couple of links to articles on the use of an MRSI in conjection w/an mpMRI for the purpose of PCa disgnosis:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495493/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1578527/

The suggestion that the cancer has NOT spread beyond the prostate into the bladder is inconsistent w/the grading of the cancer as a Gleason 9 and the location of the "ill-defined" imaging . 

So, I would regard the need for an MRSI to pinpoint the location of the cancer as particularly urgent, since (as a GS 9) the cancer must be presumed to be highly aggressive; one that requires fairly prompt (if not urgent) treatment, which should be based on the best info possible about the location and extent of the cancer before anything is done.  Information that an MRSI should be able to provide.

Of course, you could let the surgeon blindly cut into your husband and explore to see the full extent of the spread of the cancer but I would regard this as a highly dangerous, speculative and perhaps unnecessary procedure, especially if it is shown in the MRSI that the cancer is actually still confined to the prostate; in which case, radiation  treatment (IMRT and maybe even CK) combined w/hormone treatment would still  be an appropriate course of action.  I also would not think that chemotherapy would be warranted unless the cancer has spread beyond the prostate and is no longer suitable for treatment by other means; info that the MRSI should also reveal.

Just a suggestion from someone who has never had to make the decisions that face you and your husband.  So, obviously take it all w/a grain of salt.  Whatever you decide, I hope you can obtain greater certainty regarding the status of the cancer before anything unreversible is done.

Best of luck!

 

Max Former Hodgkins Stage 3

Trump

A biopsy is more definitive than any MRI, or any other scan for that matter. With the substantial amount of "indeterminate" finding in the MRI , the logical thing to do is to make judgments based on the biopsies specifics.

A Gleason of 9 as a matter of convention assumes extravascular activity, and an earlier PSA of 28 is supportive of this view.  

I would be planning radiation therapy, and if were me, would not undergo surgery.

.

Swingshiftworker

Max Former Hodgkins Stage 3 said:

Trump

A biopsy is more definitive than any MRI, or any other scan for that matter. With the substantial amount of "indeterminate" finding in the MRI , the logical thing to do is to make judgments based on the biopsies specifics.

A Gleason of 9 as a matter of convention assumes extravascular activity, and an earlier PSA of 28 is supportive of this view.  

I would be planning radiation therapy, and if were me, would not undergo surgery.

.

"A biopsy is more definitive than any MRI or any other scan"

Do you really believe this Max?

It is commonly understood that a biopsy is inherently flawed because it will only reveal cancer from those places where the tissue is drawn which is random at best.  Hence, the possibilty of false negatives. 

A 3T multiparametric MRI combined w/a MRSI is far superior to any biopsy in this respect, as would a Choline C-11 PET scan, which is similiar to the MRSI, because it can scan the entire prostate and adjoining areas for any evidence of cancer which is far beyond what any biospy can do.

desperate for hope

Swingshiftworker said:

MRSI?

Was a MRSI (magnetic resonance spectroscopic imaging) scan also done in connection w/the mpMRI?

If not, given the uncertainty associated w/the spread of the cancer at the bladder neck and base of the prostate, I suggest asking that another mpMRI with an MRSI be done to determine the exact extent of the spread of the cancer. 

An MRSI involves the injection of a contrast dye into the blood stream before the scan is done, which will highlight the presense of choline which is a marker for cancer.  I had this procedure done on me when there was worry that I may have experienced a recurrence, which the MRSI determined was NOT the case.

Here are a couple of links to articles on the use of an MRSI in conjection w/an mpMRI for the purpose of PCa disgnosis:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495493/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1578527/

The suggestion that the cancer has NOT spread beyond the prostate into the bladder is inconsistent w/the grading of the cancer as a Gleason 9 and the location of the "ill-defined" imaging . 

So, I would regard the need for an MRSI to pinpoint the location of the cancer as particularly urgent, since (as a GS 9) the cancer must be presumed to be highly aggressive; one that requires fairly prompt (if not urgent) treatment, which should be based on the best info possible about the location and extent of the cancer before anything is done.  Information that an MRSI should be able to provide.

Of course, you could let the surgeon blindly cut into your husband and explore to see the full extent of the spread of the cancer but I would regard this as a highly dangerous, speculative and perhaps unnecessary procedure, especially if it is shown in the MRSI that the cancer is actually still confined to the prostate; in which case, radiation  treatment (IMRT and maybe even CK) combined w/hormone treatment would still  be an appropriate course of action.  I also would not think that chemotherapy would be warranted unless the cancer has spread beyond the prostate and is no longer suitable for treatment by other means; info that the MRSI should also reveal.

Just a suggestion from someone who has never had to make the decisions that face you and your husband.  So, obviously take it all w/a grain of salt.  Whatever you decide, I hope you can obtain greater certainty regarding the status of the cancer before anything unreversible is done.

Best of luck!

 

Gadolinium injected

Thanks for your response. The report says Gadolinium was injected. I think this is consistent with an MRSI. The used an endorectal coil. 

We haven't ruled out RT but keep getting conflicting messages. Two rad oncs told us surgery is the way to go. One well-known urologist told us that surgery was the better option because of the extent and aggressiveness of the cancer. 

If the mp MRI is correct about ECE, SVI and LN then ensuring there are no bladder neck margins would be critical for best outcome. There is almost no literature on this. I know the bladder is somewhat sensitive so I wanted if sufficient Gys of radiation could destroy it (without damaging the bladder) and at the same time I wonder if the cutting necessary in surgery would cause permanent incontinence. 

In the meantime, my husband is on Firmagon. 

 

desperate for hope

Max Former Hodgkins Stage 3 said:

Trump

A biopsy is more definitive than any MRI, or any other scan for that matter. With the substantial amount of "indeterminate" finding in the MRI , the logical thing to do is to make judgments based on the biopsies specifics.

A Gleason of 9 as a matter of convention assumes extravascular activity, and an earlier PSA of 28 is supportive of this view.  

I would be planning radiation therapy, and if were me, would not undergo surgery.

.

Extravascular activity

Thanks for your response Trump. I was prepared for far worse findings on the MRI. When you wrote "extravascular findings" were you referring to LNI, SVI, ECE? 

Max Former Hodgkins Stage 3

Swingshiftworker said:

"A biopsy is more definitive than any MRI or any other scan"

Do you really believe this Max?

It is commonly understood that a biopsy is inherently flawed because it will only reveal cancer from those places where the tissue is drawn which is random at best.  Hence, the possibilty of false negatives. 

A 3T multiparametric MRI combined w/a MRSI is far superior to any biopsy in this respect, as would a Choline C-11 PET scan, which is similiar to the MRSI, because it can scan the entire prostate and adjoining areas for any evidence of cancer which is far beyond what any biospy can do.

Yup

Believe it....

While a template biopsy or even more advanced techniques like Artemis guidance of a biopsy can and will miss things, that further supports the opinion that his cancer is likely beyond the gland, and that surgery is counter-indicated. A biopsy report as regards volumetric involvement and Gleason will only err toward underestimating severity of the disease, almost never the reverse. Actually, what I just wrote was your own point above.

You yourself know that nothing any scan shows proves any form of cancer being present, ever. The first doctor to read my first lymphoma CT in 2009 (after the radiologist, that is) was a surgeon who said, "This is lymphoma; it is everywhere. I cannot prove it until it is biopsied, but it is lymphoma."  Same situation.  Scans yield critical and insightful information, but never trump a biopsy.

In other words, whatever a biopsy says a patient has, he has at least that, if not something worse. A Gleason of 9 and a PSA of 28 virtually (but not absolutely) proves spread, and is an assumption nearly all doctors would at least initially proceed with, with or without any form of scanning.

VascodaGama

Are the biopsy results correct?

Desperate,

Welcome back to the forum. The results you share on the mpMRI confirm what we have been discussing in your previous threads. The MRI found abnormalities at the mid zone and base of prostate but nothing at the apex which is not totally consistent with the biopsy (all needles positive) and the cystoscopy results, but confirms your theory that cancer has developed in the center of the gland. 
The PI-RADS index system does not provide a clue on the aggressivity of the cancer (Gleason 9 diagnosed in your man's case) but it provides a prediction of cancer (sensitivity) existing along benign cells. The radiologist reports finding T2w isointense signal at those areas identified in the biopsy with a smaller area at the left base of T2 hypointense. However, when he correlates the results (biopsy and MRI) he disregards the hypointense signal at the base which could refer to an higher index number 4 or 5 (with the meaning that "cancer is likely to be present"). I guess that he found nothing at T1 weight intensity so that he cannot provide a true positive rate confirming the biopsy results.

PI-RADS 3 signifies that the presence of clinically significant cancer is equivocal. In short; a biopsy is required to confirm existing cancer, and you got already one confirming the diagnosis (do you have a copy of the biopsy?). The missing piece is a sample (biopsy) of that spot at the bladder neck found in the cystoscopy.

Though a mpMRI is superb in locating probabilities of cancer it cannot diagnose cancer. Max an Swing above explain on the matter. The biopsy can miss cancer (it draws only a fraction of tissue) and a MRI can detect overall abnormalities (including the areas not sampled) but the contrast agent cannot identify the substance focus on the image (calculi, BPH, cancer). Choline agents (C11 and F18) are better than Gadolinium with fewer limitations. The best exam to provide specificity is an image produced by a PET scan using a PSMA isotope like the Gallium 68, which together with a CT or MRI to provide the location (Ga68 PSMA PET/CT) and diagnose metastases.

Your confusion when comparing the results (biopsy and MRI) is understandable but the MRI (CT, cystoscopy, colonoscopy, etc) only provides probabilities of existing cancer and its location. The negative finding regarding the lymph nodes and local tissues does not include protuberances smaller than 0.7 cm, therefore questioning the comment "no evidence of extracapsular disease".  The contrast Gadolinium is good in identifying bone lesions which have been reported negative, confirming the previous bone scan results. This is good news.

I am not a doctor but my lay opinion based on the data you have provided here is that the whole gland is positive for cancer with high probabilities of existing localized metastases. I would classify your husband with a clinically advanced localized stage T3a. RT is better for these cases but the delicate bladder neck problem may require RP intervention (the missing piece). If a biopsy of the area confirms the MRI result I would chose RP as prime therapy.

I hope my post helps in answering your questions.

Best wishes,

VGama

desperate for hope

VascodaGama said:

Are the biopsy results correct?

Desperate,

Welcome back to the forum. The results you share on the mpMRI confirm what we have been discussing in your previous threads. The MRI found abnormalities at the mid zone and base of prostate but nothing at the apex which is not totally consistent with the biopsy (all needles positive) and the cystoscopy results, but confirms your theory that cancer has developed in the center of the gland. 
The PI-RADS index system does not provide a clue on the aggressivity of the cancer (Gleason 9 diagnosed in your man's case) but it provides a prediction of cancer (sensitivity) existing along benign cells. The radiologist reports finding T2w isointense signal at those areas identified in the biopsy with a smaller area at the left base of T2 hypointense. However, when he correlates the results (biopsy and MRI) he disregards the hypointense signal at the base which could refer to an higher index number 4 or 5 (with the meaning that "cancer is likely to be present"). I guess that he found nothing at T1 weight intensity so that he cannot provide a true positive rate confirming the biopsy results.

PI-RADS 3 signifies that the presence of clinically significant cancer is equivocal. In short; a biopsy is required to confirm existing cancer, and you got already one confirming the diagnosis (do you have a copy of the biopsy?). The missing piece is a sample (biopsy) of that spot at the bladder neck found in the cystoscopy.

Though a mpMRI is superb in locating probabilities of cancer it cannot diagnose cancer. Max an Swing above explain on the matter. The biopsy can miss cancer (it draws only a fraction of tissue) and a MRI can detect overall abnormalities (including the areas not sampled) but the contrast agent cannot identify the substance focus on the image (calculi, BPH, cancer). Choline agents (C11 and F18) are better than Gadolinium with fewer limitations. The best exam to provide specificity is an image produced by a PET scan using a PSMA isotope like the Gallium 68, which together with a CT or MRI to provide the location (Ga68 PSMA PET/CT) and diagnose metastases.

Your confusion when comparing the results (biopsy and MRI) is understandable but the MRI (CT, cystoscopy, colonoscopy, etc) only provides probabilities of existing cancer and its location. The negative finding regarding the lymph nodes and local tissues does not include protuberances smaller than 0.7 cm, therefore questioning the comment "no evidence of extracapsular disease".  The contrast Gadolinium is good in identifying bone lesions which have been reported negative, confirming the previous bone scan results. This is good news.

I am not a doctor but my lay opinion based on the data you have provided here is that the whole gland is positive for cancer with high probabilities of existing localized metastases. I would classify your husband with a clinically advanced localized stage T3a. RT is better for these cases but the delicate bladder neck problem may require RP intervention (the missing piece). If a biopsy of the area confirms the MRI result I would chose RP as prime therapy.

I hope my post helps in answering your questions.

Best wishes,

VGama

Thanks VG and Swing

Thanks to both. I understand now. 

I specifically asked the doctor if a PSMA PET Scan might be helpful and he replied with a definitive "no". Did he really mean "no" or did he mean we don't posess that technology? I live in a backward country. We are years behind other developed countries. Just getting an MRI (unless of course you have connections) is a major ordeal, even when you are Gleason 9. 

I'm exhausted and I realize it doesn't matter how much research I do or what questions I ask. It's hopeless. The bloody screening guidelines will kill my husband.