Difference between mpMRI and Biopsy reports

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!

 

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. 

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 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.