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Value of having an MRI before a biopsy

hopeful and opt...
Posts: 2224
Joined: Apr 2009

Study: MRI can rule out clinically significant disease (video)
https://www.youtube.com/watch?v=t6_OH9VQWTg&feature=youtu.be

VascodaGama's picture
VascodaGama
Posts: 3013
Joined: Nov 2010

 This is a very interesting speech about the MRI in PCa diagnosis. Mark Emberton emphasizes the importance of MRI imaging and its benefits as an essential tool in the initial diagnosis, providing evident data from trials on real cases, and compares the results. However in his speech he does not subject those image benefits to a comparison of MRI against other means for obtaining the image study, which in my opinion should be the principal theme of his conference. I agree that target biopsy (image plus needle) is the most trustful way to diagnose PCa. A blind biopsy can miss cancer but so it can any form of image exam including the MRI. These two tools together provide a more reliable conclusion than one of them alone. But, would TRUS be sufficient to identify cancer when this is located in the prostate? Maybe YES.

At the beginning of the speech he introduces a case of a patient with a protuberance/lesion (0.3cc) identified on an MRI which he categorically classifies it being cancer but continues by saying that the spot is to be biopsied at the precise location (in millimeters) identified by the scan. I wonder why he doesn’t imply that the biopsy is not necessary for this case study when this conference looks for means to avoid unneeded biopsies.

I like his speech when addressing the newer techniques involving PCa3 and Phi system. In his words the MRI is better in the diagnosis of clinically significant cancer, which he refers being high Gleason patterns of 4 and 5. He totally disregards cases of lower Gleason patterns ‘1, 2 and 3 or cases of micrometastases of all Gleasons, maybe because of the lack of data on these cases, for the false negatives provided in traditional machines. Overall it is a good video demonstrating the highly benefit of guided biopsy against templates (blinded) approaches, even if these are of 12 or 14 needles instead of the traditional sextant. In my opinion the MRI is a very important exam in all cases no matter if it is used to help in the diagnosis process before or after a biopsy.

Thanks Ira for the link.

Best wishes for a good New Year and the many Ukulele parties.

VGama

kainasar
Posts: 12
Joined: Aug 2017

I am seeing this post from 2016 and want to put out concerns about having this test done. I have recurrent PCa (3+4-7) after IMRT in 2012 and PSA continues to increase from .2 in 2013 to 5.2 this month, abt .7 slope.

After an initial MRI in 2012, then in 2014, and an MRI TRUS biopsy a year ago, no indication of worsening malignency has been found - indeed pathologist reports typical radiated cancer cells of the

organi confined disease. Basic bone scan a year ago, and Axumin scan in August show nothing also. Going for a secont opinion, expert says he wants to do another MRI (with advanced tech,etc.) and then

biopsy as needed. Seems Auximin would show everything except what a Gallium PSMA type test would show. Thinking maybe I need to seek another opinion of the results I have before risking infection and

bleeding. From what I have read, as from your analysis and studies, the MRI has limits in showing alot, but is good as showing odd shapes and sizes.

-k

hopeful and opt...
Posts: 2224
Joined: Apr 2009

The MRI has and is continuing to revolutionize  diagnostic abilities for prostate cancer. Hopefully this technology along with three dimensional biopsy machines will be made available to all urologists. 

Additionally MRI's can be used to confirm if extra capsular extension exists, which is critical to treatment decisions. (Of course other imaging tests such as a PET scan can be used in conjunction)

As  more powerful magnets are used in  MRI machines, directed treatments such as HIFU will become the prefered treatments for localized cancers, with microscopic lessions being detected.

 Best wishes to you as well for a happy and HEALTHY new year. ......Enjoy the fruits from your labors.

H & O

 

VascodaGama's picture
VascodaGama
Posts: 3013
Joined: Nov 2010

Kainasar,

I did not managed in finding your story (past posts) so that I cannot provide you an opinion on your situation but your experience with image exams seems to be fair. An important fact in those exams is the experience of the radiologist in interpreting the images and then in writing their reports. Many do not have access to the full status of te patient which makes their reports less impressive for the patient. Typically they comment:

"... THE REPORT BELOW HAS BEEN PRODUCED BY THE NUCLEAR MEDICINE PHYSICIAN TO COMMUNICATE IN MEDICAL LANGUAGE THE DETAILS OF YOUR FINDINGS TO YOUR DOCTOR. THE RESULTS ARE IMPORTANT, BUT ONLY A PART OF YOUR COMPLETE CLINICAL PICTURE."

The urologist will then judge the case and sometimes miss the meaning of the reports.

Can you provide us details of your case?

Best wishes,

VG

 

kainasar
Posts: 12
Joined: Aug 2017

Thanks for your interest. I suppose I could somehow attach the reports from the MRIs and scans, as well as the parhologists. Would that help?

-k

 

VascodaGama's picture
VascodaGama
Posts: 3013
Joined: Nov 2010

Can you also tell us some more details on your pre treatment status (other health issues, symptoms, tests, etc).

Why is the doctor insisting on additional biopsy? Is it to try locating the cancer or to rule out PCa in the presence of increasing PSA?

Best wishes,

VG

VascodaGama's picture
VascodaGama
Posts: 3013
Joined: Nov 2010

Kainasar,

I received your mail but will comment here my thoughts as many reading your inquire, in similar situation, may provide ideas or even benefit in knowing your experiences and our exchanged opinions. You mail me the following;

" Thanks for taking the time to advise. What details should I forward? IMRT was focused beam at about 75g. SE have been radiation proctitis. First and 2nd MRI used coil with high contrast and no lymph node abnormalities revealed. 3rd was MRI guided biopsy = negative. Bone scan was 26.6 mCi Tc-99m MDP. The PSA rise since 2012 has been abt .1 a month until July, as described previously. My guess next step is what to do with organ confined radiated  cells making psa."

" Me - IMRT in 2012. Gleason 3 + 4, PSA at time of radiotherapy 7.4. After IMRT 2012 PSA was 0.2. Climbed since then at abt a .7 PSADT Slope until June 2017 when PSA jumped from 4.0 to 5.6 this Sept. The MRI's, CTscan, PETscan bonescan , and Auximin Petscan have been negative. Before surge in psadt medical onc said to stay with active surv. After surge he said to go to rad onc docs or urologic surgeons, as Auxumon Pet indicated organ confined only."

 

My thoughts are bellow but please note that

 I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.”

From the info you shared above with the increasing PSA, I take your present situation as recurrence. However, nobody can say for sure that the recurrence is from a failed IMRT. The image exams you describe above all are suggestive of “organ confined” leading to think that the cancer in the gland was not totally eradicated. That justifies your doctor for trying to discover the hidden bandit with a guided biopsy (that was negative).

In any case, it seems to me that he is giving preferences to the results of the image studies without focusing on the possibility of existing extracapsular extensions. I wonder why? Is he suspicious of the RT?

In fact, the 75Gy seems to be in the lower limit dose practiced in present days in RT prime treatments. Lower doses are used in SRT protocols.

Do you have any information on the radiation protocol? What was the field of attack? Did it cover the whole prostate or was it partially limited (for instance; radiation of one lobe alone, etc). Typically RT is done to cover the whole gland including the seminal vesicles which coverage is done with a typical total dose of 78Gy. When the planning includes lymph nodes extensible the Gy is higher and can reach 80 Gy. In some cases when the patient has ulcerative colitis or cancer close to the urinary sphincter (at the base) radiation is lowered or even avoided in certain areas. Many radiologists also prefer to avoid radiating lymphatic zones to avoid cases of lymphedema.

In regards to the above you could inquire with the radiologist about any possibility for missed coverage. I also think that instead of additional biopsy (as suggested by your urologist) you could look for a PSMA scan (68Ga PSMA PET/CT exam), which may be a better choice to locate the hidden cancer in soft tissues and bone.
From there you can then decide in going through a therapy aiming cure with spot SRT (if practical) or a palliative to control the bandit with hormonal treatment (HT), or the combination of chemo plus HT.

The problem with failed initial radicals (surgery or radiotherapy) is that the patient may be systemic with micrometastases difficult for being detected. In such status one should consider the quality of living when opting for an intervention. The age of the patient and other health issues are at play too. What’s your age? Do you have any other health issue?

Best wishes.

VGama

 

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