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Tests for spread

Rob.Ski
Posts: 35
Joined: Feb 2021

What tests are performed to determine if cancer has left the prostate?  Is it PET scan?   Would that be done if Gleason is 6?

Old Salt
Posts: 806
Joined: Aug 2014

First some general info from the NCI website; scroll down to Stages of Prostate Cancer

Prostate Cancer Treatment (PDQ®)–Patient Version - National Cancer Institute

 Here is some info copied from the Cancer Treatment Centers website:

Positron emission tomography/computed tomography (PET/CT) scan: A PET (positron emission tomography)/CT scan is an advanced nuclear imaging technique that combines CT scan technology with positron emission tomography into one machine. A PET/CT scan shows both the structure and function of cells and tissues in the body during a single imaging session. In the case of prostate cancer, this scan provides a more comprehensive view of the pelvis to determine the presence of abnormal activity, even before a tumor may have developed.

Whether your physician will prescribe this test remains to be seen because of your Gleason 6 status. Insurance coverage may also be an issue.

VascodaGama's picture
VascodaGama
Posts: 3368
Joined: Nov 2010

In my opinion all existing image tests have limitations in identifying localized prostate cancer or its spread. CT and MRI detect deformations (tumor volumes) taking pictures in sectional series pitched at 0.9cm and 0.4cm (CT and MRI respectively), therefore limited in identifying smaller deformations (tumors). Any tumor located between these sectional pictures would not be identified providing a false negative. CT is worse than MRI. 

The nuclear imaging with BS or PET identifies malignancy at cellular level (microscopic) but depend on the radiopharmaceuticals (tracers) capabilities in being absorbed (metabolic) by the cells targeted in the exam (bone or prostatic respectively). Apart from above capabilities, the tracer should be fully active by the timing when the picture is taken, before being excreted. This timing is crucial as too early or too late could lead to false negatives. 

The choice in radiopharmaceuticals varies but the most common aim in attaching to the most active tissues therefore using loads of glucose (energy). For instance the FDG. The typical BS uses the radioisotope Tc99m that aims/accumulates at bone lesions with  chemical changes.

In PET scans for PCa the tracer aims the particulars of the cells where the PSMA (prostate specific membrane antigen) is thought to be the most practical. However, this antigen is also active in some other type of cells (eg; saliva, etc) requiring professional reasoning to distinguish which tissues may relate to PCa.

PET scans are specific but require the 3-D capabilities of CT or MRI to provide accurate location of what has been detected by the PET machine.  Surely a PET/MRI combination will be more accurate than the PET/CT, but in treatment the difference wouldn't matter much. 

Accordingly, micrometastases spread is difficult for being detected in CT or MRI but PET scans also depend on the type of the tracer, on the timing of the picture section, on the level of activity of cells and judgement/experience of the radiologist. These apply independently of the Gleason grade of the cancerous cells. Multiparametric analyzes are the best in defining imaging study results and only a biopsy certifies cancer.

Best 

VGama 

Georges Calvez
Posts: 531
Joined: Sep 2018

Hi there,

In your case, detectable spread is so unlikely as to be discounted.
Your biopsy results are all grade 3 and there is not a great deal of it, so the chance of a detectable spot outside the prostate is vanishingly small.
I doubt you would get a doctor to authorise a scan on a publicly funded system or get an insurance company to cough up for a scan.
Maybe if you took your credit card down to a private facility they would indulge you.

Best wishes,

Georges

Rob.Ski
Posts: 35
Joined: Feb 2021

So gleason is the main indicator for escape of the prostate?  

My second biopsy was:

(RP) 100%, 70% 3+3

(RA) 30%, 10% 3+3

(LL) suspicious for low grade adenocarcinoma

(LA) 20%, 3+3

MRI did not show anything

Clevelandguy
Posts: 691
Joined: Jun 2015

Hi,

Not at all, its more where the cancer is located within your Prostate.  3+3,3+4,4+3,ect if all within the walls of the Prostate can be treated successfully.  The sooner you catch and locate the better, let any cancer escape, thats where it gets dicey.

Dave 3+4

hopeful and opt...
Posts: 2328
Joined: Apr 2009

Currently MRIs use a 1.5 or a 3.0 magnet. The 3.0 provides better definition. The MRI may show extra capsular extension. I wonder which MRI you had. 

Studies have shown that Gleason 6 will not leave the prostate. The concern is that when there is a lot of Gleason 6, a Gleason 4 may exist. The Gleason 4 can leave the prostate. 

I agree with Georges comment, the chance of extra capsular extension is low, and I doubt that a doctor would authorize   an advanced image test. 

Rob.Ski
Posts: 35
Joined: Feb 2021

Dave, 

Trying to understand how they know where it is besides removing it and doing the follow up biopsy on whole gland.   So, I'm gleason 6 with high volume in on one location.  Is there another test to better determine if its contained?  

Latest MRI results below:

TECHNIQUE:
Imaging at 3 Tesla.
Coil: Body coil
Sequences: Dedicated small field of view prostate imaging was performed. Additional large field images were also submitted.
Post-processing: Additional post-processing of MRI data was performed on a separate DynaCAD workstation, to include volumetric segmentation of the prostate (DCAD Prostate Boundary).

FINDINGS:

IMAGE QUALITY: Suboptimal secondary to motion artifact on multiple sequences and small amount of rectal gas, which somewhat limits exam. Additionally, it appears that several images are missing including 2 axial T2 slices through the mid to lower
prostate (series 12, image 16 and 17, for example are missing). Within these limitations:

HEMORRHAGE:
No areas of high T1 signal suggesting hemorrhage.

PROSTATE VOLUME:
Prostate measures: 4.6 cm TV x 3.6 cm AP x 4.5 cm CC, volume 39 cc.

Prostate volume calculated in DynaCAD Prostate Boundary segmentation: 40 cc.

PERIPHERAL ZONE:
Linear T2 hypointensity without restricted diffusion or asymmetric perfusion, which can be seen with prostatitis. No definite superimposed suspicious abnormality within the limitations detailed above.

TRANSITION ZONE:
Mild hypertrophy with heterogeneous T2-signal.
No focal areas with suspicious morphology.

SEMINAL VESICLES: Normal, symmetric.

NEUROVASCULAR BUNDLES: Normal, symmetric.

BLADDER NECK: Minimally distorted by adjacent median lobe hypertrophy. There is mild diffuse urinary bladder wall thickening and trabeculation, which can be seen in the setting of chronic outlet obstruction.

MEMBRANOUS URETHRA: Normal. Prominence of the prostatic urethra with diffuse early enhancement suggesting ureteritis.

LYMPH NODES: None enlarged.

BONE MARROW: Normal signal intensity.

OTHER: Tiny fat-containing left inguinal hernia.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3659
Joined: May 2012

Rob,

The guy's above have all given good insight.  A few, like Vasco, gave a wonderful technical overview.   I think everything said distills down to two main observations:

1.  Scanning, even the best scans, are of limited value in detecting PCa, and miss it as often as they detect it.  The exception to this is if it is widespread and significant, and in that case, it is too widespread to hope for a cure anyway, and you are looking at a future of hormonal therapies;

2.  It is correct that most insurance coverages will not pay for a PET scan, based on your current numbers.  I doubt Medicare would either.  Most urologists would not recommed scans anyway.

 

max

Rob.Ski
Posts: 35
Joined: Feb 2021

Ok, then Clevelandguys comment makes no sense to me.  How would I know where the cancer is within the prostate without taking it out? 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3659
Joined: May 2012

Rob,

First of all, not everything in medical science makes sense; much of it does not.  Related to this, there are many desirable-to-know clinical things that doctors do not know.  I currently have an extremely rare autoimmune condition that was detected in the monitoring of my former lymphoma.   The condition is almost totally not understood, no cause is known, and there are no treatments.   

A matrix biopsy is the best and most accurate indicator of where the tumors are.   Other biopsy results, such as whether there is perineural involvement or positive margins, are also of high value.   But you nailed it:  the ULTIMATE way to know what is where in the gland is a pathology analysis in a removed gland; nothing else comes close.   I do not 'recommend' RP, or anything else, just sharing factual observations.    If you are highly anxious over this question, then given your very minor specifics, either RP or RT would likely cure your disease, the same as it would likely cure any other man with your specific results

Clevelandguy
Posts: 691
Joined: Jun 2015

Hi Rob,

Try a PET scan and see if that picks it up, see Vasco's comments above.  3+3 is not agressive but it still is cancer so in my humble opinion you need to know where it is inside your Prostate.  There are cases reported on this forum where 3 grade has later turned into a 4 grade. Repeated biopsies should let you know when it turns into a 4 If it ever does that. If nothing shows up on the PET scan then the only thing you can do is monitor via biopsy.  Just trying to help you step through this process so you have all the info at hand to help you make decisions on your Prostate cancer.

Dave 3+4

Rob.Ski
Posts: 35
Joined: Feb 2021

Guess that gets me back to my original post.  PET scan.  Might be best option but, doctors and insurance might not agree.  Going to get second opinion on SBRT as primary treatment tomorrow, see what they have to say.

 

Thanks to everybody for the replies.

Clevelandguy
Posts: 691
Joined: Jun 2015

Hi,

SBRT is a good way to go, people have had lots of success with treatments like Cyberknife..

Dave 3+4

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3659
Joined: May 2012

Yes, Cyberknife (identical to another brand of machine, known as 'Varian TrueBeam') has very high success rates, and the fewest side-effects of all curative modalities.

hopeful and opt...
Posts: 2328
Joined: Apr 2009

A T3 mri can show suspicious lesions within the prostate and rank them by the likelihood of being a significant cancer, 3+4 or above. The scale that measures this is called pirad. The scale goes from 1to 5, 5 being most likely. Pirad was not included in your report. The mri can show if it in one lobe or two, and where within the prostate.

A gallium contrast can be used for more accuracy. it does not look like a contrast was administered.

Additionally there was a problem in doing your mri since you were not completely prepared. 

Also several images were missing from your mri  

Basically in my layman's opinion your mri left a lot to be desired

 

Rob.Ski
Posts: 35
Joined: Feb 2021

My MRI was with and without contrast.   I'm not sure how I wasn't completely prepared?  Followed all instructions for fasting and enima.  I noticed the report saying some pics were missing but, my doctor doing the biopsy that requested the MRI didn't mention it.

Clevelandguy
Posts: 691
Joined: Jun 2015

Hi,

So you had two MRI's, one with contrast and one without?  I would think the contrast die should have picked up some of the cancer.

Dave 3+4

Rob.Ski
Posts: 35
Joined: Feb 2021

It was an MRI with and without contrast.  They did some scans then, injected the contrast die and did some more scans.  This is how my first MRI a year ago was done also.  The surgeon at Hopkins that did my biopsy said MRI was clean.

Rob.Ski
Posts: 35
Joined: Feb 2021

Cyberknife doc recommends surgery or AS for me being 50 with potential 30 years ahead.  Said recurrence after radiation over a 30 year period could be 20% and options after radiation not great.  Of course he is recommending surgery with the best surgeons in the area, they all are not equal for outcomes.   This is the 2nd RO that has recommended this as well as every surgeon I've talked to.

1945's picture
1945
Posts: 2
Joined: Jun 2021

New PSA test shows 52.46 as new result. So afraid cancer has spread. Anyone with this high number after radiation & seed implant? Had prostate cancer diagnosis in 2011 & last test results until now was in 2019 with a score of 19. Help would be appreciate.

Old Salt
Posts: 806
Joined: Aug 2014

Please start a new thread.

In the meantime, it looks like immediate action (within a month or so) is required. In fact, if the 2019 PSA value of 19 is to be trusted, action should have been taken at that point. But that's water over the dam. Most important now, it seems to me, is to see whether the cancer has spread beyond the prostate. An appropriate scan should give important info on that issue.

VascodaGama's picture
VascodaGama
Posts: 3368
Joined: Nov 2010

You will find in this board many eager to help you but you need to provide more details on the cronology of events/occurrences along the ten years since diagnosis, PSA histology and present situation symptoms. I would start by repeating the test to certify the result.

You may want to create your own thread to appeal for more answers. 

Best wishes for luck in your journey. 

VG

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