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3T MRI Needed to determine best treament options

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Posted 7/24/2013 1:06 AM (GMT 0)
Hello,

I have the stats listed below and wanted to know if I should request a 3T MRI to possibly see where the tumors reside on the gland?

What is involved with this procedure and does it give you much more info to determine best treatment plan.  Also where can they perform this and will most insurance plans cover it?

I have had a bone scan which was negative

Thanks

Posted 7/24/2013 1:17 AM (GMT 0)
Kdeinv,
..T3 should of been done before biopsy. Makes for a cleaner image and then they could target any suspected nodes. If you are going to get a T3 after biopsy, you must let the prostrate heal a bit usually six weeks. Just my experience with this PAc stuff. My info does not qualify as medical professional..

..Appleseed.....
Posted 7/24/2013 1:59 AM (GMT 0)
Nope, no debate
+5 of 12...

My advice: Get it OUT!!!
Posted 7/24/2013 2:32 AM (GMT 0)
The value of MRI for prostate is controversial. Dr. Walsh wrote in his book that they have proven unreliable ("I have seen too many patients who have been told that the tumor extended outside the prostate on the left when, in fact there turned out to be relatively little tumor on the left or the major tumor extended outside the prostate on the right.")

I talked to several surgeons and got different opinions.

My local urologist said he has been ordering them for a while, done by a specific radiologist who knows what he is doing, and has found them useful for planning the surgery. However my surgeon at Hopkins did not seem very sold on the value.

I decided to go ahead and have it done as another data point with the intention to take the results with a grain of salt unless they suggested something alarming (e.g. ECE, in which case I might have rethought bi-lateral nerve sparing). I had a 1.5T with endorectal coil and contrast. It turned out to be pretty accurate in showing the tumor location, extent and grade.
Posted 7/24/2013 2:40 AM (GMT 0)
With a confirmed G6 on a second pathology reading by an expert like Bostwich there is no need for an MRI, especially if you are set on surgery. Tumors in the apex, near the margin or involving the nerves can be identified on a 3 T MRI, and would be better served by radiation. A color Doppler ultrasound will do the same thing at half the price. You have to be willing to change your treatment option based on the image results, but with a G6 it most likely won't matter as these are rarely life threatening.
Posted 7/24/2013 6:31 AM (GMT 0)
I agree with John T -- if you know you want to get the gland out of your body, what use is an MRI at this point? The surgeon will see what's in there when he cuts in, and he will decide then whether he can safely spare the nerves. If it revealed extracapsular extension or other invasion, you'd have to be willing to have radiation for it to make a difference.
Posted 7/24/2013 10:50 AM (GMT 0)
Kdienv, I agree with JT and Allen, i.e. further testing is really only useful if you are open to exploring treatment options. Personally, I think you should and I would go with Color Doppler. Non of us are surprised that your bone scan was negative...with your Gleason and PSA many doctors feel that is an unnecessary test and would not have ordered it.

Jim
Posted 7/24/2013 12:06 PM (GMT 0)
Kdeinv,

My sequence was:

--rising psa and dre+ at annual physical in home city

--because work away from home, followed up with an internist in work city; he said an mri might be useful in this situation; it showed "prostate lesion which affects contour of prostate; 11mm nodule of decreased T2 signal, restricted diffusion, as well as abnormality of permeability and extravascular extracellular space; requires attention at biopsy to exclude neoplasm". Sorry don't know the xT of mri, but there was no rectal coil. Cost me about $600 out of pocket on good insurance, but it was early in year (meeting deductibles), so don't go by my costs. Internist referred me on to urologist.

--------

edited to add this "funny but true incident" about when the internist first called me with the mri results:

internist, reading and interpreting off the mri report:  "looks like you have a tumor the size of a golf ball..."

me:  What???!!!

pause about 10 secs

internist:  "oh, wait, sorry, that's the size of the prostate...the lump on the mri is about 11mm ..etc etc"

it didn't take too long to clean up my car seat when I got home; leather is better than cloth upholstry..."

------------


--saw the urologist in work city; she thought I was overwrought and made a comment about probably had nothing and the use of mri for my case was "akin to malpractice"--or words to that effect; she did biopsy following week, then, surprise, surprise, see my stats and she apologized twice for not taking me seriously.

--had RALP in home city, different uro, obviously; funny thing, it was T2C, capsule contained, no sign of EPE, but there was a large thrombosed vein adjoining prostate which he removed gratis; the guess is that was the bulge on mri and deceptive

If I were you, I would go for treatment of some kind. But with your stats, you have enough time to work on your health, fitness, and kegels, before treatment, which will help recovery a lot.

I know this is scary. You will be ok.

Robert

Posted 7/24/2013 12:32 PM (GMT 0)
Thanks

I asked my Dr to order the bone scan because my back had been hurting over the last few years and wanted to rule out anything.

Thanks

 

Posted 7/24/2013 4:52 PM (GMT 0)
FYI

The subject of "inappropriate imaging" has gained a lot of traction with the focus on out-of-control medical costs.

In this analysis of the Medicare database, they found that 45% of men diagnosed with PCa had received inappropriate imaging. "Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate."

In Sweden they tried to reduce inappropriate imaging by making such use public -- sort of shaming the doctors who prescribed it. They got the level down from 45% to 3% over 10 years.

Prostate Cancer Imaging Trends After a Nationwide Effort to Discourage Inappropriate Prostate Cancer Imaging
Posted 7/24/2013 5:31 PM (GMT 0)
I think in kdeinv's case a bone scan was probably not appropriate not just from a cost perspective but an unnecessary dose perspective.

MRI, however, involves no ionizing radiation and may provide a helpful data point on location, extent and grade (and to my knowledge color dopler US cannot provide an indication of tumor grade like is available from diffusion-weighted MR) for his decision making.

I don't think individuals who have been faithfully paying their insurance premiums should be guilted into forgoing a diagnostic procedure that their insurance determines to be covered.
Posted 7/24/2013 11:45 PM (GMT 0)
Some facts about prostate MRI

It is still evolving and getting better.
It is not sensitive for detection of extraprostatic extension because it does not detect 3mm or less invasion well when compared to the pathology specimen. However, if the MRI scan is positive for extraprostatic invasion, the accuracy is high.
It is being used with success to identify prostate cancer in men with an initial negative biopsy and persistent clinical suspicion.
It is being studied in AS in order to identify men with larger tumors than were suspected from standard 12 core biopsy results.
Although not common, a prostate may still harbor a clinically significant cancer even if the MRI is negative.
Posted 7/24/2013 11:58 PM (GMT 0)
A study using 1.5T at MSK found that "for low-risk patients, the incremental value of MRI in the decision to change the surgical approach is minimal."(p.2660)

The Role of Preoperative Endorectal Magnetic Resonance Imaging in the Decision Regarding Whether to Preserve or Resect Neurovascular Bundles during Radical Retropubic Prostatectomy

In the following study of 67 patients, they tried to find out if 3T mpMRI could detect extracapsular extension (ECE) before a prostatectomy. It was pretty poor at doing that, with a sensitivity of just 60% (lots of false negatives). But when it did find ECE, it was usually found to be true by later pathology with a specificity of 86% (few false positives).

Efficacy of using three-tesla magnetic resonance imaging diagnosis of capsule invasion for decision-making about neurovascular bundle preservation in robotic-assisted radical prostatectomy.

In the following retrospective study of 385 patients using 1.5T, they found pretty much the same thing -- sensitivity only 42%, but specificity of 92%, with the sensitivity being even lower in the low risk group. They conclude "Preoperative eMRI in patients with low-risk criteria is not recommended as a routine assessment modality."

Accuracy of preoperative endorectal MRI in predicting extracapsular extension and influence on neurovascular bundle sparing in radical prostatectomy.

Similarly, this study decried the low sensitivity and found that the positive margin rate increased as a result: "The usefulness of endorectal MRI in detecting ECE is limited. Patients with eMRIs suggesting no ECE demonstrated a trend towards more aggressive NVB sparing and an increased positive surgical margin rate at laparoscopic prostatectomy."

Impact of preoperative endorectal MRI stage classification on neurovascular bundle sparing aggressiveness and the radical prostatectomy positive margin rate.

Interobserver variation in reading these MRIs is very high, with experienced readers able to see things that less experienced radiologists cannot. Similar to CDUS in that respect. In expert hands, CDUS can "see" cancers about half the size of 3T eMRIs.

The best argument I've seen for pre-surgery MRI is for its use with robotic surgery. Because the surgeon is unable to touch the prostate to feel where the cancer is ("haptic feedback"), the authors of the following review think that as the technology evolves, it may be able to fill in some of the information lost without haptic feedback:

Radical prostatectomy: value of prostate MRI in surgical planning.

- Allen
Posted 7/25/2013 11:49 AM (GMT 0)
Allen, thanks! Helpful as always.

I've had some reservations about my 3T MRI, as it was saying there is evidence of bulging ECE and neurovascular bundle involvement bilaterally. Some question the use of MRIs, so I thought, "Gee maybe it's not really there". But, we're treating as if it is due to other corroborating factors from the biopsy too. My urologist said at the time if we did surgery we couldn't do the luxury things like nerve-sparing. From what he saw on MRI he would have to do a "wide excision", with pretty significant side-effect impact.

To see the stats about MRIs supporting their accuracy in positive findings is helpful, since it further supports the rationale for my treatment plan. It seemed all the arrows pointed the same direction for my cancer's staging.

Of course, it would actually be better if there was *not* ECE....
Posted 7/25/2013 1:06 PM (GMT 0)
Allen,

This explains why my husband's EPE (ECE) was not detected on the MRI that he had done prior to surgery, something that I have wondered about. His surgeon realized he had ECE during the surgery though, and his final pathology showed negative margins.
Posted 7/25/2013 5:05 PM (GMT 0)
Thanks for everyones comments.

I had a colonoscopy today at age 49.  I decided to get one prior to starting any prostate cancer treatment plan.  It came back negative and so I am good for 10 years on that front.

My urologist was not going to order a bone scan as he felt it was not necessary but I pushed for it to calm my nerves about back pain I had been experiencing.

I have scheudled to consult with 2 robotic surgeons.  One in Atlanta Ga (Dr. Nikhil Shah) and one at Vanderbilt (Dr, Joseph Smith).  I may go to Birmingham and get a consult with Dr. Scott Tully's group.

I have several pages of questions for each surgeon as I try to narrow down  who I will select to perfom my robotic surgery.

One question will about a 3t MRI's usefulness in performing such an operation using a robot.  The other is do they do an initial biopsy while the patient is under to determine the margins.  (I would think this would be important before the surgery is wrapped up so that additional tissue can be removed and/or lymph nodes).  Also the number of robotic procedures that have been performed and the results (Cancer control, Incontinence, Impotence, and positive margin rates)

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