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mpMRI and guided biopsy or mpMRI and TRUS biopsy

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Prostate Cancer
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Posted 7/28/2014 11:42 PM (GMT 0)
I’ve decided to have a mpMRI, but I have 2 choices as to location. VCU in Richmond, VA is within driving distance at 4 hours each way. I talked with the chief radiologist today, Dr Yu, who explained that he will read the MRI immediately and let me know if I need a biopsy the next day. If not needed I can return home the same day if I choose. If needed, I will stay overnight; take some antibiotics and probably an enema. For the biopsy I will have another MRI the next day and the mpMRI suspicious images from the previous day will be brought up on a separate screen and viewed together to enable Dr Yu to perform a guided biopsy.
At Wake Forest in Winston Salem, NC, close to home, I can have a similar mpMRI but the results will be sent to my urologist who will recommend the next step, presumably a TRUS biopsy. My urologist is on vacation this week but I spoke with his nurse who thought he might not like the idea of VCU doing the biopsy; he prefers to do them himself.
I favor the VCU approach, even though it means driving 8 hours and maybe staying overnight if a biopsy is necessary. I think the accuracy of the biopsy will definitely be better. Your comments will be very welcome.
Posted 7/29/2014 2:00 AM (GMT 0)
In my opinion, the MRI to locate suspicious nodules..if any, then a MRI Guided biopsy to target any suspect area is the way to go.
The random 12 cores in a usual biopsy will eventually be fazed out due to its hit and miss results. Yes, it's more expensive but it's the future!
Just my two cents worth!
Posted 7/29/2014 3:05 AM (GMT 0)
I know I'm a newbie here but here are some other things that might impact your decision:

--strength of magnet (1.5 vs 3.0);
--skill and experience of person reading MRI results;
--who is the pathologist who will be examining the biopsy samples (prostate or GU pathologist?);

All things being equal, if you think the accuracy of the VU biopsy will be better, then that's the way to go.

Good luck!
Posted 7/29/2014 4:27 AM (GMT 0)
hrpufnstuf-

I'm confused. I thought you had decided to have proton therapy. What's the mpMRI for?

- Allen
Posted 7/29/2014 11:39 AM (GMT 0)

Tall Allen said...
hrpufnstuf-

I'm confused. I thought you had decided to have proton therapy. What's the mpMRI for?

- Allen

My proton therapy is scheduled for January 5, 2015. That will be roughly 7 months from my positive biopsy. With my Gleason 6, almost all opinions about waiting that long for treatment were positive. Many suggested AS. My extensive reading however suggests that the likelihood of additional cancers being present is about 30%. Plus, the 1mm positive cancer found may be part of a larger tumor which is in the vicinity of a seminal vesicle. Although he didn't recommend it, my urologist thinks it might be a good to have the mpMRI if I want to delay treatment until January just to see how much cancer is near the SV. Lastly, and I don't know why the radiation folks don't recommend this before treatment, numerous studies have shown the benefit of ADT for radiation patients with intermediate and high risk PC, yet they accept the biopsy Gleason (usually with 2 opinions) to determine pre and post treatment. The surgery patients have the benefit of a post surgical biopsy to see if additional treatment may be necessary. If I go down to UFPTI with my Gleason 6 and 1mm tumor there will be no discussion of ADT. If the mpMRI finds additional cancer with Gleason 4+3 or higher I'm pretty sure HT will be offered. If I find anything worse than what I know today I will reschedule treatment for late September.

Post Edited (hrpufnstuf) : 7/29/2014 5:42:56 AM (GMT-6)

Posted 7/29/2014 4:01 PM (GMT 0)
It's because when there is an upgrading, it's very rarely more than one notch higher. So GS 3+3s may get upgraded to GS 3+4s, but very rarely beyond that (to 4+3, etc.). I would expect the 30% upgrade average is much lower when the slides have been read by Bostwick or Epstein. There has never been a study that has shown a benefit to ADT for either 3+3 or 3+4, but it does increase the SEs of treatment. This is especially true of insignificant amounts of cancer like yours. The danger is much more overtreatment than undertreatment.

You should be aware too that mpMRIs are good, but not as good as you may believe. They are not very good at detecting insignificant amounts of cancer. It will miss 3/4 of GS6 and nearly 40% of GS7 cancers below .5 ccs, the size where yours is most likely to be. When used to guide a biopsy, they are always combined with cores taken randomly throughout throughout the prostate to find what it may have missed.

I should also add that hypofractionated radiation (SBRT or HDR brachy) has excellent control rates for all GS 6 and GS 7, and does not work any better whether ADT is added to it or not. However, you strike me as the kind of person who really needs to see a post-op pathology report - is there a reason you can't have surgery?

- Allen
Posted 7/29/2014 4:33 PM (GMT 0)
Allen -- How good are 3T MRIs at detecting insignificant amounts of cancer?

-- Tigerfan
Posted 7/29/2014 5:19 PM (GMT 0)
If you're talking about non-parametric 3T MRIs, they don't actually detect cancer so much as they find lumps. So they're good for locating, say a lump that penetrates the prostate capsule or a lump growing into the seminal vesicles. mpMRIs, which are often 3T, find cancers directly by their metabolic and other parameters.
Posted 7/29/2014 5:27 PM (GMT 0)

Tigerfan53 said...
Allen -- How good are 3T MRIs at detecting insignificant amounts of cancer?

-- Tigerfan

You didn't specifically ask me, but I hope that you will allow me to respond.

The MRIs (any of them) aren't so much used for detecting insignificant amounts of cancer.  Insignificant amounts of prostate cancer is a natural outcome of aging, and is commonly found in men as they age.  What the mpMRIs look for (what they are designed to look for) is significant cancer, or specifically the high-grade (Gleason pattern 4 or 5) cancer which has a different cellularity and ductal morphology.  The rest of it looks "normal."

Even standard biopsies today are not so much looking for the presence of prostate cancer in men (doctors know that if they look hard enough, they will find it); instead, they are looking for high-grade PC that needs treatment.

 

Post Edited (NKinney) : 7/29/2014 11:33:51 AM (GMT-6)

Posted 7/29/2014 7:29 PM (GMT 0)
I may not have been clear in my reasons for deciding to have the mpMRI. So let me try to be clearer:
1. As prostate cancer is a multifocal disease, at my age (68), I realize that I may have several foci of clinically insignificant (GS 6 or <) small cancers, much like the one I know about from the biopsy. I am not particularly worried about these. One is enough for me to get treated, so learning that I have others similar means little at this point. However, I would like to know if the small cancer found on biopsy is part of a larger tumor because of its proximity to a seminal vesicle. Maybe the mpMRI will show this; maybe not.
2. With a PSA of 9.4, I am aware of the possibility that I may have clinically significant cancers that were not found on either of my 2 biopsies. I have a large prostate, and even the 2 TRUS biopsies with 36 needles still could have missed something significant. If I have other significant cancers, I’d like to know it. My hope is the mpMRI will find any that exist.
3. Going to UFPTI with my current diagnosis, I’m pretty sure of what my treatment will consist of. If the mpMRI finds additional cancer with Gleason 4+3 or higher, my treatment at UFPTI may be modified as a result.

Post Edited (hrpufnstuf) : 7/29/2014 2:11:46 PM (GMT-6)

Posted 7/29/2014 9:59 PM (GMT 0)

hrpufnstuf said...
 If I have other significant cancers...

Did anybody indicate to you thus far that what you have is a significant cancer...?

From what I can tell from your description, you have the very smallest possible amount of clinically detectable PC.  5% of one core out of 36 samples was 3+3.  Is this correct?

 

Posted 7/29/2014 10:39 PM (GMT 0)

NKinney said...
hrpufnstuf said...
If I have other significant cancers...





Did anybody indicate to you thus far that what you have is a significant cancer...?



From what I can tell from your description, you have the very smallest possible amount of clinically detectable PC. 5% of one core out of 36 samples was 3+3. Is this correct?

Yes, that is correct, except there were two biopsies 15 months apart: 12 cores on 1st; 24 cores on 2nd. 1st was negative.
My cancer is considered low risk based on the Gleason, number of cores positive, and size of the cancer found.
If the cancer had to be found, I'm grateful for what little was found. However, as I said earlier in this thread, I'm well aware that with a PSA of 9.4 I could easily have other, higher risk cancers present, just not yet found. That is the primary reason for the mpMRI. Biopsies and mpMRI's aren't perfect, but combined they can increase the diagnostic confidence.
Posted 7/29/2014 10:56 PM (GMT 0)
hrpufnstuf,

You seem to be under the misapprehension that mpMRI-targeted biopsy is the gold standard for detecting significant higher grade PC. It is not. What they sometimes measure it against is a transperineal saturation mapping biopsy. Even there, Gleason grading of the cores is subject to error. Reading an mpMRI is an art, and some are a lot better at it than others. It is followed by a biopsy to determine whether the areas that are scored as suspicious are indeed so. You may be more comfortable with the assurance of a saturation biopsy instead.

With 5-yr bRFS rates in the high 90% range for biopsy-detected low risk PC, the new proton therapies are highly curative. So is every other therapy, if AS is not an option for you.

- Allen
Posted 7/30/2014 2:28 AM (GMT 0)
What is also very interesting--and informative--is that those rates FOR LOW RISK MEN are the SAME without or without treatment. Informative on many levels.
Posted 7/30/2014 8:42 PM (GMT 0)
I had a 3T multiparametric MRI with and without contrast. Due to the suspicious lesion found on the images, I had a MR guided biopsy. I had previously refused the 12 core trus biopsy that was suggested by my Uro. Three cores were taken from the lesion. Dx 4+4 by Bostwick. 2nd opinion confirmed. Several doctors that reviewed my images told me the random needle biopsy would not have hit the tumor. Needless to say, I would definitely suggest you get the 3t mp MRI with and without contrast. An endorectal coil was not used. Make sure, as was previously suggested, that the Doc that looks at your images knows what he is doing and has the experience to properly evaluate the images. You can also send a disc containing your images to other doctors (as I did) for additional opinions. I would not sign up for any treatment without trying to obtain the most accurate diagnosis. I opted for HT, IMRT/IGRT (25), and Brachytherapy. Just my story and my opinion. Good luck with whatever you decide.

P
Posted 7/30/2014 8:57 PM (GMT 0)
Below is a link to the facility that did my prostate MRI. Dr. Cohen read the images and then performed the MRI guided biopsy. I know it is a long way from where you are, but, the information may be useful in your decision making process. Good luck.

http://www.mriprostatecancer.com/
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