I found something interesting in my MRI report...

Hi All,

So for going up to Boston they requested that I get disk copies of my bone scan and MRI reports. I went to stick my MRI report into my computer to take a peek (as if I have any idea what I'm looking at) and a written report fell out.

Reading the report there are a couple of things that are of interest but one thing in particular really bugs me. For the lymph nodes it states "Several tiny mesorectal lymph nodes questional significance" That is exactly how it was spelled. I'm assuming questional was supposed to be questionable.

The thing is my Urologist said my test came back with negative metastasis. That is all he told me. He didn't mention this part of the report at all.

The other thing is that it says that the cancer "abuts capsule without evidence of extracapsular extension". This makes me a bit more concerned as it sounds like while the cancer hasn't spread outside the prostate, it is near the boundary of the "capsule"... Maybe I'm just reading too much into that but it sounds like it is closer to breaking though than if it was deeper in the interior of the organ.

Anyway... does anybody think this is stuff the Urologist should have mentioned rather than ... the MRI came back with "no obvious signs of metastasis"? That is all he told me.

Thank you,
Tim

Hi Andrew,

OK. Maybe it is that my older brother had a pretty bad case of rectal cancer (made it to his lungs and liver) that I'm reading into this a bit. But "mesorectal lymph nodes" sounds like, given his problems (which I had mentioned to the Urologist) is of more interest to me than the average guy out there.

Thank you,
Tim

My staging mpMRI noted a "bulging area of low T2 weighting signal intensity". Then, "The bulging appearance suggests extra-capsular extension with possible neurovascular bundle involvement by adenocarcinoma.". And, "...bilaterally the findings remain suspicious for extracapsular disease". Nothing visible in seminal vesicles or lymph nodes. So, I suppose more than "abutting" my capsule, mine was actually bulging.

So, that to me says cT3a. My uro onc was more equivocal, saying could be either T2b or T3. His summary said "High-risk clinically localized with possibly microscopically locally advanced prostate cancer, Gleason 9 tumor T2b vs T3NXM0". He offered surgery, but thought radiation might be a better bet too.

Since MRI's are more likely to miss things than to see things that aren't there, when it's "suggestive" of something I'm inclined to think it's probably there, and probably more than it appears. I lean more toward the cT3 staging and have acted on that assessmentl.

Such mpMRI results, combined with a G9 5+4, suggested surgery might not be my best bet. These factors weighed heavily in my decision to pursue radiation and ADT.

If the mpMRI saw "questionable significance" lymph nodes, they had to be big enough to be seen. I don't know what a "mesorectal" lymph node is, but one can guess by the name. Lack of sensitivity is a main limitation of MRI, so again, if it saw them then they're likely there. I've never noticed discussion of anything like that in the context of prostate cancer imaging, for what it's worth.

Hi Gemlin,

So your report has similarities to mine. If I understand, in the end the lymph nodes were fine but there was some capsule breakthrough that the MRI didn't reveal (or was missed somehow).

Are you of the opinion that if you had radiation some of the "breakthrough" might have been missed? At least that is one of the strengths of surgery, the benefits of the post-surgery pathology report itself.

Thank you,
Tim

TimOz - the MRI missed my EPE so clinically I was a T2 and after surgery a T3. Whether surgery or radiation is better (survival wise) for cT3 is controversial and subject to ongoing RCT in Europe. Anyway the surgeon did a fantastic job on me with all margins negative, so far undetectable PSA (2.5 years).
I wonder if anyone really could know for this "subgroup" (cT2 that in reality is T3) if surgery or radiation has better outcomes. Is the radiation wide enough if you are incorrectly classified as T2? Do the surgeon cut wide enough if you are incorrectly classified as T2? (Well, mine did and I don't regret my choice.)
With radiation you never get to know what your real T classification is. Only surgery gives the accurate and precise pathological staging of your tumor. What that knowledge is worth is up to each of us to value individually.

You are correct that the decline in PSA after treatment will be different depending on the treatment.

It had better go down fast and completely after surgery or it means surgery failed. Successful surgery removes the source of PSA, the prostate and the cancer and had better be undetectable and soon.

It will also go down quickly due to ADT. I went from 59 to <0.10 in about 90 days thanks to Eligard.

If you only use radiation it will take generally 2-5 years to reach the PSA nadir. First you will retain some of the functioning prostate that will still emit PSA. Some of the cancer will die quickly and contribute to lowering the PSA. But some of the cancer will be too damaged to divide, but not damaged enough to die yet. Prostate cells and thus their cancer cells are some of the longest living cells in the body so their programmed cell death (apoptosis) is much longer than most other cells. Finally when they do give up the ghost they often cause an increase in PSA often 18-36 months after treatment. This referred to as the bounce and can be a bit unnerving if one doesn't know to expect it.

If you combine ADT with radiation, the PSA will drop quickly due to the ADT.

To the comments from Dana Farber, that indicates you are at a higher risk to experiencing a failed surgery. Those are the cases where radiation and ADT are preferred in order to reduce the side effects and treatment damage inherent with surgery.