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How long post biopsy to get a Mp-MRI? Blood/hemorrhage an issue?

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Posted 9/26/2017 12:16 PM (GMT 0)
Hi all, Im struggling to find more than just a bit of information on this topic. I have seen a study and read on a different forum that one should wait 8 weeks or more between biopsy and MpMRI. This is because the earlier its done the more blood/hemorrhaging form the biopsy might interfere with the images. Apparently it takes 4-12 weeks for the hemorrhaging to completely stop, and that at 8-10 weeks MRIs will have full effectiveness?

My MpMRI is scheduled for 4 weeks out from my biopsy, and after asking my Dr about this concern he said it was fine to keep the appointment and go forward. Anyone have any color/thoughts on this?


Thanks
Posted 9/26/2017 4:03 PM (GMT 0)
I agree that at least 8 weeks is typical. It's not so much hemorrhaging as the pooled blood. The DWI-MRI detects restricted fluid movement. What's the rush?
Posted 9/26/2017 6:43 PM (GMT 0)
Hi Tall Allen.....Im a low risk/AS candidate. Got my biopsy on 9/1 showing 3/12 cores...3+3 (15, 25, 25%), psa 3.1 (<.15 psid). Im hopeful to go with AS...but want to get a few tests...perhaps unnecessary...to be as sure as I can. Im getting the mpMri, genomic testing, and perhaps a 2nd opinion on my biopsy at J Hopkins.

So, there is no rush....except for a) two different Drs told me 4 weeks between biopsy and mpmri is fine and will have very little to no impact on what they will look for on the mpmri. b) in the event higher risk cancers/situations are found in any of the tests I will consider Cyber Knife. Should I complete that by calendar year end I win the American game of beat that deductible. Sad/pathetic...yes...but its the world we live in.

So life or death vs cancer....no rush. But for my psychology (knowing sooner than later) and wallet there might be a rush. Since two doctors dont think its rushing it Im just digging around to see if anyone else knows anything concrete....because it seems this forum has a cumulative knowledge base better than many doctors!
Posted 9/26/2017 6:56 PM (GMT 0)
Mine was done quite soon after a biopsy, less than two weeks later.

For me, the issue was my G9 5+4 biopsy with six positive cores, all G9 and a couple at 100% involvement, led to rather high concern (translation - I was pretty freaked out). We expected there would be compromises in the imaging, and there certainly were. The residual blood there created a lot of bright artifacts and did interfere with some of the measurements. It did show enough to indicate extracapsular extension, and also that the seminal vesicles weren't involved. That staging was what we wanted to see, primarily to help decide if surgery was a good idea or not; even with a G9 sometimes it is a very good option.

We decided in my case not to pursue surgery, in significant measure due to that mpMRI. So for me, even though we couldn't see everything we might have wanted to, we were able to see what was important.

For a lower risk case I'd sure advise waiting a bit for all that blood to clear out of there. It's a slow-growing disease typically, and there doesn't necessarily need to be a big rush.
Posted 9/26/2017 7:13 PM (GMT 0)
Kev-

No one knows what's going on inside you, in particular. Everyone just goes by statistical averages that predict for the population, but not for the individual. If you want to risk an earlier mpMRI, and you understand that the pooled blood might create a false positive, it's entirely up to you. But if you're concerned about wasting money on your medical bills, that might waste more money than waiting.

The way that confirmatory mpMRI-targeted biopsies are given in many AS programs are within a year of the initial biopsy - not a month. And note that I said biopsy and not just imaging. Whatever you may have heard, mpMRI is not a test for cancer. It only highlights areas suspicious for high grade cancer. Only a biopsy can confirm or deny cancer and its Gleason score. It is ridiculous and dangerous, imho, to have a confirmatory mpMRI without a biopsy, or to forgo a confirmatory biopsy when on AS.

You may state that your reasons are all economic, but your drive to have expensive and unnecessary tests tells a different story. We've all been there. At a month after diagnosis, you are still in the thralls of the "cancer panic" we all went through. This is not a time for making decisions, it's a time for deciding not to decide. With time, that initial panic passes and becomes more background than foreground, allowing for more rational decision making. Nothing will happen if you wait until next year, and no matter what you decide then, AS or treatment, you will meet your deductible.
Posted 9/26/2017 9:03 PM (GMT 0)
Great feedback. Thanks guys. I also got a good laugh at myself. Yip, maybe a bit of over analysis due to cancer panic.

Ok so stepping back just a bit...do you guys think an MPMRI for me (say in 4 weeks and not part of AS follow up) is a good idea? I will certainly do my AS 3 month psa and dre, and 6 month psa/dre/biopsy (not sure if mri guided or not at this point). But before all that Im just wondering if the mpMRI could add enough color to tip the decision making scales. For example, if the cancer made it to the seminal vesicles or is in/outside the prostate wall? If not perhaps it is just a waste of money.

slooowwww down.....sloowwww downnnn
Posted 9/26/2017 9:44 PM (GMT 0)
I surely don't have as much well-rounded knowledge as some of the other well-informed gents around here, but I was just diagnosed with a Gleason 6 (see signature) and am pursuing AS at Sloan Kettering in NYC. Because I just had a MRI in June and a biopsy in August, the docs recommended no other testing (e.g., confirmatory biopsy, PSA, MRI) for at least six months for the most accurate results.
Posted 9/26/2017 10:38 PM (GMT 0)
My first mri was done 3 weeks after biopsy when I was called in early because of a cancellation. The results were a 9 x 14mm pirads 3 lesions in the transition zone. The report also noted that the peripheral zone was obscured due to blood from the biopsy. The second mri at 5 months post biopsy found a pirads 5 12 x 24mm lesion in the transition zone plus a pirads 4 14mm lesion in the peripheral zone.
I would wait longer than 4 weeks post biopsy for an mri in order to get the best result.
Posted 9/27/2017 1:32 AM (GMT 0)

KevC said...
do you guys think an MPMRI for me (say in 4 weeks and not part of AS follow up) is a good idea?

I don't know how to make this more clear. There is absolutely no use for you for an mpMRI outside of its use for a confirmation biopsy for AS. If you want to waste money, that's your decision. But there is no validated purpose for it at this point. A year from now, it is a very good idea to have one in conjunction with a biopsy to determine whether AS is indeed your best course of action.

I have no idea what you mean by "color" but imaging at this point is not useful. Neither is genomic testing - that's just for cases that could go either way. Yours is clearly on the good side for now.

I can't tell you how rare it would be for a biopsy-detected GS6 to be T3 - much less than a 1% chance. It is only if your doctor felt a lump at the seminal vesicles or on the prostate capsule during a DRE, or saw that on the ultrasound, that such a thing would be remotely suspected. And even then, they would use a T1 or T2 MRI, not an mpMRI for the purpose.

Yes, slow it down. Decide not to decide.
Posted 9/27/2017 3:40 PM (GMT 0)
All great info thanks. First, I moved my mpMri back to mid Nov. At that point I will have about 11 weeks between biopsy and the mpmri. Cant argue against the logic behind that.

Tall Allen, Id like to play a bit of devils advocate - not because I disagree with you, but because I have a lot to learn and would love anyones input. Also note Im a fan of the idea of AS. BUT - here is what I know: AS vs immediate treatment for low risk patients has the same survival rate 15 years out (but AS has less side effects as long as the AS journey continues). Great. Im fine with that. But, obviously there are no long term studies regarding how those stats play with 1) genomic testing results nor 2) mpmri because these are such new technologies.

We could ignore any input from new technologies until adequate proof has been obtained re their merit. That would give us the conclusion that low risk = AS and stay on it until some gleason 4s or an increase in stage occurs. Again, thats reasonable.

Or we can make some safe assumptions to improve our odds. Here are some pretty dang likely to be true assumptions: 1) Genomic testing does have at least some predictive value. 2) mpmri images can, at least sometimes, identify higher and lower risk situations. Therefore, I think its a dang safe assumption that getting these tests done can alter prediction odds by at least some minimal amount some of the time.

So take the long term studies done re AS vs immediate treatment over 15 years....and then assume we could add in another couple % to the stats either way with both genomic results AND mpmri. In my opinion, with a higher risk genomic score the 15 year survival odds for AS diminish RELATIVE to immediate treatment (knowing that a higher risk genomic score would also give the immediate treatment subset a higher risk also). Further, an mpmri might identify higher risk situations in an otherwise low risk candidate, further skewing the odds.

In the end, perhaps the numbers then skew a bit. Say rather than 50% of AS patients needing treatment over 15 years that number might go to 55 or 60% in higher risk and 40-45% in lower risk (Id wager it would skew more...but this is guesswork so Im trying to be conservative). Then lets add on the survival rate change. Lets say that if genomics and mpmri suggest higher risk, then the AS group now has a 90% instead of 95% 15 year survival rate but the lower risk group has a 98% survival rate.

Last, none of the studies I have found go more than 15 years. Any slight deviation in odds has a larger impact the longer out you go.

In the end, I cant agree that these studies are a waste of money. These new technologies show great promise and while not fully proven they absolutely are showing predictive value. Im 43. a few % swing means a great deal over what I hope is another 30+ years.

Im ready to be proven wrong (again). thanks for taking the time...
Posted 9/27/2017 5:26 PM (GMT 0)
I think you misunderstood what I was saying. Perhaps you should re-read what I wrote. I am certainly not arguing against mpMRI/US fusion-guided biopsy. In fact, I wrote the opposite. I wrote that I think you should have one within a year of your first biopsy (but not NOW) and only if your decision is to go on AS. Actually, my urologist (who is in charge of the AS program at UCLA) considers Day 1 of AS to be after a patient gets the results of the confirmation biopsy (up to a year after the first biopsy).

As for the genomic tests, I am not saying they are always a waste of a lot of money, I'm saying they are a waste of money for you NOW. A year from now, such tests may or may not have some decision value to you, but they don't NOW. The cases where a genomic test may be helpful is if there are signs that the cancer may be more aggressive than at first supposed. Such signs may include presence of any Gleason pattern 4, many cores with cancer, high volume of cancer within the cores, high PSA density, suspicious bulges on DRE or imaging, PNI, African American, and family history. Genomic profiles change over time and vary among cores - for that reason it is best to wait and only do it on cores taken from the mpMRI when there are known risk factors. You have no such indication NOW.

AS depends on the fact that even high risk PC is slow growing (most low risk cancer NEVER progresses), and that we have adequate means to monitor progression in plenty time to treat it and cure it, if necessary. It does NOT depend on knowing any of that in advance. It depends on knowing what one can know on an AS program as you know it.

Of course a really crazed and wealthy patient could get monthly genomic tests and mpMRIs, but that sort of patient should not go on AS in the first place. It would drive him (and his doctors) crazy.

The longest running AS program is Klotz's and he has reported 20-year results. 55% of the men on his program have been able to go without treatment for over 20 years. The ones who did get treated did it in enough time to cure their PC - and that was back in the day before mpMRIs and genomic tests. The protocols in place now are working just fine.
Posted 9/29/2017 2:56 PM (GMT 0)
Thanks all for the responses. I think my cancer diagnoses freak out period is subsiding. I am standing down, no further tests until my 3 month AS dre and psa bloodwork. Next year Ill stay all over this, and get an mpmri before the biopsy to get more color.

Thanks for walking me through these decisions
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