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MRI?Bone Scan? Should you have one?

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Posted 10/6/2014 11:57 PM (GMT 0)
See below for stats and I have a previous post somewhere for additional info. I see a lot of people on forum that before making treatment decisions had MRI or a bone scan. We are still scheduled for second opinion on the 16th and the only tests have been the PSA, biopsy, and cystoscope. So my questions is, with hubby's stats is it wise to go ahead and have an MRI or bone scan if they are suggested or make the treatment decision based on the PSA and biopsy results. Will the MRI or bone scan even make a difference in the long run as far as treatment is concerned. Waiting on Dr. Walsh's book to come in, from the two books I have read (the ones they give you at the urologist office) from what I'm understanding usually PSA and biopsy are all you need to decide on your treatment, that MRI will only pick up a very large tumor and the bone scan CAN give false positives if you have some other conditions. Anyone want to weigh in or give an opinion? Did you have an MRI or bone scan? Thanks everyone.
Posted 10/7/2014 12:10 AM (GMT 0)
Bone scan is a complete waste for him, and is not part of standard protocol for intermediate risk.

What is his stage? T1c? If not, an MRI could be useful if there is suspicion of ECE, and he is considering surgery. If he gets radiation, they will have to give him an MRI as part of treatment planning, so it is useless to get it now.

An mpMRI could be useful only if he is considering Active Surveillance.
Posted 10/7/2014 12:26 AM (GMT 0)
My doctor said a bone scan wasn't needed in my case (likely wouldn't show anything interesting except that broken rib I got once), but he'd send me for one if I really wanted.

I didn't get a MRI until after I selected my method of treatment. Then they didn't some CT studies to figure out how to focus the IMRT radiation treatments.

with numbers you list, I'd be surprised if those scans showed up anything that would change your mind on what treatment to do.

Andrew
Posted 10/7/2014 5:19 AM (GMT 0)
A bone scan was critical for us as it kept us from being rushed into robotic surgery. With a triple digit PSA, it WAS essential for us before determining treatment. And it and petscan revealed a small bone met on sacrum.
Posted 10/7/2014 1:00 PM (GMT 0)
It depends very much on the biopsy and PSA.

For me (9/12 positive, G4+3 & 4+4 biopsy) Bone & CT scans were advised.

In reality they showed nothing but all my broken bones as a kid, but as I have progressed with bone mets, it was invaluable to establish that the progression is current-disease related. That has helped in some of my insurance battles.

If you are working with a urologist who specializes in PCa, I would follow his advice if you are comfortable with it. If not, get an additional opinion. I visited several uros and radiation therapists, and found consistent advice.
Posted 10/7/2014 3:27 PM (GMT 0)
High risk patients should get bone scans. All others are just wasting money. Unnecessary scans are one reason our medical costs are so high. CT scans fall into the same category. An MRI would be useful if one used the information to rule out the surgical option because of tumor location or volume. An MRI would also be useful for those considering AS.
Posted 10/7/2014 5:42 PM (GMT 0)
I agree with the posters that stress only high risk patients need bone scans. I was and about to become again, a triple digit PSA. This means that I have had 4 scans in the past 7.5 years. If you ever do need one they are mildly uncomfortable especially if you have claustrophobia issues. I would say that you don't need one at a 4.1 PSA. . . . Q
Posted 10/7/2014 6:16 PM (GMT 0)
I would get a bone scan and MRI. Yes, normally, only high risk men sre a good value proposition for this but I did not care about the economic value. I wanted all the information I could get with helping me with my decision on treatment. If you find the cancer has spread in an MRI or bone scan, that information, to me is critical in choosing a treatment. I was told I was low risk and a bone scan was not approved bit I got it approved through my company. For me, originally diagnosed as Gleason 6, both Johns Hopkins Dr. Epstein and my local dr. recommended I get these if I could
Posted 10/7/2014 8:16 PM (GMT 0)

AR ANGEL,

I first want o advise to get a second opinion. For me, I would most assuredly go not with only a Urologist, get with(or add) and experienced Oncologist. The others posting here know more about this subject than I do, especially Tall Allen, so I hesitate to post and I preface this by saying that my case is different than your husbands. For me, after the biopsy confirmed G7, I was in the high risk group, with a very high PSA, so a MRI was not an option. I needed a bone scan, and it confirmed Bone mets. For your husband, I would (EDIT) NOT have it done at this time, Tall Allen just told us the baseline concept at this point is pointless. I would think it could be done possibly later if and when the PSA is over 20 or the GS is over 7. At that time it would be very valuable.  Keep the Faith, Dan in So. Cal

Tall Allen- I do not know what a ECE is or a mpMRI, those are not in the abbreviation list. Thanks for all your posts, research, and insights.

Posted 10/7/2014 8:33 PM (GMT 0)
Hi turp54,
Did you get a bone scan? What were the results?
Posted 10/7/2014 10:43 PM (GMT 0)
With your statistic, low PSA and low PCA yield a mpMRI or bone scan would probably show nothing.
As part of a study going on, I had a multiparametric MRI (with & without contrast, over 2600 images) and it didn't show anything.

Bottom line, if it is for peace of mind then go for it, otherwise the cost probably isn't justified.
Posted 10/8/2014 1:06 AM (GMT 0)
Ok, given the info you guys provided, I can see it being beneficial to have a baseline for future reference for mets. How or what would make them think ECE (extra capsular extension) is present? The only thing that flags me (haha in my medical knowledge) would be the presence of PNI and from reading on here that's a mixed bag of it being outside of the capsule. As far as the question of staging, I have searched and searched path with nothing stating this so called the urologist (the jerk that we don't like and doesn't want to see us for three months if we get a second opinion) and according to them they can't stage until the prostate is out. If I were guessing I would stage at a T2a (I'm thinking it's confined to one side since all of his cancer was found on the left, none on the right). I don't even know what his risk is except what has been stated here and my internet research which places him at intermediate risk. You all have given me more to think about, I can understand the matter of the cost to the insurance company so that plays a part as well. We have really good insurance now (Thank the Lord). Right before hubby was diagnosed we qualified for medicaid, our company insurance was costing us $400 a month with a 6500 dollar deductible that has now went to no premiums and a 605 dollar out of pocket max with no deductible for us. We qualified because hubby's work cut their pay almost 800 dollars a month over the past few years. So at least right now as far as coverage we are good but I still don't believe in unnecessary tests just because we don't have to pay out of pocket for it because I know someone down the line DOES have to pay for it.
Posted 10/8/2014 1:22 AM (GMT 0)
Do NOT cheat yourself of tests because of the next guy down the road. Take what you are entitled to if you feel it needed. Who knows what is over the next hill. In other words, put yourself first.

Staging - there are two types. Preop is simple, and based on how they diagnosed the PCa, and what the DRE and biopsy report. Actually, pre-op staging is not exciting unless it is devastating. If you have the prostate removed, post-op pathology / staging is very accurate. If you don't remove it, you won't know that bit of data with certainty.

Don't hold a uro at blame for a vague diagnosis unless you've done all the tests. But at the same time any uro who fears that you'll get a second opinion is not working for you. Mine DEMANDED that I do multiple opinions. I did. In my case, all similar docs had similar opinions.

They might see evident of ECE in scans/ ultrasounds, or feel something in the DRE that makes them think the extension is large.
Posted 10/8/2014 1:33 AM (GMT 0)
Our urologist told us "You have cancer, your prostate has to come out, this will be done with robotic surgery called the Da Vinci", me "How many have you done and how long have you been doing them?" (I knew to ask this from reading here before he was even diagnosed). Urologist "A year, I was originally trained in open prostatectomy." Me (shocked expression on face)" I think we need to research all the options available to us." Urologist "You can do that but I will tell you right now if you see anyone else on the matter you cannot come back here for three months". That is when I was finished with him.
Posted 10/8/2014 2:03 AM (GMT 0)
I think he asked to be dumped. A uro who is not confident enough in his diagnosis to be challenged is not working for the patient. If I was accused of not working for my customer (patient), I would be fired so fast I wouldn't realize it had happened until the dust settled.
Posted 10/8/2014 4:12 AM (GMT 0)
The idea of a "baseline" bone scan with a PSA of 4.1 is ridiculous. A bone scan will show nothing with a PSA and GS that low, so there is no baseline.

You can't do staging by intuition. It is based on what was clinically apparent to the doctor who examined you. It has nothing to do with biopsy results. The doctor may have told you that he feels a small lump or he feels nothing. You can call his office and ask him what your stage is. If you're like most guys, he felt and saw nothing, and your stage is T1c. If he felt a bulge there, further imaging may be useful, otherwise it isn't.

If nothing was felt or seen on ultrasound, neither bone scan nor imaging will make any difference to an informed decision at this point. The only case where it might make a difference is if you want to pursue Active Surveillance, in which case a confirmatory mpMRI-targeted biopsy would be useful.

- Allen
Posted 10/8/2014 4:20 AM (GMT 0)
On original DRE (which lasted 10 seconds total, I don't know if they are always that fast or not because that was the first time I was present when one was performed), he had said that he felt a slight enlargement on one side and that was all. He didn't elaborate after bx if that enlargement meant that it was a large tumor or not. I'm telling you this urologist didn't want to discuss anything except hurry up and let's do surgery. All I know is what the path report says and that he has cancer. I am hoping and praying this new doctor is one that sits down and answers questions. *Edit* I did call today and asked them what stage he is and the nurse said "You can't stage a patient until the prostate comes out".
Posted 10/8/2014 5:02 AM (GMT 0)
A good reason never to rely on info from nurses (there are exceptions)! I hope his next Uro takes more time doing the DRE. My primary care doctor did a 2 second in-and-out feel and felt nothing, but 2 Uros and an RO did indeed feel a lump. If it's just soft, smooth and enlarged, that's BPH. If there is hardness or lumps, there may be something else.What can raise a red flag, and may indicate further imaging, is if he feels something bulging through the capsule. I guess some doctors are either too embarrassed to do a thorough exam or perhaps don't know how to palpate properly. There have been tests with mechanical devices that seem to do a better job.
Posted 10/8/2014 8:33 PM (GMT 0)

Wings of Eagles said...
Tall Allen- I do not know what a ECE is or a mpMRI, those are not in the abbreviation list.

ECE= Extracapsular Extension. It is similar to Extraprostatic Extension (EPE). EPE is the term used on post-op pathology reports, whereas ECE is used in the clinical (pre-treatment) diagnosis.

mpMRI= Multiparametric MRI. MRI can be looked at using various parameters, such as T2, DWI, DCE and MR Spectroscopy. In the hands of an expert radiologist, these MRIs can be used to help detect higher grade and larger cancers - the ones we are most concerned about. For this reason, mpMRIs are gaining an increasingly important role in Active Surveillance protocols to identify and monitor only those cancers that require treatment.

Perhaps the moderators can add these to the list of abbreviations.

- Allen
Posted 10/8/2014 9:11 PM (GMT 0)
As a G9'ner, I had MRI and CT scans BEFORE intervention. I'm a firm believer in the more DIAGNOSTIC upfront the BETTER.
.
Posted 10/8/2014 10:22 PM (GMT 0)
If and when you select a urologist to do the surgery, either open or robotic, make sure he has done many. The robotic surgery has a learning curve and recent papers published states at least 200 to 500 robotic surgeries. My urologist oncologist had over 600 robotic surgeries and trained at M.D. Anderson. My surgery lasted 2 1/2 hours, blood lost of 50 ml (approx 1.6 ounces). I went into surgery at 2:00 pm and went home the next morning around 10 am after I eat a big breakfast. I experience zero ED or incontinence problems.

Of course there are no guarantees whenever surgery is done, but you can hedge your bets with a skillful surgeon.
Posted 10/28/2014 6:05 PM (GMT 0)

Tall Allen said...
The idea of a "baseline" bone scan with a PSA of 4.1 is ridiculous. A bone scan will show nothing with a PSA and GS that low, so there is no baseline.

With my recent upgrade from G6 to G7 on a targeted biopsy, I'm looking at my treatment options again. My oncologist recommends a bone scan before any treatment saying "I never want to put 100% stock in PSAs."

So with a bone scan, when and where is the procedure done? Would the same RO doing the treatment (SBRT or HDR) do the bone scan, or could I go and have it performed now by any local lab?
Posted 10/28/2014 6:22 PM (GMT 0)
super max,

You certainly are not putting 100% stock in PSAs. You've had an mpMRI that showed complete containment.

Bone scans will only show mets with PSAs over 10, preferably 20. But they will show sclerotic bone lesions at any PSA. AUA does not recommend them for men who are not high risk. They are not just an unnecessary expense, and an additional exposure to radiation. They can be hazardous. Ask Lupron Jim. On the basis of a bone scan he was told he had mets and his PC was incurable. He went through years of hormone therapy before someone realized that the mets weren't mets after all. So he might have been cured years earlier and might not have had to suffer with the anguish and years of extra hormone therapy.

I'm sure a local imaging center will be happy to take your money.

- Allen
Posted 10/28/2014 6:45 PM (GMT 0)

Tall Allen said...
super max,

You certainly are not putting 100% stock in PSAs. You've had an mpMRI that showed complete containment.

Allen, thanks.

What's concerning my oncologist, and his likely reason for recommending the bone scan, is an earlier (6/14) CDUS from Dr Bahn that showed "inferior extension of the disease to the level of the external sphincter. .... It might already be a T3a stage malignancy."
Posted 10/28/2014 6:50 PM (GMT 0)
The oncologist I saw yesterday at Emory said basically the same thing as Tall Allen above.

We were worried because I have back pain, primarily in the mornings and after sitting at my desk too long.

With a PSA below 5 he said he'd be beyond shocked, and that bone cancer pain is much different than what I feel when waking up.
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