Raising Awareness about MRI Imaging of the Prostate

Guys and Gals -- I wanted to share this for those who do not receive the PCRI newsletter (Prostate Cancer Research Institute). I'm really excited about the 3T mp MRI technology and what it can do for PCa screening and treatment...

By Mark Scholz, MD

Prostate cancer screening presents a unique challenge. Prostate cancer is a very common, but only a minority of cases are deadly. This creates a serious problem. It’s good to detect high-grade disease because early treatment reduces mortality. But PSA screening detects a lot of men with low-grade disease and these men are harmed. Why? Well-intentioned but over-enthusiastic doctors recommend treatment even though it’s truly medically unnecessary.

Why We Over Diagnose
So what can be done? Physician propensity for overtreatment will only change slowly. The shortest pathway out of this dilemma is to stop diagnosing so much low-grade disease. The crux of the problem is the random needle biopsy, a “blind” procedure that is widely considered to be the necessary first step for evaluating elevated PSA. A million men undergo biopsy annually; 250,000 men are diagnosed; around a 100,000 have low-grade disease the can be safely monitored with “active surveillance.”

The Next Evolutionary Step
Three-Tesla multiparametric MRI (MP-MRI) scans developed by Siemens, Philips and GE can reliably detect high-grade disease without over diagnosing low-grade disease; these scanners accurately differentiate high-grade from low-grade tumors. The availability of these new scanners makes random biopsy as currently utilized by most urologists archaic. Random biopsy involves inserting 12 needles into the rectum. Beyond its propensity for over-diagnosis, 3% of men are hospitalized with serious infections. Also, it is relatively inaccurate, failing to detect high grade disease over 15% of the time.

New Technology Growing Pains
Most internists and urologists are still unaware of these important technological advances. Even those who are aware are still learning how to translate these new imaging reports into practical recommendations for their patients. Also, there is the challenge of maintaining quality control in this rapidly expanding world. Despite these barriers the advantages of using imaging as a first step can’t be ignored. We have posted a list of centers that perform this type of imaging. While we have some familiarity with these centers, for liability reasons we are unable to offer any official certification of their quality and accuracy. On the other hand, new as this technology is, we feel it would be a disservice not to spread the word about its availability. We are raising awareness about prostate cancer imaging

PSA3DOT7 - I had a color doppler by none other than Dr. Fred Lee, a number of years ago when I had an elevated PSA in my 40s. The doppler signal keys on vascularity, seeing locally concentrated blood flow which tumors tend to exaggerate (blue and red, for flow direction). He saw a colorful area on the display, and targeted that area. But it turned out to only be inflammation. Color doppler has a somewhat controversial history, being helpful with really practiced docs in specific cases.

The MP-MRI is quite different, and yields MUCH more information. The images are pretty nicely detailed. I haven't studied this to see how they distinguish between the different types of tumor tissue, but seeing the tumor tissue itself is rather clear in the images. I had a 3T-MRI with some of the tests performed in MP-MRI, and as a layperson it's still quite evident where the issues are.

(Here's an interesting side note, that I don't dwell on. My eventually discovered G9 case was actually concentrated right in the area where Dr. Lee saw the colorful areas 10 years ago. In the intervening years my PSA went back down below 2 and stayed there for several years, until finally diagnosed at age 55. Not sure what that means, but I find it more than coincidental...)
Jerry

I agree with John T, that interpreting the color doppler scan (CDUS) is an art that takes a long time to learn. I had my CDUS done by Dr. Lam who works with Mark Scholz in their Marina del Ray, California practice. Their standard procedure for someone with high PSA is to first do a CDUS and/or mpMRI, and then if the scan(s) show suspicious areas, do a targeted biopsy, sampling only the suspicious areas. In my case they they only took 5 cores, and 4 of them showed PCa. Several months later I had a 3T mp MRI done at UCLA. The report from the MRI was pretty much in line with what Dr. Lam had gotten from the CDUS. I am sure that if the CDUS had been done by someone less experienced, it would not have been worth anything.

Redwing57,

Speaking of Fred Lee, here is a video of a presentation he gave in 2007. He speaks about his own diagnosis of PCa "back in the dark ages" in 1984, and all that he has learned about PCa since then. He also talks about how he spent 2 years doing ultrasounds on prostates that had been surgically removed to learn how find tumors. If you don't want to watch the whole thing, start the video at 14:30. He gets pretty worked up about the failure of urologists to improve on the way that they diagnose and treat PCa.

vimeo.com/11316564

Anyone considering Active Surveillance (AS) as a means of tracking their PCa should definitely investigate the use of advanced imaging as part of any biopsy. You should not just accept the old (1980's style) random biopsy results since it can miss important details that could be the difference between early treatment of a small tumor or later treatment after the tumor has grown to become a problem.

In a conventional biopsy (1980's style) the samples are collected based on a random 12 box grid that the doctor and technician generate. The grid is not based on any information about the prostate; it simply divides the prostate into a certain number of boxes that are used to identify the samples. There are no "GPS" coordinates on your prostate, so there are no identifying details on each sample other than the "grid coordinate" it came from. This means that the doctor only has generalizations about the locations for last year's samples. I remember reading that the biopsy samples 1% of the prostate or less.

Enter another new technology!!
UCLA now has a new prostate-imaging technology that fuses MRI with real-time, three-dimensional ultrasound. Dr. Leonard Marks, a professor of urology at the David Geffen School of Medicine at UCLA noted "that the new technology may be most beneficial for patients who fall into one of two categories: those who had prior negative biopsies but have persistently elevated prostate-specific antigen (PSA) levels, and "active surveillance" patients — those with low-risk prostate cancers who are being carefully monitored over time to see if their cancer progresses or becomes more aggressive." The UCLA team found that targeted biopsy was about five times more likely to find cancer than non-targeted, systematic biopsy. Additionally, the re-biopsy (or possibly next year's biopsy) of a suspicious site was found to be accurate within a few millimeters. see article at: http://newsroom.ucla.edu/releases/new-technology-fuses-ultrasound-200438

Unfortunately for me, the newer technique raised me from a Gleason 3+3 to 3+4, which meant AS wasn't an option anymore. Had open RP 12/1/14 as a result.