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Interpretation of PET MR GA PSMA verbage question

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Posted 1/6/2023 12:09 AM (GMT 0)
I'm trying to decipher a few statements on my PET/MR PSMA report. The MRI report states in the Impression NO evidence for extraprostatic disease. In the report detail, however, it is stated "the above described left posterior peripheral zone lesion in the gland apex abuts the left posterolateral prostatic capsule without evidence of frank extraprostatic tumor extension." The PET report states in the Impression NO findings characteristic for locoregional or distant disease. In the Abdomen & Pelvis report detail, it is stated that "in the pelvis, known prostate carcinoma at the left posterior apex peripheral zone on dedicated pelvis slice #53 with maximum SUV of 20.7. No other suspicious foci are evident. No findings characteristic for locoregional or distant disease." So I know they are both talking about the same PiRad 4 lesion. Abut is defined as to touch or end at one side. How close to the edge of the capsule? Enough to be contained? This seems too damn close for my comfort. Although it appears that this radiologist was more wordy, all previous 5 MRI’s just indicated No evidence without any additional comment. Any thoughts would be appreciated. Also, I’ve never come across SUV. It appears 20.7 is not great. Thanks.
Posted 1/6/2023 1:40 AM (GMT 0)
No expert here (and obviously not a doctor either), but I'll give you my 2 cents.

EPE is usually tumor growth through the thin prostate capsule, ranging from microscopic to extensive. It can, however, be growth just into, but not through, the capsule (the latter IMO being the "frank EPE" mentioned). Your reading shows no evidence of either. It looks like there is tumor growth right up to, but not into or through the capsule--hence the "abuts". However, I don't know how well the scan can distinguish no penetration from microscopic penetration into the capsule.

You should discuss the report findings with your docs. If they are unsure, you could contact the radiologist who read the scan and/or do research on your own. I wouldn't panic at all, but clearly you want to plan treatment rather than postpone it too long. Gleason 6 (3+3) itself doesn't metastasize, but it does (infrequently) grow out of the prostate in the form of EPE.

Keep in mind that all imaging techniques have a limit of resolution. The key word here is "evidence." It seems the cancer is still prostate-confined; however, you can't be sure what a microscopic exam of your whole prostate would show. There might be growth into the capsule, or, if some cancer cells were seen coming through the capsule at just one spot, it would be labelled "focal EPE" in a post-RP path report. After that comes "multifocal," followed by "non-focal," used to describe more extensive EPE.

If your cancer is, in fact, all G6, this could all lose significance, since, as mentioned, it doesn't metastasize. However,G6 men can progress, leading to the growth higher-grade lesions. Nor do you want G6 overstaying its welcome if it leaves the prostate and grows up against other structures, like the bladder.

Also ask about whether the findings should influence the usual RP vs. RT treatment choice most men have.

Please keep us posted with what you learn and decide: we learn, too.

Djin
Posted 1/6/2023 4:07 AM (GMT 0)
Today is the two year anniversary of my RALP. PSA remains undetectable, next test is next month. Prior to surgery my surgeon said "MRI shows the cancer confined to the gland so I will attempt to save both nerve bundles." The nerve sparing procedure was VERY successful!😁 Post operative biopsy showed EPE ( focal). Imaging cannot show microscopic activity. Biopsy also showed no cancer in perioprostatic fat, Seminal vesicles or lymph nodes.
Posted 1/6/2023 12:48 PM (GMT 0)
No expert here either but I doubt the resolution of the PSMA scan is capable of determining the level of detail necessary to establish conclusions regarding EPE. The MRI would be the better scan but it is also limited. I have had a few doctors tell me about the limitations of scans in that they tend to be 2D images so the angles come in to play and telling if something actually crosses a line is an experienced estimate many times.

SUV (standardized uptake value) seems to be commonly reported with PET. I tend to agree that 20 is probably a high number but know little about the significance of the measurement. Probably just another factor to consider with the rest of them. Sounds like everything is pointing to treatment at this point with your elusive lesion.

I had a CT for a hernia which was negative even though my doctor(s) and I could see and touch it. Surgeon said that happens sometimes and to ignore it.
Posted 1/6/2023 4:28 PM (GMT 0)
More and more guys coming here seem to be having PSMA scans. I wonder how well established the skill is for interpreting these scans.

about a year ago an ENT guy looked at my throat with a scope that goes through the nostrils. He noted that one side of my septum was slightly enlarged. A few months later I was reviewing an old CT scan of my head and neck. The radiologist did note the enlargement of septum. I got a chuckle out of that, and I was impressed.
Posted 1/6/2023 5:40 PM (GMT 0)
Excellent advice so far.
Unfortunately, one can never be 100% sure about issues such as the one presented by ejc61.

It looks like another biopsy would be appropriate. The last one appears to be more than 4 years ago.
Posted 1/6/2023 11:37 PM (GMT 0)
Thanks for the responses. My two previous biopsies resulted in two hospitalizations due to SIRS without infection in both cases. Basically a temp of 101°F with chills. This occurred even with antibiotics both orally for several days before and IV form a hour before. Usually a 2 day hospital stay for observation and IV antibiotics. This imaging was recommended as a possible way to get more information on the PiRad 4 without putting me through another biopsy. I am curious about the added line about the abutment. Otherwise, nothing has really changed from last April. Even if I had another biopsy, and say it’s still a GS 6 with low involvement, what would be changed? Should I feel comfortable about it possibility inching its way over the line? This abutment comment makes me want to seriously consider treatment. I’ve been on AS for almost 6 years. I’ve sent my urologist a calm measured portal message about my understanding of the results only. I have my appointment with him and a RO in a few weeks.
Posted 1/7/2023 12:37 AM (GMT 0)
I suspect you'll be told that you are no longer a good candidate to remain on AS. On the other hand, you might be the ideal candidate for a transperineal prostate biopsy, which has a remarkably low risk of infection.

Djin
Posted 1/7/2023 2:49 AM (GMT 0)
Definitively a transperineal biopsy is good idea based on your infection history. It also samples differently which might help with the search. You are probably overdue for a biopsy since 2018 was last one.
Posted 1/8/2023 4:52 PM (GMT 0)
https://www.acr.org/-/media/ACR/Files/RADS/PI-RADS/PIRADS-V2-Lexicon.pdf

I ran across this if anyone is interested. I wasn’t aware of all the staging terms. Then again, why would I?
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