Multiparametric Prostate MRI . . . before biopsy.

Personally I like the Mark 1 eyeball approach at the appropriate time.

Cheers, Doug

Houserocker,

The first question, which PDA alludes to, is whether you are a candidate for a biopsy at all, let alone one with sophisticated and expensive targeting. If you have high PSA, and other causes have been eliminated (i.e., prostatitis, BPH, strictures, sex or bike riding within 48 hrs of the test). A good next step is PHI, which includes PSA, % free PSA, and-2proPSA.

mpMRI is usually not done on a first biopsy. It's only when no cancer is found - and 2/3 are negative - and suspicion remains (e.g., PSA continues to rise, or something is felt) - that other measures may be taken. Even then, a PCA3 test is a better next step.

mpMRI, aside from being expensive, is highly dependent on the the skill of the radiologist. There is a disturbingly high interobserver variation, so choosing the right radiologist is key. While it is good at finding higher grade and larger tumors, it is poor at finding Gleason 6 and small tumors. That's not necessarily a bad thing, just something to keep in mind.

I was part of a trial using MRI scanning before biopsy. Then a MRI guided biopsy was conducted where 4 cores were taken. I then had to endure 12 random cores to make a comparison.

The MRI guided cores hit the target to record G4+3 while the 12 random found nothing.

Had I just had a normal random biopsy I would have been given the all clear...to let PCa continue growing until the next biopsy test.

lapilot said...
Houserocker,

I was in a study by my urology oncologist involving mpMRI as a tool for targeting suspicious areas prior to biopsy.
Well, my study included over 2,900 images with & without contrast and all of the modes. They found one suspicious area in the images. So during the 12+1 biopsy (regular biopsy plus the suspicious one) you can see from my tag line of the 13 cores 6 were positive and the suspicious area was negative. So in my case the MRI was totally unsuccessful as a planning tool.

Unless you have a positive DRE, a high PSA and higher cancer yield the outcome from the mpMRI might not be positive for the expense.

Hi lapilot,

Where was location that your Multiparametric Prostate 3T MRI study done?

So you already had the mpMRI. What I took out of it is that it identifies 3 sources for your elevated PSA - significant BPH, a history of prostatitis, and some bladder outlet obstruction. Your PSA density is actually quite low for your prostate size. You mentioned no semen - is that attributable to obstruction, or are you taking an alpha-blocker? Are you taking Proscar or Avodart to shrink your prostate? I think that other sources of PSA ought to be ruled out by taking a 5ARi and a course of antibiotics, in your case, to render PSA a better predictor. There's also PHI, which is a bit more accurate than PSA.

The mpMRI you had (T2, DWI & DCE) identified an area of mild to moderate suspicion, but it was hard to really assess it because of signal interference from your hip prostheses. If you don't want a biopsy, you might want to repeat the mpMRI in a year to see if that area has increased in size.

If a transrectal biopsy scares you, you can request a transperineal biopsy. It has lower risk of infection.

- Allen

The trial was conducted in Brisbane, Queensland in conjunction with a research being carried out in Netherlands.

Multiparametric 3T prostate MRI. T2 weighted imaging in 3 planes. DWI. DCE.

A dye was injected...that's all I know!

Tall Allen said...
So you already had the mpMRI. What I took out of it is that it identifies 3 sources for your elevated PSA - significant BPH, a history of prostatitis, and some bladder outlet obstruction. Your PSA density is actually quite low for your prostate size. You mentioned no semen - is that attributable to obstruction, or are you taking an alpha-blocker? Are you taking Proscar or Avodart to shrink your prostate? I think that other sources of PSA ought to be ruled out by taking a 5ARi and a course of antibiotics, in your case, to render PSA a better predictor. There's also PHI, which is a bit more accurate than PSA.

The mpMRI you had (T2, DWI & DCE) identified an area of mild to moderate suspicion, but it was hard to really assess it because of signal interference from your hip prostheses. If you don't want a biopsy, you might want to repeat the mpMRI in a year to see if that area has increased in size.

If a transrectal biopsy scares you, you can request a transperineal biopsy. It has lower risk of infection.

- Allen

Tall Allen,

I took your advice by having another mpMRI done a year later. The first was done 03/19/2014 and this new one was done on 03/31/2015. JHH in Baltimore did a 1.5 Tesla mpMRI. I was impressed with all the prostate detail that was included in the report. The report also picked up my L5 disc problem in my lower back.

Tall Allen -I would like to get your review of this new report . . . . . and anyone else is also free to comment.

I am sharing the report below for anyone who is thinking about using mpMRI as a part of the screening process.

Notice that the report is using Prostate Imaging-Reporting and Data System (PIRADS).

********************************************************************************
Exam 1: MBM 2050 - MRI 3D RECON POST INDEPNT WKSTN. - Mar 31, 2015 09:59 Acc#:14454878
Exam 2: MBM 6055 - MRI PROSTATE WO PROBE W/WO CONT - Mar 31, 2015 09:59 Acc#:14454877
**********************************************************************************
RESULT: HISTORY: Elevated PSA, PSA 6.1 date 8/07/2014, no history of biopsy

COMPARISON: Prostate MRI 3/19/2014

TECHNIQUE:
Imaging at 1.5 Tesla performed at JHH. Imaging was performed on 1.5T, as the patient has bilateral hip arthroplasties.

Coil: Body Matrix coil
Sequences: Large field of view images of the pelvis were obtained: axial
T2 weighted with fat suppression, 3D T2 weighted, and axial T1 weighted
with fat suppression after contrast administration. Small field of view
imaging of the prostate was performed with axial, sagittal, and coronal
T2 weighted imaging. Diffusion weighted imaging (DWI) was performed with
apparent diffusion coefficient (ADC) mapping. Axial T1 weighted imaging
pre-contrast and dynamic contrast enhanced (DCE) imaging was performed
following injection of 0.1 mmol/kg gadolinium IV. Offline post-processing
of DCE data was performed on a dedicated Invivo DynaCAD workstation to
generate pharmacokinetic maps. Glucagon 1 mg was injected IM.

Additional post-processing of MRI data was performed on a separate
DynaCAD workstation, to include volumetric segmentation of the prostate
(DCAD Prostate Boundary) and contouring of the region(s) of interest
(DCAD ROI) for target nodules in the prostate.

FINDINGS:

IMAGE QUALITY: T2 images and dynamic enhancement images are diagnostic.
Diffusion weighted images are non-diagnostic.

HEMORRHAGE: no areas of high T1 signal suggesting hemorrhage

PROSTATE VOLUME: prostate measures 5.1 cm TV x 4.5 cm AP x 5.1 cm CC,
volume 56 cc. Prostate volume calculated in DynaCAD Prostate Boundary
segmentation 54 mL

PERIPHERAL ZONE: Abnormal signal on T2-weighted images, and/or on ADC
maps, and/or abnormal perfusion on DCE in the peripheral zone, as follows:

Lesion #1:
- Side: left
- Level: midgland
- Zone: peripheral zone
- location: posteromedial
- Diagram - sector: PZm
- Size: 9 x 4 mm on T2-weighted imaging
- Relation to capsule: abuts less than 1 cm of capsule
- Assessment categories:
- T2 = 3/5
- DWI-ADC = inadequate
- DCE = +
- Overall PI-RADS = 4/5
- Series 7 Image 21

Lesion #2:
- Side: left
- Level: midgland to base
- Zone: peripheral zone
- location: posteromedial
- Diagram - sector: PZm
- Size: 8 x 4 mm on T2-weighted imaging
- Relation to capsule: abuts less than 1 cm of capsule
- Assessment categories:
- T2 = 3/5
- DWI-ADC = inadequate
- DCE = -
- Overall PI-RADS = 3/5
- Series 7 Image 18

There is also heterogeneous bandlike signal intensity in the mid peripheral zone, as well, that is likely benign.

TRANSITION ZONE: Mild hypertrophy with heterogeneous T2-signal but no focal areas with suspicious morphology.

Seminal vesicles: Normal, symmetric.

Neurovascular bundles: Normal, symmetric.

Bladder neck: Normal

Membranous urethra: Normal

Lymph nodes: No abnormal nodes.

Bone marrow: No suspicious bony marrow signal intensity

Other:
Bladder is distended with mural trabeculation, suggesting outlet obstruction.

Bilateral hip arthroplasties. There is a moderate geographic regions of
high signal intensity within the left acetabulum, as well as a lobulated,
well-circumscribed mass extending from the inferior portion of the left
hip joint that demonstrates heterogeneous signal intensity (mixed high
and low signal internal intensity) well as a hypointense
well-circumscribed border. Similar regions of multiple cystic areas that
demonstrate hypointense rim are seen surrounding the left hip
arthroplasty on the superior aspect, as well. Artifact from the metal
limits evaluation. There is increased fluid within the left hip joint and
synovial thickening.

Lumbosacral junction demonstrates severe degenerative disc disease and at
least moderate facet hypertrophy that cause at least moderate/severe
bilateral foraminal narrowing.
___

IMPRESSION:
1. Organ confined disease. Dominant nodule Lesion# 1, overall PI-RADS =
4/5. Other nodules, as above. This is unchanged. Hip arthroplasties
renders diffusion weighted images nondiagnostic.

2. Left hip arthroplasty demonstrates mild/moderate synovitis with
geographic osteolysis of the acetabulum, as well as regions of adverse
local tissue reaction. This is unchanged, in retrospect. MRI left hip
(MARS arthroplasty protocol, attention: Dr. Jan Fritz) at Johns Hopkins
is recommended for further evaluation.

3. Lumbosacral level degenerative disease with moderate/severe bilateral
foraminal narrowing.

Overall Assessment Categories (PI-RADS V2):
Likelihood that a clinically significant cancer is present based on MRI parameters
1. Very low (clinically significant cancer is highly unlikely to be present)
2. Low (clinically significant cancer is unlikely to be present)
3. Intermediate (the presence of clinically significant cancer is equivocal)
4. High (clinically significant cancer is likely to be present)
5. Very high (clinically significant cancer is highly likely to be present)