MRI Communications with Patients Needs Work

I hope that the radiologists are doing a better job than the weather forecasters

My radiation oncologist did a better job of explaining my MRI imaging to me than my urologist. I suspect that is because he sees imaging every day where urologists get what they need from the report.

My imaging shows one lesion clearly and the other was just a smudge area that I still can’t find. Both lesions were found in prostate pathology, one worse than the other, so the MRI interpretation was pretty accurate in my case.

Prostate cancer grows slow so it is hard to differentiate from normal cells but at least they are static and not swirling around.

Mumbo, according to your signature you had a PIRADS 5, and that one seems to correlate with a lot of G7+ 8,9 or 10 cancers. Do most PIRADS 3,4,5 ratings accurately reflect their later assigned Gleason scores? Isn't clinically significant PC a minimum of G7+? If a PIRADS 4 or 5 lesion says high risk csPCa is likely to be present doesn't that usually mean they expect to find 7 or 8+ on biopsy?

Mumbo's point (Uncertainty is the name of the game) is right on.

I just don't get the push to interpret an MRI yourself. One needs to be a reasonably bright college graduate who then goes to med school for four years and, following that, receives further training to become a radiologist who can interpret MRI images.

As an aside, I had (a prostate) one not too long ago and the technician that shoved me into the instrument told me that prostate MRIs are especially difficult to interpret.
The report should be all that is needed for the patient to intelligently map the next step. As has been mentioned several times by now, the MRI should be used to focus on suspicious lesions during the biopsy.

Post Edited (Sr Sailor) : 6/28/2024 2:00:58 PM (GMT-8)

Oh, we all have our dark days. The waiting is the hard part.

Here's some things to do: When the biopsy report comes back (usually about a week from the biopsy), get the PDF or hard copy. Please share it here, we can help you translate it. What it will indicate is how many samples they took, and the locations. Then there will be some technical language and a Gleason score. The G score is listed as 2 numbers, a dominant number and a secondary number for each sample. For example, it might say Gleason 3+3, total 6, or 4+3 total 7.

These are the important numbers. Prostate cancer begins at G6, and goes up to G10. Each sample will have scores from 3 to 5, as dominant and secondary. The higher the number, the higher the risk. G6 is the one that bears regular watching, and (maybe) nothing else for a long time. G10 is worst case. It's very rare, in fact.

I was diagnosed at G6. I chose to treat, and my post surgery pathology came in at G7. And I'm doing just fine 9 1/2 years later.

Mumbo makes a good point. PCa is not like other cancers--most of the time. It tends to be slow growing and asymptomatic until it's really bad. Let's contrast that with the other common ones--and a few uncommon ones.

Colo-rectal, for example, is also generally asymptomatic, and is frequently diagnosed when a blockage appears--and in that case it usually IS stage 4, and the prognosis, even with treatment, is pretty bad. Pancreatic might be IMO the worst: It frequently goes from no symptoms to diagnosis to death in months.

PCa, on the other hand, is something most American men will have, even if it is never diagnosed. The understanding is that by the time it is diagnosed, it has been there for years. For most men, it is something that is treatable, and even if it not curable, it can be managed for a long time, and is something we will die with, not of.

I guess what I'm saying is that we first have a lot of learning to do, as men. We also have to do a lot of unlearning. This also leads to some uncomfortable realities. There is a sort of unreality to the rest of the world. PC is no big deal. "Nobody dies of it anymore". Treatment is not a big deal (it is). ETC. I remember, at the time I was planning my surgery, that my boss expected me back at work, at 100% capability, in 3 weeks. When, not a few years before, a coworker went through colon cancer and there was no issue with him being off 5-6 weeks after surgery and then out 1-2 days a week for the next year for chemo.

Anyway, the first thing for you is to get your biopsy report back. Please share it with us. And then, and only then, is it time to think about treatment options--and again, it's not something you have to decide on day 1. Or even day 10.

Where do all of you guys that have walked this crazy path even get such resilience? I'm nowhere near your level in dealing with this but I had better figure it out and fast.

Time heals all - You are generally not conversing with men now in the first months of their PCa adventure (adventure is the operative word here). With time and experience comes patience and resilience to better deal with the situation. In some ways, those who get a straight forward cancer diagnosis move along much quicker mentally as next steps are quickly determined and working on the solution is right around the corner. PCa diagnosis is a much slower walk as there is so much variance in the possible situation, not a binary yes or no then move to next steps.

There are a lot of questions such as do I have the "good cancer" or the bad version of the good cancer? I didn't like the DRE so how the heck are they going to do the biopsy with equipment? and so on. Since we know the answer to all these questions, our minds are clear to worry about other things.

My simple story - I retired in June 2018 with my future plans all figured out. I had Social Security and Medicare figured out, savings in place, and my wife would retire in 2019 (then came Covid). One month after retirement I had my annual physical and my PSA jumped,"Game Over Man" is what I clearly heard. All my plans went out the window and now I am focused on the next events which cannot occur quick enough, starting in Aug and surgery in Nov. However, I am not clear until March waiting on first post-op PSA. But wait, there is still more. All subsequent information obtained after surgery is not so good so more treatment in April after much study.

So when does the mind settle down? The few weeks before surgery were peaceful, I had a plan in place and just waiting for the event. about a week after surgery, the pathology was available which started the next sequence of events which was similar to getting to the treatment decision, another decision has to be made. So basically it was a year of bad times until I was done and my mental state was getting better as things were getting done.

Summary - The time from PSA increase to a few weeks before treatment (after decisions were made and no more testing was being done) was the worst. Once the information is collected and the decisions made, anxiety drops and you start looking at the period after treatment. On the other hand, if no treatment is mandated such as with Active Surveillance, one lives in a purgatory-like situation never knowing exactly where they stand. So a PCa diagnosis is a curse no matter how it turns out, you cannot un-see the diagnosis and pretend it never happened.

You will make it through this, we all do.

[quote= "Should I get a 2nd opinion"

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Absolutely. Get it from Johns Hopkins. Even though Dr. Epstein is no longer there, they have a staff of highly trained pathologists with experience reading PCa slides. And, it's just as important that you get it if you have a PCa diagnosis as if not. I had a friend whose garden-variety pathologist graded him G7. It was really a G8 and G9; highly unusual patterns that JHU was able to identify. Much different treatment approach.

Jim

Very good advice and good info with those John Hopkins links. I might just pay for that 2nd opinion if I can't get insurance to cover it. I have one other question I'd like to ask.

1) "Not differentiated" vs "poorly differentiated"??? I think the news may be good in my case at least as far as what the MRI report says. Since "poorly differentiated" cells differ greatly from normal cells a reading of "Not differentiated" would mean they appear to look like and are likely just normal cells, is this correct? I can't find anything online to specify poorly differentiated vs not differentiated. I know that the biopsy results are the only thing that can verify the MRI report but if the lesion cells are not differentiated from the other ones the pathology report would have a better chance at showing nonaggressive non mutated cells and hopefully a low Gleason score.

"There is a focal region of early enhancement measuring 1.1cm at 3:00 in the left peripheral zone at the mid gland. This is not differentiated from the remainder of the patchy T2 hypointense signal throughout the peripheral zone. It does demonstrate early enhancement and may have washout. On diffusion there is mildly increased signal and mild decreased signal on the ADC map PIRADS 4

Prato has the right idea, you can not change anything by worrying and even when you have some information, the adventure has to play out which takes time, no shortcuts.

I peppered my late father with questions as my adventure unfolded (he had PCa but heart got him at 96). He said: "You are beginning to over study the cancer issue. At this point you should be looking at other issues. If you keep studying the problem, you may have to make application for medical school. The path you are on has a lot of waiting with few decision points for virtually the rest of your life. When you reach one of these decision points and you want to discuss it, I’ll offer comments if Alzheimer’s hasn’t got me in its grip.

Do not confuse MRI and pathology with regard to "differentiated cells", apples and oranges. The MRI is an aerial view that may make some macro observations vs. a microscopic analysis. Only pathology looks at the actual cells and makes that determination. More waiting....