Will be going for follow up imaging and i see experts here recommend 3T mp MRI
The centre i am going to says they have a new Vida 3T MRI but they were not familiar with the mp acronym. i understand the key is 3T is 2x SNR of the 1.5 for better spatial resolution, but the multi parametric part - is that part of the Vida or should i be seeking a new imaging centre?
And is there anything else i should be checking on - they say this is a new machine in Nov 2019 and that they do prostate everyday.
Thank you so much, 45
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45RPM
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Multiparametric MRI is actually 3 different scans on the same (3T) MRI machine: T2, DCE, and DWI. The center you go to has to have a radiologist experienced at reading those 3 different scans and analyzing them using a system called PIRADS. The machine matters less than the radiologist.
Neither of those people are radiologists. It's a common error. Radiologists are doctors who read scans, like MRIs. Radiation oncologists are doctors who treat patients with radiation.
No one comes to mind, but I'm sure SCCA or Swedish have good radiologists. Call and ask how much experience they have at reading multiparametric MRIs.
May I ask what the mpMRI is for? From your profile, it seems like you've already had a biopsy, and it is usually given to target a biopsy. You seem to be a great candidate for active surveillance. If that is what you want it for, it should be done in conjunction with a targeted biopsy. Such "confirmation biopsies" are done within a year of the first biopsy - there is no rush. Many top institutions fuse the image from the mpMRI with a real-time 3D ultrasound image to guide a biopsy. (Some places (very few) actually do the biopsy while you're in the MRI machine.) If that is your intention, you have to ask if they do "fusion biopsies" as well.
If you are contemplating treatment... Some surgeons like to have one to help plan their surgery, but you may not need an mpMRI for that. If you are planning on having radiation, they will require a CT and an MRI after fiducials have been placed, so you would be getting the wrong type of imaging for planning. You should let the therapist, whether a surgeon or a radiation oncologist, specify the kind of imaging he requires to do his planning. BTW- if you want a top radiation oncologist in the Seattle area, I recommend Robert Meier at Swedish.
Yes of course, i appreciate you asking and your recommendation on RO.
While i am not driving the decision to go for the MRI (my RO suggested it), I understood the intent was to determine more the extent of the cancer, and whether it has left the prostate, to aid in the decision of treatment or not. I could be mistaken and i will speak to my RO next week.
Here's the thing for me though - based on the info I have now, plugging into the models, the risk level is intermediate, somewhere between favourable and unfavourable. My Dr's refer to ncaa and recommend treatment due to my life expectancy. They are concerned it is more unfavourable - my RO says the PNI and the low PSA complicate - he says 5% of men have PSA which doesn't indicate - or as you say, is it because 'cancer amount is low'? To be prudent, this uncertainty causes me to tilt towards unfavourable treatments. Of course i prefer AS, but would rip this sucker out in a heartbeat if i had more info that pointed towards a more aggressive cancer - it worries me a bit that a year ago it was not detectable at that point (or my GP missed it?), so it grew over a year to be detectable (?). And it worries me that the 12c biopsy is random and that it doesn't get to the back of the prostate, so there is a material chance that growth risk is underestimated at this point. The models seem helpful to bucket the average patient population, but they are not me specifically. So data, data, more data please is what i am thinking now and hoped the MRI was going to help, or at least it can't hurt?
Looking for input on what other possible tests or opinions i can gather to help me decide between AS and some treatment - so any suggestions are appreciated.
I apologize: I didn't notice the PNI, so you are right, that makes AS more problematic.
So moving on to treatments, I still don't really understand why your RO is asking for an mpMRI. If you have extracapsular extension or SVI, the radiation planned target will be contoured to include that bulge plus a comfort margin around the prostate. Your RO will require an MRI and a CT scan (after fiducials are placed) to plan the target volume.
I do not agree with you about "data, data, more data please." Tests are only useful if they can potentially change treatment decisions. If they can't, they add to costs and anxiety.
Curious if the MRI can detect more aggressive cancer in the prostate and confirm if it has left the prostate? And i understand the MRI may miss cancer that has left?
I understand the point on data - only if it is needed to assist in treatment decisions.
An mp MRI cannot detect cancer. It can only detect regions that are suspicious for cancer. The only way to detect cancer is with a biopsy. You've already had a biopsy. When you say "left the prostate," I think you mean that it extending beyond the prostate capsule. Both the planning MRI and the CT will show that, and the RO will contour the beams to account for that (but the CT has to be done after the fiducials are inserted). An mpMRI will not show distant metastases because it will only image the area immediately around the prostate. If you were high risk, they would look for distant metastases using other kinds of imaging.
The reason it's not factored into the risk stratification models is because it's a minor risk factor compared to Gleason score, stage, and PSA category. There are a host of such minor risk factors (e.g., PSA density, African-American, age, cancer volume, heredity/genomics, etc.) that may make a difference when one is on the fence about AS vs treatment. There is some controversy about whether it really provides any information after risk category is taken into account.
Arguably, it may also be useful in "unfavorable intermediate risk" men in deciding whether to add any ADT to their radiation treatment.
This explains about biopsy-discovered PNI (it's not an independent risk factor and is very commonly discovered in post-prostatectomy whole-mount pathology):
I did it in only 5 treatments. Especially during the covid-19 pandemic, shorter is better, and is recommended in current guidelines. Robert Meier is one of the experts at this.
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