Non-invasive diagnostic for prostate margin determination

[EaNa]

Is there any noninvasive diagnostic (CT-scan, MRI, etc.) that can determine with reasonable certainty if there is cancer in the prostate margins or extracapsular involvement without having a prostatectomy? I’m looking for something more certain than nomograms and other types of statistic tables.

[dentaltwin]

Not to my knowledge. In fact, my pre-op MRI was read as "suspicious for extracapsular extension"; but the surgical path found the tumor confined to the gland. Just to be clear--based on the biopsy I was going to get the RP anyway, so the postop path was a big relief.

[EaNa in reply to dentaltwin]

Interesting. If you don’t mind, what was it in your biopsy that made you decide to go for the RP? Thanks!

[dentaltwin in reply to EaNa]

As opposed to active surveillance? Or as opposed to RT?

[EaNa in reply to dentaltwin]

As opposed to RT if that was a choice you had.

[dentaltwin in reply to EaNa]

In retrospect, it was at least partly an emotional decision. Most studies find results very similar, at least out 10 years. Some have shown a slight benefit for RP if you go out far enough.

The real expert here is Tall_Allen, who gets far more granular with specific flavors of RT for low-intermediate risk PC.

In my case several years ago I had a (dental) patient who had had RT as primary therapy. He had a recurrence, followed by rescue surgery. The results were not good--he developed a chronic urethral-rectal fistula, and wound up in a nursing home.

Now, that was perhaps an overly-dramatic example of a general truth (which I know professionally from cases of head/neck cancer)--that surgery in tissue that has been irradiated is...challenging. Rescue RT after surgery is less risky.

I should point out that I did NOT consult with radiologist prior to therapy; my father had had advanced PC; my younger brother had also had PC treated at MSKCC probably 8 or 9 years prior to my diagnosis, so my inclination was to go that way anyhow. I was also upset that my former internist (now retired) had been watching my PSA rise steadily over the course of 6 to 8 years without notifying me before my new internist did a PSA and told me to see a urologist. I was already (so I thought) several years late with a diagnosis, and I wanted (probably unnecessarily) to move quickly.

My point here is that the decision process for me was not exactly balanced. Mind you, I'm doing well and overall I'm not disappointed with the result. In early to moderate disease either can work well. Sometimes it's tougher to make a decision when you're faced with 2 apparently equally satisfactory choices; still, it's better than a dilemma between 2 shitty choices.

[EaNa in reply to dentaltwin]

Thanks for that reply. I'm in the position of having two equal choices and having to make a decision. Hardest decision in my life for sure. When I posted this question I thought perhaps there was a way to decide if one could find out with some certainty if there's anything going on at the margins w/o RP, but it looks like that's a dead end. Now talking to my RO I found out that even if there was it doesn't automatically translate to adjuvant therapy, there's a possibility that the PSA never rises or that it does very slowly. It's all so much more complex than I even imagined. Now I understand why they keep saying the decision should be based on whatever you feel more comfortable with and possible side effects from each, not much more.

[dentaltwin in reply to EaNa]

If there were strong statistics one way or another, they would be out there. (They are, too, but most of them are still fairly close). In any case, I strongly suspect that the skill of the surgeon or RO is far more significant to the outcome than the choice between RP and RT.

Best of luck to you.

[Tall_Allen]

No. MRIs have low sensitivity for EPE.

europeanurology.com/article...

[EaNa in reply to Tall_Allen]

Thanks!

[dadzone43]

No. Think about it: marginal extension is a _microscopic_ event. No external machine currently provides that precise an image.

[EaNa in reply to dadzone43]

Is all extracapsular extension microscopic?

[dadzone43 in reply to EaNa]

I would say it _starts_ microscopic. Eventually it grows big enough to be seen on MRI. The more practiced the radiologist, the earlier it can be discerned by MRI.

[Currumpaw]

Hey dadzone43!

You would know. You are the man with the certificates on the wall!

Currumpaw

[EaNa in reply to Currumpaw]

[tsim]

This is something that is still in trials but has promise for the future. Spectroscopic MR mapping of the prostate and surrounding regions for citrate and choline levels. I don't believe anyone is doing commercially yet. Can be done on 3T magnets but best on higher field. Many initial trials were done around 2012-2013, not sure why this is moving so slowly.

onlinelibrary.wiley.com/doi...

[EaNa in reply to tsim]

Thanks!

[doc1947g]

I guess it depend if they found tumors close to the capsule.

For me the TRUS did not show anything. But the biopsies were G(4+3=7) Grade 3, Unfavourable Intermediate Risk. with perineural invasion in my Right lobe.

Then when they did the Planning CT-Scan, they founded many tumors in both lobes and a few very close to the capsule.

So VMAT in the whole pelvic area including the prostate, the 2 Seminal vesicules and the pelvic Lymphes Nodes and ADT.

Now my PSA = 0.03 ug/L & Testosterone = <0.2 nmol/L or <5.7684 ng/dL.

[EaNa in reply to doc1947g]

Thanks. I'll have to ask about my CT-scan, what can be inferred from it.

[doc1947g in reply to EaNa]

Every thing will depend of the size of the tumors. If they are too small, you will not know.

For me there was one very close to the left capsule near the base( close to the bladder) and another one very close to the right capsule near the apex, and a third one very close to the right capsule neard the middle third.

Very unlucky with a very aggressive PCa.

[EaNa in reply to doc1947g]

We're gonna be Ok. We'll be PC palls.