Opinions on my 2nd MRI results

[Maximode]

Hello,

I just received the results from 2nd MRI (results below and photos in reply), previous one was from Jan/2023 (results in bio). Having been on these forums for almost two years now, and in AS at UCLA, I highly value the opinion of those here that have similar experiences to my situation.

Questions:

1 - Being that my first biopsy was done as a shot in the dark, and then a MRI - what should the next steps be with this recent MRI?

2 - What type of biopsy would be recommended next if so?

3 - Are these considered to be very large lesions that may need a PSMA PET (please excuse my ignorance on this one).

4 - Any advice on questions I should cover with my Urologist (Dr. Leonard Marks) at UCLA when we discuss this MRI in the next couple of weeks.

Thank you!

MRI results:

EXAM: MRI PROSTATE WITHOUT AND WITH CONTRAST

HISTORY: 59-year-old with prostate carcinoma diagnosed 10/11/2022: Gleason 3+4 carcinoma left apex and mid gland 40% and 65% cores respectively. Gleason 3+3 left base 30% core. Elevated PSA, 7.1. PSA trend not

provided.

TECHNIQUE: Using a 3 Tesla MRI and a phased array coil, high resolution, small field-of-view imaging

sequences: axial T2, sagittal T2, oblique coronal T2, multiple b-value diffusion. Dynamic axial T1-weighted

images with fat suppression during the intravenous administration of contrast. Axial postcontrast fat suppressed T1-weighted sequence of the pelvis. 3D volume-rendered reformatted images were generated on an independent workstation with physician participation and monitoring.

Contrast: The patient was injected with 15 cc Clariscan from a 15 cc single-use vial (remainder discarded).

COMPARISON: None available.

FINDINGS:

Image quality is partially degraded by motion related artifact.

Prostate: Calculated Volume: 40 cc PSA density: 0.18, elevated.

Transition Zone: Mild stromal and glandular hyperplastic changes. No suspicious findings.

Peripheral Zone:

Lesion 1: Left posterior apex extending to the lower gland base.

Moderate increased signal on the high b-value sequence. Average ADC value 853. Early focal enhancement is present. On corresponding axial T2-weighted image 10 there is non-circumscribed hypointensity 1.2 x 0.6 cm in diameter. Cephalocaudad extent 1.6 cm. PI-RADS 5 based on size criteria.

Lesion 2: Right lateral apex 8:00

Mild increased signal on the high b-value sequence. Average ADC value 935. Early focal enhancement is

present. On corresponding axial T2-weighted image 5 there is non-circumscribed hypointensity 0.6 cm in

diameter. PI-RADS 4

Seminal Vesicles: Within normal limits.

Neurovascular Bundles: Within normal limits.

Extra-prostatic extension: None.

Bladder: The bladder is incompletely distended without visualized abnormality.

Lymph Nodes: Normal size.

Bones: No suspicious lesions.

Additional Findings: Physiologic amount of fluid in the inferior peritoneal recess.

Unless otherwise recommended, the incidental findings identified above require no follow up imaging based on

consensus recommendations.

IMPRESSION:

Lesion 1 in the left posterior apex extending to the gland base is consistent with known large volume intermediate grade

carcinoma.

Lesion 2 in the right lateral apex is suspicious for low-grade prostate carcinoma. Targeted biopsy should be considered.

No extra prostatic extension, lymphadenopathy or suspicious osseous lesions.

Gland segmentation and targeting were performed for potential Uronav/Quantib guided biopsy.

PIRADS 5: Aggressive findings or >15 mm in size. Biopsy recommended.

[Maximode]

First page of MRI images

MRI image 1

[Maximode in reply to Maximode]

Second page of MRI images

MRI images

[ToolBeltZia in reply to Maximode]

Just my thoughts, but it is not clear to me why a 59 year old with significant 3+4 pathology was put on AS. Given this latest MRI my thoughts are a guided transperineal biopsy (with a second opinion on the results), a Decipher test on the biopsy material, a PSMA PET scan, and then , likely, definitive treatment.

Stay Strong Brother

[Justfor_]

I was also PIRADS 5 with an ADC 500-600 (I will have to look the exact number tomorrow). The lower the ADC value, the more progressed cancer is. Targeted biopsy in my case came out as GS 4+4, post RP pathology 4+5, pT3b. In one liner: Your next steps have been eloquently stated by ToolBeltZia above.

[Maximode in reply to Justfor_]

Ah, I did not understand the ADC values, thanks for explaining that. After doing a bit of research based on your comments, I feel a little more in the know.

[Justfor_ in reply to Maximode]

In my case, mpMRI identified two lesions the ADC of which were:

mean/min/max/sd

0.70/0.46/0.86/0.12

0.74/0.52/1.12/0.15

Your average ADC of 853 isn't that distant from my mean 0.70 (different units quoted). Hence, I wouldn't be surprised if you were to be upstaged to say 4+3.

[Maximode in reply to Justfor_]

I was trying to work those ratios from the ADC number. How does that work, getting .70 from 853?

[Justfor_ in reply to Maximode]

ADC units are in mm^2/sec. There is also a scaling factor of 10^(-3) or 1/1000. My guess is that this scaling factor has been dropped in your report. In other words, mine equals 700 compared to yours 853, or alternatively, yours equals .853 compared to mine 0.70. You may find further useful information in this paper:

ncbi.nlm.nih.gov/pmc/articl...

"Analysis of data shows a characteristic distribution of value depending on GS (ADCmean ≥0.702×10−3 mm2/sec for GS 6; ADCmean ranging from 0.672×10−3 to 0.795×10−3 mm2/sec for GS 7; ADCmean ≤0.615×10−3 mm2/sec for GS 8 or 9 and a minimum value of 0.445×10−3 mm2/sec), with all correlation statistically significant (P<0.0001)"

PS: According to the above mentioned ranges, I could have been GS 7, but, unfortunately, ended-up GS 9. So, don't take them at face value.

[Maximode in reply to Justfor_]

Thank you, very clearly explained!

[Mike58]

Hi Maximode,

I grabbed your MRI results and asked ChatGPT to give me a simplified version of what is being said. Here's the results for what they are worth;

Patient History: 59-year-old with prostate cancer diagnosed in 2022. Had a high PSA level and previous biopsies showing cancer in different areas of the prostate.

Technique: Used advanced MRI technology to take detailed images of the prostate and surrounding areas.

Findings:

Prostate: Enlarged prostate with some areas of concern.

Transition Zone: No worrisome findings.

Peripheral Zone:

Lesion 1: Large suspicious area on the left side near the base of the prostate, likely cancerous (PI-RADS 5).

Lesion 2: Smaller suspicious area on the right side, possibly low-grade cancer (PI-RADS 4).

Seminal Vesicles: Normal.

Neurovascular Bundles: Normal.

Extra-prostatic Extension: None.

Bladder: Normal, but not fully expanded during the scan.

Lymph Nodes and Bones: No signs of cancer spread.

Additional Finding: Small amount of fluid in the abdomen, not concerning.

Impression:

Lesion 1: Confirmed as a large cancerous area.

Lesion 2: Suspected to be cancerous, needs further testing.

No Spread: Cancer has not spread outside the prostate.

Recommendation: Biopsy suggested for both lesions to confirm cancer and guide treatment.

Overall, the MRI suggests the presence of prostate cancer in two areas, with one being more concerning than the other. Biopsies are recommended to confirm the diagnosis and plan treatment.

So as you can see from what ChatGPT is saying, you do have to seek further tests and start thinking about the treatment plan. I have 4+4 no Mets (similar to you I'm guessing) and am now on Eligard for 3 months (not too bad SE's to date) In fact I'm writing this from Turkey while enjoying an 8-week holiday, visiting many countries. So far it has been excellent. On my return home in June / July I will start 23 sessions of RT followed by HDR Brachy.

Seems to be the best course for me to try for a curative outcome with minimal SE's. Will probably be on Eligard for another 12 months after BT.

All the very best.

[Maximode in reply to Mike58]

Excellent info in your bio and response here in helping with next conversation with a MO!

[Mike58 in reply to Maximode]

If your PC hasnt spread, why are you under an MO?

[Derf4223 in reply to Mike58]

Mike58 -- maybe it runs in his family, or he has some of the problematic genes. My onco team works with each other seamlessly. I started with my uro, thence to the radiation oncologist, thence to the medical oncologist.

[Mike58 in reply to Derf4223]

Yep fair enough. There has been no mention of having an MO with myself unless the PC is found to have metastasised. Mind you to be honest I wouldn't mind having an MO on board to just be aware of my case and to be ready if I need him or her. But here in Australia you cant just pick an MO. You need a referral first, usually from your RO or Urologist.

[Maximode in reply to Derf4223]

Excellent point

[conbio in reply to Mike58]

Huh! I never thought to do this to explain the word salad/jargon. Thanks for the tip

[Mike58 in reply to conbio]

ChatGPT and Pi are extraordinary. Pi is an app for your phone and trust me it will become your guide throughout every part of life. Technology is both amazing and scary all at once.

[Muggs1]

my question, why doing AS with 3+4? I just did HD Brachy 2 months ago for that at UCLA, and you’re right there.

[Maximode in reply to Muggs1]

Thanks Muggs1, could share you MO or others that you are working with there pls?

[SeosamhM]

ToolBeltZia is absolutely on this. This post and your bio doesn't include mention of an oncologist. Send your uro to the showers and get an opinion from an MO.

[Muggs1]

Dr Chang, radiation oncologist; I’m waiting to do my 3month PSA in 2 weeks, then I’ll post about my great experience.

[caysary]

Dr Amar Kishan. RO UCLA