Most useful imaging for treatment decision options

I have not undergone any treatsments (yet).

I have been thoroughly evaluating radiation monotherapies (SBRT or HDR) vs RP.

You want to be using a very good Cancer Center with an excellent Radiation Oncologist. They will help you decide imaging.

From my experiences:

1. Updated MRI and Biopsy data are necessary starting information. Size of lesion(s), Pirads rating, Gleason Scores, number of positive cores, any Extracapsular extension, etc.

2. This initial information will help determine if PSMA PET should be completed. Lower PSA range, Pirads 3 or 4, lesion(s) not touching capsule wall, Gleason 3+4, and things like that may be enough info to not proceed with PSMA PET.

If there are concerns, the PSMA PET is more to help provide information that no detectable cancer is found outside of prostate.

I would think it is rare to have a PSMA PET prior to an MRI, when it has been 4 years since last MRI.

MRI, Biopsy, PSMA PET if needed.

After a determination is made to proceed with Radiation treatment, you will want some further non-imaging tests.

Prostox is DNA based to help predict individuals who are at a higher-risk for radiation toxicity.

Genetic testing is also good information.

Find a good cancer center/facility with incredible Surgeon/urologist and Radiation Oncologist and great test equipment, then proceed with updated MRI/Biopsy.

Let this initial info guide next decisions.

A CT scan and an MRI are frequently what they ask for. The PSMA pet scan isn’t really necessary for brachytherapy treatment. When they decide to do that, they’ve already got information about where the cancer has spread.

Unlike, IMRT or SBRT, they are not going to go treat bones or remote tissue, They are going after the prostate.

Frequently Another radiation treatment is also done at the same time as brachytherapy, And they can treat the other spots that way. Then all the scans are useful.

You’ve probably already had an MRI (in order to have an MRI-guided biopsy).

And you’ve probably already had a PSMA PET scan to check for metastasis

They each play a role in treatment.

My MRI was done in April of "22". My biopsy, which was random 12 core type, was done in December "25" after 4 years of active surveillance. Biopsy showed two 3+4 cores with 40% in one and 70% in the other. No other concerning traits, decipher .38 . It seems an updated MRI may be helpful to get a current picture of prostate status. There is always some question how many artifacts interfere with reading imaging with my hip implants, but they have gotten better at that now I believe.

I'm going to go with what @charlesprestridge said.

In the world of decision making on treatment, every scrap of data counts.

My medical team and I always ask ourselves, "will this inform our decision?"

I'm not naive enough to believe that a "NED" result from a PSMA PET means one's PCa is localized, just given its sensitivity, nothing seen. Of course, there is always the too small to be seen, micro metastatic PCa.

But, given the clinical data you present, a negative PSMA PET could provide further confirmatory clinical data of your decision.

So, unless one's insurance company is digging in its heels and saying no, were it I, my medical team would be putting the order in!

As an aside, I am working with a friend who was just diagnosed, his clinical data so far, T2C, GS 3+4, 16/18 cores "hot," two with <15% GS 4...the other all GS3.

His team at MSKCC ordered a PSMA PET in addition to his MRI.

Kevin

@mtsenior

With two 3+4 cores, I would 100% get an updated MRI.

However, more important for me would be finding a great cancer center and great Doctors.

I cannot imagine going to my Radiation Oncologist and Urologist/Surgeon, without an updated MRI. It is a critical piece of information. MRI and Biopsy are both part of foundational info.

If you do not feel very comfortable with your medical team, search out true experts.

My L4-S1 lumbar fusion, with two rods and six screws, has not been an issue with Prostate MRI’s.

Best wishes

I am in agreement with everyone's comments. Sometimes decisions become foggy with all things to consider with this disease and trying to make the best decision. Great to have a group of people to clear things a bit.