Multiparametric MRI (mpMRI) over diagnosis?

Well I have a similar but also not similar problem with my MRI.

2021 MRI had 1 pirads 5 lesion transition zone, biopsy (trans-rectal can only hit posterior transition zone) - result was a 3+3 and nothing else on other needles
2022 MRI had Pirads 2 at same location (transition zone), basically MRI report downplayed anything at all - no biopsy as a result.
2023 MRI had no pirads rating at all - but due for biopsy since I had the original reporting cancer - so they went ahead with trasnperineal biopsy. Biopsy had 4+4 in the anterior transition zone (original lesion but with transperineal they reach anterior transition zone), and another needle on one side had 3+4. All other needle nothing. Doctors say MRI show nothing but on sending out MRI images Dr Scionti in FL says look at the diffusion weighted images and you can see both lesion crystal clear. I can see them on my laptop too but looking at diffusion weighted not the contrast enhanced images. PSMA confirmed. Had Tulsa Pro.

My conclusion is the MRI contrast dye does all kinds of weird things, for me at least diffusion weighted MRI images are the way to go along with PSMA. Contrast dye type MRI doesn't work for me. PSMA is better than contrast MRI, showed my lesions exactly as do diffusion weighted MRI.

@bjroc: Thanks for the helpful post! Your experience with an “under read” MRI is interesting. I asked my doc whether I should get a 2nd opinion on my MRI, AFTER receiving the results of my biopsy.

This all happened quite fast, if had known how “operator sensitive” MRI readings can be, I may have waited before getting my biopsy.

Getting a PIRADS 5 lesion report made me think the worst…only to find it was Gleason 3 + 3.

Of course, I’m thankful it wasn’t worse. I decided to go with AS and have significantly changed my diet and upped my exercise routine. I have already lost 8 lbs since I started 5 weeks ago.

Now I’m waiting for a 2nd opinion on the biopsy, a Decipher analysis of the biopsy cores and my first PSA result, which will be taken 3 months after my biopsy.

What is an MPMRI?

The 1.5T MRI should be accurate in identifying the troublesome spot. Probably not going to tell you much more than that.

I think you are trying to minimize the results (very much like I did). You don't mention your age. It is a pretty important variable that matters.

No need to rush to treatment but ....

Just found your other thread.
https://connect.mayoclinic.org/discussion/selecting-active-survelliance-based-gg1-and-small-amount-of-gg2/
If it were me, I would wait another 6 months, check my PSA (I would not want to have another biopsy) and take it from there.

Why would I say that? I waited almost 6 years and watched my PSA go from about 6 to 18 over that time. I am not suggesting that you should wait until your PSA is 18....in fact I think 12 or so might be the sweet spot.

In most cases, prostate cancer is very, very slow growing but everyone's risk profile is unique and it is you who ultimately has to make the big decisions. It isn't easy but we all wish you the best.

@ ozelli:
You are probably right, I’m still in the “denial/minimization” phase of the diagnosis.

That said, I have learned and implemented an immense amount information regarding the contribution of diet and exercise to overall prostate health, in a very short time.

I’ve been a researcher for 45 years and prostate health and its disease have become my latest research project 🙂

At this point, my plan is to do exactly as you indicate. The last 2 months of my life have seen a whirlwind of change and, surprisingly, they have been for the good (besides weight loss, local joint inflammation issues have vanished).

I enjoy my new diet; along with the increase to 10 miles/week of running exercise.

So the first benchmark will be my 3 month PSA result. If it continues to increase, along with the subsequent 6 month PSA result, then I will feel I’ve done everything possible to slow the progression via diet/exercise and it’s time to get serious regarding some type of treatment.

However, I need to move in my current direction to assure myself that treatment is really necessary (in my case) and to determine if there may be another way to address my particular situation.

Thanks for your comment!

We started the same Pirads 5 and a 3+3, I hope you end there with all the stuff you are doing. Perhaps the contrast dye stops working well in some people or who knows what happened after my original, just I know enough to not trust these contrast MRI as speaking for me now. At one time I found there are like 5 makers of MRI contrast, maybe some are better and some are not so good. Hard to say that will happen to you, but it is possible. I always had 3 T MRI, but the weak point for me seems to be the contrast dye not the MRI machine. The MRI machine picks up what I have on diffusion weighted, so the machine is picking things up.

Just some other thoughts....I didn't find Decipher that useful, interesting but not that useful. Sometimes the differing genetic tests disagree too because they look at some differing SNP's. I still had decipher though. Also on biopsy second opinions, not too sure on that without Epstein anymore. Not sure I would opt for what is out there, seemed like some political grabs took over prostate biopsy second opinions and I had enough politics at work (now retired) to last a lifetime so no need for more.

What is an MPMRI?
multi-parametric magnetic resonance imaging, sometimes shown as mpMRI or MP-MRI.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2747475
[This is a link to a fulltext article from 2019 that supports the use of mpMRI to improve diagnosis.] In 2022, my transperineal biopsy was actually "guided by" an mpMRI conducted a day or two earlier using ultrasound. This resulted in very successful targeting of the biopsies that was confirmed by the pathology after the radical prostatectomy a month later.

@ bjroc:
I’ve read and heard mpMRI’s are known for their lack of consistency among interpretations by radiologists and that one is not “fully trained” until having seen nearly a 1000 or so scans. Don’t know about “contrast dye” vs “diffusion weighted” interpretations, but I appreciate your experience.

Regarding genomic testing, I spoke to someone from Myriad Genetics about the Polaris test, but my doc recommended Decipher when I asked that genomic testing of my biopsy cores be performed.

My reasoning is that genomic test is another independent, risk assessment tool. Apparently the Decipher test is the only gene expression test with Level 1 evidence for validation, as it compares the genetic fingerprint of one’s PCa to that in their database of >110K men, regarding the propensity of ones cancer to metastasize.

Since my diagnosis, at this point, is technically “Intermediate Risk - Favorable”; if my Decipher score is under 0.50 it will mean my PCa’s “genetic fingerprint” indicates it is no more likely to metastasize as a man with a “very low risk” or “low risk” diagnosis. This will boost my confidence regarding my AS decision. Of course, if higher than 0.5 the reverse will be true. Genetic info is a double edged sword….

At this point, I’m comfortable with the reasonable risk approach of AS. Especially when juxtaposed alongside the high risk of short term side effects and significant risk of longer term side effects of ALL treatments options for which I’m currently aware.

I do think you are doing all the right things from sound of it.

The thing is diffusion weighted MRI is the way all MRI of other places in body work to pick up tumors. Have an MRI of the brain looking for tumors, well they are going to look at diffusion weighted images. So it is a inherent part of MRI itself, unlike contrast agents which are external and injected. All my MRI of prostate went through Mayo, even several radiologists. None used the diffusion weighting so contrast has too much say in the prostate field - at least it says that to me.

With genetics there can be 50 differing polymorphisms (SNPs) that pooled together give a kind of risk probability. One company may use 12 of the SNP's, another company overlaps and does a few more. Probably none uses all the polymorphisms known as relating to PCa. But some tests are slightly better - but it is still a bit Las Vegas right now. One still does it to confirm AS, but some places just look at BRCA1 gene or something I understand. For whatever reasons they say it is just as good as an indicator, but I can't say why. Hopefully the insurance covers it too as it can get tricky on those tests.

Thanks for the MRI information.

From my research, the BRCA1 gene (and others) are evaluated via “germline genetic testing” from a person’s DNA profile obtained from blood or saliva samples. It is looking for inherited genetic mutations.

“Genomic testing” is done on cancerous tissue taken from the prostate (either biopsy or after RP) in order to provide information about how one’s prostate cancer might behave in the future.

Decipher, Prolaris and Oncotype DX are genomic tests, all of which vary in purpose but are used to evaluate aspects of the genetic makeup of the cancer cells themselves.

For those in my situation (initial diagnosed with low or intermediate risk PCa) it seems genomic testing would be the only one of interest.

For advanced PCa, where the efficacy of various ADT therapies are in question, genetic germline testing may be useful to determine the “best” chemical treatment.

Of course, family members who are curious as to whether they have inherited a genetic propensity toward PCa, because it runs in the family, may also take this particular germline genetic test…but I’m not sure what they would do about a “positive risk” result.

IMHO there are some questions that are best left unanswered. It may be easier to live with this kind of a question, than an undesirable answer….but others may think differently….