Use of MRI in Diagnosing and Managing Men with Prostate Cancer
INCREASING THE ACCURACY AND SELECTIVITY OF MEN WITH PROSTATE CANCER.
Multiparametric MRI (mp-MRI) imaging has recently been employed to determine the location and volume of prostate cancer in men with elevated PSA, as well as recurrent prostate cancer. Studies of magnetic resonance (MR) spectroscopic imaging (1H-MRSI) have been done in conjunction with dynamic contrast-enhanced MR (DCEMR). In combination, these studies have shown a significant improvement in the detection of men with higher grade prostate cancer, extension of prostate cancer outside the prostate, and recurrence of men previously treated. This is with a sensitivity of 86% and a specificity of 100%.
Mp-MRI is state of the art at detecting and localizing both newly diagnosed and recurrent prostate cancer. I have utilized multiparametric MRIs for a number of years at Southwest Diagnostics at Presbyterian Hospital with improved accuracy, and in the past six months have started referring patients to UTSW where the results have been astonishing. At UTSW using endorectal MRI on men with suspected prostate cancer, using a Likert score of 1-5 (in conjunction with fusion ultrasound) 87% of men with Likert 5 have been found to have significant prostate cancer and in 48.8% of men with Likert 4 have been found to have significant prostate cancer.
Prostate cancer is the second leading cancer in men, 250,000 new cases diagnosed per year and 30,000 men dying from prostate cancer per year. These figures do not include men who develop metastatic disease which affects their quality of life.
These numbers tell us two things. 1) More men are diagnosed then are dying and 2) We are either doing a great job of treating prostate cancer or are diagnosing too many men?
The PSA screening test (prostate specific antigen) has been much maligned by the government. But, the truth is that we have decreased death from prostate cancer by 70% in the last 20 years and those numbers are mostly due to better early detection with the PSA test.
Now our task is to make sure that we are not over-treating men with prostate cancer and treating appropriately men who have been diagnosed based on the aggressiveness of their cancer (grade) and extent of their cancer.
MRI (magnetic resonance imaging) is providing me with useful information and is considered better than any other imaging modality. Up until recently, the standard treatment for men with an elevated PSA (taking into consideration free to total ratio and a PCA3 which is a urine test for prostate cancer gene) my accuracy with random 12 core biopsies has been approximately 45-50%. Unfortunately, some of the men who are diagnosed have low grade disease (Gleason 6) which recent studies show with the use of active surveillance, there is no impact on mortality at 10 and possibly 15 years. The charge for urologists then is to find only the men with higher grade disease (Gleason 7 and higher) who are at risk ot having their lives impacted either in terms of quality or longevity. At the same time, we must find the appropriate treatment for these men.
The urologic and radiologic literature is full of studies demonstrating that MRI is an accurate way of diagnosing men with prostate cancer and determining if there is any extension of the cancer outside of the prostate. With the addition of special software, one can take the images from an MRI, fuse them into an ultrasound in such a way that the specific lesions that are identified with the higher Likert score other than targeted. As I mentioned previously, men with Likert 5/5 at UTSW have a 95%+ chance of having prostate cancer. Likert 4 is 50% which is still greater than the random biopsies. Moreover, few of the men are diagnosed with a low grade insignificant cancer. Additionally, if, in fact there is extension outside the prostate then the surgeon can attempt to go wider on that side or, if necessary, take the neurovascular bundle on the involved side. This leads to greater chance of success with surgical excision as well as selecting men who would be better served by radiation therapy. With this new modality, we are well on our way to appropriately diagnosing and treating of men with prostate cancer and leaving men alone who do not have significant disease.
Needless to say, the biggest issue at the present time is not the men undergoing the endorectal MRI but rather the insurance companies willingness to cover this test. Hopefully, as time goes on, more studies will demonstrate its utility and result in it being accepted into standard urologic guidelines. Below you will find more information regarding MRI in general.
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