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Active Mgmt & MRI guided biopsy


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Old 08-09-2018, 02:59 PM   #1
ohawk
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Active Mgmt & MRI guided biopsy

Recently diagnosed with prostate cancer (Gleason 3+3) and have decided to follow the active management route for the time being. I am 69 years old. I had the transrectal biopsy done initially followed up by the MRI guided version which confirmed some presence of cancer.

My question is can I request the MRI guided version for any f/u biopsies in the future vs the transrectal procedure? I found the latter to be very painful vs the MRI version under general anethesia. Seems like the common procedure for active management is the transrectal approach. Am I sacrificing anything by requesting the MRI version? Would the MRI version be approved for insurance purposes? Would most doctors honor this request?

Thanks.

 
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Old 08-11-2018, 12:40 PM   #2
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Re: Active Mgmt & MRI guided biopsy

Hi ohawk and welcome to the Board!

You raise an interesting question that poses a logical scenario – use of mpMRI guided biopsy for follow-on biopsies instead of just transrectal ultrasound (TRUS) guidance. I had not run into this question before, but, if it were me, I would want the mpMRI at least for the confirmatory biopsy that is done at the one year point.

As you are new here, you may not yet have discovered the wonderful resource known as PubMed that we pay for with our tax dollars. (It’s under the NIH’s National Library of Medicine, and it electronically displays descriptions in English of studies published all over the world. It’s highly searchable. I just searched www.pubmed.gov using this string – follow-up MRI guided biopsy AND prostate cancer – with filters activated for humans and publication within the past five years (easy to do – just two clicks on the filters at the left), and got 86 hits.

One of them was a study in the US published within the past few months, https://www.ncbi.nlm.nih.gov/pubmed/29732281 , and it had the following key sentence, which confirmed my impression: “…At present, no robust data is available to recommend the substitution of regular biopsies with mpMRI in the follow-up of patients on AS and efforts are being made to determine the role of integrating genomic markers with imaging with the objective of minimizing the need of biopsies during the follow up period….” In other words, doctors don’t have published studies yet that strongly support this approach – I’ll emphasize the words “at present” and “robust” in the sentence. It seems they are looking forward to this to add to some existing but non-robust data already in hand, and by the time you need it, in a year, there is a fairly good chance that there will be some published studies that support it.

I only looked at a few of the first hits in the list, and you may get a more definitive answer from checking some of the other studies. As this field is fast moving, it's quite possible that the authors of the study I cited did not know of other work being published during the time their study was under review and final preparation for publication. By clicking the + sign for author information, you can see where the authors work, and you could search for other studies by the same authors. There are a lot of ways to use the PubMed tool. Try it for active surveillance if you want to have some fun.

In the meantime, I think it’s fairly likely that some insurers would support it while others would not. I suspect that a doctor who supported mpMRI guidance for the initial biopsy work would be willing, if not eager, to do it again. Use of mpMRI is advancing rapidly. Also, there are now some good genetic tests that can help sort out the potential of AS for a specific patient, and more useful genetic tests are no doubt coming soon.

Good luck.

 
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Old 08-11-2018, 01:03 PM   #3
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Re: Active Mgmt & MRI guided biopsy

Thanks so much for taking the extra time to research this. I guess the outcome of these studies will likely have our answer of one vs. the other for f/u in active mgmt cases.

When I asked my urologist after the initial cancer meeting he seemed a bit surprised by the question and simply said I've never proceeded that way using MRI. I'm under the impression that the transrectal approach is more like a shotgun and the MRI biopsy approach is more like a rifle. Can the MRI approach also take 12 core samples from various parts of the prostate? If so, it would seem they are doing the same thing. I could understand why MRI might not be used for f/u if the costs are much higher and the equipment less available but I'm trying to avoid the unpleasant transrectal procedure IF the MRI approach is at least equal in monitoring for add'l cancer progression.

In any case, thanks for the response and references.

 
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Old 08-11-2018, 05:22 PM   #4
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Re: Active Mgmt & MRI guided biopsy

You’re welcome. I’m glad to help.

Actually, the multiparemetric MRI is independent of the biopsy method: theoretically you could take just six biopsy samples, as was done some years ago, or you could take 12, which is fairly common, or you could take more, all the way up to a “mapping’ biopsy where a core is taken every 5 mm throughout the prostate. (It hurts just to think about that.) Moreover, the cores could be random, or from typically used target areas, or at least in part guided by input about possible or likely target areas as seen on the mpMRI. The latter is what happens with an mpMRI guided biopsy, and that approach makes a lot of sense to me. Multiparametric MRI is very good at detecting areas of potentially significant prostate cancer; it makes sense to sample tissue in those areas with biopsy cores.

In a way the transrectal TRUS guided biopsy is similar to a shotgun approach as there isn’t much effective targeting, beyond some fairly vague clues from the TRUS imaging; the probes are spread over the whole prostate, but each probe can be “responsible” for a fairly large area, and it may miss a tumor that is aggressive but fairly small. On the other hand, in a way the mpMRI imaging is like a shotgun because it covers the entire prostate rather thoroughly; then the mpMRI guided follow-up biopsy cores are like rifle shots at the promising areas. There is hope that someday, possibly in the near future, mpMRI will be so good that biopsies are no longer necessary. There is a lot of “buzz” about that in the active surveillance medical community.

 
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Old 12-06-2018, 03:51 PM   #5
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Re: Active Mgmt & MRI guided biopsy

I chose active management as my course of action for the time being and will now be having my first visit with my urologist since being diagnosed with prostate cancer (Gleason 3+3=6, 1/3 cores involved, <5% total volume, and no perineural invasion or extra prostatic extension). I believe it is classified as T1C and notes on the pathology report indicate the location of the cancer as right mid. Also, I did get a 2nd opinion on the pathology reading and it was confirmed as originally read. I am 69 years old and there is a history of cancer in my family. My father had prostate cancer but did not die from it.

I am now having my first six month f/u appt with him since meeting with him to learn of my cancer and discussing treatment options. This will not be a biopsy as he scheduled that for 12 months after the initial confirmation. Are there any other factors moving forward that I should be aware of besides PSA levels and biopsy results? Other questions you might ask of the urologist at this point in my situation?

Thank you.

 
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