-
Screening prostate MRI
No discussion on this? This is big news imo. Prostate MRI for screening will become standard in the coming years.
Imaging will continue to grow in importance and volume imo.
Let’s face it – many things we do in medicine are archaic with the currently available imaging techniques.
MRI is a complete game changer for prostate disease IMO.
-
32 Replies
-
I doubt it will grow significantly. The society doesn’t care about men’s health and wellness that much.
-
Quote from OnsiteRad
I doubt it will grow significantly. The society doesn’t care about men’s health and wellness that much.
If MRI becomes an alternative to non-targeted prostate biopsy, I imagine most men would prefer that than a probe and needle up in there.
-
Nah I can see this growing big time. Urologists will be the new orthopedic surgeons of owning their own MRIs.
-
we need to redo our Prostate MR protocols, our images look like crap
-
-
-
-
Quote from Waduh Dong
No discussion on this? This is big news imo. Prostate MRI for screening will become standard in the coming years.Imaging will continue to grow in importance and volume imo.
Let’s face it – many things we do in medicine are archaic with the currently available imaging techniques.
MRI is a complete game changer for prostate disease IMO.
I started reading these a few months ago. Easily one of the most soul-sucking , time-consuming exams to interpret, particularly when you throw in contouring on DynaCad. You are trying to pick up subtle/subjective pathology on a population that invariably have abnormal appearing glands.
With that said, volumes have really picked up significantly.
At this point in time, it’s too expensive and cumbersome of an exam to act like screening tomo. Even if one created a “Fast” equivalent used with breast MR. Think it’s a tough sell. We just don’t know enough about prostate CA. Many men die with this, not of it. I’m guessing there will be some type of blood/genetic test that will eventually be developed for screening purposes if needed-
Quote from jd4540
Quote from Waduh Dong
No discussion on this? This is big news imo. Prostate MRI for screening will become standard in the coming years.
Imaging will continue to grow in importance and volume imo.
Let’s face it – many things we do in medicine are archaic with the currently available imaging techniques.
MRI is a complete game changer for prostate disease IMO.
I started reading these a few months ago. Easily one of the most soul-sucking , time-consuming exams to interpret, particularly when you throw in contouring on DynaCad. You are trying to pick up subtle/subjective pathology on a population that invariably have abnormal appearing glands.
With that said, volumes have really picked up significantly.
At this point in time, it’s too expensive and cumbersome of an exam to act like screening tomo. Even if one created a “Fast” equivalent used with breast MR. Think it’s a tough sell. We just don’t know enough about prostate CA. Many men die with this, not of it. I’m guessing there will be some type of blood/genetic test that will eventually be developed for screening purposes if needed
Any good resources on Body MRI ?
-
Honestly, I feel like this could pick up and be really clinically useful if its done right-that seems to be the big caveat.
-
This is not a good screening test. Its just not high enough sensitivity. Honestly PSA is a really good screening test, cheap, high sensitivity, low specificity which is ok cause you confirm the diagnosis with more specific tests ie prostate mri or biopsy. Mri May end up being used more as the confirmatory test rather than biopsy. But the fundamental reason psa fell out of favor is that prostate ca is just not a disease where there is a big mortality benefit to early diagnosis. Its just not a dangerous cancer most of the time
-
Quote from Alwaysbereading
This is not a good screening test. Its just not high enough sensitivity. Honestly PSA is a really good screening test, cheap, high sensitivity, low specificity which is ok cause you confirm the diagnosis with more specific tests ie prostate mri or biopsy. Mri May end up being used more as the confirmatory test rather than biopsy. But the fundamental reason psa fell out of favor is that prostate ca is just not a disease where there is a big mortality benefit to early diagnosis. Its just not a dangerous cancer most of the time
What? PSA is not a good screening test. The inventor of the PSA said he wished he had never discovered it.
MRI can help direct biopsy, as well as find cancers that random/saturation biopsies didn’t find, especially tumors like the anterior transition zone. It can also be used effectively for interval follow up for lesions that aren’t definitive.
I don’t see any way MRI would be used “as the confirmatory test rather than biopsy.”-
Agreed. Prostate mri is excellent for biopsy planning and could decrease # of biopsies needed before definitive treatment. Patients are also generally knocked out for fusion biopsies. Not the case for the routine random biopsies.
Get the PSA, get the MRI, then do fusion biopsy as needed. Before, it was get PSA, do random biopsy, get mri if biopsy shows low grade tumor, then fusion biopsy if needed.
With a honed in protocol, high grade lesions should pop on most 3T scanners. 1.5T can be variable. Ive seen shaky quality even on scans performed at major academic centers.
-
Prostate MRI is excellent at picking up clinically significant cancers (Gleason 7+) and not finding the clinically insignificant cancers that people die with. I also think this is going to increase in volume and hopefully be better for mens health.
-
The treatments still have a relatively high incidence of lifelong, life changing complications like incontinence and impotence. Chasing cancers that men will die with and not of will be a bad thing.
-
Quote from Jbachler
Prostate MRI is excellent at picking up clinically significant cancers (Gleason 7+) and not finding the clinically insignificant cancers that people die with. I also think this is going to increase in volume and hopefully be better for mens health.
Absolutely this. I read thousands of prostate MRIs, and was working with a large urology group to get the prostate MRI and fusion biopsy program going years ago and so had path correlation. Yes there is a steep learning curve. And yes you need a good magnet to get good DWI. But done well it is *excellent* at picking up clinically signifiant disease (~all 4+3, ~all 3+4 of reasonable size, and almost all large G6).
It is disturbing to see the reads coming out of places that are just getting started (generally, marking a bunch of random stuff in the TZ). But everyone was there at some point.-
The prostate gets a much less attention compared to mammography because the prostate is an obscure male organ tucked down there somewhere by the rectum and urinary bladder and is not glamorous at all. Men deserve better.
Yes, most PCa are low risk, but also remember cases like Dan Fogelberg, Frank Zappa, Gunther on Friends, Ben Stiller (Gleason grade 2 or 3),
Track your PIRADS 3-5 biopsies and review them. It will dramatically improve your sensitivity and specificity.
If you decide to start reading prostate MRI go to a course search like the ACR education center course where are you actually read prostate MRIs.
Also, there are urine genomic markers for in addition to PSA for prostate cancer screening that radiologists should know about: ExoDx and Select MDX.
-
The prostate gets a much less attention compared to mammography because the prostate is an obscure male organ tucked down there somewhere by the rectum and urinary bladder and is not glamorous at all. Men deserve better.
Yes, most PCa are low risk, but also remember cases like Dan Fogelberg, Frank Zappa, Gunther on Friends, Ben Stiller (Gleason grade 2 or 3), Bill Bixby, Frank Burns of MASH.
Track your PIRADS 3-5 biopsies and review them. It will dramatically improve your sensitivity and specificity.
If you decide to start reading prostate MRI go to a course search like the ACR education center course where are you actually read prostate MRIs.
Also, there are urine genomic markers for in addition to PSA for prostate cancer screening that radiologists should know about: ExoDx and Select MDX.
-
The prostate gets a much less attention compared to mammography because the prostate is an obscure male organ tucked down there somewhere by the rectum and urinary bladder and is not glamorous at all. Men deserve better.
Yes, most PCa are low risk, but also remember cases like Dan Fogelberg, Frank Zappa, Gunther on Friends, Ben Stiller (Gleason grade 2 or 3), Bill Bixby, Frank Burns of MASH.
Track your PIRADS 3-5 biopsies and review them. It will dramatically improve your sensitivity and specificity. Prostate biopsies are not like needle breast biopsies. No one dies of sepsis from a breast biopsy. Dont over call lesions.
If you decide to start reading prostate MRI go to a course like the ACR Education Center course where are you actually read prostate MRIs.
Also, there are urine genomic markers for in addition to PSA for prostate cancer screening that radiologists should know about: ExoDx and Select MDX.
-
-
-
-
-
-
-
-
Quote from OnsiteRad
Any good resources on Body MRI ?
For something like prostate MR I would recommend the ACR course. I know its expensive and a hassle to get there etc but you cannot beat the format-didactic lectures, more than enough cases on a work-station, and access to expects in the field during the course.-
Quote from jd4540
Quote from OnsiteRad
Any good resources on Body MRI ?
For something like prostate MR I would recommend the ACR course. I know its expensive and a hassle to get there etc but you cannot beat the format-didactic lectures, more than enough cases on a work-station, and access to expects in the field during the course.
Thank you.
-
-
Quote from OnsiteRad
Any good resources on Body MRI ?
I would be happy to help anyone interested in learning to read prostate MR or body MR in general. Feel free to PM me-
We used to get these referrals for patients dx recently with prostate cancer to look for extracapsular disease. Then we got a bunch of newly minted urologists and we get about 5 a day now for screening at one place and even now some of the older ones who I remember talking to about screening mri ans basically told me its just a gimmick have begun ordering these. We get another 1-2 a day from them too. A few times its been after a negative biopsies but elevated PSA.
-
I work in the UK and we have a new “best timed pathway” for prostate cancer. The GP rings a nurse with an abnormal PSA case and an urgent MR is done. PR never done. Result is a lot of BPH being scanned urgently with a low pickup rate. Urologist referral is much better but they go on the routine list but have a better pickup rate.
My MR reporting is now only prostates to cope with the increase in volume. It can be really tedious.
We try and refuse under 50 and over 80 year olds. Under 50 MR is really hard to report while over 80 is pointless as the purpose of the MR is to decide on curative surgery or radiotherapy. In over 80 yr olds doing that worsens outcomes. Do a CT instead to stage
New 1.5T high gradient machines can produce excellent images with less artifact than 3T machines with good techs and good application specialist advice. I report on 3T and 1.5T and prefer the 1.5.
Screening will have to have limited sequences with no contrast to make it viable. it might be the new mammography with all that implies. Be careful what you wish for.-
As an IR that does a lot of Prostate Embolization, I order these studies multiple times a week. It helps me decide if the Pt is a good candidate for PAE (low risk for prostate cancer, Prostate size larger than 50g).
I find the studies incredibly useful.-
All vascular IR is done in one central Hospital in my city of around 3 million(beware the term reconfiguration as it might mean losing a chunk of your department). We were stopped from doing any vascular IR many years ago. Our urologists do refer a small number of cases to the vascular team but probably do too many steam or traditional TURP’s as it is a slow process to refer.
We occasionally get asked to scan BPH but >95% is for cancer. The vascular centre usually want their own scans.
-
-
Quote from NLynch
I work in the UK and we have a new “best timed pathway” for prostate cancer. The GP rings a nurse with an abnormal PSA case and an urgent MR is done. PR never done. Result is a lot of BPH being scanned urgently with a low pickup rate.
Is this NHS? So anyone with an abnormal PSA gets an urgent prostate MRI? Odd, and particularly odd for a system that is supposedly so strapped for resources.
Is the hope that the negative ones won’t see a urologist and a negative MRI will basically be the end of the workup for them, thus perhaps saving resources overall?-
Yep the good old NHS.
Cancer gets priority in the NHS and I would never go privately for cancer treatment or diagnosis
It does depend on local demographics. PSA is not offered routinely but does happen a lot in the more affluent areas. Patients can demand a test from their GP if they know how to go about it. Some do go privately for scanning but governance is weaker. Most radiologists who report private cases are based in the NHS and are uroradiologists but not all.
The demand is growing and it is difficult to meet. I’m doing less and less of everything else on my MR list so am bored with prostates, especially the iffy young patients. We discuss them at cancer meetings -some get a biopsy and some don’t based on PSA density and history. We mark the area of suspicion on the images prior to biopsy. All biopsies are transperoneal under local. There are not many volunteers for repeat biopsy.
We get follow up at the cancer meeting. We have had several cases of completely normal MR scans with positive histology even on retrospect but mostly the scan correlates with the histology.
-
Interesting, thank you.
-
-
-
-
-
-
-
-
It’s an interesting time to be involved with prostate imaging, that’s for sure.
I picked it up a few years ago when the rad who’d been doing it decided to move on. I’ll admit self-interest (I’m an old guy with a prostate) but it was a good fit for my “learn-one-new-thing-a-year” professional philosophy and like something that had the potential for great benefit. As I read somewhere along the line: “What other organ is randomly biopsied as part of standard, accepted practice to search for cancer?” Imagine if breast cancer were diagnosed this way….
Anyway, as to the nuts and bolts of prostate MRI…. Having a 3T machine is a must, IMO. I’ve seen studies done on 1.5T machines and, thank you but no. Being able to obtain high b-value series also key. Interestingly, in my experience calculated high b-value series seem better than those obtained “raw.” Following up biopsy results is invaluable in getting better at these. Transition zone lesions are very tricky. Yes, it is A LOT of work to get good at these and maintain a high-quality operation. Really helps to have a rad that is into it and treats it like a priority.
Prostate MRI as a primary screening tool for CA? Not ready for prime time yet, IMO. Current practice of MRI for evaluation of elevated PSA, or even better for evaluation of rising PSA, seems more cost-effective.
Another hat I wear at work is that of the NM guy. PSMA PET-CT volumes are dramatically rising; some days it’s as much as 40% of the PET scanner volume (and we’ve got a lot of FDG and DOTATATE PET too). Very interesting to correlate PET and MRI. We’re starting Pluvicto therapy later this year.
As I said at the beginning, it’s a great time to be involved in prostate imaging and therapy. Very gratifying to be able to offer something beyond DRE, PSA, and random 12-core biopsies.
-
I see a future with fast mri protocols without contrast and super high or extrapolated B values. Just need sm fov T2 in 3 planes, sm fov T1 fat sat axial, and dwi/add 0 -50, 800, and 1500 plus…this can be done in 20 min…add in one of the trendy AI applications like quantib, ProstateID, or RSI, and you are gtg.
-
-
Quote from Waduh Dong
No discussion on this? This is big news imo. Prostate MRI for screening will become standard in the coming years.
Imaging will continue to grow in importance and volume imo.
Let’s face it – many things we do in medicine are archaic with the currently available imaging techniques.
MRI is a complete game changer for prostate disease IMO.
I probably should get some training on this, but anytime I look at prostate MR images, I can’t help to think that I am trying to predict tomorrows weather based on the shape of todays clouds. It’s like a modern version of the V/Q scan.-
The first rule of a good screening exam is that it is inexpensive and easy to use.
FAILNot to say MR wont be a great tool. Its just not a good screening tool.
-
Quote from fw
……
I probably should get some training on this, but anytime I look at prostate MR images, I can’t help to think that I am trying to predict tomorrows weather based on the shape of todays clouds. [u][b]It’s like a modern version of the V/Q scan.[/b][/u][edited and emphasis added]
LOL, being “the NM guy” in my practice is probably one of the reasons prostate MRI appeals to me.
Fortunately, most of them are obviously negative or positive (though we’ve had a few COMPLETELY negative ones that had cancer on standard 12 core bx obtained b/c PSA continued trending up). However, the ones that are “in between” can be a real head-scratcher. Transition zone lesions are particularly tricky. Most of the urologists I deal with will biopsy (or try to) anything PIRADS-3 or higher, so we’ve gotten some good feedback on those equivocal lesions. As mentioned above, following up your reads with biopsy results is crucial to improving.
-
Quote from fw
Quote from Waduh Dong
No discussion on this? This is big news imo. Prostate MRI for screening will become standard in the coming years.
Imaging will continue to grow in importance and volume imo.
Let’s face it – many things we do in medicine are archaic with the currently available imaging techniques.
MRI is a complete game changer for prostate disease IMO.
I probably should get some training on this, but anytime I look at prostate MR images, I can’t help to think that I am trying to predict tomorrows weather based on the shape of todays clouds. It’s like a modern version of the V/Q scan.
I’ve read most modalities at some point and prostate MR is up there when it comes down to difficultly/bandwidth consumption. Contouring with dynamic-cad exponentially contributes to the pain. Inter/intra-rater reliability likely not great but I suppose its the best we have as of now.
-
