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    Prostate MRI has value, but results are not ‘gospel’

    Scott Eggener, MDScott Eggener, MDMagnetic resonance imaging (MRI) of the prostate may be used in many clinical scenarios, including primary screening, active surveillance, and in patients with a previous negative biopsy and rising PSA. In this interview, Scott Eggener, MD, explains whether MRI is warranted in each of these situations and the benefits and challenges this technology presents. Dr. Eggener is associate professor of urology and director of the Prostate Cancer Program at the University of Chicago. Dr. Eggener was interviewed by Urology Times Editorial Consultant J. Brantley Thrasher, MD, professor of urology at the University of Kansas Medical Center, Kansas City.

     

    Please tell us what you consider a quality MRI of the prostate.

    That’s a very important question. There’s a wide variety of methods on how MRI is done. The single most important thing at an individual center is to have a meaningful discussion with the radiology team and a radiologist who has a specific interest in developing a prostate MRI program so they can gain experience and expertise. As you and the readers know, there are 1.5 Tesla magnets, 3 Tesla magnets, endorectal coils, and body phased array coils.

    Also see: Research reveals possible predictor of PCa germline mutation

    In general, most of the data suggest a 3 Tesla magnet with an endorectal coil gives the best pictures and the most accurate information. However, not every center has a 3 Tesla magnet, and a lot of centers do without the endorectal coil for patient comfort and workflow. You have to decide at your center what is best for your patient population, knowing that you may not have the highest level magnet. We tend to use endorectal coils because our best prostate radiologist swears by them and believes they provide higher quality pictures. Patients are forewarned that the endorectal coil will be used.

     

    Do you do these in a radiology suite or in the urology suite?

    All of the MRIs are conducted in the radiology suite. The prostate biopsies are done in the urology clinic.

     

    Where do you see the value of MRI of the prostate?

    Undeniably, the load of research suggests MRI images provide additional information for specific men at risk for prostate cancer or already diagnosed with prostate cancer. But I think it’s critically important for patients and urologists to realize that MRI is not perfect and will give false-negative and false-positive results. We can’t take the MRI information as gospel in every patient. It’s a guide for identifying potential cancers, where extra samples from certain areas may help us make smart decisions.

    Next: "I do not think it’s good-quality care right now for every man going for his first biopsy to have an MRI beforehand"

    J. Brantley Thrasher, MD
    Dr. Thrasher, a Urology Times editorial consultant, is professor and chair of urology at the University of Kansas Medical Center, Kansas ...

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    • UBM User
      I am a medical oncologist specializing in prostate cancer (PC) since 1983, and have had an extended experience with prostate MRI for over 2 decades. The discussion above by Eggener and Thrasher is very reasonable but a few points are worth mentioning. 1. I would not want any patient under my guidance studied with a 1.5T MRI. At the very least 3T should be routine. In the near future we will likely see 7T being used given the more discrete anatomy revealed. 2. There should be OBJECTIFIED data and less emphasis on "narrative", the latter of which tends to encourage a CYA approach. I want to know the index lesions, where they are, their size, the findings on T2WI (T2-weighted imaging), DWI (diffusion weighted imaging) with the apparent diffusion coefficient (ADC) values given, and 3. When contrast is used I want to know which Gadolinium (Gd)-based contrast agent (GBCA) is intended & to be sure it is one in the cyclic & ideally non-ionic category (e.g., Gadovist, ProHance) to minimize toxicity. 4. Of course I want a PI-RADS v2 score rendered. 5. In the best of worlds I would like to see snapshots of the area(s) of concern and have the radiologist label pathologic findings so that I and other medical oncologists become more educated about imaging in PC patients. 6. Lastly, urologists should always defer prostate biopsies until at least 6 weeks after or during the mp-MRI since hemorrhage invariably occurs and results in a more problematic interpretation. These are some issues important to me in my care of PC patients. Stephen B. Strum, MD, FACP

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