Originally published 7/3/2017
Every man who has a multiparametric MRI of the prostate is entitled to a copy of his written report by the radiologist, and at least one CD containing the images. (Secure electronic medical records make it easier to get copies of your visits, test results, etc, and we encourage patients to keep their own home file with copies of all medical records.) When you get your MRI report, should you accept it at face value? No. All prostate cancer (PCa) advocacy programs encourage patients to get a second opinion from an experienced prostate imaging specialist. It is not uncommon for an expert reviewer to pick up details missed by the first reader. Studies repeatedly show “an important level of discordance between mpMRI reports,”[i] though the more aggressive the image-revealed prostate cancer (PCa), the greater the agreement among readers. This is because the larger and more dangerous-looking the suspicious area, the more evident it is high risk—even to less experienced readers—and a biopsy is warranted. However, most PCa is detected when it is at a low or intermediate risk level. For less experienced readers, ambiguous details (that is, it’s hard to tell if it’s PCa or not) can lead to over-estimating or under-estimating the tumor. Treatment decisions based on inaccurate interpretations can lead to unfortunate consequences.
A 2021 paper by Li, et al. describes differences between initial MRI reports made by community radiologists vs. second readings by a review board of specialized radiologists who assigned PI-RADS scores for the detection of clinically significant PCa. The agreement between initial readers and the board was “fair”[ii], highlighting the importance of second opinions. Their evidence is supported by an earlier (2019) study that likewise found spotty interreader agreement between community radiologists’ initial reports and review by specially trained radiologists at an academic center. In fact, “According to imaging second opinion, roughly half of targeted biopsies could be avoidable and 34.5% of men could skipped prostate sampling.”[iii]
In keeping with the recommendations of all PCa patient support organizations, the Sperling Prostate Center welcomes requests for second opinions of mpMRI prostate scans. Not only is Dr. Sperling a leading authority in mpMRI, but our Center also utilizes the power of today’s Artificial Intelligence to boost the accuracy of image-based PCa detection. Contact us for more information.
Did you ever read the name of a book or movie and think, “Wow, I wish I had thought of that title!”? I just read a poster presentation abstract from this year’s American Urological Association meeting (Boston, May 12-16, 2017). If the title weren’t already taken, it’s so good I might have used it for this blog: “Prostate MRI: The Truth Lies in the Eye of the Beholder.”[iv] This means that the “beholder” better be very good at reading and interpreting multiparametric MRI (mpMRI) of the prostate.
These days, it’s getting easier to have a prostate scan done on a powerful 3T (3 Tesla) magnet. The advantages of 3T over the standard 1.5T magnets that are most widely available has to do with the resolution and fidelity of the resulting images (and of course, shorter imaging time for patients). Using a 3T magnet with great imaging software means the images will be superior in quality over those from a 1.5 magnet. However, this does not automatically mean that the quality of the interpretation will be better. Instead, how much experience the reader has with prostate MRI is what separates more accurate reports from less accurate.
This is exactly what the AUA paper is all about. The poster presentation by Dr. Joseph Riney (Penn State Health Mission) reviewed the work of his research team to compare the interpretations of less experienced and more experienced readers when reviewing the same scans. They based their research on 233 consecutive prostate cancer patients who were scheduled for prostatectomy and each had a pre-surgical 3T MRI whole body scan. The purpose of the scan was to detect any extracapsular extension (tumor spread outside the prostate) and seminal vesicle invasion before the patient went under the scalpel. Each scan was first read by a fellowship-trained body radiologist who was relatively inexperienced, followed by a senior radiologist who was blinded to the first person’s report.
As you may have anticipated, the more experienced senior radiologist’s second opinions were more accurate when correlated with the surgery results. What this tells us is that experience matters.
If you have recently had a 3T multiparametric MRI done to check out suspicion of prostate cancer, before you rely 100% on your report to make decisions about the next step, we invite you to contact the Sperling Prostate Center and arrange an expert second opinion. I can’t begin to tell you the number of patients who were either overdiagnosed or underdiagnosed by a first reader. Prostate cancer – or any cancer, for that matter – should always be taken seriously until proven otherwise. Why make decisions with potentially inadequate or incorrect information? If you are interested, contact the Sperling Prostate Center to make arrangements to send us your image CD. You will be glad you did.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Luzzago S, Petralia G, Musi G, Catellani M et al. Multiparametric Magnetic Resonance Imaging Second Opinion May Reduce the Number of Unnecessary Prostate Biopsies: Time to Improve Radiologists’ Training Program? Clin Genitourin Cancer. 2019 Apr;17(2):88-96.
[ii] Li JL, Phillips D, Towfighi S, Wong A et al. Second-opinion reads in prostate MRI: added value of subspecialty interpretation and review at multidisciplinary rounds. Abdom Radiol (NY). 2021 Dec 16:1–11. Full article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674412/
[iii] Luzzago, et al. Ibid.
[iv] Riney JC, Sarwani NE, Siddique S, Raman JD. Prostate MRI: The Truth Lies in the Eye of the Beholder. Poster presentation, 2017 American Urological Association (May 12-16, Boston, MA). https://www.urotoday.com/conference-highlights/aua-2017/aua-2017-prostate-cancer/95582-aua-2017-prostate-mri-the-truth-lies-in-the-eye-of-the-beholder.html