Quick prostate question

[FrostyHammer]

Clinical staging of prostate cancer -- this may be a dumb question but I swear I have seen multiple ways used in my institution. Is clinical staging "overruled" by a DRE, biopsy, and/or MRI? In other words, let's say a guy had cT1c disease because it was all found on screening PSAs.

- What if this guy had a DRE that showed a suspicious right sided nodule without ECE/SVI - do you still call it T1c or is it T2b?

- What if this guy then had a biopsy and found to have prostate cancer bilaterally - do you call it T1c, T2b, or T2c now?

- What if this guy then had an MRI and found to have microscopic ECE - do you call it T1c, T2b, T2c, or T3a now?

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[BobbyHeenan]

Caveat - I have the AJCC 8th edition for staging/coding, but not the full book yet....

It's still not completely clear from the materials I have, but for T2 designation they still use the word "palpable." The word "palpable" is not present for T3 designation.

So to answer your question - a R sided nodule with no ECI/SVI I believe is considered T2a/b. Biopsy still keeps it at T2a/b; I would not up stage to T2c because you only "palpated" disease on one side even if biopsy is present in both sides of the prostate. If MRI shows ECE then I believe you can up stage to T3 because you have medical imaging suggesting as such.

 

[evilbooyaa]

Agree with above. cT1c is limited to - no palpable nodule, biopsy shows prostate Ca (usually in the setting of some elevation of PSA). I don't know that I've ever seen a T1a/b (maybe if you had a prostatectomy as part of a cystectomy for bladder cancer?)

If you feel a nodule (regardless of why the PSA was checked or elevated) its cT2a/b. If biopsy shows bilateral disease, to me that's still cT2a/b, because without the nodule, patient would be cT1c.

Radiological imaging factors into clinical staging - radiographic ECE = cT3a.

 

[BobbyHeenan]

I've seen a T1a/b in the setting of incidentally found on TURP for BPH. The path reports will tell you what % of submitted tissue has adenocarcinoma in it.

 

[scarbrtj]

CAVEAT: THIS IS ALL AJCC 7th BASED; I AM POOR AND CAN"T AFFORD AJCC 8th YET
CAVEAT: I AM A KNOWN PEDANT

The staging NEVER changes. However, who is the stager? Who's the decider???

Once YOU have finally staged a patient, the stage doesn't change. I can't think of a situation where you would be T1c where you had NEVER had a DRE or an ultrasound (or MRI). My assumption would be if you're T1c you've had a negative DRE and ultrasound (or MRI) almost by definition.

Thus... if someone comes to you with a positive biopsy and elevated PSA and you have NO evidence that there was a DRE and the biopsier does not provide you with an MRI or US report, you may stage as T2 if you feel a nodule; you are thus not in conflict with previous data and the patient as far as you know was sort of cTx beforehand. If you have evidence that there was a DRE and a biopsy report and no one called a nodule from their US or MR guidance, I would be loathe to call T2 myself and change the "de facto" pre-existing stage.

"Bilateral disease" on biopsy is too subjective and doesn't determine clinical T stage; cT2c will always be bilateral nodules by DRE or imaging of some sort. Biopsy results don't change clinical stage. Per staging rules cT1c is: "tumors found in 1 or both lobes by needle biopsy but not palpable or reliably visible by imaging."

If you get new staging info before treatment e.g. MRI that shows new information it can change the clinical stage accordingly.

 

[evilbooyaa]

There are certainly times where elevated PSA is seen, DRE is not performed by the Urology PA, no imaging is pursued, templated biopsy note in all quadrants does not note or deny presence of any nodules, then they present to your clinic as a 'T1c' and you palpate a nodule.

If the staging is wrong, then change the stage at least for your notes. At least that's my thought.

 

[echod]

Direct quote from AJCC 8th Edition:

"Neither imaging information nor tumor laterality information from the prostate biopsy should be used for clinical staging. A tumor that is found in one or both sides by needle biopsy, but is not palpable or visible by imaging, is classified as T1c. Clinical T category should always reflect DRE findings only."

 

[FrostyHammer]

Meaning that MRI doesn't count anymore for cT3a/b?? I'm sure the sensitivity of ECE/SVI of a DRE is much lower than an MRI...

 

[scarbrtj]

Clinical T category should always reflect DRE findings only.

Like I said, I don't have an 8th handy, but if the staging manual says that (and we are not taking it out of context) I'm throwing it away. Like I can palpate the difference between T2c and T3a. Or feel a T3b versus a T3a. Or that endorectal MRI showing T3b is not cT3b; i.e., we can not accept the staging of a radiologist. That's gotta be wrong... right?

 

[scarbrtj]

There are certainly times where elevated PSA is seen, DRE is not performed by the Urology PA, no imaging is pursued, templated biopsy note in all quadrants does not note or deny presence of any nodules, then they present to your clinic as a 'T1c' and you palpate a nodule.

If the staging is wrong, then change the stage at least for your notes. At least that's my thought.

My point was, in this scenario of yours, the staging was not wrong--the patient was unstaged. (In AJCC 7th, ultrasound could stage cT2.) I can't recall not seeing a physical exam note from a urologist when I've seen a prostate cancer patient; I must only work with urologists who do exams...
But that brings up another point I was trying to make, "If the staging is wrong." The urologist says anodular and assigns a formal stage in his notes; the radiation oncologist feels a nodule. I would go with the initial (urologist) stage. There's no right answer.

 

[scarbrtj]

Ok now that I have the 8th edition, I would like to beat this dead horse a bit more.

Direct quote from AJCC 8th Edition:

"Neither imaging information nor tumor laterality information from the prostate biopsy should be used for clinical staging. A tumor that is found in one or both sides by needle biopsy, but is not palpable or visible by imaging, is classified as T1c. Clinical T category should always reflect DRE findings only."

Let me be legalistic and say that the word "should" is not normative. That is to say, the law reads not: "Thou should not murder another person"; it's "Thou SHALL not (or must not) murder another person." So AJCC is saying you should not, not that you must not. Furthermore, in the immediately following section "IMAGING" after "CLINICAL CLASSIFICATION":

"Although imaging could one day potentially improve clinical staging accuracy, interobserver reproducibility, issues with patient selection, and contradictory results have limited the utility of imaging in clinical staging and imaging alone cannot replace the DRE as the clinical staging standard. Thus, for local T category assignment no imaging test is explicitly required."

So, I still reserve my God-given clinician right to augment physical exam findings with imaging findings... and IMHO this does not conflict per se with AJCC 8th. Truly though, one cannot stage the cT sans the DRE per the 8th. Regrettable. (The 8th seems to allow MRI for cT3.)

 

[Chartreuse Wombat]

Clinical staging of prostate cancer -- this may be a dumb question but I swear I have seen multiple ways used in my institution. Is clinical staging "overruled" by a DRE, biopsy, and/or MRI? In other words, let's say a guy had cT1c disease because it was all found on screening PSAs.

- What if this guy had a DRE that showed a suspicious right sided nodule without ECE/SVI - do you still call it T1c or is it T2b?

- What if this guy then had a biopsy and found to have prostate cancer bilaterally - do you call it T1c, T2b, or T2c now?

- What if this guy then had an MRI and found to have microscopic ECE - do you call it T1c, T2b, T2c, or T3a now?

I went directly to the source and emailed a member of the committee that created the AJCC 8th manual with this question.

In a patient with non-palpable prostate cancer can an MRI “suspicious” for ECE lead to an appropriate stage of T3?

Answer verbatim below-

He’s T1C because MRI is not allowed.


But, the AJCC has plans for tracking the “MRI stage” for future comparison.


Since MRI is not universally available (the UICC is also involved), it was deemed important to maintain the commonest denominator for clinical staging.


From a clinical perspective this was not unanimous and some felt strongly MRI should be included.

 

[evilbooyaa]

I admit that I'm wrong, but that's dumb, IMO. If MRI shows ECE I'm going to treat that patient as if they are T3a. Similar to cervical cancer staging not allowing imaging, but hopefully nobody is ignoring positive lymph nodes on PET/CT during their treatment.

 

[DoctwoB]

Keep in mind that widespread use of prostate MRI is a new phenomenon, and is not recommended in all patients at this time, and as such will not be part of routine staging. That being said it does seem silly to disregard higher quality information in staging patients, and this I'm sure will be updated in future editions.

One thing to keep in mind though. While MRI is certainly more sensitive for ECE then DRE, note that all data regarding outcomes/treatment of cT3 and cT4 disease is based on DRE/clinical exam, which is likely reasonably specific but poorly sensitive. A patient with cT3 disease based on MRI will likely have better outcomes then a cT3 patient based on DRE, as the DRE patient likely has more gross extraprostatic disease.

 

[evilbooyaa]

For definitive prostate radiation treatment, most academic institutions and I'd expect many community sites are getting MRI to assist with contour delineation, if possible, given the overdrawing that happens with CT based contouring alone.

Surgeons don't routinely get MRIs because what do you do if it does show radiographic ECE? Not operate given that the patient is intimately high-risk for obviously ECE? Of course not. They'll operate, leave a positive margin or show pT3a disease, and leave it for salvage RT when the patient recurs.

 

[scarbrtj]

Ah, so a standard of care for a T1c patient that is Gleason 3+4, PSA 10, and who has documented SV invasion by MRI is... brachy monotherapy? "Doctor, you did not treat the seminal vesicles in this case; the MRI showed involvement?" "No, the AJCC has disallowed doctors from making clinical decisions on the basis of MRI in prostate cancer."

Answer verbatim below-

He’s T1C because MRI is not allowed.

It would be interesting to ask this staging fellow you emailed where in the AJCC 8th manual it says MRI is not allowed (hint: it doesn't say that it is not allowed). Perhaps the DRE, as you fight through the flatus, will give this guy staging afflatus.

 

[Krukenberg]

Keep in mind that widespread use of prostate MRI is a new phenomenon, and is not recommended in all patients at this time, and as such will not be part of routine staging. That being said it does seem silly to disregard higher quality information in staging patients, and this I'm sure will be updated in future editions.

One thing to keep in mind though. While MRI is certainly more sensitive for ECE then DRE, note that all data regarding outcomes/treatment of cT3 and cT4 disease is based on DRE/clinical exam, which is likely reasonably specific but poorly sensitive. A patient with cT3 disease based on MRI will likely have better outcomes then a cT3 patient based on DRE, as the DRE patient likely has more gross extraprostatic disease.

I think this is key. Part of the importance of staging is for prognostication, and I’m sure the survival of T3 by DRE is different than T3 by MRI. It’s not the same prognostic group

 

[Chartreuse Wombat]

Ah, so a standard of care for a T1c patient that is Gleason 3+4, PSA 10, and who has documented SV invasion by MRI is... brachy monotherapy? "Doctor, you did not treat the seminal vesicles in this case; the MRI showed involvement?" "No, the AJCC has disallowed doctors from making clinical decisions on the basis of MRI in prostate cancer."


It would be interesting to ask this staging fellow you emailed where in the AJCC 8th manual it says MRI is not allowed (hint: it doesn't say that it is not allowed). Perhaps the DRE, as you fight through the flatus, will give this guy staging afflatus.

You are conflating two issues. Staging as defined by AJCC and clinical judgment. The ROC for mpMRI SVI is robust enough (in my judgment) to dictate treatment decisions but it doesn't (at the present time) factor into staging according to AJCC/UICC.

 

[scarbrtj]

You are conflating two issues. Staging as defined by AJCC and clinical judgment.

100%; the clinical judgment gleaned from something like an MRI is difficult to un-conflate. I am henceforth never going to do a DRE until I've seen the patient's MRI or US reports and/or images; however, I swear never to use these imaging studies for clinical T staging. But the imaging really helps me know where to aim my finger. I'm going to call it IGDRE: the image-guided digital rectal exam.

 

[seper]

Just curious, do you all now think MRI should be ordered on all prostate cancers when "active treatment" is recommended? Let's say for for the 2018 oral boards purposes.

 

[DoctwoB]

Just curious, do you all now think MRI should be ordered on all prostate cancers when "active treatment" is recommended? Let's say for for the 2018 oral boards purposes.

No. No evidence of any benefit for surgery. In theory knowing that there may be ECE in a given area could effect surgical planning, especially with regards to nerve sparing, but once again no evidence of benefit or lowered margin rates, etc. In practice we have some attendings that order it in lieu of CT scan for staging of high-risk patients, while some just get the standard CT/bone scan. Per our guidelines no imaging is indicated in low risk and favorable intermediate risk prostate cancer prior to surgery.

 

[evilbooyaa]

Just curious, do you all now think MRI should be ordered on all prostate cancers when "active treatment" is recommended? Let's say for for the 2018 oral boards purposes.

You can see the urologist's answer above.

For Rad Oncs, I wouldn't say it's mandatory, but I think it's certainly defensible for Rad Onc oral boards given the shrinking of volumes you can do along the pelvic floor. Maybe not for Urology boards though.

 

[CptCrunch]

Just curious, do you all now think MRI should be ordered on all prostate cancers when "active treatment" is recommended? Let's say for for the 2018 oral boards purposes.

Agree with evilbooyaa, not mandatory but certainly helpful for identifying the prostate apex. For oral boards purposes, you are expected to know prostate anatomy on MRI.

 

[scarbrtj]

Evidently, good radiologists attempt to give a clinical TNM stage on the basis of F18-choline PETs now
How we read FCH-PET/CT for prostate cancer

 

[seper]

wow
is it an approved by CMS test now?

 

[evilbooyaa]

Haven't seen these tests be approved in definitive cases. Medicare I believe does approve it in the recurrent setting to rule out metastases. Not sure about other insurers (as of yet).

 

[danibrittany]

Thank you for putting up the question. Although did not go through all the codes but I have a fair idea about it. However, medical imaging is considered substantial evidence and can help determine and suggest the right staging of the problem.