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MRI of spine best identifier of metastases


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J Clin Oncol. 2007 Aug 1;25(22):3281-7.

Magnetic resonance imaging of the axial skeleton for detecting bone metastases in patients with high-risk prostate cancer: diagnostic and cost-effectiveness and comparison with current detection strategies.

Lecouvet FE, Geukens D, Stainier A, Jamar F, Jamart J, d'Othée BJ, Therasse P, Vande Berg B, Tombal B.

Source

Department of Radiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium. lecouvet@rdgn.ucl.ac.be

Abstract

PURPOSE:

To evaluate the diagnostic performance, costs, and impact on therapy of one-step magnetic resonance imaging (MRI) of the axial skeleton (MRIas) for detecting bone metastases in patients with high-risk prostate cancer (PCa).

PATIENTS AND METHODS:

Sixty-six consecutive patients with high-risk PCa prospectively underwent MRIas in addition to the standard sequential work-up (SW) of bone metastases (technetium-99m bone scintigraphy [bS] completed with targeted x-rays [TXR] in patients with equivocal BS findings and with MRI obtained on request [MRIor] in patients with inconclusive BS/TXR findings). Panel review of initial and 6-month follow-up MRI findings, BS/TXR, and all available baseline and follow-up clinical and biologic data were used as the best valuable comparator to define metastatic status. Diagnostic effectiveness of MRIas alone was compared with each step of the SW. Impact of MRIas screening on patient management and costs was evaluated.

RESULTS:

On the basis of the best valuable comparator, 41 patients (62%) had bone metastases. Sensitivities were 46% for BS alone, 63% for BS/TXR, 83% for BS/TXR/MRIor, and 100% for MRIas; the corresponding specificities were 32%, 64%, 100%, and 88%, respectively. MRIas was significantly more sensitive than any other approach (P < .05, McNemar). MRIas identified metastases in seven (30%) of 23 patients considered negative and eight (47%) of 17 patients considered equivocal by other strategies, which altered the initially planned therapy. Economic impact was variable among countries, depending on reimbursement rates.

CONCLUSION:

MRIas is more sensitive than the current SW of radiographically identified bone metastases in high-risk PCa patients, which impacts the clinical management of a significant proportion of patients.

Comment in

J Clin Oncol. 2007 Dec 20;25(36):5837-8; author reply 5838-9.

Eur Urol. 2009 Sep;56(3):573.

J Clin Oncol. 2008 Mar 1;26(7):1189-90; author reply 1190-1.

PMID: 17664475 Forum: Other prostate cancer topics including radiation Title: MRI of spine best identifier of metastases

[Above this line - report by expert researchers. Below this line interpretation by non-doctor, non-researcher, non-expert]

Jim:

My interpretation of the paper mentioned above (IANAD):

Standard sequential work-up (SW) = standard practice:

bs = standard bone scan (an X-ray that is taken (often a few on the same day at different times) after you have been injected with a tracer (technetium-99m))

txr = targeted x-rays

MRI = x-ray like images made with magnetism

MRIor = MRI on request.

MRIas = MRI of the axial spine

In short the usual practice if you suspect metastasis:

You do a bone scan. (BS)

Anything not clear but suspicious - take X-rays of the part. (TXR)

Anything not clear but suspicious after the bone scan + X-ray (BS/TXR) - do an MRI.

This was compared with just starting with an axial MRI of your spine. (MRIax) (Axial just means direction the pictures are taken in. Bascially parallel to the soles of your feet)

The key result was:

Sensitivities were:

46% for BS alone,

63% for BS/TXR,

83% for BS/TXR/MRIor, and

100% for MRIas; (So an MRI correctly identified all people with metastases, while a bone scan alone missed 54% of them).

The corresponding specificities were 32%, 64%, 100%, and 88%, respectively. (So the MRI incorrectly identifies 12% of people without metastases as having metastases).

The very important result:

MRIas identified metastases in seven (30%) of 23 patients considered negative and eight (47%) of 17 patients considered equivocal by other strategies, which altered the initially planned therapy.

i.e. Starting with MRI by itself identified metastases that were missed by other strategies.

Hope this is a little clearer.

The importance of this is that if metastases are found at an early stage (at fewer than 6 sites), they can be effectively treated with spot burning radiation - sometimes effective for years.

(Remember: I am not a doctor.)

This extract can be found on http://PubMed.com, and is in the public domain.

On PubMed.com there will be a link to the full paper (often $30, sometimes free).

Any highlighting (except the title) is not by the author, but by Jim Marshall.

Jim is not a doctor.

This page was found on the Advanced Prostate Cancer Community for Australian men at http://advancedprost...lia.ipbhost.com.

The link is hard to remember.

An easier way to find it is to go to JimJimJimJim.com and click on Prostate.

That's the word Jim four times, no spaces, followed by .com.

If you need other help - to perhaps find someone to talk to or a local support group:

Click on the Contact Jim button at http://JimJimJimJim.com.

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Jim

Think I had an X ray (as well as CT and bone scan) before my radical in 2003 – but no X rays since.

You and the MRI article keep talking about X rays but never mention CT (I don’t think).

Why do you emphasise X rays when CT seems the norm as far as I am aware?

Tony

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The role of CT or CAT scanning in the diagnosis of prostate cancer is really very limited today because almost anything one can do with a CT scan can be done just as well or better with an MRI scan. The one place where CT scans appear to have a small advantage is in the early identification of soft tissue metastases (as opposed to bone metastases). However, the need for this type of information outside clinical trials is relatively limited.

Jim,

But MRI is not covered by Medicare whereas CT is (for prostate cancer) - so hardly anybody has MRI and lots of people have CT.

That is my understanding of it.

Agree that CT is not as good in most situations.

Regards Tony

As I read the abstract, the X-rays referred to here are not for search, but "targeted X-rays" presumably aimed at the "fuzzy" spots on the bone scan.

You can read the topic here:

http://prostatecance...sts/mri-ct-etc/

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