MRI or CT during active surveillance?

[confidentcoyote]

Hi All,


The last discussion on this forum about MRI versus CT during active surveillance is from 2011 (http://www.tc-cancer.com/forum/forum...rapy-mri-vs-ct).

I am wondering if common practices have changed since then. Has anyone discussed the possibility of using MRIs instead of CT scans during post-orchiectomy active surveillance? The TRISST study that compares CT versus MRI and low-frequency versus high frequency imaging is still underway, and I don't think there are any result yet (http://www.ctu.mrc.ac.uk/our_researc...isst_mrc_te24/).


In my own case, it's a Stage IA pure seminoma, mid-sized tumor (4.0cm, pT1), pre- and post-op markers were negative, post-op CT was negative. We decided to go with active surveillance and my doctor seems comfortable with recommending MRI instead of CT (assuming my insurance covers it). I'll have 3-month, 6-month and 12-month scans for the first year. On the one hand, I'm happy that I'm avoiding CT. On the other hand since my markers were negative even before pre-op, imaging seems like the only option to capture a relapse in time and that makes me a bit nervous.


I would appreciate if you share your experiences if you considered MRIs, what your doctor recommended and what kind of specifications the scanner should have for reliable images in the case of TC.

[Davepet]

Seems like the jury is still out on this, but most places I have heard about stick to CT.I have no idea if it's out of cost or accuracy of the images. I do believe the MRI takes longer, & ear plugs might be a good idea ( they are very noisy)..

Dave

[Mike]

Some countries, such as Sweden and Norway, do use MRI but this is also done in centralized locations that have experienced radiologists in using MRI to monitor for retroperitoneal disease. I have actually communicated with one of the TRISST physicians and at the time of the communication a few years ago, they do not use MRI outside of their trial.

A review of clinical stage I testicular cancer relapse patterns was published a few years ago and the vast majority of seminoma patients that relapsed were detected via CT/MRI imaging of the abdomen. http://ascopubs.org/doi/pdf/10.1200/JCO.2014.56.2116 Interestingly, in this article these experts stated that, "MRI imaging should be restricted to centers with the necessary technical requirements (MRI abdomen protocol) and a high MRI experience."

While MRI may be used to me the risk of the center missing or falsely identifying a relapse via MRI is a higher risk than the risk of any secondary malignancy risk due to radiation exposure from CT. This is assuming that your CT schedule is reasonable and that they are using dose controls to reduce the radiation exposure (low-dose CT). We also have a campaign about low-dose CT and things that you can do to try to reduce your exposure risk at http://dialitdown.org/ that may be of interest.

Mike

[lautreamont]

Edited - What i read on UK Forum "CT scan for squishy bits, MRI for bony bits in my experience.
PET CT scan is the gold standard scan for seminoma - it combines a PET scan and a CT scan, and they overlay one on the other. The CT scan shows what is there, the PET scan shows what its doing. A short half-life radioactive glucose solution is injected and any part of the body actively consuming glucose uses it up, so you sit very still and quiet for an hoour, and then have the scan. If any nodes have active cancer they glow on the picture.
A CT scan is pretty safe, the odd one now and then makes little or no difference to your lifetime exposure."
PS CT Scan of abdomen + pelvis ~ 1400mrem, the max allowed per international standard to people handling Nuclear products is 5000mrem / y so 3 CT Scans get you there)

[billandtuna]

I'm using MRIs.
This was a major sticking point with my first oncologist, so I switched to one who is more flexible (and more experienced).
The MRI's are definitely more expensive, take longer, and are even less pleasant than CT's. You may have trouble getting insurance to cover them.
The jury is out about whether the MRI's have sufficient resolution of the retroperitoneal lymph nodes (hence the on-going TRISST study) to provide similarly valuable information about relapse at the earliest stages.

If, like me, you are willing to swap a bit of uncertainty about resolution for the certainty of reduced radiation burden, MRI's may be an option, but you may need to shop around a bit to find an oncologist willing to work with you.

Please note those of you who are quick to take offense of any deviation from standard protocols, that I am not advocating that MRI's are preferable for anyone, let alone everyone. I'm not even sure they are preferable for me. What I am advocating for is informed patients making informed decisions about trade-offs and acceptable levels of uncertainty with informed clinicians.

[chad-in-berlin]

I'm using MRIs. My urologist left it up to me. Not sure if it's a German thing or a specific-to-this-guy thing, but he said the increased accuracy of the CT (about twice the resolution, to oversimplify it) wasn't worth the trade-off of increased risk of secondary cancer from scan radiation. I argued for an MRI and he didn't need much pushing, said "That makes sense to me, as long as you understand the trade-off."

[lautreamont]

So I had the same conversation with my urologist today (I think we are both going to Stanford but different doctors). Same staging 1A pure seminoma. My tumor was slightly smaller (2.2cm) but basically same diagnosis.
We had a good talk about CT Scan vs MRI and just like you he was totally OK doing either. His philosophy was that even if the MRI only detects the lymph node growth a little later, the treatment was just as likely to be successful. I am more on the anxious side so we agreed that at 3 months we will do a CT Scan and if clear, at 6 months we would do an MRI. Now this is assuming insurance approves. MRI are a lot more expensive. Since I have already reached my 2018 max out of pocket, he said: if you want an MRI, let's be one of your 2018 check-ups. So the 6 month one would work OK. Two CT Scans in a year is not that bad from radiation stand point. If I can get a break from the 3rd one, I think it would be a good trade-off.

[voltron]

Hi everyone, haven't posted in a while, but thought I may be able to add another point here on this discussion. I was treated in Switzerland and the center in Zurich seemed to prefer MRI over CT as quality was deemed comparable and favorable long-term side effects (i.e. radiation). However another topic still pending here, is the use of gadolinium contrast agents in MRI settings. Background are studies showing that in patients receiving repeat MRI scans with gadolinium contrast agents, deposits of gadolinium were found in their brain with unclear effect on health. It looks like the US FDA cleared the use after a 2 year review in 2017, however I believe the EU including Switzerland are still fairly cautious, respectively there is an ongoing discussion (see link). In my case when I used to do MRI's in the past, I was hence able to do them without using contrast agents at all. The less the better I guess.

[lautreamont]

There is also this calculator. You can enter the number of CT Scans, your age and see if cancer risk increase. http://www.xrayrisk.com/calculator/c...al-studies.php

[JoeTheAstronaut]

My oncologist said MRIs are much more expensive and the process is longer and more complex. Good on you, Mike, for your work with Dial It Down!!

[S P]

As others have mentioned, MRIs can be used in place of CT scans for TC f/u, but because they can be much harder to read and interpret, they're best done by someone with a lot of experience reading MRIs specifically for cancer follow-up. And yes, they're much more expensive. You're probably better off sticking with CT scans.

As a note, the NCCN Testicular Cancer board has significantly reduced the number of follow-up CT scans required for most patients. If you were treated a few years ago or of if you have a pretty heavy scan schedule, you should check he latest guidelines to see if you still need that many scans. In many cases, you might not need nearly as many scans anymore.

I wrote a blog about this here:

http://www.stevepake.com/cancer-blog/2017/1/19/negotiating-surveillance-and-long-term-follow-up-for-testicular-cancer