0:00

We've talked about why MRI in other vignettes,

0:04

but I'd like to drill a little bit deeper regarding

0:07

indications, especially as they relate to surveillance.

0:11

Now in other vignettes, you've already heard about

0:13

the three-tiered system that is used by urologists in

0:16

Europe and in the United States, and we said patients

0:19

that are survey candidates are tier one individuals.

0:24

And who are tier one individuals?

0:26

People with a PSA of 10 or less, people

0:29

with a Gleason score of 6 or less.

0:32

And people with a T category of T1C or

0:37

T2A, also known as staging categories.

0:42

We said there may be a subset of individuals

0:44

in Tier 2 that are candidates for surveillance.

0:47

So let's talk about Indications for surveillance.

0:52

First, attention is paid to changes

0:55

in size or stage of the prostate.

0:59

So if there's a change, for instance, if there's a

1:02

physical examination in somebody with BPH and the

1:05

prostate feels substantially bigger to the clinical

1:09

examining physician, then that might be an indication

1:12

that the patient should start undergoing surveillance.

1:16

Now, you might notice that the Gleason

1:18

score is already up here on the tiers.

1:20

And one of the indications for surveillance

1:22

is somebody that's already had a biopsy.

1:26

Because you can't get a Gleason score without a biopsy.

1:29

So if you had a biopsy, you're in the Tier 1

1:31

category, you're a candidate for surveillance.

1:35

But if there has been any kind of a change

1:38

in an existing lesion, then you're going

1:42

to either survey, if it's a big change,

1:44

then you're going to go in and biopsy.

1:46

If there's a minor change, you're

1:47

going to continue surveying.

1:49

So, let's talk a little bit

1:51

about minor changes for a minute.

1:53

There's a change in an existing lesion that you're

1:56

surveying that perhaps already had some biopsies

2:00

that were negative, or a biopsy that was negative,

2:02

and that lesion is three millimeters in size.

2:05

It is awfully challenging to detect a change

2:08

from that lesion to the next interval.

2:11

You're going to ask, well, what is that interval?

2:13

We'll get to that in a minute.

2:15

So in those little tiny lesions, that's a

2:18

situation when you're surveying where the

2:20

dynamic contrast-enhanced MRI becomes more

2:24

important and quantifying the intensity of

2:28

enhancement and the curve becomes more important.

2:31

However, for the most part, dynamic contrast-

2:34

enhanced MRI is perhaps the least important

2:38

aspect of the survey examination, paling

2:42

in comparison in importance to the T2.

2:46

diffusion-weighted portion of the MRI and ADC map.

2:50

Now another question you're probably asking is,

2:54

what should be the interval of surveillance?

2:56

And my answer to you is, it really depends.

3:00

There is no definable criteria that is

3:03

published that says, you should survey every

3:06

year, or six months, or one and a half years.

3:13

Where a BI-RADS 3 is gonna be 6 months

3:16

and a BI-RADS 2 would be 1 year.

3:19

So we haven't come to that point yet.

3:21

But the decision is gonna be based on

3:23

some common sense and clinical judgment.

3:26

So, the rise in the PSA levels, the

3:28

PSA density, the result, as we said

3:31

earlier, of a digital rectal examination.

3:34

The patient's anxiety.

3:35

Very anxious patients may want to

3:37

be screened at shorter intervals.

3:40

And the initial MR findings.

3:42

Now, if the lesion was extremely tiny

3:44

initially, you're not going to get much

3:46

benefit going back at three or six months.

3:49

You're going to have to wait a longer interval in time.

3:53

Now, what are some inclusion

3:55

criteria for active surveillance?

3:59

Well, let's say we've already

4:00

done a biopsy and we're in Tier 1.

4:02

And we're in Tier 2.

4:03

Your Gleason score right here.

4:06

You have to have a biopsy.

4:08

Well, the number of, and remember when

4:10

you do a biopsy, it's not just a biopsy.

4:13

It may be as many as 12 samples in

4:15

different quadrants of the prostate.

4:18

So the number of positive results from the transrectal

4:22

cores may influence you one way or the other.

4:25

In other words, if it's very few, you'd survey.

4:28

If it's very many, then you're

4:30

probably going to be more aggressive.

4:32

And go forward with some type of

4:34

intervention and maybe even prostatectomy.

4:39

If it's a very high percentage,

4:41

you're going to be more aggressive.

4:43

If it's a lower percentage, that

4:45

patient is a survey candidate.

4:48

The Gleason score of the cancer.

4:50

We already said that we want

4:52

a Gleason score of 6 or less.

4:54

The further down the scale you

4:56

go, the more confident you are.

4:58

At least in 2, 3, 4.

5:01

The more confident you are that

5:02

surveillance is the right thing to do.

5:05

The serum PSA levels.

5:07

You know, are they stable or are

5:09

they rising very, very slowly?

5:11

As opposed to a more precipitous

5:13

rise or a change in the curve.

5:15

For instance, if the PSA was rising

5:17

at this level and it starts to go this

5:19

way, you're going to be more aggressive.

5:21

But if it stays very linear and consistent, that's,

5:26

that's a person that's more of a survey candidate.

5:31

But all those things taken together, if you've

5:34

got a Gleason score, let's say you've gone back

5:36

and done a second biopsy, you've been surveying

5:40

and you see something that, that looks like this,

5:44

or you have some other reason to do a second

5:45

biopsy, the Gleason score trumps everything.

5:49

Or if you're tiering a patient and deciding if

5:53

they're a survey candidate and this number looks good.

5:56

Let's say this number was seven.

5:58

And let's say this number was a

5:59

T1C, but the Gleason score is 8.

6:04

The Gleason score trumps everything.

6:05

The patient is no longer a Tier 1 candidate, and

6:09

they are going into the more aggressive workup

6:11

category, or the more aggressive treatment category.

6:17

Let's stop right there, because that's

6:18

a lot of information for one vignette,

6:21

and I'm going to let you digest that.