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Imaging modalities in prostate cancer Bahjat moussa PGY4 urology Dr Georges Assaf Moderator 24-04-14.

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Presentation on theme: "Imaging modalities in prostate cancer Bahjat moussa PGY4 urology Dr Georges Assaf Moderator 24-04-14."— Presentation transcript:

1 Imaging modalities in prostate cancer Bahjat moussa PGY4 urology Dr Georges Assaf Moderator

2 PET in PC patients Role of functional imaging – not well established yet The aim of this review – to offer an overview about the main applications of choline PET in PC patients

3 Detection of intra-prostatic cancer

4 Use of choline PET/CT for initial diagnosis and local staging of prostate cancer – not recommended as a first line screening method The only potential application of PET/CT – increase the detection rate of cancer on repeated TRUS-guided biopsies – in patients in which at least 2 inconclusive TRUS- guided biopsy have been already performed

5 Staging

6 The use of choline PET/CT for preoperative LN staging – showed very contradictory results – However good specificity and PPV – limited to patients with very high risk for LN positive status according to nomograms

7 At the present time – routine clinical use of choline PET/CT cannot be recommended in staging patients with PC

8 A negative Choline PET/CT – is not sufficient to rule out a lymph-adenectomy PET could be useful to exclude from surgery – patients with high surgical risk in which the presence of LN lesions were assessed by PET (high PPV)

9 PET/CT showed – sensitivity 60% – a much better specificity 97%

10 Restaging

11 Imaging should be able to find the site of recurrence – distinguish between local failure and distant metastasis

12 Detection of LN and distant recurrence in PC patients with biochemical recurrence – significantly high detection rate – relationship between detection rate and Trigger PSA values – a relationship between detection rate and PSA kinetics a crucial role as first diagnostic procedure in patients who demonstrate a fast growing PSA kinetics and low Trigger PSA

13 In case of slow growing PSA kinetics – sensitivity of PET does not seems to be so high – questionable if a PET/CT should be performed as first imaging procedure

14 In case of local relapse – TRUS and/or pelvic endorectal MR remain the first procedures – choline PET/CT could have only a complementary role to exclude the presence of distant metastasis, before a local RT salvage treatment

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16 Conclusion Use of choline PET/CT for initial diagnosis and staging – is not recommended as a first-line method Most important application of choline PET/CT – restaging of the disease in case of biochemical relapse for the detection of LN and distant recurrence

17 Conclusion Choline PET/CT – could play a crucial role as first diagnostic procedure in PC patients who show a fast growing PSA kinetics

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20 The diagnostic evidence is stronger in restaging than in staging settings

21 Proper patient selection – PSA level – PSA doubling time – initial tumor stage is the key to avoiding FN results up front

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23 The use of choline PET/CT scanning – May accurately provide the localisation of the site of prostate recurrence in a single step Choline PET/CT’s detection rate of recurrences rises together with the increase in PSA serum value

24 According to the current available data – the routine use of choline PET/CT scanning cannot be commonly recommended for PSA values <1 ng/ml

25 Independent predictors of positive choline PET/CT – PSA DT – previous biochemical failure – locally advanced tumour – pathologic lymph node disease at initial staging

26 Can choline positron emission tomography/computed tomography help individualise treatment decisions?

27 Confirmatory data are still needed Choline PET/CT imaging has recently been proposed to allow new opportunities for individualised treatment on recurrent lesions after radical treatment for PCa

28 Patients with local recurrence after RP – best treated by salvage RT when the PSA serum level is <0.5 ng/ml Choline PET/CT scanning is not commonly useful in this scenario – low detection rate for PSA serum values <1 ng/ml

29 Choline PET/CT scanning, providing whole- body information on Pca spread – may be useful in selecting patients to be referred to local treatment – by distinguishing those patients with local recurrences from those who present with distant metastases

30 Salvage lymphadenectomy Choline PET/CT scanning – very useful for indicating the presence of lymph nodal involvement in patients who present with a progressive PSA increase after radical treatment it provides a basis for further treatment decisions

31 Role of MRI

32 According to the guidelines PSA increase over a threshold of 0.2 ng/ml later than 6 to 12 months after radical prostatectomy suggests treatment failure with a high risk of local recurrence increase within a shorter period correlates with distant metastasis For EBRT; biochemical failure increasing PSA level after a nadir level

33 Transrectal ultrasound-guided biopsy The current reference standard for the detection of local recurrence in patients with biochemical failure Invasive may fail to depict some tumours because only a small fraction of the gland is sampled

34 Computed tomography Not widely used for the detection of local recurrence – low accuracy in the differentiation of local recurrence from postsurgical scarring

35 MRI MRI can accurately detect local recurrences after EBRT and radical prostatectomy – DCE MRI is particularly accurate The addition of 1H-MRSI to DCE MRI – significantly improve the diagnostic accuracy of local prostate cancer recurrence

36 MRI – usually used for local staging in intermediate and high risk patient groups – useful in low risk patients as well – sensitivity and specificity 75% and 95% respectively

37 Functional MRI techniques – diffusion-weighted magnetic resonance (DW-MR) – dynamic contrast-enhanced (DCE-MR) – MR spectroscopy

38 Conventional MRI – only able to diagnose metastatic lymph nodes bigger than 10 mm A newly invented MRI technique lymphotropic superparamagnetic nanoparticles – detect occult lymph node metastasis smaller than 10 mm – 100% sensitivity and 95.7% specificity

39 MR Spectroscopy Measures the level of specific metabolites in the prostate gland – Combination of choline and creatine is measured in MRS – The other metabolite that MRS measures is citrate accumulate in peripheral zone high in normal prostate tissue but decreases in malignant tissues

40 MR Spectroscopy The ratio of Cho+Cr/Ci – used for evaluation of prostate cancer Higher ratio – in favor of higher risk of malignancy – more than 0.75 is considered as significant and is consistent with prostate cancer

41 MR Spectroscopy More accurate in detecting prostate cancers with high grade of malignancy – in low grade cancers its accuracy is limited

42 Dynamic Contrast Study Works based on neo angiogenesis in tumor cells Angiogenesis rate is high – newly made vessels have low integrity in their wall – more permeable than normal vessels

43 Dynamic Contrast Study Gadolinium contrast agent is injected – then serial 3D T1- weighted images are obtained Fast leakage of contrast agent from leaky tumoral vasculature – early enhancement of tumoral tissue in T1 - weighted MRI – early wash out of contrast agent are seen in prostate cancer

44 Diffusion Weighted Imaging Works based on water molecules movements – Water molecules movement decrease in a high cellular environment – so diffusion become lower Sensitivity and specificity of DWI when added to T2-Weighted MRI for detecting prostate cancer is about 84% and 87% respectively

45 MRI Ability to Detection Bony Metastasis The most sensitive and specific technique in detecting bony metastasis

46 Whole-body DW imaging The most newly MRI technique Very helpful in detection of prostate cancer and its metastasis as well as post cancer therapy fallow up

47 Local Staging of Prostate Cancer High resolution MR images – especially with the use of endorectal coil – can show with high accuracy whether the tumor is confined to prostate gland or there is extra capsular extension

48 The gold standard approach for: – Diagnosis – Staging and management of prostate cancer Is using 1.5 T MR machines with both endorectal and pelvic phased-array coils

49 Evaluation of Local Recurrence After Treatment MR spectroscopy detects recurrence after radical prostatectomy – 84% and 88% sensitivity and specificity respectively DWMRI – capable to detect cancer recurrence after radical prostatectomy in patients that conventional MRI has missed recurrence

50 DW-MR imaging alone shows low sensitivity in cancer recurrence detection after radiotherapy (25%) In combination with T2-Weighted MRI – sensitivity increases to 62% – Specificity in both condition is acceptable (92% vs 97%)

51 High resolution Multiparametric MR imaging includes: – regular T1 weighted and T2 weighted images – dynamic contrast-enhanced MRI – diffusion weighted imaging – MR spectroscopy

52 High resolution Multiparametric MR imaging Obtained in 1.5 T MR machines with simultaneous use of pelvic and endorectal coils – best imaging modality in prostate cancer useful for – detection and local staging of prostate cancer – follow-up of patients after radical prostatectomy or radiation therapy – detection of skeletal metastasis – targeting biopsies in patients highly suspicious of prostate cancer but with previous negative TRUS guided biopsies

53 References

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