Comparison of choline-PET/CT, MRI, SPECT, and bone scintigraphy in the diagnosis of bone metastases in patients with prostate cancer: a meta-analysis

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

OBJECTIVE

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).

EVIDENCE ACQUISITION

The panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.

EVIDENCE SYNTHESIS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.

CONCLUSIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

Updated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

The prevalence and locations of bone metastases using whole-body MRI in treatment-naïve intermediate- and high-risk prostate cancer

Objective

The aim of this study was to assess the prevalence and distribution of bone metastases in treatment-naïve prostate cancer patients eligible for a metastatic workup using whole-body MRI, and to evaluate the results in light of current guidelines.

Methods

This single-institution, retrospective study included all patients with treatment-naïve prostate cancer referred to whole-body MRI during 2016 and 2017. All were eligible for a metastatic workup according to the guidelines: PSA > 20 ng/ml and/or Gleason grade group ≥ 3 and/or cT ≥ 2c and/or bone symptoms. The definition of a metastasis was descriptive and based on the original MRI reports. The anatomical location of metastases was registered.

Results

We included 161 patients with newly diagnosed prostate cancer of which 36 (22%) were intermediate-risk and 125 (78%) were high-risk. The median age and PSA were 71 years (IQR 64–76) and 13 ng/ml (IQR 8–28), respectively. Bone metastases were found in 12 patients (7%, 95% CI: 4–13), and all were high-risk with Gleason grade group ≥ 4. The pelvis was affected in 4 patients, and the spine + pelvis in the remaining 8. No patients demonstrated metastases to the spine without concomitant metastases in the pelvis. Limitations are the small number of metastases and retrospective design.

Conclusion

This study suggests that the overall prevalence of bone metastases using the current guidelines for screening is quite low. No metastases were seen in the case of Gleason grade group ≤ 3, and further studies should investigate if it necessary to screen non-high-risk patients.

Key Points

• The overall prevalence of bone metastases was 7% in the case of newly diagnosed intermediate- and high-risk prostate cancer.

• The prevalence in high-risk patients was 10%, and no metastases were seen in patients with Gleason grade group ≤ 3.

• The pelvic skeleton is the main site, and no metastases occurred in the spine without concomitant pelvic metastases.

What's New for Clinical Whole-body MRI (WB-MRI) in the 21st Century

Whole-body MRI (WB-MRI) has evolved since its first introduction in the 1970s as an imaging technique to detect and survey disease across multiple sites and organ systems in the body. The development of diffusion-weighted MRI (DWI) has added a new dimension to the implementation of WB-MRI on modern scanners, offering excellent lesion-to-background contrast, while achieving acceptable spatial resolution to detect focal lesions 5 to 10 mm in size. MRI hardware and software advances have reduced acquisition times, with studies taking 40-50 min to complete.The rising awareness of medical radiation exposure coupled with the advantages of MRI has resulted in increased utilization of WB-MRI in oncology, paediatrics, rheumatological and musculoskeletal conditions and more recently in population screening. There is recognition that WB-MRI can be used to track disease evolution and monitor response heterogeneity in patients with cancer. There are also opportunities to combine WB-MRI with molecular imaging on PET-MRI systems to harness the strengths of hybrid imaging. The advent of artificial intelligence and machine learning will shorten image acquisition times and image analyses, making the technique more competitive against other imaging technologies.

Impact of 68 Gallium prostate-specific membrane antigen tracers on the management of patients with prostate cancer who experience biochemical recurrence

OBJECTIVE

To investigate the impact of ⁶⁸ Gallium prostate-specific membrane antigen (⁶⁸ Ga-PSMA) tracers on the management of prostate cancer (PCa) patients with biochemical recurrence (BCR) by conducting a systematical review and meta-analysis.

MATERIALS AND METHODS

We performed a literature search of the PubMed, Embase and Web of Science databases up to 29 October 2019. We included studies that reported the proportion of patients whose management changed after ⁶⁸ Ga-PSMA tracers were used in patients with BCR. We used the Quality Assessment of Diagnostic Accuracy Studies-2 tool to evaluate the quality of the included studies. The proportion of patients with management changes were pooled using a random-effects model. Subgroup analyses and meta-regression analyses were performed to explore the source of heterogeneity. A Sankey diagram was used to show treatment change from before to after the use of ⁶⁸ Ga-PSMA tracers.

RESULTS

We included 20 eligible studies (2026 patients). The pooled proportion of patients with management change was 53% (95% confidence interval [CI] 46-60) in patients with BCR and 51% (95% CI, 34-67) in patients with early BCR (prostate-specific antigen [PSA] <0.5 ng/mL). The pooled positron-emission tomography-positive rate in patients with BCR was 68% (95% CI 59-78). Fourteen studies reported management change, with most changes being intermodal in nature (42%, vs 17% intramodal change).

CONCLUSIONS

The use of ⁶⁸ Ga-PSMA tracers altered the management of more than half of PCa patients with BCR, including those with early BCR. ⁶⁸ Ga-PSMA tracers might be used to guide individualized treatment in patients with BCR, particularly those with early BCR.

Bone metastases

Bone is the most frequent site for metastasis for many cancers, notably for tumours originating in the breast and the prostate. Tumour cells can escape from the primary tumour site and colonize the bone microenvironment. Within the bone, these disseminated tumour cells, as well as those arising in the context of multiple myeloma, may assume a state of dormancy, remaining quiescent for years before resuming proliferation and causing overt metastasis, which causes bone destruction via activation of osteoclast-mediated osteolysis. This structural damage can lead to considerable morbidity, including pain, fractures and impaired quality of life. Although treatment of bone metastases and myeloma bone disease is rarely curative, disease control is often possible for many years through the use of systemic anticancer treatments on a background of multidisciplinary supportive care. This care should include bone-targeted agents to inhibit tumour-associated osteolysis and prevent skeletal morbidity as well as use of appropriate local treatments such as radiation therapy, orthopaedic surgery and specialist palliative care to minimize the impact of metastatic bone disease on physical functioning. In this Primer, we provide an overview of the clinical features, the pathophysiology and the specific treatment approaches to prevent and treat bone metastases from solid tumours as well as myeloma bone disease.

Magnetic Resonance Imaging of Prostate Adenocarcinoma: Detection and Staging

Prostate cancer (PCa) is common among men worldwide and is a major cause of morbidity and mortality. The detection of PCa has historically followed a stepwise process of prostate-specific antigen screening followed with systematic transrectal ultrasound-guided biopsy. Magnetic resonance imaging (MRI), utilizing a set of sequences to assess morphology and function, has gained clinical acceptance to detect, characterize, and stage PCa. The Prostate Imaging - Reporting and Data System has helped facilitate the standardization of reporting across institutions and increased adoption of this method. In this review, we will (1) discuss the strengths and weaknesses of conventional diagnostic methods; (2) describe the clinical utility of prostate MRI, specifically addressing its uses in the detection and staging of PCa; and (3) list important technical parameters required for state-of-the-art prostate MRI.

Does whole-body bone SPECT/CT provide additional diagnostic information over [18F]-FCH PET/CT for the detection of bone metastases in the setting of prostate cancer biochemical recurrence?

BACKGROUND

To assess whether whole-body (WB) bone SPECT/CT provides additional diagnostic information over [18F]-FCH PET/CT for the detection of bone metastases in the setting of prostate cancer biochemical recurrence (PC-BR).

METHODS

Patients referred for a PC-BR and whom benefited from a WB bone SPECT/CT and FCH PET/CT were retrospectively included. Tests were classified as positive, equivocal, or negative for bone metastases. A best valuable comparator (BVC) strategy including imaging and follow-up data was used to determine the metastatic status in the absence of systematic histological evaluation.

RESULTS

Between January 2011 and November 2017, 115 consecutive patients with a PC-BR were evaluated. According to the BVC, 30 patients had bone metastases and 85 patients did not present with bone lesions. The sensitivity, specificity, positive and negative predictive values were respectively 86.7% [69.3-96.2], 98.8% [93.6-100.0], 96.3% [78.7-99.5], and 95.5% [89.4-98.1] for WB bone SPECT/CT and 93.3% [77.9-99.2], 100.0% [95.8-100.0], 100.0 and 97.7% [91.8-99.4] for FCH PET/CT. There was no significant difference in diagnostic accuracy of bone metastases between WB Bone SPECT/CT (AUC 0.824 [0.74-0.90]) and FCH PET/CT (AUC 0.829 [0.75-0.90], p = 0.41).

CONCLUSION

Despite good performances for the diagnosis of bone metastases in PC-BR, WB bone SPECT/CT does not provide additive diagnostic information over concomitant FCH PET/CT.

Diagnostic Performance of PET Imaging Using Different Radiopharmaceuticals in Prostate Cancer According to Published Meta-Analyses

A significant number of meta-analyses reporting data on the diagnostic performance of positron emission tomography (PET) in prostate cancer (PCa) is currently available in the literature. In particular, different PET radiopharmaceuticals were used for this purpose. The aim of this review is to summarize information retrieved by published meta-analyses on this topic. The first step included a systematic search of the literature (last search date: June 2020), screening two databases (PubMed/MEDLINE and Cochrane Library). This combination of key words was used: (A) “PET” OR “positron emission tomography” AND (B) “prostate” OR “prostatic” AND (C) meta-analysis. Only meta-analyses on Positron Emission Tomography/Computed Tomography (PET/CT) or Positron Emission Tomography/Magnetic Resonance (PET/MR) in PCa were selected. We have summarized the diagnostic performance of PET imaging in PCa, taking into account 39 meta-analyses published in the literature. Evidence-based data showed the good diagnostic performance of PET/CT with several radiopharmaceuticals, including prostate-specific membrane antigen (PSMA)-targeted agents, radiolabeled choline, fluciclovine, and fluoride in restaging and staging settings. Less evidence-based data were available for PET/MR with different radiotracers. More prospective multicentric studies and cost-effectiveness analyses are warranted.

Reporting and handling of equivocal imaging findings in diagnostic studies of bone metastasis in prostate cancer

BACKGROUND

Equivocal scanning results occur. It remains unclear how these results are presented and their management influence diagnostic characteristics.

PURPOSE

To investigate the reporting and handling of equivocal imaging findings in diagnostic studies of bone metastases, and to assess the impact on diagnostic performance of the methods used to analyze equivocal findings. The conceptual issue was reified based on two actual observations.

MATERIAL AND METHODS

A recent meta-analysis of bone metastases in prostate cancer was conducted and data were obtained from a large clinical trial with a true reference of bone metastasis, where diagnostic characteristics were calculated with equivocal scans handled by: removal; considered malignant; considered benign; and intention-to-diagnose.

RESULTS

The meta-analysis included 18 trials where the median proportion of reported equivocal results was 27%. Eleven (61%) studies reported an equivocal option for the index test, 42% reported equivocal results and described how these were analyzed. The clinical trial included 583 prostate cancer patients with 20% equivocal results. The different methods of managing equivocal findings resulted in highly variable outcomes: sensitivity = 85%-100%; specificity = 78%-99%; and positive and negative predictive values = 44%-94% and 97%-100%, respectively. The diagnostic performances obtained using the four methods were differentially susceptible to the proportion of equivocal imaging findings and the prevalence of bone metastases.

CONCLUSION

Reporting of equivocal results was inadequate in bone imaging trials. The handling of equivocal findings strongly influenced diagnostic accuracy.

Molecular imaging of prostate cancer: Review of imaging agents, modalities, and current status

INTRODUCTION

The clinical course of Prostate cancer (PCa) are markedly diverse, ranging from indolent to highly aggressive disseminated disease. Molecular imaging techniques are playing an increasing role in early PCa detection, staging and disease recurrence. There are some molecular imaging modalities, radiotracers agents and its performance are important in current clinical practice PCa.

OBJECTIVE

This review summarizes the latest information regarding molecular imaging of PCa and is designed to assist urologists with ordering and interpreting these modalities and different radiotracers for different patients.

EVIDENCE ACQUISITION

A PubMed-based literature search was conducted up to September 2019. We selected the most recent and relevant original articles, metanalysis and reviews that have provided relevant information to guide molecular imaging modalities and radiotracers use.

EVIDENCE SYNTHESIS

In this review, we discuss 3 main molecular imaging modalities and 7 radiotracer technologies available.

CONCLUSIONS

The use molecular imaging modalities and radiotracers has a unique role in biochemical recurrence and diagnosis of ganglionar and bone progression of PCa. In the present time, no one of these molecular imaging modalities can be recommended over the classical work-up of abdominopelvic CT scan and bone scan, and large-scale and multi-institutional studies are required to validate the efficacy and cost utility of these new technologies.

Phantom and clinical evaluation of bone SPECT/CT image reconstruction with xSPECT algorithm

BACKGROUND

Two novel methods of image reconstruction, xSPECT Quant (xQ) and xSPECT Bone (xB), that use an ordered subset conjugate gradient minimizer (OSCGM) for SPECT/CT reconstruction have been proposed. The present study compares the performance characteristics of xQ, xB, and conventional Flash3D (F3D) reconstruction using images derived from phantoms and patients.

METHODS

A custom-designed body phantom for bone SPECT was scanned using a Symbia Intevo (Siemens Healthineers), and reconstructed xSPECT images were evaluated. The phantom experiments proceeded twice with different activity concentrations and sphere sizes. A phantom with 28-mm spheres containing a 99mTc-background and tumor-to-normal bone ratios (TBR) of 1, 2, 4, and 10 were generated, and convergence property against various TBR was evaluated across 96 iterations. A phantom with four spheres (13-, 17-, 22-, and 28-mm diameters), containing a 99mTc-background at TBR4, was also generated. The full width at half maximum of an imaged spinous process (10 mm), coefficients of variance (CV), contrast-to-noise ratio (CNR), and recovery coefficients (RC) were evaluated after reconstructing images of a spine using Flash 3D (F3D), xQ, and xB. We retrospectively analyzed images from 20 patients with suspected bone metastases (male, n = 13) which were acquired using [99mTc]Tc-(H)MDP SPECT/CT, then CV and standardized uptake values (SUV) at the 4th vertebral body (L4) were compared after xQ and xB reconstruction in a clinical setup.

RESULTS

Mean activity concentrations with various TBR converged according to increasing numbers of iterations. The spatial resolution of xB was considerably superior to xQ and F3D, and it approached almost the actual size regardless of the iteration numbers during reconstruction. The CV and RC were better for xQ and xB than for F3D. The CNR peaked at 24 iterations for xQ and 48 iterations for F3D and xB, respectively. The RC between xQ and xB significantly differed at lower numbers of iterations but were almost equivalent at higher numbers of iterations. The reconstructed xQ and xB images of the clinical patients showed a significant difference in the SUVmax and SUVpeak.

CONCLUSIONS

The reconstructed xQ and xB images were more accurate than those reconstructed conventionally using F3D. The xB for bone SPECT imaging offered essentially unchanged spatial resolution even when the numbers of iterations did not converge. The xB reconstruction further enhanced SPECT image quality using CT data. Our findings provide important information for understanding the performance characteristics of the novel xQ and xB algorithms.

Imaging diagnosis of metastatic breast cancer

Numerous imaging modalities may be used for the staging of women with advanced breast cancer. Although bone scintigraphy and multiplanar-CT are the most frequently used tests, others including PET, MRI and hybrid scans are also utilised, with no specific recommendations of which test should be preferentially used. We review the evidence behind the imaging modalities that characterise metastases in breast cancer and to update the evidence on comparative imaging accuracy.

Evaluation of bone metastasis burden as an imaging biomarker by quantitative single-photon emission computed tomography/computed tomography for assessing prostate cancer with bone metastasis: a phantom and clinical study

Metabolic bone volume (MBV), standardized uptake value (SUV), and total bone uptake (TBU) are new imaging biomarkers for quantitative bone single-photon emission computed tomography/computed tomography. The purpose of this study was to validate the quantitative accuracy and utility of MBV, SUV_mean, and TBU for the assessment of bone metastases in prostate cancer. We used a bone-specific phantom with four hot spheres (φ = 13, 17, 22, 28 mm) filled with different Tc-99 m activities to simulate uptake ratios of 3 and 7, corresponding to normal and metastatic values. We calculated the error ratio (%Error) by comparing MBV, SUV_mean, and TBU with true values for various parameters, including bone lesion size, uptake ratio, and SUV cut-off level. Differences for MBV, SUV_mean, TBU, and bone scan index (BSI) were calculated to verify their utility in assessing bone metastases. Receiver-operating characteristic curve (ROC) analysis was performed to calculate the area under the curve (AUC) for each biomarker. MBV, SUV_mean, and TBU were affected by lesion size, uptake ratio, and SUV cut-off level; however, TBU demonstrated the most stable %Error. The TBU %Error was within 15% in spheres 17 mm or larger when the SUV cut-off level was 7, regardless of the uptake ratio. The ROC analyses revealed the AUCs of BSI (0.977) and TBU (0.968). Additionally, TBU was able to assess bone metastasis when BSI provided false-negative results, but TBU also provided false-positive results by degenerative changes. The synergy between TBU and BSI could potentially improve diagnostic accuracy.

Non-metastatic castration-resistant prostate cancer: current status and future directions

INTRODUCTION

The emergence of novel hormonal therapies and the increase availability of sensitive next-generation imaging techniques has significantly changed the management of recurrent prostate cancer.

AREAS COVERED

In this review, we summarize the definition, diagnosis, treatment, and ongoing clinical trials in non-metastatic castration resistant prostate cancer (M0CRPC). We have also discussed the role of newer imaging modalities in the detection of advanced prostate cancer.

EXPERT OPINION

M0CRPC is a disease state in prostate cancer when serologic progression (PSA only disease) occurs despite castrated levels of testosterone and imaging shows no evidence of metastasis. With the availability of next-generation imaging, more patients are migrating from M0CRPC to mCRPC space. This stage migration impacts the treatment options currently available in clinical practice and requires the integration of novel imaging in prospective studies moving forward. Until that data become available men with M0CRPC should be considered for therapy with any of these three novel oral AR inhibitors, with a positive impact in metastasis-free and overall survival. Treatment selection should be based on Quality of Life, side effects, and drug-drug interactions.

A prospective intra-individual comparison of [68Ga]Ga-PSMA-11 PET/CT, [68Ga]Ga-NODAGAZOL PET/CT, and [99mTc]Tc-MDP bone scintigraphy for radionuclide imaging of prostate cancer skeletal metastases

PURPOSE

Prostate cancer (PCa) commonly metastasizes to the bones. There are several radionuclide techniques for imaging PCa skeletal metastases. We aimed to compare the lesion detection rate of [⁶⁸Ga]Ga-PSMA-11 PET/CT, [⁶⁸Ga]Ga-NODAGA-zoledronate ([⁶⁸Ga]Ga-NODAGA^ZOL) PET/CT, and [^99mTc]Tc-MDP bone scan in the assessment of bone metastases in patients with advanced PCa.

METHODS

We prospectively recruited two cohorts of patients (staging and re-staging cohorts) with advanced prostate cancer. The staging cohort was treatment-naïve PCa patients who showed skeletal metastases on bone scan. These patients were subsequently imaged with [⁶⁸Ga]Ga-PSMA-11 PET/CT and [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT. Re-staging cohort was patients who were previously treated with PSMA-based radioligand therapy and were experiencing PSA progression. The re-staging cohort was imaged with [⁶⁸Ga]Ga-PSMA-11 PET/CT and [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT. We performed a per-patient and per-lesion analysis of skeletal metastases in both cohorts and made a comparison between scan findings.

RESULTS

Eighteen patients were included with a median age of 68 years (range = 48-80) and a median Gleason score of 8. There were ten patients in the staging cohort with a median PSA of 119.26 ng/mL (range = 4.63-18,948.00) and eight patients in the re-staging cohort with a median PSA of 48.56 ng/mL (range = 6.51-3175.00). In the staging cohort, skeletal metastases detected by [⁶⁸Ga]Ga-PSMA-11 PET/CT, [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT, and bone scan were 322, 288, and 261, respectively, p = 0.578. In the re-staging cohort, [⁶⁸Ga]Ga-PSMA-11 PET/CT and [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT detected 152 and 191 skeletal metastases, respectively, p = 0.529. In two patients with negative [⁶⁸Ga]Ga-PSMA-11 PET/CT findings, [⁶⁸Ga]Ga-NODAGA^ZOL detected one skeletal metastasis in one patient and 12 skeletal metastases in the other.

CONCLUSION

In patients with advanced prostate cancer, [⁶⁸Ga]Ga-PSMA-11 PET/CT may detect more lesions than [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT and [^99mTc]Tc-MDP bone scan for the staging of skeletal metastases. In patients who experience PSA progression on PSMA-based radioligand therapy, [⁶⁸Ga]Ga-NODAGA PET/CT is a more suitable imaging modality for the detection of skeletal lesions not expressing PSMA. In the setting of re-staging, [⁶⁸Ga]Ga-NODAGA^ZOL PET/CT may detect more lesions than [⁶⁸Ga]Ga-PSMA-11 PET/CT.

Whole-body magnetic resonance imaging (WB-MRI) for cancer screening in asymptomatic subjects of the general population: review and recommendations

Background

The number of studies describing the use of whole-body magnetic resonance imaging (WB-MRI) for screening of malignant tumours in asymptomatic subjects is increasing. Our aim is to review the methodologies used and the results of the published studies on per patient and per lesion analysis, and to provide recommendations on the use of WB-MRI for cancer screening.

Main body

We identified 12 studies, encompassing 6214 WB-MRI examinations, which provided the rates of abnormal findings and findings suspicious for cancer in asymptomatic subjects, from the general population. Eleven of 12 studies provided imaging protocols that included T1- and T2-weighted sequences, while only five included diffusion weighted imaging (DWI) of the whole body. Different categorical systems were used for the classification and the management of abnormal findings.

Of 17,961 abnormal findings reported, 91% were benign, while 9% were oncologically relevant, requiring further investigations, and 0.5% of lesions were suspicious for cancer.

A per-subject analysis showed that just 5% of subjects had no abnormal findings, while 95% had abnormal findings. Findings requiring further investigation were reported in 30% of all subjects, though in only 1.8% cancer was suspected. The overall rate of histologically confirmed cancer was 1.1%.

Conclusion

WB-MRI studies of cancer screening in the asymptomatic general population are too heterogeneous to draw impactful conclusions regarding efficacy. A 5-point lesion scale based on the oncological relevance of findings appears the most appropriate for risk-based management stratification. WB-MRI examinations should be reported by experienced oncological radiologists versed on WB-MRI reading abnormalities and on onward referral pathways.

Cost-consequence analysis of 18F-fluciclovine for the staging of recurrent prostate cancer

Background: Current detection methodologies are often unable to identify the location and extent of recurrent prostate cancer (PCa) leading potentially to 'futile' local therapies in the presence of metastatic disease. The use of ¹⁸ F-fluciclovine PET/CT may lead to better patient management. Objective: The aim of this study was to quantify the economic impact and cost-consequence of using ¹⁸ F-fluciclovine PET/CT in PCa recurrence. Study design: A decision analytic model based on recurrent PCa imaging guidelines. Setting: US hospital. Participants: PCa patients experiencing biochemical recurrence. Intervention: ¹⁸ F-fluciclovine PET/CT was compared to conventional imaging. Main outcome measure: Budget impact, correct diagnoses, futile treatments, and cost-consequence (cost per correct diagnosis) Results: For a hypothetical hospital serving 500,000 individuals, the model showed the use of ¹⁸ F-fluciclovine reduced 'futile' therapies by 19.2%. Re-imaging costs were reduced by 40.2% ($8.2 million); however, when assuming diagnostic and staging costs only, the total costs increased from $31.2 to $34.6 million (10.9%), driven by ¹⁸ F-fluciclovine imaging agent and procedure costs. The cost per 'correct' diagnosis declined $30,673 (46.8%). When including subsequent 5-year patient management, the cost per 'correct' diagnosis declined $410,206 (49.2%). Conclusion: ¹⁸ F-fluciclovine PET/CT imaging may improve the clinical management of men with recurrent PCa with minimal increase in healthcare spending.

Comparison of 18F-sodium fluoride PET/CT, 18F-fluorocholine PET/CT and diffusion-weighted MRI for the detection of bone metastases in recurrent prostate cancer: a cost-effectiveness analysis in France

Background

The diagnostic performance of ¹⁸F-sodium fluoride positron emission tomography/computed tomography (PET/CT) (NaF), ¹⁸F-fluorocholine PET/CT (FCH) and diffusion-weighted whole-body magnetic resonance imaging (DW-MRI) in detecting bone metastases in prostate cancer (PCa) patients with first biochemical recurrence (BCR) has already been published, but their cost-effectiveness in this indication have never been compared.

Methods

We performed trial-based and model-based economic evaluations. In the trial, PCa patients with first BCR after previous definitive treatment were prospectively included. Imaging readings were performed both on-site by local specialists and centrally by experts. The economic evaluation extrapolated the diagnostic performances of the imaging techniques using a combination of a decision tree and Markov model based on the natural history of PCa. The health states were non-metastatic and metastatic BCR, non-metastatic and metastatic castration-resistant prostate cancer and death. The state-transition probabilities and utilities associated with each health state were derived from the literature. Real costs were extracted from the National Cost Study of hospital costs and the social health insurance cost schedule.

Results

There was no significant difference in diagnostic performance among the 3 imaging modalities in detecting bone metastases. FCH was the most cost-effective imaging modality above a threshold incremental cost-effectiveness ratio of 3000€/QALY when imaging was interpreted by local specialists and 9000€/QALY when imaging was interpreted by experts.

Conclusions

FCH had a better incremental effect on QALY, independent of imaging reading and should be preferred for detecting bone metastases in patients with biochemical recurrence of prostate cancer.

Trial registration

NCT01501630. Registered 29 December 2011.

Bone Metastasis: Current State of Play

Bone metastasis (BM) in cancer remains a critical issue because of its associated clinical and biological complications. Moreover, BM can alter the quality of life and survival rate of cancer patients. Growing evidence suggests that bones are a fertile ground for the development of metastasis through a "vicious circle" of bone resorption/formation and tumor growth. This review aims to outline the current major issues in the diagnosis and management of BM in the most common types of osteotropic cancers and describe the mechanisms and effects of BM. First, we discuss the incidence of BM through the following questions: Are we witnessing an increase in incidence, and are we now better equipped with modern imaging techniques? Is the advent of efficient bone resorption inhibitors affecting the bigger picture of BM management? Second, we discuss the potential effects of cancer progression and well-prescribed drugs, such as multitarget tyrosine kinase inhibitors, inhibitors of the mammalian target of rapamycin, and immune checkpoint inhibitors, on BM. Finally, we examine the duality of the effects of some therapies that may help in cancer treatment but may also contribute to further BM.

Imaging for Metastasis in Prostate Cancer: A Review of the Literature

Background: Initial staging and assessment of treatment activity in metastatic prostate cancer (PCa) patients is controversial. Indications for the various available imaging modalities are not well-established due to rapid advancements in imaging and treatment.

Methods: We conducted a critical literature review of the main imaging abnormalities that suggest a diagnosis of metastasis in localized and locally advanced PCa or in cases of biological relapse. We also assessed the role of the various imaging modalities available in routine clinical practice for the detection of metastases and response to treatment in metastatic PCa patients.

Results: In published clinical trials, the most commonly used imaging modalities for the detection and evaluation of therapeutic response are bone scan, abdominopelvic computed tomography (CT), and pelvic and bone magnetic resonance imaging (MRI). For the detection and follow-up of metastases during treatment, modern imaging techniques i.e., choline-positron emission tomography (PET), fluciclovine-PET, or Prostate-specific membrane antigen (PSMA)-PET provide better sensitivity and specificity. This is particularly the case of fluciclovine-PET and PSMA-PET in cases of biochemical recurrence with low values of prostate specific antigen.

Conclusions: In routine clinical practice, conventional imaging still have a role, and communication between imagers and clinicians should be encouraged. Present and future clinical trials should use modern imaging methods to clarify their usage.

Optimum Imaging Strategies for Advanced Prostate Cancer: ASCO Guideline

PURPOSE

Provide evidence- and expert-based recommendations for optimal use of imaging in advanced prostate cancer. Due to increases in research and utilization of novel imaging for advanced prostate cancer, this guideline is intended to outline techniques available and provide recommendations on appropriate use of imaging for specified patient subgroups.

METHODS

An Expert Panel was convened with members from ASCO and the Society of Abdominal Radiology, American College of Radiology, Society of Nuclear Medicine and Molecular Imaging, American Urological Association, American Society for Radiation Oncology, and Society of Urologic Oncology to conduct a systematic review of the literature and develop an evidence-based guideline on the optimal use of imaging for advanced prostate cancer. Representative index cases of various prostate cancer disease states are presented, including suspected high-risk disease, newly diagnosed treatment-naïve metastatic disease, suspected recurrent disease after local treatment, and progressive disease while undergoing systemic treatment. A systematic review of the literature from 2013 to August 2018 identified fully published English-language systematic reviews with or without meta-analyses, reports of rigorously conducted phase III randomized controlled trials that compared ≥ 2 imaging modalities, and noncomparative studies that reported on the efficacy of a single imaging modality.

RESULTS

A total of 35 studies met inclusion criteria and form the evidence base, including 17 systematic reviews with or without meta-analysis and 18 primary research articles.

RECOMMENDATIONS

One or more of these imaging modalities should be used for patients with advanced prostate cancer: conventional imaging (defined as computed tomography [CT], bone scan, and/or prostate magnetic resonance imaging [MRI]) and/or next-generation imaging (NGI), positron emission tomography [PET], PET/CT, PET/MRI, or whole-body MRI) according to the clinical scenario.

Whole-body MRI: a powerful alternative to bone scan for bone marrow staging without radiation and gadolinium enhancer

PURPOSE

Whole-body magnetic resonance imaging (WB-MRI) is a radiation-free alternative to the ^99mTc-HDP bone scan (BS) for the detection of bone metastasis. The major drawback is the long examination time and application of gadolinium enhancer. The aim of this study is to analyze (i) the performance of WB-MRI versus the BS and (ii) the diagnostic benefit of gadolinium (WB-MRI + Gd) compared to a non-enhanced protocol (NE WB-MRI).

METHODS AND MATERIALS

1256 eligible WB-MRI scans were analyzed retrospectively with a single inclusion criterion, a clinical 12-month follow-up or a biopsy as ground truth. N = 285 patients received both a WB-MRI and a BS within 12 months. All the patients were imaged with a coronal T1w and a STIR, and n = 528 (42%) received an additional T1w-mDixon with gadoteridol (0.1 mmol Gd-DTPA/kg).

RESULTS

From 1256 eligible patients, n = 884 (70%) had breast cancer as a primary disease, n = 101(8%) prostate cancer, and n = 77(6%) lung cancer. The sensitivity (Se) and negative predictive value (NPV) of the WB-MRI was 98/99%, significantly higher compared to BS with 82/89%, P < 0.001 Mc Nemar's test. The specificity (Spe) and positive predictive value (PPV) of the WB-MRI and BS was 85/82% and 91/86%, respectively. The interobserver agreement between WB-MRI and BS was 71%, Cohen's kappa 0.42. Analysis of the added diagnostic value of gadolinium revealed Se/Spe/PPV/NPV of 98/93/92/98% for the NE WB-MRI and 99/93/85/100% for the WM-MRI + Gd, P > 0.05 binary logistic regression with Fischer's exact test.

CONCLUSION

WB-MRI exceeds the sensitivity of BS without compromising the specificity, even after omitting the gadolinium enhancer.

Diagnostic value and clinical significance of MRI and CT in detecting lymph node metastasis of early cervical cancer

Diagnostic value and clinical significance of magnetic resonance imaging (MRI) and computed tomography (CT) in detecting lymph node metastasis of early cervical cancer were investigated. From April 2015 to April 2019, 160 patients with lymph node metastasis (stage I–II) of early cervical cancer in Jining No. 1 People's Hospital were retrospectively analyzed. All the patients underwent MRI, CT diagnosis and MRI combined with CT diagnosis before operation. Sensitivity, specificity and diagnostic accordance rate, the diagnostic value and clinical significance of MRI, CT and MRI combined with CT in the diagnosis of lymph node metastasis of early cervical cancer were compared. The sensitivity, specificity and diagnostic accordance rate of MRI in the diagnosis of lymph node metastasis of early cervical cancer in stage Ia-Ib were 75.00, 72.92 and 77.50%, respectively, which were significantly higher than those of PET/CT in the same period (P<0.05). The sensitivity, specificity and diagnostic accordance rate of MRI combined with CT in the diagnosis of early cervical cancer in stage Ia-Ib were 78.13, 87.50 and 83.75%, respectively, which were significantly higher than those of MRI or CT alone (P<0.05). However, the sensitivity, specificity and diagnostic accordance rate of MRI combined with CT in the diagnosis of lymph node metastasis of early cervical cancer in stage IIa-IIb were 91.66, 82.81 and 88.13%, respectively, which were significantly higher than those of MRI or CT alone (P<0.05). MRI is superior to CT in the diagnosis of lymph node metastasis of early cervical cancer. However, the diagnostic efficiency of combined scans of the two is far higher than that of MRI or CT alone, which has more diagnostic value. In clinic, MRI and CT should be combined to improve the diagnostic accuracy of diseases.

Comparison of PSMA-PET/CT, choline-PET/CT, NaF-PET/CT, MRI, and bone scintigraphy in the diagnosis of bone metastases in patients with prostate cancer: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis to compare the diagnostic performance of prostate-specific membrane antigen (PSMA)-PET/CT, choline-PET/CT, Sodium Fluoride (NaF) PET/CT, MRI, and bone scintigraphy (BS) in detecting bone metastases in patients with prostate cancer.

METHODS

We searched PubMed and Embase for articles published between January 1990 and September 2018. Two evaluators independently extracted the sensitivity, specificity, the numbers of true and false positives, and true and false negatives. We calculated the pooled sensitivity, specificity, and 95% confidence intervals (CI) for each method. We calculated the tests' diagnostic odds ratios (DOR); drew the summary receiver operating characteristic (SROC) curves; and obtained the areas under the curves (AUC), Q* values, and 95% CIs.

RESULTS

The per-patient pooled sensitivities of PSMA-PET/CT, choline-PET/CT, NaF-PET/CT, MRI, and BS were 0.97, 0.87, 0.96, 0.91, and 0.86, respectively. The pooled specificities were 1.00, 0.99, 0.97, 0.96, and 0.95, respectively. The pooled DOR values were 504.16, 673.67, 242.63, and 114.44, respectively. The AUC were 1.00, 0.99, 0.99, 0.98, and 0.95, respectively. The per-lesion pooled sensitivities of PSMA-PET/CT, choline-PET/CT, NaF-PET/CT, MRI, and bone imaging were 0.88, 0.80, 0.97, 0.81 and 0.68, respectively.

CONCLUSIONS

According to the meta-analysis, PSMA-PET/CT had the highest per-patient sensitivity and specificity in detecting bone metastases with prostate cancer. The sensitivities of NaF-PET/CT and MRI were better than those for choline-PET/CT and BS. The specificity of PSMA-PET/CT was significantly better than BS. Others were similar. For per-lesion, NaF-PET/CT had the highest sensitivity, PSMA-PET/CT had higher sensitivity than choline-PET/CT and MRI, and BS had the lowest sensitivity.

Clinical association between pre-treatment levels of plasma fibrinogen and bone metastatic burden in newly diagnosed prostate cancer patients

BACKGROUND

Due to the different treatments for low-volume metastatic prostate cancer (PCa) as well as high-volume ones, evaluation of bone metastatic status is clinically significant. In this study, we evaluated the correlation between pre-treatment plasma fibrinogen and the burden of bone metastasis in newly diagnosed PCa patients.

METHODS

A single-center retrospective analysis, focusing on prostate biopsies of newly diagnosed PCa patients, was performed. A total of 261 patients were enrolled in this study in a 4-year period. All subjects were submitted to single-photon emission computerized tomography-computed tomography to confirm the status of bone metastasis and, if present, the number of metastatic lesions would then be calculated. Clinical information such as age, prostate-specific antigen (PSA), fibrinogen, clinical T stage, and Gleason score were collected. Patients were divided into three groups: (i) a non-metastatic group, (ii) a high volume disease (HVD) group (>3 metastases with at least one lesion outside the spine), and (iii) a low volume disease (LVD) group (metastatic patients excluding HVD ones). The main statistical methods included non-parametric Mann-Whitney test, Spearman correlation, receiver operating characteristic (ROC) curves, and logistic regression.

RESULTS

Fibrinogen positively correlated with Gleason score (r = 0.180, P = 0.003), PSA levels (r = 0.216, P < 0.001), and number of metastatic lesions (r = 0.296, P < 0.001). Compared with the non-metastatic and LVD groups, the HVD group showed the highest PSA (104.98 ng/mL, median) and fibrinogen levels (3.39 g/L, median), as well as the largest proportion of Gleason score >7 (86.8%). Both univariate (odds ratio [OR] = 2.16, 95% confidential interval [CI]: 1.536-3.038, P < 0.001) and multivariate (OR = 1.726, 95% CI: 1.206-2.472, P = 0.003) logistic regressions showed that fibrinogen was independently associated with HVD. The ROC curve suggested that fibrinogen acts as a predictor of HVD patients, yielding a cut-off of 3.08 g/L, with a sensitivity of 0.684 and a specificity of 0.760 (area under the curve = 0.739, 95% CI: 0.644-0.833, P < 0.001).

CONCLUSIONS

Pre-treatment plasma fibrinogen is positively associated with bone metastatic burden in PCa patients. Our results indicate that fibrinogen might be a potential predictor of HVD.

The Established Nuclear Medicine Modalities for Imaging of Bone Metastases

Background:

The skeleton is one of the frequent site of metastases in advanced cancer. Prostate, breast and renal cancers mostly metastasize to bone.

Discussion:

Malignant tumors lead to significant morbidity and mortality. Identification of bone lesions is a crucial step in diagnosis of disease at early stage, monitoring of disease progression and evaluation of therapy. Diagnosis of cancer metastases is based on uptake of bone-targeted radioactive tracer at different bone remodeling sites.

Conclusion:

This manuscript summarizes already established and evolving nuclear medicine modalities (e.g. bone scan, SPECT, SPECT/CT, PET, PET/CT) for imaging of bone metastases.

Does therapy of the primary tumor matter in oligometastatic prostate cancer? A prospective 10-year follow-up study

Objective: The effect of curative treatment for oligometastatic prostate cancer patients is unsolved, both with regard to morbidity and mortality. With this study, we provide some of the first long-term follow-up data on progression and mortality in oligometastatic prostate cancer patients after curative treatment of their primary tumor.

Methods: A cohort of 210 patients with diagnosed prostate cancer was established between 2008 and 2010. All patients were scheduled for intended curative treatment, and all underwent blinded ¹⁸F-choline positron-emission tomography/computed tomography at inclusion prior to curative treatment. Upon unblinding, 12 patients (6%) were recategorized as being oligometastatic. They had a mean age of 64 years, median prostate-specific antigen of 18 ng/mL, and median Gleason score of 7. Six patients were staged as T3, one T2, and five T1. The patients had a median of one bone metastasis (range 1–2). All underwent intended curative radiotherapy or prostatectomy. Mean follow-up was 10.1 (8.9–11.0) years.

Results: During follow-up of the 12 patients, three (25%) had biochemical recurrence, two developed castration-resistant disease, and one died due to prostate cancer.

Conclusion: Our results suggest that intended curative treatment of the primary tumor in oligometastatic prostate cancer may have a role in highly selected patients.

Molecular imaging of bone metastases using tumor-targeted tracers

Bone metastasis is a disastrous manifestation of most malignancies, especially in breast, prostate and lung cancers. Since asymptomatic bone metastases are not uncommon, early detection, precise assessment, and localization of them are very important. Various imaging modalities have been employed in the setting of diagnosis of bone metastasis, from plain radiography and bone scintigraphy to SPECT, SPECT/CT, PET/CT, MRI. However, each modality showed its own limitation providing accurate diagnostic performance. In this regard, various tumor-targeted radiotracers have been introduced for molecular imaging of bone metastases using modern hybrid modalities. In this article we review the strength of different cancer-specific radiopharmaceuticals in the detection of bone metastases. As shown in the literature, among various tumor-targeted tracers, 68Ga DOTA-conjugated-peptides, 68Ga PSMA, 18F DOPA, 18F galacto-RGD integrin, 18F FDG, 11C/18F acetate, 11C/18F choline, 111In octreotide, 123/131I MIBG, 99mTc MIBI, and 201Tl have acceptable capabilities in detecting bone metastases depending on the cancer type. However, different study designs and gold standards among reviewed articles should be taken into consideration.

Imaging Diagnosis and Follow-up of Advanced Prostate Cancer: Clinical Perspectives and State of the Art

The management of advanced prostate cancer has changed substantially with the availability of multiple effective novel treatments, which has led to improved disease survival. In the era of personalized cancer treatments, more precise imaging may help physicians deliver better care. More accurate local staging and earlier detection of metastatic disease, accurate identification of oligometastatic disease, and optimal assessment of treatment response are areas where modern imaging is rapidly evolving and expanding. Next-generation imaging modalities, including whole-body MRI and molecular imaging with combined PET and CT and combined PET and MRI using novel radiopharmaceuticals, create new opportunities for imaging to support and refine management pathways in patients with advanced prostate cancer. This article demonstrates the potential and challenges of applying next-generation imaging to deliver the clinical promise of treatment breakthroughs.

Consensus on molecular imaging and theranostics in prostate cancer

Rapid developments in imaging and treatment with radiopharmaceuticals targeting prostate cancer pose issues for the development of guidelines for their appropriate use. To tackle this problem, international experts representing medical oncologists, urologists, radiation oncologists, radiologists, and nuclear medicine specialists convened at the European Association of Nuclear Medicine Focus 1 meeting to deliver a balanced perspective on available data and clinical experience of imaging in prostate cancer, which had been supported by a systematic review of the literature and a modified Delphi process. Relevant conclusions included the following: diphosphonate bone scanning and contrast-enhanced CT are mentioned but rarely recommended for most patients in clinical guidelines; MRI (whole-body or multiparametric) and prostate cancer-targeted PET are frequently suggested, but the specific contexts in which these methods affect practice are not established; sodium fluoride-18 for PET-CT bone scanning is not widely advocated, whereas gallium-68 or fluorine-18 prostate-specific membrane antigen gain acceptance; and, palliative treatment with bone targeting radiopharmaceuticals (rhenium-186, samarium-153, or strontium-89) have largely been replaced by radium-223 on the basis of the survival benefit that was reported in prospective trials, and by other systemic therapies with proven survival benefits. Although the advances in MRI and PET-CT have improved the accuracy of imaging, the effects of these new methods on clinical outcomes remains to be established. Improved communication between imagers and clinicians and more multidisciplinary input in clinical trial design are essential to encourage imaging insights into clinical decision making.

Multiparametric whole-body 3.0-T MRI in newly diagnosed intermediate- and high-risk prostate cancer: diagnostic accuracy and interobserver agreement for nodal and metastatic staging

OBJECTIVES

To determine the diagnostic accuracy and interobserver concordance of whole-body (WB)-MRI, vs. 99mTc bone scintigraphy (BS) and 18fluoro-ethyl-choline (18F-choline) PET/CT for the primary staging of intermediate/high-risk prostate cancer.

METHODS

An institutional review board approved prospective cohort study carried out between July 2012 and November 2015, whereby 56 men prospectively underwent 3.0-T multiparametric (mp)-WB-MRI in addition to BS (all patients) ± 18F-choline PET/CT (33 patients). MRI comprised pre- and post-contrast modified Dixon (mDixon), T2-weighted (T2W) imaging, and diffusion-weighted imaging (DWI). Patients underwent follow-up mp-WB-MRI at 1 year to derive the reference standard. WB-MRIs were reviewed by two radiologists applying a 6-point scale and a locked sequential read (LSR) paradigm for the suspicion of nodal (N) and metastatic disease (M1a and M1b).

RESULTS

The mean sensitivity/specificity of WB-MRI for N1 disease was 1.00/0.96 respectively, compared with 1.00/0.82 for 18F-choline PET/CT. The mean sensitivity and specificity of WB-MRI, 18F-choline PET/CT, and BS were 0.90/0.88, 0.80/0.92, and 0.60/1.00 for M1b disease. ROC-AUC did not show statistically significant improvement for each component of the LSR; mean ROC-AUC 0.92, 0.94, and 0.93 (p < 0.05) for mDixon + DWI, + T2WI, and + contrast respectively. WB-MRI had an interobserver concordance (κ) of 0.79, 0.68, and 0.58 for N1, M1a, and M1b diseases respectively.

CONCLUSIONS

WB-MRI provides high levels of diagnostic accuracy for both nodal and metastatic bone disease, with higher levels of sensitivity than BS for metastatic disease, and similar performance to 18F-choline PET/CT. T2 and post-contrast mDixon had no significant additive value above a protocol comprising mDixon and DWI alone.

KEY POINTS

• A whole-body MRI protocol comprising unenhanced mDixon and diffusion-weighted imaging provides high levels of diagnostic accuracy for the primary staging of intermediate- and high-risk prostate cancer. • The diagnostic accuracy of whole-body MRI is much higher than that of bone scintigraphy, as currently recommended for clinical use. • Staging using WB-MRI, rather than bone scintigraphy, could result in better patient stratification and treatment delivery than is currently provided to patients worldwide.

Multiparametric MRI - local staging of prostate cancer and beyond

Background Accurate local staging is critical for treatment planning and prognosis in patients with prostate cancer (PCa). The primary aim is to differentiate between organ-confined and locally advanced disease with the latter carrying a worse clinical prognosis. Multiparametric MRI (mpMRI) is the imaging modality of choice for the local staging of PCa and has an incremental value in assessing pelvic nodal disease and bone involvement. It has shown superior performance compared to traditional staging based on clinical nomograms, and provides additional information on the site and extent of disease. MRI has a high specificity for diagnosing extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node (LN) metastases, however, sensitivity remains poor. As a result, extended pelvic LN dissection remains the gold standard for assessing pelvic nodal involvement, and there has been recent progress in developing advanced imaging techniques for more distal staging. Conclusions T2W-weighted imaging is the cornerstone for local staging of PCa. Imaging at 3T and incorporating both diffusion weighted and dynamic contrast enhanced imaging can further increase accuracy. "Next generation" imaging including whole body MRI and PET-MRI imaging using prostate specific membrane antigen (68Ga-PSMA), has shown promising for assessment of LN and bone involvement as compared to the traditional work-up using bone scintigraphy and body CT.

Comparison of diagnostic value of multi-slice spiral CT and MRI for different pathological stages of prostate cancer

Diagnostic value of magnetic resonance imaging (MRI) and multi-slice spiral CT (MSCT) for different pathological stages of prostate cancer was compared. A total of 112 patients with prostate cancer who underwent surgical pathology in The Affiliated Yantai Yuhuangding Hospital of Qingdao University from February 2014 to January 2016 were enrolled as prostate cancer group, and another 100 patients who received physical health examinations during the same period as the normal group. MSCT and MRI scanning were performed on patients in both groups to analyze their diagnostic value for stages A/B and C/D of prostate cancer. Based on the apparent diffusion coefficient (ADC) value generated by the diffusion-weighted imaging (DWI) in MRI, there was a significant difference in the ADC value between different stages of prostate cancer (P<0.05); the pathological stage was negatively correlated with the ADC value (r=−0.7629, P<0.05), and the higher the stage was, the lower the ADC value was. The sensitivity was significantly higher in the MRI group than that in the MSCT group (92.0 vs. 79.5%, P<0.05), and the specificity was significantly higher in the MRI group than that in the MSCT group (90.0 vs. 70.0%, P<0.05). In the diagnosis of stage A and B of prostate cancer, the diagnostic coincidence rate was 86.7% in the MRI group, and 57.8% in the MSCT group (P<0.05); the misdiagnosis rate and missed diagnosis rate were significantly lower in the MRI group than those in the MSCT group (P<0.05). The accuracy of MRI is higher than that of MSCT in the diagnosis of early prostate cancer. Both MRI and MSCT can accurately detect stages C and D of prostate cancer, but the ADC value in MRI has great clinical significance for judging the risk of the tumor. Therefore, MRI is more valuable than MSCT in the diagnosis of patients with different pathological stages of prostate cancer.

Diagnosis of metastasis in castration-resistant prostate cancer patients: decision algorithm in imaging tests

INTRODUCTION

In castration-resistant prostate cancer (CRPC), early detection of metastases is essential for the selection of treatment, and prevention of bone complications. However detecting incipient metastases remains a challenge as the conventional radiological tests (bone scintigraphy or computerised tomography) lack sufficient sensitivity. Diagnostic imaging techniques are currently available that have greater sensitivity and specificity, but are little used due to shortfalls in the recommendations.

OBJECTIVE

To create an algorithm that indicates the most suitable diagnostic imaging techniques for the different M0 CRPC patient profiles based on the scientific evidence.

EVIDENCE ACQUISITION

Meetings were held with eight experts in Urology, Pathological Anatomy, Radiodiagnostics and Nuclear Medicine organised by the Andalusian Association of Urology, in which the recommendations and scientific evidence on each of the diagnostic imaging techniques were reviewed.

SUMMARY OF THE EVIDENCE

We present the current recommendations for the detection of metastasis in M0 CRPC patients, the patients that would benefit from early detection, and summarise the evidence to support the use of each of the new techniques.

CONCLUSIONS

Techniques such as ¹⁸F-Choline PET/CT or DWWB MRI and probably open MRI have been demonstrated to have good sensitivity and specificity for patients with low PSA (<10ng/ml). Their inclusion in routine clinical practice will help improve the early detection of metastasis in CRPC patients.

Whole-Body Magnetic Resonance Imaging in Oncology: Uses and Indications

Whole-body MRI (WB-MRI) has emerged as a radiation-free method for the diagnosis, staging, and therapy response assessments in cancer patients. This article reviews the current roles for WB-MRI in the clinical context of limitations of currently used techniques, focusing on bone marrow disease applications. Indication for broader clinical use are discussed, including guideline recommendations. The emerging screening role of WB-MRI in subjects at high risk of cancer is discussed, as is normal population screening.