Sensitivity of computed tomography in detecting local recurrence of prostatic carcinoma following radical prostatectomy

Salvage therapy for prostate cancer after radical prostatectomy

More than 40% of men with intermediate-risk or high-risk prostate cancer will experience a biochemical recurrence after radical prostatectomy. Clinical guidelines for the management of these patients largely focus on the use of salvage radiotherapy with or without systemic therapy. However, not all patients with biochemical recurrence will go on to develop metastases or die from their disease. The optimal pre-salvage therapy investigational workup for patients who experience biochemical recurrence should, therefore, include novel techniques such as PET imaging and genomic analysis of radical prostatectomy specimen tissue, as well as consideration of more traditional clinical variables such as PSA value, PSA kinetics, Gleason score and pathological stage of disease. In patients without metastatic disease, the only known curative intervention is salvage radiotherapy but, given the therapeutic burden of this treatment, importance must be placed on accurate timing of treatment, radiation dose, fractionation and field size. Systemic therapy also has a role in the salvage setting, both concurrently with radiotherapy and as salvage monotherapy.

Imaging assessment of local recurrence of prostate cancer after radical prostatectomy

Definitive therapy for prostate cancer includes radical prostatectomy and radiation therapy. Treatment is elected based on patient preference, biological tumor factors, and underlying health. Post prostatectomy, men are surveyed for disease recurrence with serial PSA measurements, digital rectal exam, and imaging studies depending on nomogram predicted risk of local disease recurrence and distant metastasis. In men with rising PSA levels, pathologically incomplete surgical margins or, if symptoms of metastasis develop, imaging may be obtained to localize disease. In cases of known biochemical recurrence, imaging is used to target biopsy, to contour in salvage radiation therapy and to assess disease response. For local disease recurrence, the most commonly performed exams are pelvic MRI and transrectal US. CT can evaluate for lymph node metastasis, but is suboptimal in the evaluation of the prostatectomy bed. PET/CT and PET/MRI have been used successfully to evaluate for local disease recurrence. The PI-RADSv2.1 manual provides a risk level and lexicon for use in description of prostate carcinoma prior to prostatectomy, but does not address imaging features post-surgery. A detailed description of nodal, bony, and visceral metastasis is given elsewhere. This manuscript outlines the context in which appropriate imaging exams may be obtained and focuses on imaging findings concerning for local disease recurrence after prostatectomy on various imaging modalities including CT, US, MRI, and PET.

68Ga-PSMA PET/CT versus CT and bone scan for investigation of PSA failure post radical prostatectomy

Objective

To evaluate the use of Gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸Ga-PSMA PET/CT), compared with conventional CT abdomen/pelvis (CTAP) and whole body single photon emission CT bone scan (BS), for detection of local or distant metastasis following biochemical failure/recurrence in post-prostatectomy patients.

Methods

We conducted a review of our prospectively maintained, institutional database to identify 384 patients with post-prostatectomy biochemical failure/recurrence who underwent PSMA PET/CT, CTAP and BS from February 2015 to August 2017 in Nepean Hospital, tertiary referral centre. The results of the three imaging modalities were analysed for their ability to detect local recurrence and distant metastases. PSMA PET/CT and CTAP imaging were separately performed on the same day and the BS was performed within several days (mostly in 24 h). Difference in detection rates was determined between the modalities and the Chi square test was used to determine significance.

Results

A total of 384 patients were identified with a median prostate-specific antigen (PSA) of 0.465 ng/mL (interquartile range =0.19–2.00 ng/mL). Overall, PSMA PET/CT was positive for 245 (63.8%) patients whereas CTAP and BS were positive in 174 patients (45.3%). A total of 98 patients (25.5%) had local or distant metastasis detected on PSMA only, while 20 patients (5.2%) had recurrences detected on CTAP but not on PSMA PET/CT.

Conclusion

The use of PSMA PET/CT has a higher detection rate of predicted local or distant metastasis compared to CTAP and BS in the staging of patients with biochemical recurrences after radical prostatectomy.

Magnetic Resonance-Guided Prostate Ablation

In 2019, the American Cancer Society (ACS) estimates that 174,650 new cases of prostate cancer will be diagnosed and 31,620 will die due to the prostate cancer in the United States. Prostate cancer is often managed with aggressive curative intent standard therapies including radiotherapy or surgery. Regardless of how expertly done, these standard therapies often bring significant risk and morbidity to the patient's quality of life with potential impact on sexual, urinary, and bowel functions. Additionally, improved screening programs, using prostatic-specific antigen and transrectal ultrasound-guided systematic biopsy, have identified increasing numbers of low-risk, low-grade "localized" prostate cancer. The potential, localized, and indolent nature of many prostate cancers presents a difficult decision of when to intervene, especially within the context of the possible comorbidities of aggressive standard treatments. Active surveillance has been increasingly instituted to balance cancer control versus treatment side effects; however, many patients are not comfortable with this option. Although active debate continues on the suitability of either focal or regional therapy for the low- or intermediate-risk prostate cancer patients, no large consensus has been achieved on the adequate management approach. Some of the largest unresolved issues are prostate cancer multifocality, limitations of current biopsy strategies, suboptimal staging by accepted imaging modalities, less than robust prediction models for indolent prostate cancers, and safety and efficiency of the established curative therapies following focal therapy for prostate cancer. In spite of these restrictions, focal therapy continues to confront the current paradigm of therapy for low- and even intermediate-risk disease. It has been proposed that early detection and proper characterization may play a role in preventing the development of metastatic disease. There is level-1 evidence supporting detection and subsequent aggressive treatment of intermediate- and high-risk prostate cancer. Therefore, accurate assessment of cancer risk (i.e., grade and stage) using imaging and targeted biopsy is critical. Advances in prostate imaging with MRI and PET are changing the workup for these patients, and advances in MR-guided biopsy and therapy are propelling prostate treatment solutions forward faster than ever.

Randomized prospective phase III trial of 68Ga-PSMA-11 PET/CT molecular imaging for prostate cancer salvage radiotherapy planning [PSMA-SRT]

BACKGROUND

Salvage radiotherapy (SRT) for prostate cancer (PCa) recurrence after prostatectomy offers long-term biochemical control in about 50-60% of patients. SRT is commonly initiated in patients with serum PSA levels < 1 ng/mL, a threshold at which standard-of-care imaging is insensitive for detecting recurrence. As such, SRT target volumes are usually drawn in the absence of radiographically visible disease. 68Ga-PSMA-11 (PSMA) PET/CT molecular imaging is highly sensitive and may offer anatomic localization of PCa biochemical recurrence. However, it is unclear if incorporation of PSMA PET/CT imaging into the planning of SRT could improve its likelihood of success. The purpose of this trial is to evaluate the success rate of SRT for recurrence of PCa after prostatectomy with and without planning based on PSMA PET/CT.

METHODS

We will randomize 193 patients to proceed with standard SRT (control arm 1, n = 90) or undergo a PSMA PET/CT scan (free of charge for patients) prior to SRT planning (investigational arm 2, n = 103). The primary endpoint is the success rate of SRT measured as biochemical progression-free survival (BPFS) after initiation of SRT. Biochemical progression is defined by PSA ≥ 0.2 ng/mL and rising. The randomization ratio of 1:1.13 is based on the assumption that approximately 13% of subjects randomized to Arm 2 will not be treated with SRT because of PSMA-positive extra-pelvic metastases. These patients will not be included in the primary endpoint analysis but will still be followed. The choice of treating the prostate bed alone vs prostate bed and pelvic lymph nodes, with or without androgen deprivation therapy (ADT), is selected by the treating radiation oncologist. The radiation oncologist may change the radiation plan depending on the findings of the PSMA PET/CT scan. Any other imaging is allowed for SRT planning in both arms if done per routine care. Patients will be followed until either one of the following conditions occur: 5 years after the date of initiation of randomization, biochemical progression, diagnosis of metastatic disease, initiation of any additional salvage therapy, death.

DISCUSSION

This is the first randomized phase 3 prospective trial designed to determine whether PSMA PET/CT molecular imaging can improve outcomes in patients with PCa early BCR following radical prostatectomy.

ACRONYM

PSMA-SRT Phase 3 trial.

CLINICAL TRIAL REGISTRATION

■ IND#130649 ◦ Submission: 04.26.2016 ◦ Safe-to-proceed letter issued by FDA: 05.25.2016 ■ UCLA IRB #18-000484, ■ First submission: 3.27.2018 ■ Date of approval: 5.31.2018 ■ UCLA JCCC Short Title NUC MED 18-000484 ■ NCI Trial Identifier NCI-2018-01518 ■ ClinicalTrials.gov Identifier NCT03582774 ■ First Submitted: 06.19.2018 ■ First Submitted that Met QC Criteria: 06.27.2018 ■ First Posted: 07.11.2018 ■ Last Update Submitted that Met QC Criteria: 07.17.2018 ■ Last Update Posted: 07.19.2018 TRIAL STATUS: Current Trial Status Active as of 08/13/2018 Trial Start Date 09/01/2018-Actual Primary Completion Date 09/01/2023-Anticipated Trial Completion Date 09/01/2024-Anticipated.

MR-Guided Prostate Interventions

Prostate cancer is the most commonly diagnosed noncutaneous cancer and second leading cause of death in men. Many patients with clinically organ-confined prostate cancer undergo definitive treatment of the whole gland, including radical prostatectomy, radiation therapy, and cryosurgery. Active surveillance is a growing alternative option for patients with documented low-volume and low-grade prostate cancer. However, many patients are wanting a less morbid focal treatment alternative. With recent advances in software and hardware of magnetic resonance imaging (MRI), multiparametric MRI of the prostate has been shown to improve the accuracy in detecting and characterizing clinically significant prostate cancer. Targeted biopsy is increasingly utilized to improve the yield of MR detected, clinically significant prostate cancer and to decrease in detection of indolent prostate cancer. MR-guided targeted biopsy techniques include cognitive MR fusion transrectal ultrasound (TRUS) biopsy, in-bore transrectal targeted biopsy using robotic transrectal device, and in-bore direct MR-guided transperineal biopsy with a software based transperineal grid template. In addition, advances in MR-compatible thermal ablation technology allow accurate focal or regional delivery of thermal ablative energy to the biopsy-proved, MRI-detected tumor. MR-guided ablative treatment options include cryoablation, laser ablation, and high-intensity focused ultrasound with real-time or near simultaneous monitoring of the ablation zone. We present a contemporary review of MR-guided techniques for prostatic interventions.

The Utility of PET/CT in the Planning of External Radiation Therapy for Prostate Cancer

Radiotherapy and radical prostatectomy are the definitive treatment options for patients with localized prostate cancer. A rising level of prostate-specific antigen after radical prostatectomy indicates prostate cancer recurrence, and these patients may still be cured with salvage radiotherapy. To maximize chance for cure, the irradiated volumes should completely encompass the extent of disease. Therefore, accurate estimation of the location of disease is critical for radiotherapy planning in both the definitive and the salvage settings. Current first-line imaging for prostate cancer has limited sensitivity for detection of disease both at initial staging and at biochemical recurrence. Integration of PET into routine evaluation of prostate cancer patients may improve both staging accuracy and radiotherapy planning. 18F-FDG PET/CT is now routinely used in radiation planning for several cancer types. However, 18F-FDG PET/CT has low sensitivity for prostate cancer. Additional PET probes evaluated in prostate cancer include 18F-sodium fluoride, 11C-acetate, 11C- or 18F-choline, 18F-fluciclovine, and 68Ga- or 18F-labeled ligands that bind prostate-specific membrane antigen (PSMA). PSMA ligands appear to be the most sensitive and specific but have not yet received Food and Drug Administration New Drug Application approval for use in the United States. Retrospective and prospective investigations suggest a potential major impact of PET/CT on prostate radiation treatment planning. Prospective trials randomizing patients to routine radiotherapy planning versus PET/CT-aided planning may show meaningful clinical outcomes. Prospective clinical trials evaluating the addition of 18F-fluciclovine PET/CT for planning of salvage radiotherapy with clinical endpoints are under way. Prospective trials evaluating the clinical impact of PSMA PET/CT on prostate radiation planning are indicated.

The value of multimodality imaging in the investigation of a PSA recurrence after radical prostatectomy in the Irish hospital setting

INTRODUCTION

The diagnostic evaluation of a PSA recurrence after RP in the Irish hospital setting involves multimodality imaging with MRI, CT, and bone scanning, despite the low diagnostic yield from imaging at low PSA levels. We aim to investigate the value of multimodality imaging in PC patients after RP with a PSA recurrence.

METHODS

Forty-eight patients with a PSA recurrence after RP who underwent multimodality imaging were evaluated. Demographic data, postoperative PSA levels, and imaging studies performed at those levels were evaluated.

RESULTS

Eight (21%) MRIs, 6 (33%) CTs, and 4 (9%) bone scans had PCa-specific findings. Three (12%) patients had a positive MRI with a PSA <1.0 ng/ml, while 5 (56%) were positive at PSA ≥1.1 ng/ml (p = 0.05). Zero patient had a positive CT TAP at a PSA level <1.0 ng/ml, while 5 (56%) were positive at levels ≥1.1 ng/ml (p = 0.03). Zero patient had a positive bone at PSA levels <1.0 ng/ml, while 4 (27%) were positive at levels ≥1.1 ng/ml (p = 0.01).

CONCLUSION

The diagnostic yield from multimodality imaging, and isotope bone scanning in particular, in PSA levels <1.0 ng/ml, is low. There is a statistically significant increase in the frequency of positive findings on CT and bone scanning at PSA levels ≥1.1 ng/ml. MRI alone is of investigative value at PSA <1.0 ng/ml. The indication for CT, MRI, or isotope bone scanning should be carefully correlated with the clinical question and how it will affect further management.

Localizing sites of disease in patients with rising serum prostate-specific antigen up to 1ng/ml following prostatectomy: How much information can conventional imaging provide?

PURPOSE

Accurate identification of the source of a detectable serum prostate-specific antigen (PSA) in the postprostatectomy setting is a major challenge among the urologic community. The aim of this study was to assess positivity rates of imaging examinations performed in patients with early PSA rise after prostatectomy and to summarize the management strategies adopted in this clinical scenario.

METHODS

Institutional Review Board-approved retrospective study of 142 postprostatectomy patients with PSA rise up to 1ng/ml who underwent evaluation with combination of multiparametric pelvic magnetic resonance imaging (MRI)±whole-body or bone MRI, bone scintigraphy, computed tomography (CT) chest-abdomen-pelvis, ¹⁸F-fludeoxyglucose-positron emission tomography (PET)/CT or ¹⁸F-sodium fluoride-PET/CT at a single tertiary cancer center. Imaging results were summarized per modality and compared with pathology findings.

RESULTS

Pelvic MRI was positive in 15/142 (11%) patients (14 patients with local recurrence in the surgical bed and 1 patient with pelvic osseous metastases). Of these 15, 10 patients underwent additional imaging examinations; none revealed positive findings. Of the 127 patients with negative pelvic MRI, 54 (43%) underwent additional imaging examinations; only 1/54 had positive findings (false-positive T8 lesion on bone scintigraphy and FDG-PET/CT; biopsy was negative for cancer). Overall, 12/16 patients with positive imaging findings and 75/126 (60%) patients with negative imaging received treatment (radiation, hormones or chemotherapy).

CONCLUSION

The conventional imaging identified sites of disease, almost always in the form of local recurrence, in a minority of patients with early PSA rise postprostatectomy.

Prostate cancer post-treatment follow-up and recurrence evaluation

Recurrent prostate cancer following primary treatment is common, and the population of men with biochemical recurrence is complex. Conventional management of recurrent prostate cancer involves nontargeted and/or systemic therapies, without defining an individual patient's specific disease. However, recent advances in imaging enable a shift in the management of recurrent prostate cancer to targeted, patient-specific approaches. Specifically, MRI can detect and define local prostate cancer recurrence early in the course of disease, and prostate-specific PET imaging greatly improves nodal staging and can detect previously unknown distant metastases. The significant advances in the imaging of both local and distant tumor recurrences allows for specific selection of treatment options tailored to patients and their disease with less associated morbidity.

Recurrent prostate cancer detection with anti-3-[(18)F]FACBC PET/CT: comparison with CT

PURPOSE

To compare the diagnostic performance of the synthetic amino acid analogue PET radiotracer anti-3-[(18)F]FACBC (fluciclovine) with that of CT in the detection of recurrent prostate carcinoma.

METHODS

This was a retrospective analysis of 53 bone scan-negative patients with suspected recurrent prostate carcinoma who underwent fluciclovine PET/CT and routine clinical CT within 90 days of each other. The correlation between imaging findings and histology and clinical follow-up was evaluated. Positivity rates and diagnostic performance were calculated for fluciclovine PET/CT and CT.

RESULTS

Of 53 fluciclovine PET/CT and 53 CT examinations, 41 (77.4 %) and 10 (18.9 %), respectively, had positive findings for recurrent disease. Positivity rates were higher with fluciclovine PET/CT than with CT at all prostate-specific antigen (PSA) levels, PSA doubling times and original Gleason scores. In the prostate/bed, fluciclovine PET/CT was true-positive in 31 and CT was true-positive in 4 of 51 patients who met the reference standard. In extraprostatic regions, fluciclovine PET/CT was true-positive in 12 and CT was true-positive in 3 of 41 patients who met the reference standard. Of the 43 index lesions used to prove positivity, 42 (97.7 %) had histological proof. In 51 patients with sufficient follow-up to calculate diagnostic performance in the prostate/bed, fluciclovine PET/CT demonstrated a sensitivity of 88.6 %, a specificity of 56.3 %, an accuracy of 78.4 %, a positive predictive value (PPV) of 81.6 %, and a negative predictive value (NPV) of 69.2 %; the respective values for CT were 11.4 %, 87.5 %, 35.3 %, 66.7 % and 31.1 %. In 41 patients with sufficient follow-up to calculate diagnostic performance in extraprostatic regions, fluciclovine PET/CT demonstrated a sensitivity of 46.2 %, a specificity of 100 %, an accuracy of 65.9 %, a PPV of 100 %, and an NPV of 51.7 %; the respective values for CT were 11.5 %, 100 %, 43.9 %, 100 % and 39.5 %.

CONCLUSION

The diagnostic performance of fluciclovine PET/CT in recurrent prostate cancer is superior to that of CT and fluciclovine PET/CT provides better delineation of prostatic from extraprostatic recurrence.

Prostate-specific antigen and prostate-specific antigen velocity as threshold indicators in 11C-acetate PET/CTAC scanning for prostate cancer recurrence

PURPOSE

The aim of this study was to identify which patient characteristics are associated with the highest likelihood of positive findings on 11C-acetate PET/computed tomography attenuation correction (CTAC) (PET/CTAC) scan when imaging for recurrent prostate cancer.

METHODS

From 2007 to 2011, 250 11C-acetate PET/CTAC scans were performed at a single institution on patients with prostate cancer recurrence after surgery, brachytherapy, or external beam radiation. Of these patients, 120 met our inclusion criteria. Logistic regression analysis was used to examine the relationship between predictability of positive findings and patients' characteristics, such as prostate-specific antigen (PSA) level at the time of scan, PSA kinetics, Gleason score, staging, and type of treatment before scan.

RESULTS

In total, 68.3% of the 120 11C-acetate PET/CTAC scans were positive. The percentage of positive scans and PSA at the time of scanning and PSA velocity (PSAV) had positive correlations. The putative sensitivity and specificity were 86.6% and 65.8%, respectively, when a PSA level greater than 1.24 ng/mL was used as the threshold for scanning. The putative sensitivity and specificity were 74% and 75%, respectively, when a PSAV level greater than 1.32 ng/mL/y was used as the threshold. No significant associations were found between scan positivity and age, PSA doubling time, Gleason score, staging, or type of treatment before scanning.

CONCLUSIONS

This retrospective study suggests that threshold models of PSA greater than 1.24 ng/mL or PSAV greater than 1.32 ng/mL per year are independent predictors of positive findings in 11C-acetate PET/CTAC imaging of recurrent prostate cancer.

Gleason score at diagnosis predicts the rate of detection of 18F-choline PET/CT performed when biochemical evidence indicates recurrence of prostate cancer: experience with 1,000 patients

The objective of this study was to explore the ability of the initial Gleason score (GS) to predict the rate of detection of recurrent prostate cancer (PCa) with (18)F-choline PET/CT in a large cohort of patients.

METHODS

Data from 1,000 patients who had undergone (18)F-choline PET/CT because of biochemical evidence of relapse of PCa between 2004 and 2013 were retrieved from databases at 4 centers. Continuous data were compared by the Student t test or ANOVA, and categoric variables were compared by the χ(2) test. Univariable and multivariable analyses were performed by logistic regression.

RESULTS

The GS at diagnosis was less than or equal to 6 in 257 patients, 7 in 347 patients, and greater than 7 in 396 patients. The results of 645 PET/CT scans were positive for PCa recurrence. Eighty-one percent of the positive PET/CT results were found in patients with a PSA level of greater than or equal to 2 ng/mL, 43% were found in patients with a PSA level of 1-2 ng/mL, and 31% were found in patients with a PSA level of less than or equal to 1 ng/mL; 78.8% of patients with positive PET/CT results had a GS of greater than 7. The results of (18)F-choline PET/CT scans were negative in 300 patients; 44% had a GS of less than or equal to 6, 35% had a GS of 7, and 17% had a GS of greater than 7. PET/CT results were rated as doubtful in only 5.5% of patients (median PSA, 1.8 ng/mL). When the GS was greater than 7, the rates of detection of (18)F-choline PET/CT were 51%, 65%, and 91% for a PSA level of less than 1 ng/mL, 1-2 ng/mL, and greater than 2 ng/mL, respectively. In univariable and multivariable analyses, both a GS of 7 and a GS of greater than 7 were independent predictors for positive (18)F-choline PET/CT results (odds ratios, 0.226 and 0.330, respectively; P values for both, <0.001).

CONCLUSION

A high GS at diagnosis is a strong predictive factor for positive (18)F-choline PET/CT scan results for recurrent PCa, even when the PSA level is low (i.e., ≤1 ng/mL).

Multiparametric MRI for recurrent prostate cancer post radical prostatectomy and postradiation therapy

The clinical suspicion of local recurrence of prostate cancer (PCa) after radical prostatectomy (RP) and after radiation therapy (RT) is based on the onset of biochemical failure. The aim of this paper was to review the current role of multiparametric-MRI (mp-MRI) in the detection of locoregional recurrence. A systematic literature search using the Medline and Cochrane Library databases was performed from January 1995 up to November 2013. Bibliographies of retrieved and review articles were also examined. Only those articles reporting complete data with clinical relevance for the present review were selected. This review article is divided into two major parts: the first one considers the role of mp-MRI in the detection of PCa local recurrence after RP; the second part provides an insight about the impact of mp-MRI in the depiction of locoregional recurrence after RT (interstitial or external beam). Published data indicate an emerging role for mp-MRI in the detection and localization of locally recurrent PCa both after RP and RT which represents an information of paramount importance to perform focal salvage treatments.

Imaging of prostate carcinoma

BACKGROUND

Imaging of prostate carcinoma is an important adjunct to clinical evaluation and prostate specific antigen measurement for detecting metastases and tumor recurrence. In the past, the ability to assess intraprostatic tumor was limited.

METHODS

Pertinent literature was reviewed to describe the capabilities and limitations of the currently available imaging techniques for assessing prostate carcinoma. Evaluation of primary tumor and metastatic disease by ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine techniques is discussed.

RESULTS

Ultrasonography and MRI have limited usefulness for local staging of prostate cancer because of suboptimal sensitivity and specificity for identifying tumor extent and capsular penetration. Additional MRI techniques such as magnetic resonance-based perfusion imaging, diffusion imaging, and spectroscopy may provide incremental benefit. CT and bone scanning provide an assessment of metastatic disease but are also limited by the poor sensitivity of lymph node size as a criterion for detecting metastases. Novel imaging techniques such as hybrid imaging devices in the form of single-photon emission CT/CT gamma cameras, positron emission tomography/CT cameras, and, in the near future, positron emission tomography/MRI combined with tumor specific imaging radiotracers may have a significant impact on tumor staging and treatment response.

CONCLUSIONS

Cross-sectional imaging and scintigraphy have an important role in assessing prostate carcinoma metastases and treatment response. Increasingly, the incremental value of primary tumor imaging through MRI is being realized.

[Imaging diagnostics of advanced prostate cancer]

The diagnostic approach to prostate cancer is still a big challenge for the treating physician. Regarding an individualized and risk-adapted evaluation of different therapeutic options, precise diagnostic tools are crucial to accurately distinguish between localized and advanced prostate cancer. Imaging of advanced prostate cancer is currently changing due to numerous technical innovations. While choline-based hybrid positron emission tomography-computed tomography (PET/CT) has been established as an important diagnostic tool in clinical imaging of advanced prostate cancer, well-investigated methods, such as magnetic resonance imaging (MRI) and bone scintigraphy are currently expanding the diagnostic potential due to technical improvements. The specific use of imaging for advanced prostate cancer may help to offer the patient a well-tailored oncologic therapy. Further research is needed to evaluate whether this individualized therapy can consistently improve the prognosis of patients suffering from advanced prostate cancer.

Role of magnetic resonance imaging in the detection of local prostate cancer recurrence after external beam radiotherapy and radical prostatectomy

AIMS

To carry out a meta-analysis to assess the effectiveness of magnetic resonance imaging (MRI) during the follow-up of patients with prostate cancer after undergoing external beam radiotherapy (EBRT) or radical prostatectomy.

MATERIALS AND METHODS

MEDLINE, EMBASE and other databases were searched for relevant original articles published from January 1995 to October 2011. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Pooled estimation and subgroup analysis data were obtained by statistical analysis.

RESULTS

Fourteen of 768 initially identified studies were included in the meta-analysis. Seven studies examining patient after radical prostatectomy had a pooled sensitivity and specificity on the patient level of 82% (95% confidence interval 78-86%) and 87% (95% confidence interval 81-92%), respectively. In the subgroup analysis, compared with T2-weighted imaging (T2WI), dynamic contrast-enhanced (DCE) MRI showed higher pooled sensitivity (85%, 95% confidence interval 78-90%) and specificity (95%, 95% confidence interval 88-99%). DCE MRI combined with magnetic resonance spectroscopic imaging (1H-MRSI) had the highest pooled sensitivity (92%, 95% confidence interval 83-97%). Nine studies examining men after EBRT had a pooled sensitivity and specificity on the patient level of 82% (95% confidence interval 75-88%) and 74% (95% confidence interval 64-82%), respectively. Compared with T2WI, DCE MRI showed higher pooled sensitivity (90%, 95% confidence interval 77-97%) and specificity (81%, 95% confidence interval 64-93%). DCE combined with 1H-MRSI had the highest pooled specificity (90%, 95% confidence interval 56-100%). The pooled sensitivity and specificity on sextant analysis was 58% (95% confidence interval 53-64%) and 85% (95% confidence interval 82-88%), respectively. DCE MRI showed the highest pooled sensitivity: 71% (95% confidence interval 60-80%).

CONCLUSION

A limited number of small studies suggest that MRI can accurately detect local recurrences after EBRT and radical prostatectomy. DCE MRI is particularly accurate. The addition of MRSI to DCE MRI can significantly improve the diagnostic accuracy of local prostate cancer recurrence. The eventual role of 1H-MRSI alone remains controversial and needs to be defined further.

Prostate cancer imaging: what the urologist wants to know

No consensus exists at present regarding the use of imaging for the evaluation of prostate cancer. Ultrasonography is mainly used for biopsy guidance and magnetic resonance imaging is the mainstay in evaluating the extent of local tumor. Computed tomography and radionuclide bone scanning are mainly reserved for assessment of advanced disease. Positron emission tomography is gaining acceptance in the evaluation of treatment response and recurrence. The combination of anatomic, functional, and metabolic imaging modalities has promise to improve treatment. This article reviews current imaging techniques and touches on the evolving technologies being used for detection and follow-up of prostate cancer.

ACR Appropriateness Criteria® posttreatment follow-up of prostate cancer

Although prostate cancer can be effectively treated, recurrent or residual disease after therapy is not uncommon and is usually detected by a rise in prostate-specific antigen. Patients with biochemical prostate-specific antigen relapse should undergo a prompt search for the presence of local recurrence or distant metastatic disease, each requiring different forms of therapy. Various imaging modalities and image-guided procedures may be used in the evaluation of these patients. Literature on the indications and usefulness of these radiologic studies and procedures in specific clinical settings is reviewed. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Role of imaging and biopsy to assess local recurrence after definitive treatment for prostate carcinoma (surgery, radiotherapy, cryotherapy, HIFU)

PURPOSE

Defining the site of recurrent disease early after definitive treatment for a localized prostate cancer is a critical issue as it may greatly influence the subsequent therapeutic strategy or patient management.

METHODS

A systematic review of the literature was performed by searching Medline from January 1995 up to January 2011. Electronic searches were limited to the English language, and the keywords prostate cancer, radiotherapy [RT], high intensity focused ultrasound [HIFU], cryotherapy [CRIO], transrectal ultrasound [TRUS], magnetic resonance [MRI], PET/TC, and prostate biopsy were used.

RESULTS

Despite the fact that diagnosis of a local recurrence is based on PSA values and kinetics, imaging by means of different techniques may be a prerequisite for effective disease management. Unfortunately, prostate cancer local recurrences are very difficult to detect by TRUS and conventional imaging that have shown limited accuracy at least at early stages. On the contrary, functional and molecular imaging such as dynamic contrast-enhanced MRI (DCE-MRI), and diffusion-weighted imaging (DWI), offers the possibility of imaging molecular or cellular processes of individual tumors. Recently, PET/CT, using 11C-choline, 18F-fluorocholine or 11C-acetate has been successfully proposed in detecting local recurrences as well as distant metastases. Nevertheless, in controversial cases, it is necessary to perform a biopsy of the prostatic fossa or a biopsy of the prostate to assess the presence of a local recurrence under guidance of MRI or TRUS findings.

CONCLUSION

It is likely that imaging will be extensively used in the future to detect and localize prostate cancer local recurrences before salvage treatment.

Detection of recurrent prostate carcinoma with anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid PET/CT and 111In-capromab pendetide SPECT/CT

PURPOSE

To compare the diagnostic performance of the synthetic amino acid analog radiotracer anti-1-amino-3-fluorine 18-fluorocyclobutane-1-carboxylic acid (anti-3-(18)F-FACBC) with that of indium 111 ((111)In)-capromab pendetide in the detection of recurrent prostate carcinoma.

MATERIALS AND METHODS

This prospective study was approved by the institutional review board and complied with HIPAA guidelines. Written informed consent was obtained. Fifty patients (mean age, 68.3 years ± 8.1 [standard deviation]; age range, 50-90 years) were included in the study on the basis of the following criteria: (a) Recurrence of prostate carcinoma was suspected after definitive therapy for localized disease, (b) bone scans were negative, and (c) anti-3-(18)F-FACBC positron emission tomography (PET)/computed tomography (CT) and (111)In-capromab pendetide single photon emission computed tomography (SPECT)/CT were performed within 6 weeks of each other. Studies were evaluated by two experienced interpreters for abnormal uptake suspicious for recurrent disease in the prostate bed and extraprostatic locations. The reference standard was a combination of tissue correlation, imaging, laboratory, and clinical data. Diagnostic performance measures were calculated and tests of the statistical significance of differences determined by using the McNemar χ(2) test as well as approximate tests based on the difference between two proportions.

RESULTS

For disease detection in the prostate bed, anti-3-(18)F-FACBC had a sensitivity of 89% (32 of 36 patients; 95% confidence interval [CI]: 74%, 97%), specificity of 67% (eight of 12 patients; 95% CI: 35%, 90%), and accuracy of 83% (40 of 48 patients; 95% CI: 70%, 93%). (111)In-capromab pendetide had a sensitivity of 69% (25 of 36 patients; 95% CI: 52%, 84%), specificity of 58% (seven of 12 patients; 95% CI: 28%, 85%), and accuracy of 67% (32 of 48 patients; 95% CI: 52%, 80%). In the detection of extraprostatic recurrence, anti-3-(18)F-FACBC had a sensitivity of 100% (10 of 10 patients; 95% CI: 69%, 100%), specificity of 100% (seven of seven patients; 95% CI: 59%, 100%), and accuracy of 100% (17 of 17 patients; 95% CI: 80%, 100%). (111)In-capromab pendetide had a sensitivity of 10% (one of 10 patients; 95% CI: 0%, 45%), specificity of 100% (seven of seven patients; 95% CI: 59%, 100%), and accuracy of 47% (eight of 17 patients; 95% CI: 23%, 72%).

CONCLUSION

anti-3-(18)F-FACBC PET/CT was more sensitive than (111)In-capromab pendetide SPECT/CT in the detection of recurrent prostate carcinoma and is highly accurate in the differentiation of prostatic from extraprostatic disease.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11102023/-/DC1.

Imaging of prostate cancer with PET/CT and radioactively labeled choline derivates

PET- and PET/CT using [(11)C]- and [(18)F]-labeled choline derivates are increasingly being used for imaging of prostate cancer. The value of PET- and PET/CT with [(11)C]- and [(18)F]-labeled choline derivates in biochemical recurrence of prostate cancer has been examined in many studies and demonstrates an increasing importance. PET/CT, in comparison to PET, improves especially the lesion localization as well as characterization. Primary prostate cancer can be detected with moderate sensitivity using PET and PET/CT using [(11)C]- and [(18)F]-labeled choline derivates--the differentiation between benign prostatic hyperplasia, prostatitis, or high-grade intraepithelial neoplasia (HGPIN) is not always possible. At the present time, [(11)C]-choline PET/CT is not recommended in the primary setting but may be utilized in clinically suspected prostate cancer with repeatedly negative prostate biopsies, in preparation of a focused re-biopsy. Promising results have been obtained for the use of PET and PET/CT with [(11)C]- and [(18)F]-labeled choline derivates in patients with biochemical recurrence. The detection rate of choline PET and PET/CT for local, regional, and distant recurrence in patients with a biochemical recurrence shows a linear correlation with PSA value at the time of imaging and reaches about 75% in patients with PSA > 3 ng/ml. Even at PSA values below 1 ng/ml, the recurrence can be diagnosed with choline PET/CT in approximately one-third of the patients. PET and PET/CT with [(11)C]- and [(18)F]-choline derivates can be helpful in the clinical setting for choosing a therapeutic strategy in the sense of an individualized treatment: an early diagnosis of recurrence is crucial to the choice of optimal treatment. Especially important for the choice of treatment is the exact localization of the site of recurrence: local recurrence, recurrence as lymph node metastasis, or systemic recurrence, as it has direct influence on individual therapy. This article reviews the use of PET and PET/CT with [(11)C]- and [(18)F]-labeled choline derivates in prostate cancer imaging with special emphasis on patients with biochemical recurrence. We briefly provide an overview of PET tracers for prostate cancer imaging, the rationale of using choline derivatives for prostate cancer imaging and discuss the contribution of choline PET/CT in patients suffering from prostate cancer with an emphasis on recurrent disease. Furthermore, we provide an outlook on future prospects of choline PET/CT imaging for therapy guidance and monitoring in the framework of therapy individualization.

Influence of trigger PSA and PSA kinetics on 11C-Choline PET/CT detection rate in patients with biochemical relapse after radical prostatectomy

The purpose of this study was to investigate the effect of total prostate-specific antigen (PSA) at the time of (11)C-choline PET/CT (trigger PSA), PSA velocity (PSAvel), and PSA doubling time (PSAdt) on (11)C-choline PET/CT detection rate in patients treated with radical prostatectomy for prostate cancer, who showed biochemical failure during follow-up.

METHODS

A total of 190 patients treated with radical prostatectomy for prostate cancer who showed an increase in PSA (mean, 4.2; median, 2.1; range, 0.2-25.4 ng/mL) were retrospectively enrolled. All patients were studied with (11)C-choline PET/CT. Patients were grouped according to trigger PSA (PSA </= 1 ng/mL, 1 < PSA </= 2 ng/mL, 2 < PSA </= 5 ng/mL, and PSA > 5 ng/mL). In 106 patients, data were available for calculation of PSAvel and PSAdt. Logistic regression analysis was used to determine whether there was a relationship between PSA levels and PSA kinetics and the rate of detection of relapse using PET.

RESULTS

(11)C-choline PET/CT detected disease relapse in 74 of 190 patients (38.9%). The detection rate of (11)C-choline PET/CT was 19%, 25%, 41%, and 67% in the 4 subgroups-PSA </= 1 ng/mL (51 patients), 1 < PSA </= 2 ng/mL (39 patients), 2 < PSA </= 5 ng/mL (51 patients), and PSA > 5 ng/mL (49 patients)-respectively. Trigger PSA values were statistically different between PET-positive patients (median PSA, 4.0 ng/mL) and PET-negative patients (median PSA, 1.4 ng/mL) (P = 0.0001). Receiver-operating-characteristic analysis showed an optimal cutoff point for trigger PSA of 2.43 ng/mL (area under the curve, 0.76). In 106 patients, PSAdt and PSAvel values were statistically different between patients with PET-positive and -negative scan findings (P = 0.04 and P = 0.03). The (11)C-choline PET/CT detection rate was 12%, 34%, 42%, and 70%, respectively, in patients with PSAvel < 1 ng/mL/y (33 patients), 1 < PSAvel </= 2 ng/mL/y (26 patients), 2 < PSAvel </= 5 ng/mL/y (19 patients), and PSAvel > 5 ng/mL/y (28 patients). The (11)C-choline PET/CT detection rate was 20%, 40%, 48%, and 60%, respectively, in patients with PSAdt > 6 mo (45 patients), 4 < PSAdt </= 6 mo (20 patients), 2 < PSAdt </= 4 mo (31 patients), and PSAdt </= 2 mo (10 patients). There was no statistical difference between PET-positive and -negative scan detection rates according to the Gleason score, pT and N status, patient age, or duration between surgery and biochemical relapse. Trigger PSA and PSAvel were found to be independent predictive factors for a PET-positive result (P = 0.002; P = 0.04) and PSAdt was found to be an independent factor only in patients with trigger PSA less than 2 ng/mL (P = 0.05) using multivariate analysis.

CONCLUSION

The (11)C-choline PET/CT detection rate is influenced by trigger PSA, PSAdt, and PSAvel. This finding could be used to improve the selection of patients for scanning by reducing the number of false-negative scans and increasing the detection rate of disease in patients with early relapse and potentially curative disease.

[Which imaging methods should be used prior to salvage radiotherapy after prostatectomy for prostate cancer?]

Prostatectomy is one of the most widely used methods for treatment of adenocarcinoma of the prostate. According to anatomopathological criteria, between 10 and 40% of patients will display biochemical relapse in the absence of adjuvant radiotherapy. Anatomopathological and biochemical criteria are powerful tools for selecting patients for salvage radiotherapy. The aim of this article is to review literature on the latest progress in radiological and nuclear medicine techniques and their performance levels, in order to determine local, regional and metastatic relapses associated with the techniques and specify the radiotherapy target volume. Magnetic resonance imaging (MRI) displays the best sensitivity and specificity for examination of the prostate bed and enables simultaneous assessment of the pelvic region - thus diminishing the utility of computed tomography. The performance levels of MRI will probably continue to improve, with the use of dynamic MRI and MR spectroscopy. Despite the development of new markers like (11)C and (18)F choline and acetate, the sensitivity of positron emission tomography is still low. Prospective studies with an appropriate methodology are necessary for specifying the technique's value in this context.

[(11)C]Choline positron emission tomography/computed tomography for staging and restaging of patients with advanced prostate cancer

INTRODUCTION

To evaluate [(11)C]Choline positron emission tomography (PET)/computed tomography (CT) for staging and restaging of patients with advanced prostate cancer and to compare the diagnostic performance of PET, CT and PET/CT.

METHODS

Forty-five consecutive patients with advanced prostate cancer underwent [(11)C]Choline-PET/CT between 5/2004 and 2/2006.

RESULTS

Overall, 295 lesions were detected: PET alone, 178 lesions; diagnostic CT, 221 lesions; PET/CT (low-dose CT), 272 lesions; PET/CT (diagnostic CT), 295 lesions. Two thirds of the lesions were located in the bone; one third in the prostate, lymph nodes, periprostatic tissue and soft tissue (lung, liver). The use of diagnostic CT did not result in a statistically significant difference with respect to lesion localization certainty and lesion characterization (P=.063, P=.063). PET-negative but PET/CT-positive lesions were mostly localized in the bone (78%, 91/117) as were PET-positive and CT-negative lesions (72%, 53/74). Of the latter, 91% (48/53) represented bone marrow and 9% (5/53) cortical involvement.

CONCLUSIONS

Staging and restaging with [(11)C]Choline PET/CT in patients with advanced prostate cancer improve the assessment of local and regional recurrent as well as metastatic disease including skeletal manifestations. [(11)C]Choline PET/CT (with a low-dose CT) results in improved localization and lesion characterization. [(11)C]Choline PET/CT provides an added value for skeletal manifestations. [(11)C]Choline PET/CT changed disease management in 11 (24%) of 45 patients with advanced prostate cancer.

Endorectal magnetic resonance imaging at 1.5 Tesla to assess local recurrence following radical prostatectomy using T2-weighted and contrast-enhanced imaging

To evaluate diagnostic performance of endorectal magnetic resonance (eMR) for diagnosing local recurrence of prostate cancer (PC) in patients with previous radical prostatectomy (RP) and to assess whether contrast-enhanced (CE)-eMR improved diagnostic accuracy in comparison to unenhanced study. Unenhanced eMR data of 72 male patients (mean of total PSA: 1.23 +/- 1.3 ng/ml) with previous RP were interpreted retrospectively and classified either as normal or suspicious for local recurrence. All eMR examinations were re-evaluated also on CE-eMR 4 months after the first reading. Images were acquired on a 1.5-T system. These data were compared to the standard of reference for local recurrence: prostatectomy bed biopsy results; choline positron emission tomography results; PSA reduction or increase after pelvic radiotherapy; PSA modification during active surveillance. Sensitivity, specificity, predictive positive value, negative predictive value and accuracy were 61.4%, 82.1%, 84.4%, 57.5% and 69.4% for unenhanced eMR and 84.1%, 89.3%, 92.5%, 78.1% and 86.1% for CE-eMR. A statistically significant difference was found between accuracy and sensitivity of the two evaluations (chi(2) = 5.33; p = 0.02 and chi(2) = 9.00; p = 0.0027). EMR had great accuracy for visualizing local recurrence of PC after RP. CE-eMR improved diagnostic performance in comparison with T2-weighted imaging alone.

Role of dynamic contrast-enhanced magnetic resonance (MR) imaging and proton MR spectroscopic imaging in the detection of local recurrence after radical prostatectomy for prostate cancer

OBJECTIVES

To assess the accuracy of magnetic resonance (MR) spectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced MR (DCEMR) in the depiction of local prostate cancer recurrence in patients with biochemical progression after radical prostatectomy (RP).

MATERIALS AND METHODS

1H-MRSI and DCEMR were performed in 70 patients at high risk of local recurrence after RP. The population was divided on the basis of the clinical validation of MR results with the use of a transrectal ultrasound biopsy examination in a group of 50 patients (group A) and the prostate-specific antigen (PSA) serum level restitution after external beam radiotherapy, in a group of 20 patients (group B).

RESULTS

In group A, 1H-MRSI analysis alone showed a sensitivity of 84% and a specificity of 88%; the DCEMR analysis alone, a sensitivity of 71% and a specificity of 94%; combined 1HMRSI-DCEMR, a sensitivity of 87% and specificity of 94%. Areas under the receiver operating characteristic (ROC) curve for 1HMRSI, DCEMR, and combined 1HMRSI /DCEMR were 0.942, 0.93,1 and 0.964, respectively. In group B, 1HMRSI alone showed a sensitivity of 71% and a specificity of 83%; DCEMR, a sensitivity of 79% and a specificity of 100%; combined 1HMRSI and DCEMR, a sensitivity of 86% and a specificity of 100%. Areas under the ROC curve for each of these groups were 0.81, 0.923, and 0.94, respectively.

CONCLUSION

Our results show that combined 1H-MRSI and DCMRE is an accurate method to identify local prostate cancer recurrence in patients with biochemical progression after RP.

The detection rate of [11C]choline-PET/CT depends on the serum PSA-value in patients with biochemical recurrence of prostate cancer

PURPOSE

An increase of the serum PSA-level is a sensitive in vitro marker for recurrent prostate cancer. However, it remains difficult to differentiate between local, regional or distant recurrent disease. The aim of this study was to assess the relationship between the detection rate of [(11)C]Choline-PET/CT and the serum PSA-level in patients with a biochemical recurrence of prostate cancer with the view towards localisation of recurrent disease.

METHODS

Sixty-three patients (mean age, 68.8 +/- 6.9; range, 45-83 years) with biochemical recurrence after primary therapy for prostate cancer were included in the analysis. Mean PSA-levels were 5.9 +/- 9.7 ng/ml (range, 0.2-39 ng/ml; median, 2.15). Of the 63 patients, 17 were under anti-androgen therapy at the time of [(11)C]Choline PET/CT. Patients underwent a [(11)C]Choline-PET/CT study after injection of 656 +/- 119 MBq [(11)C]Choline on a Sensation 16 Biograph PET/CT scanner.

RESULTS

Of the 63 patients, 35 (56%) showed a pathological [(11)C]Choline uptake. The detection rate of [(11)C]Choline-PET/CT showed a relationship with the serum PSA-level: The detection rate was 36% for a PSA-value <1 ng/ml, 43% for a PSA-value 1-<2 ng/ml, 62% for a PSA-value 2-<3 ng/ml and 73% for a PSA-value >or=3 ng/ml. Anti-androgen therapy did not show a significant effect on the detection rate of [(11)C]Choline-PET/CT (p = 0.374).

CONCLUSION

As an important result our study shows that even for PSA-values <1.0 ng/ml the detection efficiency of [(11)C]Choline-PET/CT is 36%. Furthermore, the detection rate of [(11)C]Choline-PET/CT shows a positive relationship with serum PSA-levels in patients with biochemical recurrence of prostate cancer after primary therapy. Therefore, in these patients, [(11)C]Choline PET/CT allows not only to diagnose but also to localise recurrent disease with implications on disease management (localised vs systemic therapy).

Imaging prostate cancer: a multidisciplinary perspective

The major goal for prostate cancer imaging in the next decade is more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information. No consensus exists regarding the use of imaging for evaluating primary prostate cancers. Ultrasonography is mainly used for biopsy guidance and brachytherapy seed placement. Endorectal magnetic resonance (MR) imaging is helpful for evaluating local tumor extent, and MR spectroscopic imaging can improve this evaluation while providing information about tumor aggressiveness. MR imaging with superparamagnetic nanoparticles has high sensitivity and specificity in depicting lymph node metastases, but guidelines have not yet been developed for its use, which remains restricted to the research setting. Computed tomography (CT) is reserved for the evaluation of advanced disease. The use of combined positron emission tomography/CT is limited in the assessment of primary disease but is gaining acceptance in prostate cancer treatment follow-up. Evidence-based guidelines for the use of imaging in assessing the risk of distant spread of prostate cancer are available. Radionuclide bone scanning and CT supplement clinical and biochemical evaluation (prostate-specific antigen [PSA], prostatic acid phosphate) for suspected metastasis to bones and lymph nodes. Guidelines for the use of bone scanning (in patients with PSA level > 10 ng/mL) and CT (in patients with PSA level > 20 ng/mL) have been published and are in clinical use. Nevertheless, changes in practice patterns have been slow. This review presents a multidisciplinary perspective on the optimal role of modern imaging in prostate cancer detection, staging, treatment planning, and follow-up.

Management of biochemical failure following radical prostatectomy: salvage radiotherapy - a case series

A retrospective analysis of the outcome of radical prostatectomy (RP) for prostate cancer in a single centre and assessment of the role of salvage radiotherapy (RT) for patients with biochemical relapse. Hundred and thirty-seven patients underwent RP for adenocarcinoma of the prostate in our centre between December 1994 and June 2003. Fifty-four of these patients developed a biochemical relapse prostate-specific antigen (PSA > or = 0.2 ng/ml). Thirty-two patients including five from elsewhere (one with a palpable local recurrence) received salvage RT. Twenty-five of these had positive margins at resection and four had involvement of seminal vesicles. Nine had Gleason score > or = 8. Median PSA before RT was 0.55 ng/ml (range 0.2-5.0). Median age at surgery was 63.5 years (range 52-71). Median age at RT was 65 years (range 53-73). Median time from surgery to biochemical relapse was 11 months (range 0-37) and median interval from surgery to RT was 22 months (range 3-71). Twenty-seven patients received 64 Gy in 32 fractions, three patients received 55 Gy in 20 fractions and two patients received 50 Gy in 20 fractions. Twenty-seven patients were managed by observation or hormone therapy. Twenty-seven patients (84%) achieved complete biochemical remission following RT. Eighteen (56%) remain in complete remission with a median follow-up since RT for the whole group of 30 months (range 8-85). Fourteen patients have relapsed, eight of whom had either clear margins or PSA >1.0 ng/ml at the time of RT (PSA > or = 0.2 ng/ml). Salvage RT is an effective treatment for achieving biochemical remission in selected patients who relapse following RP.

Imaging of prostate cancer

The role of imaging in the diagnosis and management of prostate is reviewed. Transrectal ultrasonography, which can be used to guide biopsy, is most frequently used imaging technique in cancer detection. For determining the extent of disease, CT and MR imaging are the most commonly used modalities; bone scintigraphy and positron emission tomography have roles only in advanced disease. Currently, the role of imaging in prostate cancer is evolving to improve disease detection and staging, to determine the aggressiveness of disease, and to predict outcomes in different patient populations

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Advancing prostate cancer: treatment options for the urologist

Today's urologists often face the dilemma of how to treat patients who have advancing prostate cancer. The diversity of this patient population makes treatment decisions challenging. For over 60 years the mainstay of treatment for patients who have advancing prostate cancer has been androgen deprivation therapy. Now there are new chemotherapeutic options, novel hormone manipulations, and other adjunctive therapies available. Based on a case presentation, the authors have attempted to outline for the practicing urologist, a logical progression of treatment options for advancing prostate cancer.