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Sritharan K, Akhiat H, Cahill D, Choi S, Choudhury A, Chung P, Diaz J, Dysager L, Hall W, Huddart R, Kerkmeijer LGW, Lawton C, Mohajer J, Murray J, Nyborg CJ, Pos FJ, Rigo M, Schytte T, Sidhom M, Sohaib A, Tan A, van der Voort van Zyp J, Vesprini D, Zelefsky MJ, Tree AC. Development of Prostate Bed Delineation Consensus Guidelines for Magnetic Resonance Image-Guided Radiotherapy and Assessment of Its Effect on Interobserver Variability. Int J Radiat Oncol Biol Phys 2024; 118:378-389. [PMID: 37633499 DOI: 10.1016/j.ijrobp.2023.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE The use of magnetic resonance imaging (MRI) in radiotherapy planning is becoming more widespread, particularly with the emergence of MRI-guided radiotherapy systems. Existing guidelines for defining the prostate bed clinical target volume (CTV) show considerable heterogeneity. This study aimed to establish baseline interobserver variability (IOV) for prostate bed CTV contouring on MRI, develop international consensus guidelines, and evaluate its effect on IOV. METHODS AND MATERIALS Participants delineated the CTV on 3 MRI scans, obtained from the Elekta Unity MR-Linac, as per their normal practice. Radiation oncologist contours were visually examined for discrepancies, and interobserver comparisons were evaluated against simultaneous truth and performance level estimation (STAPLE) contours using overlap metrics (Dice similarity coefficient and Cohen's kappa), distance metrics (mean distance to agreement and Hausdorff distance), and volume measurements. A literature review of postradical prostatectomy local recurrence patterns was performed and presented alongside IOV results to the participants. Consensus guidelines were collectively constructed, and IOV assessment was repeated using these guidelines. RESULTS Sixteen radiation oncologists' contours were included in the final analysis. Visual evaluation demonstrated significant differences in the superior, inferior, and anterior borders. Baseline IOV assessment indicated moderate agreement for the overlap metrics while volume and distance metrics demonstrated greater variability. Consensus for optimal prostate bed CTV boundaries was established during a virtual meeting. After guideline development, a decrease in IOV was observed. The maximum volume ratio decreased from 4.7 to 3.1 and volume coefficient of variation reduced from 40% to 34%. The mean Dice similarity coefficient rose from 0.72 to 0.75 and the mean distance to agreement decreased from 3.63 to 2.95 mm. CONCLUSIONS Interobserver variability in prostate bed contouring exists among international genitourinary experts, although this is lower than previously reported. Consensus guidelines for MRI-based prostate bed contouring have been developed, and this has resulted in an improvement in contouring concordance. However, IOV persists and strategies such as an education program, development of a contouring atlas, and further refinement of the guidelines may lead to additional improvements.
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Affiliation(s)
- Kobika Sritharan
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom.
| | | | - Declan Cahill
- Department of Urology, Royal Marsden Hospital NHS Trust, London, United Kingdom
| | - Seungtaek Choi
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Ananya Choudhury
- Christie National Health Service Foundation Trust, Manchester, United Kingdom; University of Manchester, Manchester, United Kingdom
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Lars Dysager
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Huddart
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Colleen Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Julia Murray
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | | | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, Italy
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mark Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Aslam Sohaib
- Department of Radiology, Royal Marsden Hospital NHS Trust, Sutton, United Kingdom
| | - Alex Tan
- Sunshine Coast Hospital and Health Service, Queensland, Australia; James Cook University, Townsville, Queensland, Australia
| | | | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
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Abstract
Prostate cancer (PC) is a significant health concern worldwide, with high incidence and mortality rates. Early and accurate detection and localization of recurrent disease at biochemical recurrence (BCR) is critical for guiding subsequent therapeutic decisions and improving patient outcomes. At BCR, conventional imaging consisting of CT, MRI, and bone scintigraphy are recommended by US and European guidelines, however, these modalities all bear certain limitations in detecting metastatic disease, particularly in low-volume relapse at low prostate-specific antigen (PSA) levels. Molecular imaging with PET/CT or PET/MRI using prostate-specific membrane antigen (PSMA) targeting radiopharmaceuticals has revolutionized imaging of PC. Particularly at BCR PC, PSMA PET has shown better diagnostic performance compared to conventional imaging in detecting local relapse and metastases, even at very low PSA levels. The most recent version of the National Comprehensive Cancer Network (NCCN) guideline has included PSMA-targeted PET/CT or PET/MRI for the localization of BCR PC. There are several different PSMA-targeting radiopharmaceuticals labeled with different radioisotopes, each with slightly different characteristics, but overall similar high sensitivity and specificity for PC. PSMA-targeted PET has the potential to significantly impact patient care by guiding personalized treatment decisions and thus improving outcomes in BCR PC patients.
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Affiliation(s)
- Heying Duan
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, CA
| | - Andrei Iagaru
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, CA.
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Pecoraro M, Dehghanpour A, Das JP, Woo S, Panebianco V. Evaluation of Prostate Cancer Recurrence with MR Imaging and Prostate Imaging for Recurrence Reporting Scoring System. Radiol Clin North Am 2024; 62:135-159. [PMID: 37973239 DOI: 10.1016/j.rcl.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Detection of prostate cancer recurrence after whole-gland treatment with curative intent is critical to identify patients who may benefit from local salvage therapy. Among the different imaging modalities used in clinical practice, MR imaging is the most accurate in identifying local prostate cancer recurrence; indeed, it is an excellent technique for local recurrence detection superior to PET/CT, even at low PSA, but provides no information about extra-pelvic lymph nodes or bone metastasis. In 2021, a group of experts developed the Prostate Imaging for local Recurrence Reporting scoring system to standardize acquisition, interpretation, and reporting of prostate cancer recurrence.
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Affiliation(s)
- Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Viale Regina Elena 324, Rome 00161, Italy
| | - Ailin Dehghanpour
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Viale Regina Elena 324, Rome 00161, Italy
| | - Jeeban Paul Das
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Sungmin Woo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Viale Regina Elena 324, Rome 00161, Italy.
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4
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Awiwi MO, Gjoni M, Vikram R, Altinmakas E, Dogan H, Bathala TK, Naik S, Ravizzini G, Kandemirli SG, Elsayes KM, Salem UI. MRI and PSMA PET/CT of Biochemical Recurrence of Prostate Cancer. Radiographics 2023; 43:e230112. [PMID: 37999983 DOI: 10.1148/rg.230112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Prostate cancer may recur several years after definitive treatment, such as prostatectomy or radiation therapy. A rise in serum prostate-specific antigen (PSA) level is the first sign of disease recurrence, and this is termed biochemical recurrence. Patients with biochemical recurrence have worse survival outcomes. Radiologic localization of recurrent disease helps in directing patient management, which may vary from active surveillance to salvage radiation therapy, androgen-deprivation therapy, or other forms of systemic and local therapy. The likelihood of detecting the site of recurrence increases with higher serum PSA level. MRI provides optimal diagnostic performance for evaluation of the prostatectomy bed. Prostate-specific membrane antigen (PSMA) PET radiotracers currently approved by the U.S. Food and Drug Administration demonstrate physiologic urinary excretion, which can obscure recurrence at the vesicourethral junction. However, MRI and PSMA PET/CT have comparable diagnostic performance for evaluation of local recurrence after external-beam radiation therapy or brachytherapy. PSMA PET/CT outperforms MRI in identifying recurrence involving the lymph nodes and bones. Caveats for use of both PSMA PET/CT and MRI do exist and may cause false-positive or false-negative results. Hence, these techniques have complementary roles and should be interpreted in conjunction with each other, taking the patient history and results of any additional prior imaging studies into account. Novel PSMA agents at various stages of investigation are being developed, and preliminary data show promising results; these agents may revolutionize the landscape of prostate cancer recurrence imaging in the future. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Turkbey in this issue. The slide presentation from the RSNA Annual Meeting is available for this article.
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Affiliation(s)
- Muhammad O Awiwi
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Migena Gjoni
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Raghunandan Vikram
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Emre Altinmakas
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Hakan Dogan
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Tharakeswara K Bathala
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Sagar Naik
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Gregory Ravizzini
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Sedat Giray Kandemirli
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Khaled M Elsayes
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
| | - Usama I Salem
- From the Division of Diagnostic Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.132, Houston, TX 77030 (M.O.A.); Department of Medicine, Istanbul University-Cerrahpasa Hospital, Istanbul, Turkey (M.G.); Departments of Abdominal Imaging (R.V., T.K.B., S.N., K.M.E., U.I.S.) and Nuclear Medicine (G.R.), Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY (E.A.); Department of Radiology, Koç University School of Medicine, Istanbul, Turkey (E.A., H.D.); and Department of Nuclear Medicine, Division of Diagnostic Imaging, University of Iowa Hospitals and Clinics, Iowa City, Iowa (S.G.K.)
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Fernandes MC, Yildirim O, Woo S, Vargas HA, Hricak H. The role of MRI in prostate cancer: current and future directions. MAGMA (NEW YORK, N.Y.) 2022; 35:503-521. [PMID: 35294642 PMCID: PMC9378354 DOI: 10.1007/s10334-022-01006-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/16/2022] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
There has been an increasing role of magnetic resonance imaging (MRI) in the management of prostate cancer. MRI already plays an essential role in the detection and staging, with the introduction of functional MRI sequences. Recent advancements in radiomics and artificial intelligence are being tested to potentially improve detection, assessment of aggressiveness, and provide usefulness as a prognostic marker. MRI can improve pretreatment risk stratification and therefore selection of and follow-up of patients for active surveillance. MRI can also assist in guiding targeted biopsy, treatment planning and follow-up after treatment to assess local recurrence. MRI has gained importance in the evaluation of metastatic disease with emerging technology including whole-body MRI and integrated positron emission tomography/MRI, allowing for not only better detection but also quantification. The main goal of this article is to review the most recent advances on MRI in prostate cancer and provide insights into its potential clinical roles from the radiologist's perspective. In each of the sections, specific roles of MRI tailored to each clinical setting are discussed along with its strengths and weakness including already established material related to MRI and the introduction of recent advancements on MRI.
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Affiliation(s)
- Maria Clara Fernandes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Sungmin Woo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Hebert Alberto Vargas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
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Abstract
OBJECTIVE. In this article, we discuss the evolving roles of imaging modalities in patients presenting with biochemical recurrence after prostatectomy. CONCLUSION. Multiple imaging modalities are currently available to evaluate patients with prostate cancer presenting with biochemical recurrence after prostatectomy. Multiparametric MRI (mpMRI) focuses on the postsurgical bed as well as regional lymph nodes and bones. PET/CT studies using 18F-fluciclovine, 11C-choline, and prostate-specific membrane antigen (PSMA) ligands are useful in detecting locoregional and distant metastasis. Multiparametric MRI is preferred for patients with low risk of metastasis for localizing recurrence in prostate bed as well as pelvic lymph node and bone recurrence. Moreover, mpMRI aids in guiding biopsy and additional salvage treatments. For patients with high risk of metastatic disease, both mpMRI and whole-body PET/CT may be performed. PET/MRI using 68Ga-PSMA has potential to enable a one-stop shop for local recurrence and metastatic disease evaluation, and clinical trials of PET/MRI are ongoing.
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Abstract
Prostate cancer is the fifth leading cause of death worldwide. A variety of treatment options is available for localized prostate cancer and may range from active surveillance to focal therapy or whole gland treatment, that is, surgery or radiotherapy. Serum prostate-specific antigen levels are an important tool to monitor treatment success after whole gland treatment, unfortunately prostate-specific antigen is unreliable after focal therapy. Multiparametric magnetic resonance imaging of the prostate is rapidly gaining field in the management of prostate cancer and may play a crucial role in the evaluation of recurrent prostate cancer. This article will focus on postprocedural magnetic resonance imaging after different forms of local therapy in patients with prostate cancer.
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Prostatic Remnant After Prostatectomy: MR Findings and Prevalence in Clinical Practice. AJR Am J Roentgenol 2020; 214:W37-W43. [DOI: 10.2214/ajr.19.21345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wymer KM, Sharma V, Davis BJ, Kwon ED, Mynderse LA, Karnes RJ. Evaluating the Potential Role of Salvage Vesiculectomy for Prostate Cancer Recurrence. Clin Genitourin Cancer 2019; 17:e536-e540. [DOI: 10.1016/j.clgc.2019.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
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Barbosa FG, Queiroz MA, Nunes RF, Viana PCC, Marin JFG, Cerri GG, Buchpiguel CA. Revisiting Prostate Cancer Recurrence with PSMA PET: Atlas of Typical and Atypical Patterns of Spread. Radiographics 2019; 39:186-212. [DOI: 10.1148/rg.2019180079] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Felipe G. Barbosa
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - Marcelo A. Queiroz
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - Rafael F. Nunes
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - Publio C. C. Viana
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - José Flávio G. Marin
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - Giovanni G. Cerri
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
| | - Carlos A. Buchpiguel
- From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.)
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12
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Ward RD, Purysko AS. Multiparametric Magnetic Resonance Imaging in the Evaluation of Prostate Cancer Recurrence. Semin Roentgenol 2018; 53:234-246. [DOI: 10.1053/j.ro.2018.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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13
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Abstract
Prostate multiparametric MR imaging (mpMRI) plays an important role in local evaluation after treatment of prostate cancer. After radical prostatectomy, radiation therapy, and focal therapy, mpMRI can be used to visualize normal post-treatment changes and to diagnose locally recurrent disease. An understanding of the various treatments and expected changes is essential for complete and accurate post-treatment mpMRI interpretation.
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Sandgren K, Westerlinck P, Jonsson JH, Blomqvist L, Thellenberg Karlsson C, Nyholm T, Dirix P. Imaging for the Detection of Locoregional Recurrences in Biochemical Progression After Radical Prostatectomy-A Systematic Review. Eur Urol Focus 2017; 5:550-560. [PMID: 29133278 DOI: 10.1016/j.euf.2017.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/13/2017] [Accepted: 11/02/2017] [Indexed: 01/23/2023]
Abstract
CONTEXT Local and regional recurrence after radical prostatectomy (RP) can be treated using salvage radiotherapy (SRT). If the recurrence can be delineated on diagnostic imaging, this could allow for increasingly individualized SRT. OBJECTIVE This systematic review aimed at evaluating the evidence regarding the usefulness of positron emission tomography (PET) and magnetic resonance imaging (MRI) in identifying local and regional recurrences, with the aim to further individualize the SRT treatment. EVIDENCE ACQUISITION A systematic PubMed/Medline search was conducted in December 2015. Studies included were imaging studies of post-RP patients focusing on local and/or regional recurrence where sensitivity and specificity of MRI or PET were the primary end points. Only studies using biopsy, other histological analysis, and/or treatment follow-up as reference standard were included. Quality Assessment of Diagnostic Accuracy Studies-2 was used to score the study quality. Twenty-five articles were deemed of sufficient quality and included in the review. EVIDENCE SYNTHESIS [11C]Acetate had the highest pooled sensitivity (92%), while [11C]choline and [18F]choline had pooled sensitivities of 71% and 84%, respectively. The PET tracer with highest pooled specificity was [11C]choline (86%). Regarding MRI, MR spectroscopy combined with dynamic contrast enhanced (DCE) MRI showed the highest pooled sensitivity (89%). High pooled sensitivities were also seen using multiparametric MRI (84%), diffusion-weighted MRI combined with T2-weigthed (T2w) imaging (82%), and DCE MRI combined with T2w imaging (82%). These also showed high pooled specificities (85%, 89%, and 92%, respectively). CONCLUSIONS Both MRI and PET have adequate sensitivity and specificity for the detection of prostate cancer recurrences post-RP. Multiparametric MRI, using diffusion-weighted and/or DCE imaging, and the choline-labeled tracers showed high pooled sensitivity and specificity, although their ranges were broad. PATIENT SUMMARY After reviewing imaging studies of recurrent prostate cancer after prostatectomy, we concluded that choline positron emission tomography and diffusion-weighted magnetic resonance imaging can be proposed as the current standard, with high sensitivity and specificity.
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Affiliation(s)
| | - Philippe Westerlinck
- Department of Radiation Oncology, Iridium Cancer Network, Wilrijk (Antwerp), Belgium
| | | | - Lennart Blomqvist
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Department of Immunology, Genetics, and Pathology, Medical Radiation Science, Uppsala University, Uppsala, Sweden
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Cancer Network, Wilrijk (Antwerp), Belgium; Department of Molecular Imaging, Pathology, Radiotherapy & Oncology (MIPRO), Center for Oncological Research (CORE), Edegem (Antwerp), Belgium
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15
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Abstract
There is growing consensus that multiparametric magnetic resonance imaging (mpMRI) is an effective modality in the detection of locally recurrent prostate cancer after prostatectomy and radiation therapy. The emergence of magnetic resonance (MR)-guided focal therapies, such as cryoablation, high-intensity focused ultrasound, and laser ablation, have made the use of mpMRI even more important, as the normal anatomy is inevitably altered and the detection of recurrence is made more difficult. The aim of this article is to review the utility of mpMRI in detecting recurrent prostate cancer in patients following radical prostatectomy, radiation therapy, and focal therapy and to discuss expected post-treatment mpMRI findings, the varied appearance of recurrent tumors, and their mimics.
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Oppenheimer DC, Weinberg EP, Hollenberg GM, Meyers SP. Multiparametric Magnetic Resonance Imaging of Recurrent Prostate Cancer. J Clin Imaging Sci 2016; 6:18. [PMID: 27195184 PMCID: PMC4863405 DOI: 10.4103/2156-7514.181494] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/14/2016] [Indexed: 11/30/2022] Open
Abstract
Multiparametric magnetic resonance (MR) imaging of the prostate combines both morphological and functional MR techniques by utilizing small field of view T1-weighted, T2-weighted, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and MR spectroscopy to accurately detect, localize, and stage primary and recurrent prostate cancer. Localizing the site of recurrence in patients with rising prostate-specific antigen following treatment affects decision making regarding treatment and can be accomplished with multiparametric prostate MR. Several different treatment options are available for prostate cancer including radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, or a number of focal therapy techniques. The findings of recurrent prostate cancer can be different depending on the treatment the patient has received, and the radiologist must be able to recognize the variety of imaging findings seen with this common disease. This review article will detail the findings of recurrent prostate cancer on multiparametric MR and describe common posttreatment changes which may create challenges to accurate interpretation.
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Affiliation(s)
| | - Eric P Weinberg
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Gary M Hollenberg
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Steven P Meyers
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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Paparo F, Piccardo A, Bacigalupo L, Romagnoli A, Piccazzo R, Monticone M, Cevasco L, Campodonico F, Conzi GM, Carmignani G, Rollandi GA. Value of bimodal (18)F-choline-PET/MRI and trimodal (18)F-choline-PET/MRI/TRUS for the assessment of prostate cancer recurrence after radiation therapy and radical prostatectomy. ACTA ACUST UNITED AC 2016; 40:1772-87. [PMID: 25579170 DOI: 10.1007/s00261-014-0345-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Between 27% and 53% of all patients who undergo radical prostatectomy (RP) or radiation therapy (RT) as the first-line treatment of prostate cancer (PCa) develop a biochemical recurrence. Imaging plays a pivotal role in restaging by helping to distinguish between local relapse and metastatic disease (i.e., lymph-node and skeletal metastases). At present, the most promising tools for assessing PCa patients with biochemical recurrence are multiparametric magnetic resonance imaging (mpMRI) and positron emission tomography (PET)/computed tomography (CT) with radio-labeled choline derivatives. The main advantage of mpMRI is its high diagnostic accuracy in detecting local recurrence, while choline-PET/CT is able to identify lymph-node metastases when they are not suspicious on morphological imaging. The most recent advances in the field of fusion imaging have shown that multimodal co-registration, synchronized navigation, and combined interpretation are more valuable than the individual; separate assessment offered by different diagnostic techniques. The objective of the present essay was to describe the value of bimodal choline-PET/mpMRI fusion imaging and trimodal choline-PET/mpMRI/transrectal ultrasound (TRUS) in the assessment of PCa recurrence after RP and RT. Bimodal choline-PET/mpMRI fusion imaging allows morphological, functional, and metabolic information to be combined, thereby overcoming the limitations of each separate imaging modality. In addition, trimodal real-time choline-PET/mpMRI/TRUS fusion imaging may be useful for the planning and real-time guidance of biopsy procedures in order to obtain histological confirmation of the local recurrence.
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Affiliation(s)
- Francesco Paparo
- Unit of Radiology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128, Genoa, Italy,
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18
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Pitfalls in Interpreting mp-MRI of the Prostate: A Pictorial Review with Pathologic Correlation. Insights Imaging 2015; 6:611-30. [PMID: 26385690 PMCID: PMC4656245 DOI: 10.1007/s13244-015-0426-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/23/2015] [Accepted: 07/29/2015] [Indexed: 01/20/2023] Open
Abstract
Objectives The purpose of this pictorial review is to present a wide spectrum of prostate multiparametric MRI (mp-MRI) pitfalls that may occur in clinical practice, with radiological and pathological correlation. Methods All examinations were performed according to ESUR Guidelines protocols. Results and Conclusion mp-MRI imaging of the prostate often leads to interpreting doubts and misdiagnosis due to the many interpretative pitfalls that a tissue, whether healthy or treated, may cause. These “false-positive” findings may occur in each stage of the disease history, from the primary diagnosis and staging, to the post-treatment stage, and whether they are caused by the tissue itself or are iatrogenic, their recognition is critical for proper treatment and management. Knowledge of these known pitfalls and their interpretation in the anatomical-radiological context can help radiologists avoid misdiagnosis and consequently mistreatment. Main Messages • Some physiological changes in the peripheral and central zone may simulate prostate cancer. • Technical errors, such as mispositioned endorectal coils, can affect the mp-MRI interpretation. • Physiological changes post-treatment can simulate recurrence
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Notley M, Yu J, Fulcher AS, Turner MA, Cockrell CH, Nguyen D. Pictorial review. Diagnosis of recurrent prostate cancer and its mimics at multiparametric prostate MRI. Br J Radiol 2015; 88:20150362. [PMID: 26268143 DOI: 10.1259/bjr.20150362] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Biochemical recurrence after treatment for prostate cancer (PCa) is a significant issue. Early diagnosis of local recurrence is important for making prompt treatment decisions and is strongly associated with patient prognosis. Without salvage therapy, the average time from development of local recurrence to distant metastasis is approximately 3 years. Biochemical recurrence does not differentiate local recurrence from systemic disease; there is no reliable way to clinically diagnose local recurrence. Recent advances in multiparametric MRI (mp-MRI) techniques have markedly improved detection of local recurrence following therapy. However, a wide variety of entities can mimic recurrent PCa at mp-MRI. Therefore, the purpose of this pictorial review is to discuss the MRI findings of locally recurrent PCa and its mimics, emphasizing the key MRI features that help to differentiate local recurrence from its mimics.
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Affiliation(s)
- Mark Notley
- 1 Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Jinxing Yu
- 1 Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Ann S Fulcher
- 1 Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Mary Ann Turner
- 1 Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Charles H Cockrell
- 1 Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Don Nguyen
- 2 Department of Radiology, Allegheny General Hospital, Pittsburgh, PA, USA
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Abstract
For many clinical issues regarding prostate cancer magnetic resonance imaging (MRI) is gaining increasing importance for prostate diagnostics. The high morphological resolution of T2-weighted sequences is unsurpassed compared to other imaging modalities. It enables not only the detection and localization of prostate cancer but also allows the evaluation of extracapsular extensions. Functional MRI methods, such as diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MRI and proton magnetic resonance spectroscopy ((1)H-MRS) increase the specificity and to a lesser extent, the sensitivity of diagnostics. In accordance with the interdisciplinary S3 guidelines, prostate MRI is recommended for patients with at least one negative biopsy for cancer detection. According to the guidelines areas suspected of being cancerous should be selectively biopsied in addition to the systematic biopsy. The transmission of findings about the suspected tumor areas according to the structured PI-RADS classification system has proven its worth. The localization and staging of prostate carcinoma is best achieved with the help of MRI and is recommended in the S3 guidelines especially for tumors with a clinical stage cT3/4 or with a Gleason grading system score ≥8. In addition to these applications MRI is mainly used under study conditions for local recurrence or active surveillance.
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Affiliation(s)
- T Franiel
- Institut für Diagnostische und Interventionelle Radiologie II, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Deutschland,
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21
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Cha D, Kim CK, Park SY, Park JJ, Park BK. Evaluation of suspected soft tissue lesion in the prostate bed after radical prostatectomy using 3T multiparametric magnetic resonance imaging. Magn Reson Imaging 2014; 33:407-12. [PMID: 25527395 DOI: 10.1016/j.mri.2014.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 10/20/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the usefulness of multiparametric MR imaging (mp-MRI) at 3T for evaluating suspected soft tissue lesion in the prostate bed after radical prostatectomy (RP). MATERIALS AND METHODS Forty-three patients with biochemical recurrence (BCR) who received RP underwent mp-MRI at 3T with a phased-array coil, including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE-MRI) and were enrolled in this study. All patients with BCR had a suspected soft tissue lesion in the prostate bed, followed by transrectal ultrasound-guided biopsy. As a control group, 14 consecutive patients without BCR who received RP were also enrolled. Two experienced radiologists independently analyzed four different imaging datasets. RESULTS For predicting local recurrence, the specificity, accuracy and area under the curve for both readers were significantly greater on all combined imaging datasets than on T2WI alone (P<0.05). The sensitivity of all combined imaging datasets in both readers was not statistically different with T2WI alone (P>0.05), except for combined T2WI and DWI. Inter-reader agreements for the four different imaging datasets were moderate. CONCLUSION DCE-MRI or DWI in combination with T2WI at 3T with a phased-array coil appears to be more useful than T2WI alone in evaluating suspected soft tissue lesion of the prostate bed after RP.
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Affiliation(s)
- Dongik Cha
- Department of Radiology and Centre for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chan Kyo Kim
- Department of Radiology and Centre for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Sung Yoon Park
- Department of Radiology and Centre for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Jae Park
- Department of Radiology and Centre for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Kwan Park
- Department of Radiology and Centre for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Comparative sensitivities of functional MRI sequences in detection of local recurrence of prostate carcinoma after radical prostatectomy or external-beam radiotherapy. AJR Am J Roentgenol 2013; 200:W361-8. [PMID: 23521479 DOI: 10.2214/ajr.12.9106] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this retrospective study was to determine the respective accuracies of three types of functional MRI sequences-diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MRI, and 3D (1)H-MR spectroscopy (MRS)-in the depiction of local prostate cancer recurrence after two different initial therapy options. MATERIALS AND METHODS From a cohort of 83 patients with suspicion of local recurrence based on prostate-specific antigen (PSA) kinetics who were imaged on a 3-T MRI unit using an identical protocol including the three functional sequences with an endorectal coil, we selected 60 patients (group A, 28 patients who underwent radical prostatectomy; group B, 32 patients who underwent external-beam radiation) who had local recurrence ascertained on the basis of a transrectal ultrasound-guided biopsy results and a reduction in PSA level after salvage therapy. RESULTS All patients presented with a local relapse. Sensitivity with T2-weighted MRI and 3D (1)H-MRS sequences was 57% and 53%, respectively, for group A and 71% and 78%, respectively, for group B. DCE-MRI alone showed a sensitivity of 100% and 96%, respectively, for groups A and B. DWI alone had a higher sensitivity for group B (96%) than for group A (71%). The combination of T2-weighted imaging plus DWI plus DCE-MRI provided a sensitivity as high as 100% in group B. CONCLUSION The performance of functional imaging sequences for detecting recurrence is different after radical prostatectomy and external-beam radiotherapy. DCE-MRI is a valid and efficient tool to detect prostate cancer recurrence in radical prostatectomy as well as in external-beam radiotherapy. The combination of DCE-MRI and DWI is highly efficient after radiation therapy. Three-dimensional (1)H-MRS needs to be improved. Even though it is not accurate enough, T2-weighted imaging remains essential for the morphologic analysis of the area.
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24
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Talab SS, Preston MA, Elmi A, Tabatabaei S. Prostate cancer imaging: what the urologist wants to know. Radiol Clin North Am 2013; 50:1015-41. [PMID: 23122036 DOI: 10.1016/j.rcl.2012.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Saman Shafaat Talab
- Department of Urology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
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25
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Liauw SL, Pitroda SP, Eggener SE, Stadler WM, Pelizzari CA, Vannier MW, Oto A. Evaluation of the prostate bed for local recurrence after radical prostatectomy using endorectal magnetic resonance imaging. Int J Radiat Oncol Biol Phys 2012; 85:378-84. [PMID: 22717242 DOI: 10.1016/j.ijrobp.2012.05.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/26/2012] [Accepted: 05/06/2012] [Indexed: 01/07/2023]
Abstract
PURPOSE To summarize the results of a 4-year period in which endorectal magnetic resonance imaging (MRI) was considered for all men referred for salvage radiation therapy (RT) at a single academic center; to describe the incidence and location of locally recurrent disease in a contemporary cohort of men with biochemical failure after radical prostatectomy (RP), and to identify prognostic variables associated with MRI findings in order to define which patients may have the highest yield of the study. METHODS AND MATERIALS Between 2007 and 2011, 88 men without clinically palpable disease underwent eMRI for detectable prostate-specific antigen (PSA) after RP. The median interval between RP and eMRI was 32 months (interquartile range, 14-57 months), and the median PSA level was 0.30 ng/mL (interquartile range, 0.19-0.72 ng/mL). Magnetic resonance imaging scans consisting of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced imaging were evaluated for features consistent with local recurrence. The prostate bed was scored from 0-4, whereby 0 was definitely normal, 1 probably normal, 2 indeterminate, 3 probably abnormal, and 4 definitely abnormal. Local recurrence was defined as having a score of 3-4. RESULTS Local recurrence was identified in 21 men (24%). Abnormalities were best appreciated on T2-weighted axial images (90%) as focal hypointense lesions. Recurrence locations were perianastomotic (67%) or retrovesical (33%). The only risk factor associated with local recurrence was PSA; recurrence was seen in 37% of men with PSA >0.3 ng/mL vs 13% if PSA ≤0.3 ng/mL (P<.01). The median volume of recurrence was 0.26 cm(3) and was directly associated with PSA (r=0.5, P=.02). The correlation between MRI-based tumor volume and PSA was even stronger in men with positive margins (r=0.8, P<.01). CONCLUSIONS Endorectal MRI can define areas of local recurrence after RP in a minority of men without clinical evidence of disease, with yield related to PSA. Further study is necessary to determine whether eMRI can improve patient selection and success of salvage RT.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois 60637, USA.
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26
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Abstract
Many management options are available to patients with newly diagnosed prostate cancer. Magnetic resonance (MR) imaging plays an important role in initial staging of prostate cancer, but it also aids in tumor detection when there is clinical or biochemical suspicion of residual or recurrent disease after treatment. The purpose of this review is to describe the normal appearances of the prostatic region after different kinds of treatment for prostate cancer and to discuss how these appearances differ from those of recurrent and residual disease. Several MR imaging techniques used in evaluating patients with prostate cancer are described, including conventional MR imaging sequences (mainly T1- and T2-weighted sequences), MR spectroscopic imaging, diffusion-weighted imaging, and dynamic contrast agent-enhanced MR imaging. Clinical considerations, together with the different approaches for interpreting serum prostate-specific antigen values in the posttreatment setting, are also presented. All forms of treatment alter the MR imaging features of the prostatic region to a greater or lesser extent, and it is important to be able to recognize expected posttreatment appearances and distinguish them from the features of recurrent or residual cancer to aid subsequent clinical management.
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Affiliation(s)
- Hebert Alberto Vargas
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Radiology Academic Offices, New York, NY 10065, USA.
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27
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Croke J, Malone S, Roustan Delatour N, Belanger E, Avruch L, Morash C, Kayser C, Underhill K, Spaans J. Postoperative radiotherapy in prostate cancer: the case of the missing target. Int J Radiat Oncol Biol Phys 2012; 83:1160-8. [PMID: 22270169 DOI: 10.1016/j.ijrobp.2011.09.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 07/22/2011] [Accepted: 09/29/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Postoperative radiotherapy (XRT) increases survival in high-risk prostate cancer patients. Approximately 50% of patients on long-term follow-up relapse despite adjuvant XRT and the predominant site of failure remains local. Four consensus guidelines define postoperative clinical target volume (CTV) in prostate cancer. We explore the possibility that inadequate CTV coverage is an important cause of local failure. This study evaluates the utility of preoperative magnetic resonance imaging (MRI) in defining prostate bed CTV. METHODS AND MATERIALS Twenty prostate cancer patients treated with postoperative XRT who also had preoperative staging MRI were included. The four guidelines were applied and the CTVs were expanded to create planning target volumes (PTVs). Preoperative MRIs were fused with postoperative planning CT scans. MRI-based prostate and gross visible tumors were contoured. Three-dimensional (3D) conformal four- and six-field XRT plans were developed and dose-volume histograms analyzed. Subtraction analysis was conducted to assess the adequacy of prostate/gross tumor coverage. RESULTS Gross tumor was visible in 18 cases. In all 20 cases, the consensus CTVs did not fully cover the MRI-defined prostate. On average, 35% of the prostate volume and 32% of the gross tumor volume were missed using six-field 3D treatment plans. The entire MRI-defined gross tumor volume was completely covered in only two cases (six-field plans). The expanded PTVs did not cover the entire prostate bed in 50% of cases. Prostate base and mid-zones were the predominant site of inadequate coverage. CONCLUSIONS Current postoperative CTV guidelines do not adequately cover the prostate bed and/or gross tumor based on preoperative MRI imaging. Additionally, expanded PTVs do not fully cover the prostate bed in 50% of cases. Inadequate CTV definition is likely a major contributing factor for the high risk of relapse despite adjuvant XRT. Preoperative imaging may lead to more accurate CTV definition, which should result in further improvements in survival for patients with high-risk prostate cancer.
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Affiliation(s)
- Jennifer Croke
- Division of Radiation Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Ontario, Canada
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28
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Delineation of the Postprostatectomy Prostate Bed Using Computed Tomography: Interobserver Variability Following the EORTC Delineation Guidelines. Int J Radiat Oncol Biol Phys 2011; 81:e143-9. [DOI: 10.1016/j.ijrobp.2010.12.057] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 12/05/2010] [Accepted: 12/29/2010] [Indexed: 11/30/2022]
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An interobserver study of prostatic fossa clinical target volume delineation in clinical practice: are regions of recurrence adequately targeted? Am J Clin Oncol 2011; 34:145-9. [PMID: 20523209 DOI: 10.1097/coc.0b013e3181d2edc3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To study interphysician variability of delineation of the prostatic fossa clinical target volume (pfCTV) to be irradiated in patients with residual or recurrent microscopic prostate cancer following radical prostatectomy and to estimate the risk for a geographical miss. METHODS Thirty-eight pfCTV were delineated on postradical prostatectomy computerized tomography scans of 8 patients by 5 observers. To estimate the risk of a geographical miss, a high risk volume (HRV) was defined and the percentage of "missed" HRV was calculated for each pfCTV. RESULTS Interphysician variability was considerable with a mean pfCTV of 39.09 cm (range, 11.8-72.5 cm). At least 25% of the HRV at the bladder neck/anastomosis and the retro-vesical space was excluded in 11 pfCTVs. The mean "missed" HRV was 27.5% (range, 2.3%-78.7%). A pfCTV of less than 30 cm was associated with a geographical miss in 66% of cases versus 17.2% for pfCTV of 30 cm or more (P = 0.006). Observer identity was significantly associated with excluded HRV (P = 0.03). CONCLUSIONS pfCTV delineation is subject to considerable interobserver variability associated with a significant risk of inadequate targeting of the anastomosis/bladder neck region and the retrovesical space. The failure to recognize regions at high risk for harboring microscopic disease may be due to a lack of familiarity with tissue redistribution following radical surgery, and a lack of literature-based guidelines for pfCTV delineation. A strategy to improve pfCTV delineation is proposed.
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30
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Sefrova J, Odrazka K, Paluska P, Belobradek Z, Brodak M, Dolezel M, Prosvic P, Macingova Z, Vosmik M, Hoffmann P, Louda M, Nejedla A. Magnetic resonance imaging in postprostatectomy radiotherapy planning. Int J Radiat Oncol Biol Phys 2011; 82:911-8. [PMID: 21420244 DOI: 10.1016/j.ijrobp.2010.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 10/27/2010] [Accepted: 10/03/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate whether the use of magnetic resonance imaging (MRI) in prostate bed treatment planning could influence definition of the clinical target volume (CTV) and organs at risk. METHODS AND MATERIALS A total of 21 consecutive patients referred for prostate bed radiotherapy were included in the present retrospective study. The CTV was delineated according to the European Organization for Research and Treatment of Cancer recommendations on computed tomography (CT) and T(1)-weighted (T(1)w) and T(2)-weighted (T(2)w) MRI. The CTV magnitude, agreement, and spatial differences were evaluated on the planning CT scan after registration with the MRI scans. RESULTS The CTV was significantly reduced on the T(1)w and T(2)w MRI scans (13% and 9%, respectively) compared with the CT scans. The urinary bladder was drawn smaller on the CT scans and the rectum was smaller on the MRI scans. On T(1)w MRI, the rectum and urinary bladder were delineated larger than on T(2)w MRI. Minimal agreement was observed between the CT and T(2)w images. The main spatial differences were measured in the superior and superolateral directions in which the CTV on the MRI scans was 1.8-2.9 mm smaller. In the posterior and inferior border, no difference was seen between the CT and T(1)w MRI scans. On the T(2)w MRI scans, the CTV was larger in these directions (by 1.3 and 1.7 mm, respectively). CONCLUSIONS The use of MRI in postprostatectomy radiotherapy planning resulted in a reduction of the CTV. The main differences were found in the superior part of the prostate bed. We believe T(2)w MRI enables more precise definition of prostate bed CTV than conventional planning CT.
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Affiliation(s)
- Jana Sefrova
- Department of Oncology and Radiotherapy, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
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Gettman MT, Blute ML. Radical prostatectomy: does surgical technique influence margin control? Urol Oncol 2010; 28:219-25. [PMID: 20219563 DOI: 10.1016/j.urolonc.2009.07.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The goal of radical prostatectomy (RP) is complete removal of the prostate and seminal vesicles with negative surgical margins. Regardless of approach, the occurrence of positive surgical margins (PSMs) remains a risk associated with RP. In addition, PSMs can adversely affect biochemical and cause-specific survival. With the advent of PSA screening and introduction of new RP approaches, surgical technique has become increasingly debated in relationship to margin positivity. The issue, however, is controversial, as underlying clinical and pathologic characteristics of prostate cancer also influence margin control. This article evaluates the impact of surgical technique on margin control during RP. In addition, we evaluate the influence that stage migration, the individual surgeon, new technologic adjuncts, and specimen handling have had on margin control.
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Abstract
OBJECTIVE In patients with clinically suspected local recurrence of prostate cancer, a lobulated hyperintense mass in the radical prostatectomy fossa can be readily visualized with T2-weighted MRI, but this imaging technique is less successful after treatments such as radiation therapy, high-intensity focused ultrasound, and cryosurgery. We describe the additional value of functional techniques in the assessment of local recurrence. CONCLUSION The use of functional MRI techniques such as MR spectroscopy, diffusion-weighted imaging, and dynamic contrast-enhanced MRI has shown promise in increasing overall imaging performance in the detection of local recurrence.
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Rouvière O, Vitry T, Lyonnet D. Imaging of prostate cancer local recurrences: why and how? Eur Radiol 2009; 20:1254-66. [DOI: 10.1007/s00330-009-1647-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 09/07/2009] [Accepted: 10/09/2009] [Indexed: 10/20/2022]
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Pasquier D, Hugentobler A, Masson P. [Which imaging methods should be used prior to salvage radiotherapy after prostatectomy for prostate cancer?]. Cancer Radiother 2009; 13:173-81. [PMID: 19414277 DOI: 10.1016/j.canrad.2009.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 01/30/2009] [Accepted: 02/09/2009] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- D Pasquier
- Service de radiothérapie, centre Galilée, polyclinique de la Louvière, 59000 Lille, France.
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Functional magnetic resonance imaging in prostate cancer. Eur Urol 2009; 55:801-14. [PMID: 19185981 DOI: 10.1016/j.eururo.2009.01.027] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 01/13/2009] [Indexed: 01/12/2023]
Abstract
CONTEXT Magnetic resonance imaging (MRI) combined with magnetic resonance spectroscopy imaging (MRSI), dynamic contrast-enhanced MRI, and diffusion-weighted MRI emerged as promising tests in the diagnosis of prostate cancer, and they show encouraging results. OBJECTIVE This review emphasizes different functional MRI techniques in the diagnosis of prostate cancer and includes information about their clinical value and usefulness. EVIDENCE ACQUISITION The authors searched the Medline, Embase, and Cochrane Library databases. There were no language restrictions. The last search was performed in October 2008. EVIDENCE SYNTHESIS The combination of conventional MRI with functional MRI techniques is more reliable for differentiating benign and malignant prostate tissues than any other diagnostic procedure. At present, no guideline is available that outlines which technique is best in a specific clinical situation. It also remains uncertain whether improved spatial resolution and signal-to-noise ratio of 3-T MRI will improve diagnostic performance. CONCLUSIONS A limited number of small studies suggest that functional MRI may improve the diagnosis and staging of prostate cancer. This finding needs further confirmation in larger studies, and cost-effectiveness needs to be established.
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Endorectal and dynamic contrast-enhanced MRI for detection of local recurrence after radical prostatectomy. AJR Am J Roentgenol 2008; 190:1187-92. [PMID: 18430830 DOI: 10.2214/ajr.07.3032] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the sensitivity and specificity of endorectal MRI combined with dynamic contrast-enhanced MRI to detect local recurrence after radical prostatectomy. MATERIALS AND METHODS A total of 51 patients who had undergone radical prostatectomy for prostatic adenocarcinoma 10 months to 6 years before underwent a combined endorectal coil MRI and dynamic gadolinium-enhanced MRI before endorectal sonographically guided biopsy of the prostatic fossa. The MRI combined with MR dynamic imaging results were correlated with the presence of recurrence defined as a positive biopsy result or reduction in prostate-specific antigen level after radiation therapy. RESULTS Overall data of 46 (25 recurred, 21 nonrecurred) out of 51 evaluated patients were analyzed. All recurrences showed signal enhancement after gadolinium administration and, in particular, 22 of 24 patients (91%) showed rapid and early signal enhancement. The overall sensitivity and specificity of MR dynamic imaging was higher compared with MRI alone (88%, [95% CI] 69-98% and 100%, 84-100% compared with 48%, 28-69% and 52%, 30-74%). MRI combined with dynamic imaging allowed better identification of recurrences compared with MRI alone (McNemar test: chi-square(1) = 16.67; p = < 0.0001). CONCLUSION MRI combined with dynamic contrast-enhanced MRI showed a higher sensitivity and specificity compared with MRI alone in detecting local recurrences after radical prostatectomy.
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The role of imaging in the detection of prostate cancer local recurrence after radiation therapy and surgery. Curr Opin Urol 2008; 18:87-97. [PMID: 18090496 DOI: 10.1097/mou.0b013e3282f13ac3] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review novel MRI and nuclear medicine methods for detecting and planning salvage treatment for prostate cancer local recurrence after radical prostatectomy or radiation therapy. RECENT FINDINGS Traditional methods for detecting local recurrence (i.e., digital rectal exam or transrectal ultrasound and digital rectal exam or transrectal ultrasound-guided biopsy) have limited accuracy in determining the presence and extent of local recurrence and therefore have limited ability to guide salvage therapy. Recent studies indicate that conventional T1 and T2-weighted prostate MRI could improve the detection of recurrent prostate cancer after radical prostatectomy or radiation therapy and salvage treatment planning. Promising new sequences could further increase the accuracy of MRI. In addition, the use of technically improved PET/computed tomography scanners with new tracers like (11)C and (18)F choline and acetate might offer better assessment of recurrent prostate cancer than (18)F-2-fluoro-D-deoxyglucose-PET and monoclonal antibody imaging with the prostate specific membrane antigen antibody (111)In-capromab pendetide (ProstaScint). SUMMARY With systemic therapies for recurrent prostate cancer after radical prostatectomy or radiation therapy being noncurative, the application of MRI and nuclear medicine modalities can help to identify patients who have isolated local recurrence amenable to salvage treatment.
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The normal post-surgical anatomy of the male pelvis following radical prostatectomy as assessed by magnetic resonance imaging. Eur Radiol 2008; 18:1281-91. [DOI: 10.1007/s00330-008-0867-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 11/12/2007] [Accepted: 01/08/2008] [Indexed: 10/22/2022]
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Miralbell R, Vees H, Lozano J, Khan H, Mollà M, Hidalgo A, Linero D, Rouzaud M. Endorectal MRI assessment of local relapse after surgery for prostate cancer: A model to define treatment field guidelines for adjuvant radiotherapy in patients at high risk for local failure. Int J Radiat Oncol Biol Phys 2007; 67:356-61. [PMID: 17236961 DOI: 10.1016/j.ijrobp.2006.08.079] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 08/30/2006] [Accepted: 08/31/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the role of endorectal magnetic resonance imaging (MRI) in defining local relapse after radical prostatectomy for prostate cancer to help to reassess the clinical target volume (CTV) for adjuvant postprostatectomy radiotherapy. METHODS AND MATERIALS Sixty patients undergoing an endorectal MRI before salvage radiotherapy were selected. Spatial coordinates of the relapses were assessed using two reference points: the inferior border of the pubic symphysis (point 1) and the urethro-vesical anastomosis (point 2). Every lesion on MRI was delineated on the planning computed tomography and center of mass coordinates were plotted in two separate diagrams (along the x, y, and z axes) with the urethro-vesical anastomosis as the coordinate origin. An "ideal" CTV was constructed, centered at a point defined by the mathematical means of each of the three coordinates with dimensions defined as twice 2 standard deviations in each of the three axes. The dosimetric impact of the new CTV definition was evaluated in six adjuvantly treated patients. RESULTS The ideal CTV center of mass was located at coordinates 0 (x), -5 (y), and -3 (z) mm with SDs of 6 (x), 6 (y), and 9 (z) mm, respectively. The CTV size was 24 (x) x 24 (y) x 36 (z) mm. Significant rectal sparing was observed with the new CTV. CONCLUSIONS A CTV with an approximately cylindrical shape (approximately 4 x 3 cm) centered 5 mm posterior and 3 mm inferior to the urethro-vesical anastomosis was defined. Such CTV may reduce the irradiation of normal nontarget tissue in the pelvis potentially improving treatment tolerance.
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Affiliation(s)
- Raymond Miralbell
- Division de Radio-oncologie, Hôpitaux Universitares, Genève, Switzerland.
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