The value of computerized tomography scan and magnetic resonance imaging in staging prostatic carcinoma: comparison with the clinical and histological staging

In 21 patients adenocarcinoma of the prostate was staged preoperatively by digital rectal examination, computerized tomography and magnetic resonance imaging. Clinical staging was compared to the postoperative pathological staging. In 11 patients computerized tomography, magnetic resonance imaging and digital rectal examination findings were concordant with the histological examination showing tumors confined to the prostate. In 10 patients no correlation between preoperative staging and histology was noted. Of these cases 8 were understaged by computerized tomography, magnetic resonance imaging and digital rectal examination. In 1 patient magnetic resonance imaging showed false positive findings and in another staging with computerized tomography and magnetic resonance imaging was more accurate than digital rectal examination. Our experience indicates that computerized tomography and magnetic resonance imaging have limited value in the preoperative staging of prostatic carcinoma. Moreover, staging with computerized tomography and magnetic resonance imaging does not significantly improve the information gained by digital rectal examination.     

Magnetic resonance imaging of the prostate

Magnetic resonance imaging has been shown to be more accurate than other imaging modalities in the evaluation of both malignancies and various benign lesions of the prostate. Despite its superiority, because of its cost and low availability, magnetic resonance imaging should play a role as a problem-solver secondary to computed tomography or ultrasonography. The routine use of magnetic resonance imaging in the staging of prostate cancer before surgery cannot be justified on the basis of published data. Magnetic resonance imaging has been proved to be of value in the planning and delivery of different types of radiotherapy to patients with prostate cancer. Through the use of combined magnetic resonance imaging and the new modality, magnetic resonance spectroscopy, the accuracy and specificity of tumour detection and the delineation of tumour extent can be improved. Magnetic resonance technology is rapidly evolving, and in the near future, new possibilities such as biological imaging will have a great impact on magnetic resonance imaging of the prostate.     

Multiparametric magnetic resonance imaging: Current role in prostate cancer management

Digital rectal examination, serum prostate‐specific antigen screening and transrectal ultrasound‐guided biopsy are conventionally used as screening, diagnostic and surveillance tools for prostate cancer. However, they have limited sensitivity and specificity. In recent years, the role of multiparametric magnetic resonance imaging has steadily grown, and is now part of the standard clinical management in many institutions. In multiparametric magnetic resonance imaging, the morphological assessment of T2‐weighted imaging is correlated with diffusion‐weighted imaging, dynamic contrast‐enhanced imaging perfusion and/or magnetic resonance spectroscopic imaging. Multiparametric magnetic resonance imaging is currently regarded as the most sensitive and specific imaging technique for the evaluation of prostate cancer, including detection, staging, localization and aggressiveness evaluation. This article presents an overview of multiparametric magnetic resonance imaging, and discusses the current role of multiparametric magnetic resonance imaging in the different fields of prostate cancer management.     

(Paediatric) magnetic resonance urography: just fancy images or a new important diagnostic tool?

PURPOSE OF REVIEW: Magnetic resonance urography has become an established imaging tool in uroradiology. Its potential to assess anatomy and function makes it an ideal tool for evaluation of urinary tract malformations, renal cysts, genito-urinary tract tumours, infections and renal transplants. This review tries to highlight the potential of magnetic resonance urography in the light of new advances, particularly focusing on paediatric applications. RECENT FINDINGS: Technical innovations such as diaphragmatic tracking, parallel or propeller imaging, faster gradients and higher field strength improve applicability in infants and children. Dynamic studies enable assessment of renal functional parameters such as split renal function, glomerular filtration rate or urinary drainage. Recent advances in magnetic resonance spectroscopy, diffusion imaging and perfusion imaging and new contrast agents promise to widen the potential of magnetic resonance urography as a functional imaging tool, not only in paediatrics but also for other magnetic resonance applications in the genito-urinary tract, such as prostate imaging or in the staging of ovarian and endometrial cancer. SUMMARY: Besides ultrasound being used as the initial imaging method, particularly in children (and as computed tomography in adults), magnetic resonance urography can be envisioned as the major imaging modality for almost all (paediatric) uroradiological queries, consequently creating a growing demand for available equipment and procedural expertise.     

Imaging Prostate Cancer: An Update on Positron Emission Tomography and Magnetic Resonance Imaging

Prostate cancer is a common cancer in men and continues to be a major health problem. Imaging plays an essential role in the clinical management of patients. An important goal for prostate cancer imaging is more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information. Developments in imaging technologies, specifically magnetic resonance imaging (MRI) and positron emission tomography (PET)/computed tomography (CT), have improved the detection rate of prostate cancer. MRI has improved lesion detection and local staging. Furthermore, MRI allows functional assessment with techniques such as diffusion-weighted MRI, MR spectroscopy, and dynamic contrast-enhanced MRI. The most common PET radiotracer, ¹⁸F-fluorodeoxyglucose, is not very useful in prostate cancer. However, in recent years other PET tracers have improved the accuracy of PET/CT imaging of prostate cancer. Among these, choline (labeled with ¹⁸F or ¹¹C), ¹¹C-acetate, and ¹⁸F-fluoride have demonstrated promising results, and other new radiopharmaceuticals are currently under evaluation in preclinical and clinical studies.     

Magnetic resonance imaging in the evaluation of prostate cancer

Summary Advantages of magnetic resonance imaging (MRI) in the study of prostatic disease include a precise anatomical display in multiple planes, superb contrast resolution, and differential physicochemical characteristics that are obtained without known toxicity. In practice, however, MRI has not been shown to differentiate consistently between normal and abnormal prostatic tissue. Although normal prostatic and periprostatic anatomy is clearly defined in T₁-weighted images, controversy persists as to the precise differential characteristics of inflammatory and neoplastic disease within the prostate. Thus, MRI is not presently adequate for prostate cancer screening. MRI has been shown to be superior to computerized axial tomography (CAT) for pelvic staging of prostate cancer; however, comparative studies involving other modalities with precise histologic confirmation are limited and the improvement reported is modest. There is some evidence that MRI may be helpful in the detection of prostate cancer metastatic to bone, but, again, information is limited. Substantial advances in MRI techniques such as optimal pulse sequencing, surface coils, and, possibly, paramagnetic contrast agents will be required to secure a role for MRI in prostate cancer evaluation.     

Update of staging and risk assessment for prostate cancer patients

PURPOSE OF REVIEW: This paper will review the current staging system for prostate adenocarcinoma patients, and will also review new information that can be combined with clinical and pathological staging in order to assess a patient's risk of success or failure of treatment. RECENT FINDINGS: There has been significant stage migration of prostate cancer patients in the past 15 years, such that patients are currently being diagnosed younger, with lower clinical stages and serum prostate-specific antigen levels, and a lower risk of metastatic disease than previously. The incorporation of the results of extended prostate biopsy schemes, with stage, grade and serum prostate-specific antigen levels, improves the risk assessment of newly diagnosed prostate cancer patients. New imaging techniques, such as transrectal ultrasound Doppler flow and magnetic resonance spectroscopy hold promise for improving risk assessment. Molecular biomarkers may improve risk assessment in the future, although none are currently approved by the US Food and Drug Administration for this indication. Gene chip arrays may further refine risk assessment and assist with the identification of therapeutic targets. SUMMARY: There has been significant stage migration of prostate cancer patients in the prostate-specific antigen era. Incorporating biopsy information into nomograms and risk assessment equations improves upon clinical staging and risk assessment. New imaging techniques, molecular markers and gene chip arrays hold promise for future risk assessment.     

Prostate cancer： diagnosis and staging

Prostate cancer represents an increasing health burden. The past 20 years, with the introduction of prostate-specific antigen （PSA）, has seen prostate cancer move increasingly from a condition that presented with locally advanced disease or metastases to one that is found upon screening. More is also known about the pathology ofpre-malignant lesions. Di- agnosis relies on trans-rectal ultrasound （TRUS） to obtain biopsies from throughout the prostate, but TRUS is not useful for staging. Imaging for staging, such as magnetic resonance imaging or computed tomography, still has a low accuracy compared with pathological specimens. Current techniques are also inaccurate in identifying lymph node and bony me- tastases. Nomograms have been developed from the PSA, Gleason score and clinical grading to help quantify the risk of extra-capsular extension in radical prostatectomy specimens. Improved clinical staging modalities are required for more reliable prediction of pathological stage and for monitoring of response to treatments.     

Diagnostic and therapeutic use of radioisotopes for bony disease in prostate cancer: Current practice

Nuclear medicine techniques continue to be important non-invasive imaging tools assisting the diagnosis, monitoring and--in some cases--treatment of prostate cancer. Bone scintigraphy was the premier modality to have an extensive role in the staging of prostate cancer and has remained an integral tool for over three decades in the assessment of newly diagnosed disease or in follow-up staging. Therapeutic treatment and palliation of disseminated disease, particularly in the skeleton, has also been successful with several radioisotopes including strontium-89 chloride. Despite advances in nuclear medicine techniques and molecular imaging technology such as positron emission tomography and radioimmunoscintigraphy, bone scintigraphy still remains the gold standard in the assessment of osseous metastatic disease in prostate cancer. Thus, it is important to continually review the modalities that have remained important over time and not just to focus on newer technologies. This article summarizes the current diagnostic and therapeutic use of radioisotopes for bony disease in prostate cancer with particular reference to radionuclide bone scintigraphy and positron emission tomography.     

11C-choline positron emission tomography/computerized tomography for tumor localization of primary prostate cancer in comparison with 12-core biopsy

PURPOSE: (11)C-choline positron emission tomography is an innovative imaging technique for prostate cancer. We assessed the sensitivity of positron emission tomography used together with computerized tomography for intraprostatic localization of primary prostate cancer on a nodule-by-nodule basis, and compared its performance with 12-core transrectal biopsy. MATERIALS AND METHODS: In 43 patients with known prostate cancer who had received positron emission tomography/computerized tomography before initial biopsy, we assessed sensitivity of positron emission tomography/computerized tomography for localization of nodules 5 mm or greater (those theoretically large enough for visualization) using radical prostatectomy histopathology as the reference standard. Comparison with transrectal ultrasound guided biopsy was based on sextant assessment of all cancer foci following sextant-by-sextant matching and reconstruction. Sensitivity/specificity of positron emission tomography/computerized tomography and magnetic resonance imaging for prediction of extraprostatic extension was also assessed. RESULTS: Positron emission tomography/computerized tomography showed 83% sensitivity for localization of nodules 5 mm or greater. At logistic regression analysis only nodule size appeared to influence sensitivity. At sextant assessment positron emission tomography/computerized tomography had slightly better sensitivity than transrectal ultrasound guided biopsy (66% vs 61%, p = 0.434) but was less specific (84% vs 97%, p = 0.008). For assessment of extraprostatic extension, sensitivity of PET/CT was low in comparison with magnetic resonance imaging (22% vs 63%, p <0.001). CONCLUSIONS: Positron emission tomography/computerized tomography has good sensitivity for intraprostatic localization of primary prostate cancer nodules 5 mm or greater. Positron emission tomography/computerized tomography and transrectal ultrasound guided biopsy show similar sensitivity for localization of any cancer focus. Positron emission tomography/computerized tomography does not seem to have any role in extraprostatic extension detection. Studies of diagnostic accuracy (as opposed to tumor localization) are needed in patients with suspected prostate cancer to see whether positron emission tomography/computerized tomography could have a role in not selected patients.     

Computed tomography of the lower urinary tract

CT can be helpful in staging bladder and prostate cancer as described previously. The limitations are significant in certain aspects of staging. It is important for the future to compare state-of-the-art computed tomographic scanning with newer imaging modalities such as magnetic resonance imaging, which is currently being evaluated for staging these particular tumors.     

Bildgebung der Prostata

Prostate cancer is the most common malignancy of men with approximately 32,000 new cases of prostate cancer in Germany and approximately 11,000 men who would die of the disease each year. For early diagnosis of prostate cancer PSA testing is used, whereas at present screening cannot be recommended due to the lack of confirmed medical and economic benefits. Regarding the imaging modalities, ultrasound of the prostate, currently performed in combination with elastography and histoscanning, magnetic resonance imaging of the prostate in combination with endorectal coils and positron emission tomography combined with computed tomography (PET-CT) are the methods of choice. Using these methods benign prostatitis can be differentiated from prostate cancer and staging of the tumor can be accomplished. On the other hand using these imaging methods it is possible to define the dominant intraprostatic lesion with different sensitivities and specificities, which is important for minimally invasive therapeutic strategies.     

The role of integrated positron emission tomography-computerized tomography in evaluating and staging patients with non-small cell lung cancer

The stage of non-small cell lung cancer (NSCLC) determines that the treatment strategy and proper staging lead to improved survival. Integrated positron emission tomography/computerized tomography (CT) scan provides more accurate staging and better targets for biopsy than traditional methods such as CT scans of the chest and upper abdomen, bone scans, and magnetic resonance imaging scans. Integrated positron emission tomography/CT is the best initial test for an indeterminate pulmonary nodule that is 8 mm or greater; for the noninvasive staging of patients with NSCLC, it is the only test that produces a quantitative assessment of an NSCLC's virulence or biologic aggressiveness in a particular patient and is the best tool for restaging patients after radiation and and/or chemotherapy. Finally, its use as a tool for postoperative surveillance is under study.     

Incidental diagnosis of a PSA-negative prostate cancer by 18FDG PET/CT in a patient with hypopharyngeal cancer

Diagnosis of prostate cancer (PC) still remains critical as non-invasive screening with prostate specific-antigen (PSA) lacks to indicate malignancy of the prostate in some cases. Recent research has shown that clinically meaningful PC can develop in patients with a PSA value <4 ng/ml, frequently defined as upper limit of normal serum PSA levels. Furthermore, both morphological (computed tomography (CT), magnetic resonance imaging, transrectal ultrasound) and functional imaging with (18)fluorodeoxyglucose positron emission tomography (FDG-PET) are associated with several limitations for primary diagnosis of PC. We report a case of an incidentally diagnosed PSA-negative PC by (18)FDG PET/CT in a patient with a previous diagnosis of a hypopharyngeal cancer.     

Patient selection for magnetic resonance imaging of prostate cancer.

BACKGROUND: Routine magnetic resonance (MR) imaging for local staging of prostate cancer is controversial, due to moderate staging performance. However, MR imaging may be beneficial in a subgroup of patients with clinically localized prostate cancer. OBJECTIVE: To define the patient group in which local staging of prostate cancer using MR imaging is useful for treatment outcome. METHODS: We used a decision analytic model based on data found in the literature to define the patient subgroup which may benefit from local staging with MR imaging. We applied the threshold approach to calculate the threshold where direct surgery and surgery after MR imaging (surgery-MR imaging threshold) result in equal utility. Additionally, we calculated the threshold where direct radiation and radiation after MR imaging (MR imaging-radiotherapy threshold) result in equal utility. RESULTS: We found that the surgery-MR imaging threshold was at a probability of 45% of having stage > or =T(3) disease. The MR imaging-radiotherapy threshold was at a prior probability of 81% of having stage > or =T(3) disease. CONCLUSIONS: The application of the threshold approach indicated that MR imaging should be limited to patients with an intermediate-high risk of having stage T(3) disease.     

Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer including pelvic lymph node staging: a critical analysis of the literature

Context

Diagnosis, staging, and treatment monitoring are still suboptimal for most genitourinary tumours. Diffusion-weighted magnetic resonance imaging (DW-MRI) has already shown promise as a noninvasive imaging modality in the early detection of microstructural and functional changes in several pathologies of various organs.

Objective

To assess the potential and limitations of DW-MRI in the management of patients with kidney, prostate, and bladder cancer.

Evidence acquisition

A nonsystematic literature search using the Medline/PubMed and Embase databases for full-length papers reporting on DW-MRI for kidney, prostate, and bladder cancer was performed up to August 1, 2011. Only those articles with complete data reporting on DW-MRI applications with potential implications in solving commonly encountered clinical challenges relating to tumour detection, staging, and treatment monitoring were finally examined.

Evidence synthesis

For kidney tumours DW-MRI is a reasonable alternative to conventional cross-sectional imaging to detect and characterise focal renal lesions, especially in patients with impaired renal function. For prostate cancer, DW-MRI applied in addition to conventional T2-weighted and contrast-enhanced magnetic resonance imaging (MRI) improves tumour detection and localisation. In addition, it has shown promise for the assessment of tumour aggressiveness and for treatment monitoring during active surveillance, radiation therapy, and focal therapy. For bladder cancer, DW-MRI may improve the performance of conventional T2-weighted and contrast-enhanced MRI in the work-up of bladder cancer, helping to differentiate non-muscle-invasive from muscle-invasive tumours. For pelvic lymph nodes, initial results showed the potential to improve nodal staging of prostate and bladder cancer compared with conventional cross-sectional imaging.

Conclusions

DW-MRI holds promise to ameliorate the management of patients with kidney, prostate, and bladder cancer including pelvic lymph node staging. Current limitations include the lack of standardisation of the technique across multiple centres and the still limited expertise.     

Transurethral ultrasonography of the urinary bladder

Summary Though considered a pelvic organ, the urinary bladder, unlike the prostate, can be assessed with a variety of radiographic and imaging techniques. Intravenous urography, cystography and abdominal ultrasonography have been shown to be more useful in studying this structure in contrast to the prostate gland. Other imaging studies such as transrectal ultrasonography, computerized tomography and magnetic resonance imaging have been proven to be of value in examining both organs. Most of these latter examinations have been utilized for the purpose of staging bladder tumors and, though noninvasive tumors and tumors demonstrating significant extravesical involvement can be readily identified, these imaging examinations have genrally not been satisfactory in determining the degree of muscle involvement by an invading bladder tumor.     

Significance of PET/CT in determining actual TNM staging for patients with various lung cancers

We investigated the difference in TNM stage of lung cancer provided by PET/CT (combining positron emission tomography and computed tomography) as compared with TNM stage obtained with conventional imaging studies (CI) with contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with iron contrast media. Sixty-seven cases of lung cancer were included in this study. Overall, the rate of correction of TNM staging was 70.1% after PET/CT. The correction rate for each factor was 32.8% in T, 37.3% in N, and 37.3% in M. High rates of correction were observed in small cell lung cancer (SCLC), with 75% (6/8 cases) obtained by PET/CT. When SCLCs were divided into limited disease (n = 6) involving 1 hemithorax, including mediastinal and contralateral hilar lymph nodes, and others (extensive disease, n = 2), the correction rate was as high as 80% for limited disease. In conclusion, PET/CT can provide actual TNM staging and recognition for oncologists in staging, which would not mislead to selection of inadequate subsequent treatment.     

Bildgebende Diagnostik des fortgeschrittenen Prostatakarzinoms

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.     

Endorectal coil magnetic resonance imaging and clinicopathologic findings in T1c adenocarcinoma of the prostate

Stage T1c prostate cancer has become the most commonly diagnosed clinical stage of localized prostate cancer. Endorectal coil magnetic resonance imaging (erMRI) can be used in the staging of such patients. The purpose of this study was to correlate the preoperative erMRI findings with the pathologic characteristics of the surgical specimens. A database review of 355 radical prostatectomy specimens revealed 130 patients with T1c disease. Of these patients, 124 were clinically staged with erMRI. Standard sensitivity analysis and multivariable analysis was then applied to determine the utility of erMRI in the staging of patients with T1c prostate cancer. The mean prostate specific antigen (PSA) value was 8.3 (1.0-33.6). Most patients had Gleason score of 5 or 6 (51.6%) or 7 (33.1%), with fewer patients having Gleason scores between 2 and 4 (7.2%) or 8 and 10 (8.1%). The positive predictive value of erMRI for extracapsular disease was 38.7%, negative predictive value was 75.3%, and accuracy was 79%. Multivariable regression analysis demonstrated that erMRI and preoperative PSA were predictive for seminal vesicle involvement. However, erMRI was not predictive in multivariable or univariable analysis for extracapsular extension or margin positivity. Previous investigators demonstrated the utility and independent significance of preoperative erMRI for a select subset of patients. However, it is not a useful staging modality for patients with T1c cancer as a whole. Further stratification of the T1c patients would be necessary to identify patients within this group who may benefit from staging with erMRI.