The Role of Imaging in Suspected Prostate Cancer

Adil Ouzzane, Arnauld Villers
European Urological Review, 2011;6(2):124-127
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Abstract

Among a multitude of tests available to evaluate patients with suspected prostate cancer, modern imaging techniques seem to be the most relevant and their use is growing fast. Magnetic resonance imaging (MRI) technology is the most important imaging tool for identifying early prostate cancers, characterising tumours, helping in patient risk stratification and enabling focused use of biopsy. In addition, recent advances in transrectal ultrasonography of the prostate, such as realtime tissue elastography and contrast-enhanced ultrasonography, allow better identification of cancer. The optimal prostate cancer diagnostic strategy has to be validated. However, one way of improving identification in patients referred for screening might be pre-biopsy MRI, which would provide guidance for targeting biopsies. A ‘targeted biopsies only’ strategy (that is, without systematic biopsies) may reduce the number of biopsies (indicated only in patients with positive imaging), therefore avoiding the potentially unnecessary diagnosis of insignificant cancer. Any prospective, randomised trial testing MRI as an adjunct or replacement for biopsies will need to be carefully designed to include cost–utility and cost-effectiveness analysis of imaging.
Keywords
Prostatic neoplasm, cancer diagnosis, imaging techniques, magnetic resonance imaging, ultrasound, biopsy, observation, focal therapy
Disclosure The authors have no conflicts of interest to declare.
Received: August 08, 2011 Accepted October 10, 2011
Correspondence: Arnauld Villers, Service d’Urologie, Hôpital Claude Huriez, CHRU de Lille, rue Michel Polonovski, 59000 Lille, France. E: arnauld-villers@chru-lille.fr

Since the introduction of prostate specific antigen (PSA) screening, prostate cancer has become the most common male malignancy.1 To reduce overtreatment and functional morbidity associated with radical therapies, new approaches have been proposed, such as active surveillance and focal therapy. As we are dealing with multifocal tumours, validation and large acceptance of these modalities hinges on modern imaging development and validation, allowing accurate cancer identification and targeting. On the one hand, focal ablation requires good visualisation of significant tumour and confidence in the absence of significant tumour elsewhere. On the other hand, active surveillance may require the absence of significant cancer, e.g., negative imaging, in cases with minute cancer foci at biopsy. Important knowledge on modelling of cancer morphology – such as zone of origin and intraprostatic patterns of spread of organ-confined prostate cancers at histopathology – has been made available for imaging interpretation and treatment planning.2,3 Currently, magnetic resonance imaging (MRI) is the most important imaging tool for identifying low-volume prostate cancers, characterising tumours, helping patient risk stratification and enabling focused use of biopsy.4–7 In addition, recent advances in transrectal ultrasonography (TRUS) of the prostate, such as realtime tissue elastography and contrast-enhanced ultrasonography, allow better identification of cancer.

The main current and future imaging applications are for diagnosis, both for biopsy protocol and biopsy indication. Since most systematic and particularly saturation biopsies are taken from benign tissue, pre-biopsy imaging may reduce the number of biopsies. Using anatomical and functional imaging as triage tests in men with suspected prostate cancer because of a positive screening test and referred for biopsy thus seems to be the appropriate diagnostic pathway. This allows the use of a targeted biopsies strategy and has the potential to improve biopsy results by increasing the detection of clinically significant cancers, reducing the detection of clinically insignificant cancers and giving a more representative sampling of cancer (length and grade). The purpose of this article is to summarise the main current imaging techniques used for the diagnosis of localised prostate cancer and their role in patients with suspected prostate cancer.

References:
  1. Jemal A, Siegel R, Ward E, et al., Cancer statistics, 2008, CA Cancer J Clin, 2008;58:71–96.
  2. Bouye S, Potiron E, Puech P, et al., Transition zone and anterior stromal prostate cancers: zone of origin and intraprostatic patterns of spread at histopathology, Prostate, 2009;69:105–13.
  3. Haffner J, Potiron E, Bouye S, et al., Peripheral zone prostate cancers: location and intraprostatic patterns of spread at histopathology, Prostate, 2009;69:276–82.
  4. Mazaheri Y, Shukla-Dave A, Hricak H, et al., Prostate cancer: identification with combined diffusion-weighted MR imaging and 3D 1H MR spectroscopic imaging – correlation with pathologic findings, Radiology, 2008;246:480–8.
  5. Kim Y, Hsu IC, Lessard E, et al., Class solution in inverse planned HDR prostate brachytherapy for dose escalation of DIL defined by combined MRI/MRSI, Radiother Oncol, 2008;88:148–55.
  6. Kumar R, Nayyar R, Kumar V, et al., Potential of magnetic resonance spectroscopic imaging in predicting absence of prostate cancer in men with serum prostate-specific antigen between 4 and 10 ng/mL: a follow-up study, Urology, 2008;72:859–63.
  7. deSouza NM, Riches SF, Vanas NJ, et al., Diffusion-weighted magnetic resonance imaging: a potential non-invasive marker of tumour aggressiveness in localized prostate cancer, Clin Radiol, 2008;63:774–82.
  8. Toi A, Neill MG, Lockwood GA, et al., The continuing importance of transrectal ultrasound identification of prostatic lesions, J Urol, 2007;177:516–20.
  9. Baumann M, Mozer P, Daanen V, Troccaz J. Towards 3D ultrasound image based soft tissue tracking: a transrectal ultrasound prostate image alignment system, Med Image Comput Comput Assist Interv, 2007;10:26–33.
  10. Kuligowska E, Barish MA, Fenlon HM, Blake M, Predictors of prostate carcinoma: accuracy of gray-scale and color Doppler US and serum markers, Radiology, 2001;220:757–64.
  11. Loch T, Computerized transrectal ultrasound (C-TRUS) of the prostate: detection of cancer in patients with multiple negative systematic random biopsies, World J Urol, 2007;25:375–80.
  12. Grabski B, Baeurle L, Loch A, et al., Computerized transrectal ultrasound of the prostate in a multicenter setup (C-TRUS-MS): detection of cancer after multiple negative systematic random and in primary biopsies, World J Urol, 2011; in press.
  13. Walz J, Marcy M, Pianna JT, et al., Identification of the prostate cancer index lesion by real-time elastography: considerations for focal therapy of prostate cancer, World J Urol, 2011; in press.
  14. Mitterberger MJ, Aigner F, Horninger W, et al., Comparative efficiency of contrast-enhanced colour Doppler ultrasound targeted versus systematic biopsy for prostate cancer detection, Eur Radiol, 2010;20:2791–6.
  15. Taverna G, Morandi G, Seveso M, et al., Colour Doppler and microbubble contrast agent ultrasonography do not improve cancer detection rate in transrectal systematic prostate biopsy sampling, BJU Int, 2011; in press.
  16. Dickinson L, Ahmed HU, Allen C, et al., Magnetic resonance imaging for the detection, localisation, and characterisation of prostate cancer: recommendations from a European consensus meeting, Eur Urol, 2011;59:477–94.
  17. Delongchamps NB, Rouanne M, Flam T, et al., Multiparametric magnetic resonance imaging for the detection and localization of prostate cancer: combination of T2-weighted, dynamic contrast-enhanced and diffusion-weighted imaging, BJU Int, 2011;107:1411–18.
  18. Ouzzane A, Puech P, Lemaitre L, et al., Combined multiparametric MRI and targeted biopsies improve anterior prostate cancer detection, staging and grading, Urology, 2011; in press.
  19. Hambrock T, Somford DM, Hoeks C, et al., Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen, J Urol, 2010;183:520–7.
  20. Tan JS, Thng CH, Tan PH, et al., Local experience of endorectal magnetic resonance imaging of prostate with correlation to radical prostatectomy specimens, Ann Acad Med Singapore, 2008;37:40–4.
  21. Jung DC, Lee HJ, Kim SH, et al., Preoperative MR imaging in the evaluation of seminal vesicle invasion in prostate cancer: pattern analysis of seminal vesicle lesions, J Magn Reson Imaging, 2008;28:144–50.
  22. Yoshimitsu K, Kiyoshima K, Irie H, et al., Usefulness of apparent diffusion coefficient map in diagnosing prostate carcinoma: correlation with stepwise histopathology, J Magn Reson Imaging, 2008;27:132–9.
  23. Langer DL, van der Kwast TH, Evans AJ, et al., Intermixed normal tissue within prostate cancer: effect on MR imaging measurements of apparent diffusion coefficient and T2 — sparse versus dense cancers, Radiology, 2008;249:900–8.
  24. Gibbs P, Liney GP, Pickles MD, et al., Correlation of ADC and T2 measurements with cell density in prostate cancer at 3.0 Tesla, Invest Radiol, 2009;44:572–6.
  25. Hambrock T, Somford DM, Huisman HJ, et al., Relationship between apparent diffusion coefficients at 3.0-T MR imaging and Gleason grade in peripheral zone prostate cancer, Radiology, 2011;259:453–61.
  26. Girouin N, Mege-Lechevallier F, Tonina Senes A, et al., Prostate dynamic contrast-enhanced MRI with simple visual diagnostic criteria: is it reasonable?, Eur Radiol, 2007;17:1498–509.
  27. Klotz L, Active surveillance with selective delayed intervention: using natural history to guide treatment in good risk prostate cancer, J Urol, 2004;172:S48–50; discussion S50–1.
  28. Fuchsjäger M, Shukla-Dave A, Akin O, et al., Prostate Cancer Imaging, Acta Radiologica 2008;49(1):107–20.
  29. Haffner J, Lemaitre L, Puech P, et al., Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection, BJU Int, 2011; in press.
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