Modern Imaging of Prostate Cancer: “Impact on Management Decision”

Mohamed Abdulla M.D.Prof. of Clinical Oncology

Cairo University

Dubai, 05/03/2016

Speaker Disclosures:

Member of Advisory Board, Consultant, and Speaker for:• Amgen, Astellas, AstraZeneca, Hoffman la Roche, Janssen Cilag,

Merck Serono, Novartis, Pfizer• The content of this presentation does not relate to any product of a

commercial interest

Prostate Cancer:Landscape of Disease:

Localized – Recurrent and/or Metastatic – CRPC – Death

Hormone Sensitive or Resistant

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Prostate Cancer:Diagnostic Work up:

PSA

DRE+

TRUS

Gleason Score

Systemic Disease:• Isotopic Bone Scan• Computed Tomography• MRI• Others

Risk Stratification

Extra -Prostatic Disease

Prostate Cancer:Diagnostic Work up: Unmet Needs:• DRE: Personal Variability.• Conventional Grey Scale US:

– Isoechoic & Anterior lesions.– Multifocal Disease, Heterogonous Texture.– Capsular Infiltration & Peri-prostatic Extension.– SV involvement.

• Computed Tomographic Scans:– Limited value for local disease extent.– Superior in Bone Metastases.

• Original MRI < 1 t:– Variable Sensitivity and Specificity.

• Isotopic Bone Scan:– No direct imaging of Bone Metastases.– Difficult to quantify burden of disease.

• PET – CT Scan:– 18FDG: Glycolytic Activity and not Osteoblastic activity.

Clinical Scenario:• A 60-year-old postal employee presented for a free screening

exam.• DRE: equivocal with questionable asymmetric firmness.• PSA = 12 ng/ml• TRUS: 2 hypoechoic areas within the left side of peripheral

zone of one lobe of the gland Guided Biopsy.• 6 out of 12 biopsy cores had Gleason score of 7 (4 + 3)

adenocarcinoma.

Recurrence Risk for Clinically Localized Prostate Cancer• Low Risk:

T1-T2a and Gleason score 2-6 and PSA < 10 ng/ml• Intermediate Risk:

T2b-T2c or Gleason score 7 or PSA 10-20• High Risk:

T3a or Gleason score 8-10 or PSA > 20• Very High Risk:

T3b-T4(locally advanced)

Q:1- How Would You Stage This Patient??

1. CT scan abdomino-pelvis with contrast. 2. Multi-parametric MRI pelvis.3. Isotopic Bone Scan.4. Chest image.5. 1+3+46. 2+3+47. 2+4

CASE (Cont…..)

• Patient had conventional chest imaging, CT-Scan of the abdomen and pelvis with contrast and Isotopic Bone Scanning.

• The patient discussed therapeutic options and elected radical prostatectomy.

• The final pathology report: positive capsule penetration, a positive surgical margin, and seminal vesicle invasion. Lymph nodes are negative.

• PSA decreases to 0.01ng/ml.

What is the Proper Staging?1. Multiparametric MRI1. Diffusion Weighted Imaging (DWI).2. Prostate T2 Weighted Imaging.3. Dynamic Contrast Enhanced Images (DCE).4. Magnetic Resonance Spectroscopy Imaging (MRSI).

mpMRI is Mandatory of patients with Intermediate and High Risk Prostate Cancer & to confirm the validity of Active Surveillance.

EUA Guidelines: Isotopic Bone Scanning is NOT Indicated in:1. Asymptomatic patients.2. Well to moderately differentiated disease.3. PSA < 20 ng/ml.

What is the Proper Staging?2. Isotopic Bone Scanning:

Case Continuation:

• Patient received postoperative radiation therapy based on adverse pathologic features.

• Kept under follow up.• 2 years later, follow up PSA = 54 ng/ml while

patient was asymptomatic.

Q2:

What are the imaging techniques to be requested?1. CT-Scan of abdomen and pelvis with contrast.2. Isotopic Bone Scan.3. Axial Skeleton MRI.4. 1+25. 1+3

Imaging Recommendations:

• CT Scan & MRI.• Traditional Bone Scan is the standard except in

equivocal & suspecious negative cases Radiographs, MRI.

• PET-CT Scan FDG ?? (Bladder activity)• PET – CT Scan (Sodium Florid and Choline)

Uptodate, 2016

Case Continuation:• Bone metastases (> 4 sites) and abdomino-pelvic nodal

disease (no visceral affection).• Started ADT & Docetaxel (PSA = 2 ng/ml)• 6 months following salvage therapy re-rise of PSA (85

ng/ml) Adding anti-androgen PSA = 3.5 ng/ml. Patient was asymptomatic.

• 4 months later, tender right shoulder (-ve in bone Scan, +ve in conventional radiograph palliative Rth). PSA 263 ng/ml. Serum Testosterone maintained castrate level metastatic CRPC. Patient is relatively asymptomatic.

Q3:

What are the imaging procedures to be ordered?1. Body CT Scan with contrast.2. Isotopic Bone Scan.3. PET CT Scan.4. Axial Skeleton MRI5. 1+26. Non of the above.

Yes No Abstain

TAKE HOME MESSAGE:

• Prostate cancer is a heterogeneous disease.• Assessment of disease extent is crucial.• mp MRI is mandatory in assessment.• Tc 99m, is the standard isotopic scan.• The value of Axial Skeleton MRI is more appreciated

in CRPC phase of disease.• Sodium Floride & Choline PET Scan are under

investigations.

Thank You