The role of magnetic resonance imaging in prostate cancer

Prostate cancer has the world’s highest incidence in Australia andNew Zealand (104/100 000 men) and thus remains a significantchallenge.1 Patient history, digital rectal examination and serumprostate-specific antigen combined with biopsy remain the corner-stones for its diagnosis. Unlike other malignancies, most prostatecancers elude current imaging techniques. Thus, imaging is not usedroutinely to guide biopsies when required with a standardized tem-plate using ultrasound-dictating biopsy sites. Once diagnosed withprostate cancer, most patients being low risk will not need furtherinvestigations with imaging because metastases are unlikely.Aggressive prostate cancers are usually staged to exclude metastaticdisease with computed tomography (CT) and/or bone scan.

More recently magnetic resonance imaging (MRI) has gainedpopularity to investigate for extra-capsular extension (pT3) andguide erectile nerve sparing. MRI also assesses regional lymphnodes more accurately than CT. The current paper by Johnston et al.2

is sobering as it reminds us that standard MRI using 1.5T with basicimaging sequences is not acceptable for staging. This has beensuspected by clinicians as sensitivity for staging has varied (around50–85%) while costs combined with access has limited the role ofMRI in Australia and New Zealand. Despite this, patients oftendemand MRI and some practitioners will order the test at anygeneral radiological practice where MRI interpretation of the pros-tate is in itself limited.

As with all technology, MRI has moved forward with the adventof endorectal coils and more recently 3T machines with improvedcapabilities. More importantly, radiologists with a subspecialtyinterest in MRI able to perform multiparametric MRI or mMRI(multiple MRI sequences to give the best images of the prostate andits internal anatomy) have emerged.3 The recent European Society ofUrogenital Radiology guidelines4 based on available evidence andconsensus expert opinion are leading the way forward in this regardcalling for anything but mMRI to be abandoned and for standardizedreporting of every lesion detected by MRI being location specific.Accuracy upwards of 80% is anticipated. However, prostatic MRIshould be done in a dedicated centre with appropriate experience.

mMRI is now considered the missing piece for prostate tumourlocalization, volume calculation, grading and staging.5,6

The Urological Society of Australia and New Zealand will shortlypublish guidelines whereby mMRI does have a role in selected casesof prostate cancer for staging and in specific instances for localiza-tion. The role of this new technology will continue to evolve withemerging evidence from clinical trials. mMRI will not yet replacebiopsy nor is it at a level that may be used for monitoring low-riskpatients on active surveillance – but this may happen. Clearly, as thecurrent paper demonstrates, 1.5T standard MRI should be left wellalone in favour of new technology at specialized centres.

References1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer

statistics. CA Cancer J. Clin. 2011; 61: 69–90.2. Johnston R, Wong L-M, Warren A, Shah N, Neal D. The role of 1.5 Tesla

magnetic resonance imaging in staging prostate cancer. ANZ J. Surg.2013; 83: 234–8.

3. Raz O, Haider M, Trachtenberg J, Leibovici D, Lawrentschuk N. MRI formen undergoing active surveillance or with rising PSA and negativebiopsies. Nat. Rev. Urol. 2010; 7: 543–51.

4. Barentsz JO, Richenberg J, Clements R et al. ESUR prostate MR guide-lines 2012. Eur. Radiol. 2012; 22: 746–57.

5. Ahmed HU, Emberton M. The role of magnetic resonance imaging intargeting prostate cancer in patients with previous negative biopsies andelevated prostate-specific antigen levels. BJU Int. 2009; 104: 269–70;author reply 270.

6. Lawrentschuk N, Fleshner N. The role of magnetic resonance imaging intargeting prostate cancer in patients with previous negative biopsies andelevated prostate-specific antigen levels. BJU Int. 2009; 103: 730–3.

Nathan Lawrentschuk, MBBS, PhD, FRACSDepartment of Surgery, The University of Melbourne and Ludwig

Institute for Cancer Research, Austin Hospital, Melbourne,Victoria, Australia

doi: 10.1111/ans.12082

How others see us

The Annual Scientific Meeting of General Surgeons Australia washeld in September 2012 in Hobart. It was a highly successfulmeeting with over 400 registrants. The theme of the meeting was‘Building the Future of Cancer Care’ with an array of national andinternational speakers.

We were fortunate to have the meeting opened by His Excellency,The Hon. Peter Underwood AC, Governor of Tasmania, who notonly opened the meeting but generously invited all registrants to theGovernment House for a reception. Peter was the former ChiefJustice of the Supreme Court of Tasmania having been a judge of

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that court since 1984. He is a friend and colleague of JusticeGeoffrey Davies AO, Honorary Fellow and retired councillor of ourCollege. Geoffrey has been a great advocate both in public1 and theCouncil room for educating surgeons in the meaning of profession-alism. There is a great synergy with Geoffrey’s thoughts and theviews expressed by Peter Underwood in his thoughtful openingaddress. It is for this reason that we published an abridged version ofhis address in this issue.2

Peter makes some amusing comments about specialization but thethrust of his talk focusses on his concern about the failure of com-munication within a professional environment that has becomeengrossed in ever expanding technologies. He draws from personalexperiences in the law. He encapsulates this beautifully by stating ‘aword from the wise is of no use if it can’t be understood.’ He alsomakes an important observation that good communication, a profes-sional skill, not only conveys information but builds confidence andcomfort in the patient. This ‘patient-centred’ communication is avital skill that he suggests can be taught. He then gives an excellentchecklist of the elements of what ‘patient-centred’ communicationrequires.

In his address, he makes reference to a workshop on ‘Talking topatients when bad things happen’. I was fortunate to attend thisworkshop that was conducted by Professor Stewart Dunn. Stewart isa Sydney-based psychologist who has worked most of his academiclife in the care of cancer patients and has published extensively inthis area (http://sydney.edu.au/medicine/people/academics/profiles/

stewd.php). He has been one of the pioneers who have championedthe concept of codifying the psychology of complex communicationissues into a language that all clinicians can understand and utilize.

The College has recognized the need to improve communicationskills and has developed the Training in Professional Skills Coursefor trainees and also promotes the Non-Technical Skills for SurgeonsCourse for consultants, where these concepts are outlined. Boththese courses provide important information and practical experi-ence to improve communication skills in the clinical environmentboth to patients and colleagues. Further information about thesecourses can be found on the RACS web site.

It is rare to have such a stimulating opening address. It is pleasingto be able to report that we are being proactive in this area ofeducation.

References1. Davies G. Professionalism: the James Pryor memorial lecture. ANZ J.

Surg. 2007; 77: 818–23.2. Underwood P. The essentials and importance of good communication

between the surgeon and his or her patient. ANZ J. Surg. 2013; 83:199–200.

Phil Truskett, MBBS, FRACSDepartment of Surgery, Prince of Wales Clinical School, Sydney,

New South Wales, Australia

doi: 10.1111/ans.12085

Potential preventive measures against quad bike injuries

Dr Wood and his colleagues from Hamilton, New Zealand attemptedto describe the burden of quad bike injuries presenting to theirtrauma centre.1 They identified 101 admitted patients during a 4-yeartime frame (~25 admissions/year) with a median length of stay of 5days, median injury severity score of 9, 27% of whom were severelyinjured (ISS > 15), and estimated cost of NZ$1.5 million for thehospitalization and rehabilitation projected for the year of 2012 inWaikato Hospital alone.

These results, especially the increasing incidence, with only 46%compliance with helmet use and associated high rate of head injuriesare the most alarming facts. The findings are not fundamentally new,similar results are available from both the Australasian and theinternational literature. We do not believe that we need more data toprove that actions are needed on potentially preventable morbidityand mortality related to quad bikes. Some local patterns may bedifferent; our institution experiences over 30 presentations/yearfrom mainly recreational quad bike injuries in contrast the mainlyfarm work-related injuries in Waikato.

The Trauma Committee of the Royal Australasian College ofSurgeons has developed its position paper, which includes the rec-ommendations for injury prevention.2 The document highlights theneed for increased public and industrial awareness, potential modi-fications of the vehicle design, the recommendation-specific helmetuse and the application of age and speed limits.

We agree with the authors that the legislation and its enforcementare highly unlikely to be successful, but the education has a fairchance in injury prevention. Compulsory safety course for all ridersat the time of the purchase or at the renting locations would be a verysensible next step. From that point the owners need to take respon-sibility to direct all potential other users to the safety course.

References1. Wood A, Duijff JW, Christey GR. Quad bike injuries in Waikato, New

Zealand: an institutional review from 2007–2011. ANZ J. Surg. 2013;83: 206–10.

2. The Royal Australasian College of Surgeons. Surgeons call for tighterregulation of quad bikes. [PDF on Internet]. The Royal AustralasianCollege of Surgeons. 2011. [updated 14 September 2011; Cited 22 Feb2012.] Available from URL: http://www.surgeons.org/media/293490/MED_2011-09-14_PubMedSurgeons_call_for_tighter_regulation_of_quad_bikes.pdf

Zsolt J. Balogh, MD, PhD, FRACSAngela Fischer, RN

Department of Traumatology, John Hunter Hospital andUniversity of Newcastle, Newcastle, New South Wales, Australia

doi: 10.1111/ans.12105

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