MRI for managing intermediate & low risk prostate cancer
© Padhani; licensee BioMed Central Ltd. 2014
Published: 9 October 2014
Intermediate risk disease
Pathological status: PSA 10–20 ng/mL, or biopsy Gleason score 7, or clinical stage T2b or T2c
Clinical note: Heterogeneous group with a wide incidence of biochemical relapse & numerous curative therapy options.
If initial active surveillance is considered, then it is important not to underestimate tumor grade/ volume/stage
For external beam radiotherapy, the presence of unfavourable disease affects duration of adjuvant hormonal therapy.
For focal therapy, index lesion localization is needed
For surgery, accurate staging to enable curative treatment with negative margins & nerve sparing if possible
Type of MRI :
Lesion detection and localisation protocol with T2W, DW-MRI and DCE-MRI ± MRSI for low ADC lesions to assess aggressiveness
Staging with multi-planar T2W, DW-MRI ± DCE-MRI for ECE/SVI
High risk disease
Pathological status: PSA >20 ng/mL, or Gleason score 8–10, or clinical stage >T2c
Clinical note: Highest risk of biochemical recurrence and cancer specific mortality but substantial population heterogeneity
Prognostic subgroups :
■ Good prognosis subgroup: one single risk factor (any)
■ Intermediate prognosis subgroup: two risk factors (PSA >20 ng/ml and stage cT3–4); No Gleason 8+ disease
■ Poor prognosis subgroup: GS >7 and stage cT3–4 and/or PSA >20 ng/ml
Clinical sub-groups: localized, locally advanced & metastatic
Problems with categorization: Local staging accuracy & the detection of metastatic disease
local and nodal staging: to detect extensive ECE/SVI that would preclude radical surgery with negative margins. Nerve sparing rarely undertaken.
To detect nodal and bone metastases
Accurate local staging and pelvic nodal assessments
Bone scan + CT abdomen or WB-MRI
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