RC 516 - A multidisciplinary approach to prostate cancer: can we make a difference?
1. To understand the pathophysiological properties of prostate cancer and its impact on diffusion-weighted imaging and dynamic contrast-enhanced MRI.
2. To understand the necessity of functional MRI (compared with mere morphological MRI) in the assessment of prostate cancer.
3. To learn about PiRADS classification system.
4. To learn about the role of MRI in selecting patient-tailored therapy.
5. To learn about the option of active surveillance vs immediate treatment.
The session deals with the multidisciplinary approach to prostate cancer. First, we will learn about the diagnostic challenges in prostate cancer from the urologist’s point of view. This includes an outline of current treatment options and the role of imaging in therapeutic decision-making. Next, the radiologist’s point of view will be presented, providing an outline of how to perform and interpret multiparametric MRI and how to use the PIRADS classification system. A radiation oncologist will then outline the rationale for focal treatment of prostate cancer including strategies as to how these treatments can be guided by multiparametric MRI. The session will conclude with a discussion among the speakers and the audience.
1. To understand how a diagnosis is established by PSA evaluation and biopsy.
2. To learn about different treatment options: surgery, radiotherapy, local ablative and hormonal treatment; as well as active surveillance.
3. To learn how imaging impacts treatment selection.
4. To understand what the urologist needs to know from the radiologist.
Prostate cancer is the third cause of cancer death in men. While systematic screening is not promoted, an individual early diagnosis is standard of care. Based on risk factors (such as family history), PSA and DRE, pathology obtained after sonography-guided biopsies is the only diagnostic possibility. If indicated a normal mpMRI should not rule out the biopsy decision. Although a systematic mpMRI before a first biopsy is not yet recommended, it is standard of care before rebiopsying. This increases the biopsy reliability using a combination of 12 systematic plus targeted scores. The treatment policy is based on individual life expectancy, patient’s wishes and staging. The classical risk categories (known as d’Amico’s classification) are more and more challenged by information from image results. Apart from biopsy results (number of positive scores, Gleason score) and DRE, the local staging (T stage) is based on MRI. Its sensitivity is mild (intraprostatic localisation, microscopic extracapsular extension). But its specificity is acceptable and the MRI is a must in intermediate-/high-risk situations. It is also mandatory before considering active surveillance. N staging is poorly done, even with the PET. As for M staging, PSMA might represent the future, but remain experimental in 2017. For M staging, bone scan should be replaced by a whole body MRI. However, for mCRPC progression characterisation, bone and CT scan remain standard, as no consensus definition of progression with MRI exists yet.
1. To learn how to perform and interpret multiparametric MRI.
2. To become familiar with the PiRADS classification system.
3. To become familiar with the role of imaging for patient stratification and treatment planning.
Prostate cancer diagnosis is challenged by significant variability in cancer multifocality and biologic heterogeneity. Risk stratification is urgently required for individualized patient management, particularly as active surveillance and various focal therapy options are nowadays emerging. Several clinical studies have demonstrated that multiparametric MR imaging (mpMR) is advantageous for detection and localisation of significant cancer, for biopsy guidance as well as for local staging. Transrectal or transperineal TRUS/MR image fusion biopsy methods with targeted +/- random biopsies have been proven beneficial for improved diagnosis and risk assessment, particularly also in case of negative (cancer free) results. In active surveillance the combination of morphologic and functional MR data represent important objective and reproducible biomarkers for monitoring individual temporal changes of cancer size and aggressiveness. Standardization and quality assurance of mpMR is challenging, however, particularly concerning DWI, which has been proven most important for detection and characterisation of peripheral zone cancers. Standardised high-quality mpMR including standardized reporting according to PI-RADS has been proven to be important for individualised decision making. Standardisation is of clinical relevance concerning improved image acquisition, interpretation, documentation and communication. This lecture will provide detailed knowledge about evidence-based “state-of-the-art” mpMRI according to PI-RADS. It will specify how mpMRI can improve the complex management of prostate cancer patients.
1. To learn the rationale and scientific basis for focal therapies for prostate cancer.
2. To learn how focal therapies are performed in prostate cancer.
3. To learn through personal experience and from literature how multiparametric MRI can guide focal therapies of the prostate.
Various treatment techniques are successfully used for treating prostate cancer (PCa) with irradiation. In conventional radiation therapy, the tumour volume is irradiated with a homogeneous dose and clinical practice is to carry out treatment planning based on a computed tomography (CT). A morphological MRI is often used in addition. However, technology developments and achievements made in radiation oncology during the last decade enable to focus the high-dose irradiation very precisely on the tumour, while sparing of the surrounding normal tissue. Improved precision of treatment planning and delivery warrant equally precise tumour definition; moreover, new treatment concepts are stimulated by the advancements in medical imaging to visualize and quantify biological, physiological and pathological processes. During the last years, positron emission tomography (PET), perfusion computed tomography (CT) and especially multiparametric magnetic resonance imaging (mp-MRI) have been continuously explored for lesion characterization, improved target definition and response assessment for radiotherapy of PCa. Elucidating tumour biology and identifying subvolumes of more aggressive behaviour, which are often radiotherapy resistant, are feasible with mp-MRI. The concept of inhomogeneous tumour irradiation according to its biological behaviour, called dose painting, is motivated by selective dose escalation based on biological tumour characteristics. This approach may lead not only to higher local control but also to better sparing of normal surrounding tissue. With the clinical implementation of dose painting, improvements in the therapeutic outcome can be expected. Due to the existing technical challenges, extensive collaboration between radiation oncologists, radiologists, medical physicists and radiation biologists is needed.