EUO Collaborative Review – Priority ArticleThe Role of Magnetic Resonance Imaging and Positron Emission Tomography/Computed Tomography in the Primary Staging of Newly Diagnosed Prostate Cancer: A Systematic Review of the Literature
Introduction
While localized prostate cancer (PCa) is curable using surgery or radiation therapy, cure remains unlikely in the presence of metastatic disease. Therefore, appropriate assessment of the extent of PCa at diagnosis is critical in guiding initial treatment.
Current guidelines recommend abdominopelvic imaging as well as bone scintigraphy in selected men with intermediate-risk disease and in all men with high-risk disease [1]. Unfortunately, conventional imaging with computed tomography (CT) and bone scintigraphy suffer from a lack of sensitivity and specificity in identifying metastatic cancer, which has prompted the search for new imaging techniques with better diagnostic accuracy [2]. For local tumor and lymph node (LN) staging, multiparametric magnetic resonance imaging (mpMRI) has gained more and more attention. In 2012, the European Society of Urogenital Radiology (ESUR) standardized MRI reporting by introducing the Prostate Imaging Reporting and Data System (PIRADS) and updated this version in collaboration with the American College of Radiology to PIRADS v2 in 2015 [3].
Hybrid positron emission tomography (PET)/CT or PET/MRI combines the advantages of morphological and anatomical information derived by CT/MRI with additional functional (metabolic/biochemical activity) information provided by PET. By using MRI instead of CT, ionization radiation is spared. Newer tracers, such as 18 F-sodiumfluoride (NaF), 18 F-/11C-choline, 18 F-fluciclovine (FACBC), and 68Ga-labeled prostate-specific membrane antigen (PSMA) have recently been developed and analyzed further. Introduced in 2012, the 68Ga-labeled PSMA-targeted radioligand Glu-NH-CO-NH-Lys-[68Ga-(HBED-CC)] (68Ga-PSMA-HBED-CC or 68Ga-PSMA-11) revolutionized PCa imaging. PSMA, a large extracellular type-2 transmembrane glycoprotein, is highly overexpressed in PCa and can easily be targeted by this ligand for imaging purposes [4].
While PET/CT is already widely adopted within staging of recurrent PCa, only few studies reported on its role for primary staging [5].
This prompted us to perform a systematic review of the current literature on modern imaging modalities for tumor (T), nodal (N), and metastatic (M) staging (TNM staging) of newly diagnosed PCa.
Section snippets
Search strategy
We performed a systematic review of the literature using MEDLINE and Web of Science databases between 2012 and 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines [6].
The search strategy used the following keywords and/or free texts: (“prostate cancer” OR “prostate neoplasm”) AND (“MRI” OR “PET CT”) AND (“staging” OR “tumor stage” OR “lymph nod*” OR “metastas*”). Furthermore, cited references from selected articles and from review
Evidence synthesis
The heterogeneity of the studies entailed that summary statistics from different studies could not be combined meta-analytically. Hence, we summarized the results narratively.
Conclusions
A variety of studies on modern imaging techniques for TNM staging in newly diagnosed PCa exist. For T and N staging, reported sensitivity of imaging modalities such as mpMRI or PET/CT varied widely, preventing clear recommendations. For M staging, the most promising technique is PSMA-PET/CT.
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Cited by (25)
Quality assessment of prostate MRI by PI-QUAL score: Inter-reader agreement and impact on prostate cancer local staging at 3 Tesla
2023, European Journal of RadiologyIncorporating Prostate-specific Membrane Antigen Positron Emission Tomography in Management Decisions for Men with Newly Diagnosed or Biochemically Recurrent Prostate Cancer
2023, European UrologyCitation Excerpt :While mpMRI has augmented the paradigm for PCa diagnosis, accumulating evidence supports the use of PSMA PET for greater accuracy in detecting the index lesion and secondary lesions [17]. Although mpMRI has demonstrated accuracy of >90% in identifying index lesions, its accuracy in identifying secondary foci and smaller clinically significant PCa (csPCa) lesions is less established [18,19]. On per-lesion analysis, mpMRI misses between 16% and 25.4% of csPCa tumor foci [20], and significantly underestimates the actual tumor volume in comparison to whole-gland histology [17,21].
Nascent Prostate Cancer Heterogeneity Drives Evolution and Resistance to Intense Hormonal Therapy
2021, European UrologyCitation Excerpt :The range of residual tumor volumes lends itself to several possible strategies for patient management determined according to prognostic factors at baseline. Combined with MRI, which is increasingly common for staging and guiding biopsies of primary prostate cancer [29], and a series of straightforward immunostains readily available in most hospital laboratories, use of a commercial cancer sequencing panel would provide enough information to determine the probability of response to NADT according to the five-factor model. For patients in the INR group, those with the largest residual tumor volumes often harbored three or four histogenomic factors, and thus may benefit from either immediate surgery (with or without adjuvant radiotherapy) or systemic chemotherapy before surgery.
Case of the Season: Prostate Specific Membrane Antigen (PSMA) Positron-Emission Tomography (PET)-MRI to Evaluate Neoadjuvant Radiation Therapy Response
2021, Seminars in RoentgenologyCitation Excerpt :However, these new reporting criteria have not yet been validated in the literature. The performance of MRI and PSMA PET for the detection of SVI varies.9 One analysis found that PSMA PET was superior for SVI while MRI was superior for extraprostatic extension.10
Patterns of Recurrence, Detection Rates, and Impact of 18-F Fluciclovine PET/CT on the Management of Men With Recurrent Prostate Cancer
2021, UrologyCitation Excerpt :Several PSMA binding ligands exist and studies have generally shown superior diagnostic performance when compared to other radiotracers in the detection of biochemical recurrence of prostate cancer following definitive therapy.22 However, FACBC PET/CT has been shown to be better in detecting localized curable recurrence as PSMA accumulates in the bladder and appears to obscure avid findings.23–29 In conclusion, FACBC PET/CT detects recurrent prostate cancer with improved detection rates with increasing PSA levels.