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mpMRI in Prostate cancerA Urologist’s Perspective
DiagnosisTreatment ChoiceSurgical Planning
Dr. Peter Heathcote, Adjunct Professor APCRC-Q QUT, Senior Urologist PAH and GPH
Age-adjusted death rate in US Men
LL Lung
Colon
Nerve-sparing radical prostatectomy
PSA Testing
Mortality results from the Göteborg randomised population-based prostate-cancer screening trialJonas Hugosson et al. Lancet Oncol 2010; 11: 725–32
20,000 patients randomisedMedian follow up 14yrsARR of death from CaP 0.9% -> 0.5%
“This study shows that prostate cancer mortality was reduced almost by half over 14 years. However, the risk of over-diagnosis is substantial and the number needed to treat is at least as high as in breast-cancer screening programmes.”
What is the problem?
• Life time risk of being diagnosed with CaP is 17%
• 10000 men/yr diagnosed in Australia
• Life time risk of dying from prostate cancer is 3%
• 3000 men /yr die in Australia
SEER cancer statistics review 1975–2004. Bethesda, MD: National Cancer Institute,
2007 (http://seer.cancer.gov/csr/
1975_2004).
This is the problem!
The Goteberg study again*To prevent one prostate cancer death
293 men need to be screened12 men need to be diagnosed8 men need to be treated
Over-diagnosisOver –treatment
* Lancet Oncol 2010 11:725-32
What role mpMRI?
OVER-DIAGNOSIS?Reduce number of biopsies.
?Reduce number of insignificant cancers diagnosed.
BUTIs there a risk of missing significant cancers?
What role mpMRI?
• Over–treatment
Can MRI facilitate greater use of Active Surveillance?
Compare mpMRI to TRUS
**1003 patients 12 core TRUS v MRI/MRGB 2007-2014
MRI/MRIGB diagnosed 248(25%) high risk and 213(21%) low risk
TRUSGB diagnosed 211(21%) high risk and 258(26%) low risk
BUT not the same cancers in 30% cases
*223 patients 12 core TRUS v MRI/MRGB
MRI/MRGB diagnosed 93(41%) high risk and 6(3%) low risk
TRUSGB diagnosed 79(35%) high risk and 47(21%) low risk
BUT TRUSGB “missed” 29(13%) high risk cases diagnosed by MRIGB
TRUSGB “found” 5(2%) high risk cases missed by MRIGB
***150 patients compared 30 core TRUSGB to 1.5T & 3T TMRI (no MRGB)
PIRADS 1-2 NPV 100-94%
PIRADS 3-5 PPV 73-100%
“mpMRI/MRGB diagnoses more significant cancers compared to TRUS utilizing fewer biopsies and finding fewer insignificant cancers”
BUT BOTH modalities miss some significant cancers (5-13%)
**M. Minhaj Siddiqui et al JAMA. 2015;313(4):390-397. NCI
*Pokorny et al Euro Urol 6 6 (2 0 1 4 ) 2 2 – 2 9 Wesley, Brisbane
***Thomson et al J Urol Vol. 192, 67-74, July 2014 St Vincents Sydney
Compare MRI to standard mount Radical Prostatectomy (RRP)
Of those 50 34% had Gleason grade >= 7
i.e. 17 /157 (11%) have significant disease missed by mpMRI
H. Samaratunga et al 2015
Total reported
No. reported as
UNILATERAL on MRI
No. reported as UNILATERAL
on RRP
Number of tumours missed
by MRIPIRADS
3 42 29 14 154 109 61 37 245 159 67 56 11
TOTALS 310 157 107 50Percentage 50.65% 68.00% 31.9%
Compare MRI to whole mount Radical Prostatectomy (RRP)(THE gold standard)
• 20 patients -> 80 tumours -> 47 high risk• MRI detected 36 of those 47 tumours (77%)• MRI detected ALL index tumours Rhee et al 2015, PAH/GPH
• 122 patients -> 283 tumours ->134 high risk• MRI detected 96 of those 134 tumours (72%)• MRI detected 80% of index tumours• MRI detected 72% of tumours > 1cm Le et al European Urology 67 (2015) 596-576. UCLA
TAKE HOME MESSAGE
• MRI finds more significant tumours than TRUS• MRI finds fewer insignificant tumours than TRUS
BUT• TRUS finds some tumours missed by MRI• MRI misses up to 28% of significant tumours in radical prostatectomy
specimens.
The solution to Overdiagnosis
Improved diagnostic accuracy requires a multimodal cooperative approach
between Urologists and radiologists
MRI/MRIGB/TRUSGBDRE, PSAv, PSAD.
What role mpMRI?
OVER-TREATMENTCan mpMRI facilitate selection of patients for Active Surveillance?
Active surveillance with selective delayed intervention is the way to manage ‘good-risk’* prostate cancerLaurence Klotz University of Toronto**
*Gleason score 6 or less PSA less than 10ug/L Non palpable disease or small nodule Less than 1/3 cores positive Less than 50% involvement of any core
**Nature Clinical Practice Urology March 2005 Vol 2 No 3
Active SurveillanceKlotz et al 2010 J Clin Onc 28: 126-131
N = 452
Median follow up 7yrs
Cancer specific survival 97%
Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63:597–603.
BUT!!
Only 1 in 3 choose AS over active treatment**
Only 2 in 3 stay on surveillance (Klotz et al)
**Daubenmier et al 2006 J Urol 67:125-130
Active Surveillance
• Why has take up of AS has been incomplete?• Only 1 in 3 opt for AS• Only 2 in 3 stay on AS
• Literature not yet mature, short follow up• Risk of undergrading
• Up to 33% of AS cases have higher Gleason Grade on repeat biopsy or subsequent radical prostatectomy. (Porten et al J Clin Oncol 2011;29:2795-800)
Active SurveillanceImproved diagnostic accuracy requires a multimodal
cooperative approachbetween Urologists and radiologists
MRI/MRIGB/TRUSGBDRE, PSAv, PSAD.
• Guidelines starting to include MRI in AS protocols• TRUS biopsy numbers have fallen by 17% in the last
4yrs*
*MBS
MRI planning in Robotic Prostatectomy