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  • Review Article
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Imaging and evaluation of patients with high-risk prostate cancer

Nature Reviews Urology volume 12, pages 617–628 (2015)Cite this article

Subjects

Key Points

  • Imaging high-risk prostate cancer is predominantly conducted using radionuclide bone scan, CT, and MRI

  • Multiparametric-MRI (mpMRI) and positron emission tomography (PET)–CT, using novel imaging techniques and radiopharmaceuticals, are currently being investigated and incorporated into clinical use

  • mpMRI and PET–CT are more advanced approaches than conventional techniques and offer improved sensitivity and specificity, enabling more accurate assessment of disease

  • Integrated PET–MRI could provide a comprehensive assessment of local disease extent, lymph nodes, and bones, as well as functional assessment of tumour aggressiveness and prognosis

  • Continued studies are warranted to further establish the role of new modalities in the management of patients with high-risk prostate cancer

Abstract

Approximately 15% of men with newly diagnosed prostate cancer have high-risk disease. Imaging is critically important for the diagnosis and staging of these patients, and also for the selection of management. While established prostate cancer staging guidelines have increased the appropriate use of imaging, underuse for high-risk prostate cancer remains substantial. Several factors affect the utility of initial diagnostic imaging, including the variable definition of high-risk prostate cancer, variable guideline recommendations, poor accuracy of existing imaging tests, and the difficulty in validating imaging findings. Conventional imaging modalities, including CT and radionuclide bone scan, have been employed for local and metastatic staging, but their performance characteristics have generally been poor. Emerging modalities including multiparametricMRI, positron emission tomography (PET)–CT, and PET–MRI have shown increased diagnostic accuracy and could improve accuracy in staging patients with high-risk prostate cancer.

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Figure 1: An algorithm for imaging patients with high-risk prostate cancer.
Figure 2: Assessment of extraprostatic extension on multiparametricMRI.
Figure 3: Assesment of seminal vesicle involvement evaluated using multiparametic-MRI.
Figure 4: 18F-PET–CT for initial staging of prostate cancer in a newly diagnosed 70 year old with a serum PSA level of 73.6 ng/ml, demonstrating focal uptake in the left aspect of the prostate gland that is consistent with the primary tumour.
Figure 5: Initial prostate cancer staging using 18F-choline-PET–CT, demonstrating focal uptake within a 5 mm right external iliac lymph node (arrow), consistent with a nodal metastasis, in a 70-year-old patient with newly diagnosed prostate cancer and serum PSA level of 73.6 ng/ml.
Figure 6: Initial staging workup showing metastatic disease to bone in an 85-year-old patient with a de novo non-CRPC diagnosis.
Figure 7: Differentiating metastatic lesions from benign lesions on 18F-NaF-PET–MRI.
Figure 8: Differentiating metastatic lesions from benign lesions on 18F-NaF-PET–MRI.

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Authors and Affiliations

  1. Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, 10016, NY, USA

    Marc A. Bjurlin & Samir S. Taneja

  2. Department of Radiology, New York University Langone Medical Center, New York, 10016, NY, USA

    Andrew B. Rosenkrantz, Luis S. Beltran & Roy A. Raad

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  1. Marc A. Bjurlin
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All authors made substantial contributions to discussion of article content, writing; reviewing, and editing the article before submission. M.A.B., A.B.R., L.S.B. and R.A.R. researched data for the article.

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Correspondence to Samir S. Taneja.

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S.S.T. has been a speaker for Eigen, a consultant for Hitachi-Aloka Medical and HealthTronics, and a sponsored trial investigator for Trod Medical. All other authors declare no competing interests.

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Bjurlin, M., Rosenkrantz, A., Beltran, L. et al. Imaging and evaluation of patients with high-risk prostate cancer. Nat Rev Urol 12, 617–628 (2015). https://doi.org/10.1038/nrurol.2015.242

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