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IMAGING IN 2018

Practice changing for prostate cancer: a vision of the future

Nature Reviews Urology volume 16, pages 71–72 (2019)Cite this article

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2018 has been an exciting year for imaging in urology, especially in the field of prostate cancer. In this context, multiparametric MRI and molecular imaging targeting prostate-specific membrane antigen provide practice-changing developments for detection and diagnostic work-up.

Key advances

  • Targeting biopsies in patients with abnormal findings on multiparamentric MRI (mpMRI) is superior to standard ultrasonography-guided biopsy in detecting clinically significant prostate cancer at initial evaluation1.

  • A minority of patients with negative mpMRI develop clinically significant prostate cancer at 4 years. Increasing PSA levels and higher PSA density predict increased likelihood of disease development3.

  • In biochemically recurrent prostate cancer, detection rates by 68Ga-PSMA-PET are ~55% and ~70% for patients with PSA values between 0.2 and 0.5 ng/ml and between 0.5 and 1.0 ng/ml, respectively5.

  • Results from 68Ga-PSMA-PET change management in approximately half of patients with biochemically recurrent prostate cancer6.

  • Novel fluorinated PSMA ligands might replace 68Ga-based PSMA ligands for PET staging of prostate cancer owing to reduced urinary excretion and advantageous pelvic imaging, easier handling and increased availability8.

The landmark study of imaging in prostate cancer in the past year was the PRECISION trial1, which complements the results of the PROMIS study2 that showed the superiority of using multiparametric MRI (mpMRI) to triage men for biopsy to standard systematic biopsy to detect clinically significant prostate cancer at initial evaluation. The recent PRECISION trial1 further elucidates the role of mpMRI in this setting. In this trial, the authors evaluated whether targeted biopsy alone in patients with abnormal findings on mpMRI was noninferior to standard template ultrasonography-guided biopsy in detecting clinically significant prostate cancer at initial evaluation. In total, 877 patients with suspicious PSA levels (≤20 ng/ml) and/or suspicious digital rectal examination (without suspicion of advanced disease) without previous prostate biopsy were screened and 500 were randomized to receive either standard 10–12-core biopsy or mpMRI plus targeted biopsy only if suspicious lesions were detected on mpMRI (defined as a PI-RADS v2 score of 3–5).

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Fig. 1: 68Ga-PSMA-PET–CT of a 74-year-old patient with recurrent prostate cancer (initial Gleason score 7) after radical prostatectomy and local salvage radiotherapy with rising serum PSA value (1.76 ng/ml at the time of assessment).

References

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  2. Ahmed, H. U. et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 389, 815–822 (2017).

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  6. Han, S. et al. Impact of 68Ga-PSMA PET on the management of patients with prostate cancer: a systematic review and meta-analysis. Eur. Urol. 74, 179–190 (2018).

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Authors and Affiliations

  1. Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Tobias Maurer

  2. Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Tobias Maurer

  3. Department of Nuclear Medicine, Technical University of Munich, Munich, Germany

    Matthias Eiber

Authors
  1. Tobias Maurer
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  2. Matthias Eiber
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Correspondence to Tobias Maurer.

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Maurer, T., Eiber, M. Practice changing for prostate cancer: a vision of the future. Nat Rev Urol 16, 71–72 (2019). https://doi.org/10.1038/s41585-018-0134-6

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