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An Update on Oncology Imaging

Prostate Cancer - mp-MRI and PSMA PET-CT

Dr Joe Feltham - Radiologist Pacific Radiology and Wellington Hospital

Detection

Breast Ca, Lung ca, HCC

Staging MRI for local staging (T of TNM)

rectal, cervical, prostate CT staging - great for metastases (M) - not so good for nodes (N) PET-CT improved sensitivity - but $$$

Surveillance CT again sometimes PET-CT for problem solving

Role of imaging in Cancer

Detection

No historical role - Clinical, PSA and TRUS

Staging

CT staging of distant disease

Bone scan for skeletal disease

MRI for local staging (last 10 years)

Surveillance

CT scan +/- bone scan

Historical role of imaging of Prostate Cancer

Multiparametric MRI More evolution really Advances in understanding, technology, and supportive studies - diffusion weighted scanning, 3 Tesla scanners PI-RADS reporting system = greater consistency of reports

PSMA PET-CT Revolutionary - targets prostate specific membrane antigen Only shows prostate cancer - incredibly sensitive for nodal and bony disease Previously required isotope to be flown in from Australia - now here as of April

2016 - The Prostate imaging revolution

PROMIS study Lancet 2017 740 men - PSA >15 and no prior biopsy MRI, followed by standard TRUS biopsy - vs TP template biopsy TRUS - 48% sensitivity only (96% spec and PPV 90%) mp-MRI - 93% sensitivity but only 41% specificity (NPV 89%) for Gleason 4+3 cancer - Gleason 3+4 disease very similar results 27% of men would have avoided biopsy had MRI results been followed scanning all done on 1.5T MRI scanners, so better results with 3T

mp-MRI - evidence

67 year old man, PSA 6.3, no prior biopsy

Targeted TRUS - Gleason 4,4

65 year old man, PSA 5, no prior biopsy

Gleason 4,4 on transperineal biopsy - T3N0 on resection

72 year old man, PSA 8.6, no prior biopsy

Gleason 3,4 on targeted TRUS, rest of gland clear Far anterior apical tumour

57 year old man - negative TRUS 2014

far left apical tumour - 16mm repeat targeted TRUS - Gleason 4,3 - T3aN0 on resection

63 year old - negative TRUS 2016 - PSA inc to 18

No result yet, but MRI has bilateral PIRADS 4 lesions - 14mm = high suspicion clinically significant cancer

MRI-US fusion biopsy Possibly the way of the future Consensus guidelines suggest MRI if TRUS negative and high suspicion still Fusion of MRI onto US with improved targeted trans-perineal biopsy

mp -MRI plus TRUS 80% sens mp-MRI 90%+ sens for mp-MRI plus TRUS

Translating MRI results to biopsy?

Afshar-Oromieh et al Eur J Nuc Med 2015 87% sens vs 70% for FDG PET-CT 100% specificity for positive nodes!

Giesel et al Eur J Nuc Med Mol Imaging 2015 Can detect nodes as small as 2.5mm Early days, so more evidence coming every month

PSMA PET-CT - evidence - less mature at this stage

76 year man - prior 2010 - PSA rising to 11.9

local recurrence only

67 year old man - radiotherapy 2011 - PSA rising

local recurrence only

72 year old man - PSA 2.8 - prior radiotherapy

Local recurrence plus hot node only 4mm, so would not be called positive on CT scan

69 year man - rising PSA after prior prostatectomy multiple bone metastases

Thank You!