an update on oncology imaging - home | acurity site no historical role - clinical, psa and trus...
TRANSCRIPT
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!