The impact of imaging modalities in changing the treatment decision

1. Modern Imaging of Prostate Cancer:
“Impact on Management Decision”
Mohamed Abdulla M.D.
Prof. of Clinical Oncology
Cairo University
Dubai, 05/03/2016

2. Speaker Disclosures:
Member of Advisory Board, Consultant, and Speaker for:
• Amgen, Astellas, AstraZeneca, Hoffman la Roche, Janssen Cilag,
Merck Serono, Novartis, Pfizer
• The content of this presentation does not relate to any product of a
commercial interest

3. Prostate Cancer:
Landscape of Disease:
Localized – Recurrent and/or Metastatic – CRPC – Death
Hormone Sensitive or Resistant
Asymptomatic or Symptomatic

4. Prostate Cancer:
Diagnostic Work up:
PSA
DRE
+
TRUS
Gleason
Score
Systemic Disease:
• Isotopic Bone Scan
• Computed Tomography
• MRI
• Others
Risk
Stratification
Extra -
Prostatic
Disease

5. Prostate Cancer:
Diagnostic Work up: Unmet Needs:
• DRE: Personal Variability.
• Conventional Grey Scale US:
– Isoechoic & Anterior lesions.
– Multifocal Disease, Heterogonous Texture.
– Capsular Infiltration & Peri-prostatic Extension.
– SV involvement.
• Computed Tomographic Scans:
– Limited value for local disease extent.
– Superior in Bone Metastases.
• Original MRI < 1 t:
– Variable Sensitivity and Specificity.
• Isotopic Bone Scan:
– No direct imaging of Bone Metastases.
– Difficult to quantify burden of disease.
• PET – CT Scan:
– 18FDG: Glycolytic Activity and not Osteoblastic activity.

6. Clinical Scenario:
• A 60-year-old postal employee presented for a free screening
exam.
• DRE: equivocal with questionable asymmetric firmness.
• PSA = 12 ng/ml
• TRUS: 2 hypoechoic areas within the left side of peripheral
zone of one lobe of the gland  Guided Biopsy.
• 6 out of 12 biopsy cores had Gleason score of 7 (4 + 3)
adenocarcinoma.

9. Recurrence Risk for Clinically Localized
Prostate Cancer
• Low Risk:
T1-T2a and Gleason score 2-6 and PSA < 10 ng/ml
• Intermediate Risk:
T2b-T2c or Gleason score 7 or PSA 10-20
• High Risk:
T3a or Gleason score 8-10 or PSA > 20
• Very High Risk:
T3b-T4(locally advanced)

10. Q:1- How Would You Stage This
Patient??
1. CT scan abdomino-pelvis with contrast.
2. Multi-parametric MRI pelvis.
3. Isotopic Bone Scan.
4. Chest image.
5. 1+3+4
6. 2+3+4
7. 2+4

11. CASE (Cont…..)
• Patient had conventional chest imaging, CT-Scan
of the abdomen and pelvis with contrast and
Isotopic Bone Scanning.
• The patient discussed therapeutic options and
elected radical prostatectomy.
• The final pathology report: positive capsule
penetration, a positive surgical margin, and
seminal vesicle invasion. Lymph nodes are
negative.
• PSA decreases to 0.01ng/ml.

12. What is the Proper Staging?
1. Multiparametric MRI
1. Diffusion Weighted Imaging (DWI).
2. Prostate T2 Weighted Imaging.
3. Dynamic Contrast Enhanced Images (DCE).
4. Magnetic Resonance Spectroscopy Imaging (MRSI).
mpMRI is Mandatory of patients with Intermediate and High
Risk Prostate Cancer & to confirm the validity of Active
Surveillance.

13. EUA Guidelines: Isotopic Bone Scanning is NOT
Indicated in:
1. Asymptomatic patients.
2. Well to moderately differentiated disease.
3. PSA < 20 ng/ml.
What is the Proper Staging?
2. Isotopic Bone Scanning:

14. Case Continuation:
• Patient received postoperative radiation
therapy based on adverse pathologic features.
• Kept under follow up.
• 2 years later, follow up PSA = 54 ng/ml while
patient was asymptomatic.

15. Q2:
What are the imaging techniques to be
requested?
1. CT-Scan of abdomen and pelvis with
contrast.
2. Isotopic Bone Scan.
3. Axial Skeleton MRI.
4. 1+2
5. 1+3

16. Imaging Recommendations:
• CT Scan & MRI.
• Traditional Bone Scan is the standard except in
equivocal & suspecious negative cases 
Radiographs, MRI.
• PET-CT Scan FDG ?? (Bladder activity)
• PET – CT Scan (Sodium Florid and Choline)
Uptodate, 2016

17. Case Continuation:
• Bone metastases (> 4 sites) and abdomino-pelvic nodal
disease (no visceral affection).
• Started ADT & Docetaxel (PSA = 2 ng/ml)
• 6 months following salvage therapy  re-rise of PSA (85
ng/ml)  Adding anti-androgen  PSA = 3.5 ng/ml.
Patient was asymptomatic.
• 4 months later, tender right shoulder (-ve in bone Scan,
+ve in conventional radiograph  palliative Rth). PSA 
263 ng/ml. Serum Testosterone  maintained castrate
level  metastatic CRPC. Patient is relatively
asymptomatic.

18. Q3:
What are the imaging procedures to be ordered?
1. Body CT Scan with contrast.
2. Isotopic Bone Scan.
3. PET CT Scan.
4. Axial Skeleton MRI
5. 1+2
6. Non of the above.

20. Yes No Abstain

21. TAKE HOME MESSAGE:
• Prostate cancer is a heterogeneous disease.
• Assessment of disease extent is crucial.
• mp MRI is mandatory in assessment.
• Tc 99m, is the standard isotopic scan.
• The value of Axial Skeleton MRI is more appreciated
in CRPC phase of disease.
• Sodium Floride & Choline PET Scan are under
investigations.

22. Thank You