Prostate CancerRole of Dynamic Contrast-Enhanced Magnetic Resonance (MR) Imaging and Proton MR Spectroscopic Imaging in the Detection of Local Recurrence after Radical Prostatectomy for Prostate Cancer☆
Introduction
At present, tumor recurrence or progression after radical prostatectomy (RP) is assessed by prostate-specific antigen (PSA) serum level measurements and pathological findings of the tumor [1], [2]. In particular, a PSA increase over a threshold of 0.2 ng/ml later than 6–12 mo following RP suggests treatment failure with a high risk of local recurrence [3], [4], whereas a PSA increase within a shorter period strongly correlates with the presence of distant metastasis progression [5]. In patients with biochemical failure after RP, a diagnostic imaging procedure is often performed to distinguish between local cancer recurrence and distant spread of disease [6], [7]. This information influences further therapeutic decisions. Computed tomography (CT) imaging is not widely used for the detection of local recurrence because of the low accuracy of this technique in the differentiation of post-RP local recurrence from postsurgical scarring [8]. Immunoscintigraphy [9] and carbon11 choline positron emission tomography-computed tomography [10] have been introduced as innovative imaging modalities for the detection of disease relapse, but their role is still incompletely defined. Transrectal ultrasound (TRUS) in combination with a TRUS-guided biopsy of the prostatic fossa is considered the most accurate postprostatectomy method to detect local cancer recurrence [11]. However, in the early phase of relapse, when cancer volume is low, Saleem et al [12] have shown that almost 30% of patients have biopsy-proven local recurrence if serum PSA level is <1 ng/ml and that no positive biopsy was found in patients with PSA <0.5 ng/ml. Other studies have reported that the higher serum PSA level after RP is correlated with a higher positive biopsy rate [13], [14].
The efficacy of radiotherapy in the treatment of patients with low-volume local recurrences validates the importance of developing a diagnostic technique to detect early post-RP cancer recurrence [15]. Several studies have shown that MR imaging possesses high-contrast and spatial resolution, and may represent a promising technique for accurate evaluation of patients with biochemical relapse after RP [16]. A large number of studies [17], [18] have shown that combined 1H-spectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced MR imaging (DCEMR) could represent a powerful tool for the initial detection of prostate cancer, and for the early diagnosis of postoperative recurrence [19], [20], [21], [22]. However, to our knowledge, no prior study has evaluated the sensitivity and specificity of 1H-MRSI and DCEMR individually and in combination in the detection of prostate cancer local recurrence after RP. Therefore, the purpose of this study was to perform this analysis in a group of patients with biopsy-proven cancer recurrence and in a second group with reduction in PSA level (>50%) following radiation therapy in whom a TRUS biopsy is difficult to perform because of the low volume of the suspected locoregional cancer.
Section snippets
Study approval and patient population
The protocol was approved by the local ethics committee and all subjects gave written informed consent before inclusion in the study. Between January 2006 and May 2007, we included in the study 70 consecutive male patients who were at high risk for local cancer recurrence after RP on the basis of the pathological stage and postoperative PSA increase, and who were candidates for external beam radiotherapy. All patients were submitted to RP in the urological department of our university.
Results
Three patients in group A did not have a reliable TRUS biopsy and were therefore excluded from further analysis. In particular these patients had uncertain TRUS biopsy findings, and their MR images demonstrated abundant postsurgical fibrosis, so the demarcation between postsurgical changes and tumor recurrence could not be made. No patients were excluded from group B and CG. Table 1 summarizes patient characteristics and clinical findings.
Discussion
Serial PSA measurements after RP represent the usual follow-up approach for the early detection of prostate cancer recurrence. Clinical nomograms based on PSA or postsurgical pathological parameters have been used to predict whether a recurrence is more likely local or metastatic [7]. Several imaging modalities also have been introduced in the last two decades to support the decision of urologists and oncologists in the therapeutic planning of prostate cancer recurrence: The selection of a
Conflicts of interest
The authors have nothing to disclose.
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