EAU 2017: Controversies in prostate cancer detection: Multiparametric MRI is a must
Dr. Futterer subsequently presented the argument for utilizing multiparametric MRI (mpMRI) for all patients when clinically indicated for prostate cancer. He highlighted that mpMRI truly encompasses three different entities: prostate (i) anatomy (T2-weighted imaging (T2W)), (ii) biology (diffusion-weighted imaging (DWI)), and (iii) vascularity (dynamic contrast enhancement (DCE)). T2W imaging allows for an excellent assessment of the transitional and peripheral zones of the prostate, as well as the neurovascular bundles. DCE, Dr. Futterer argues, is essential for local recurrence detection and has high sensitivity for detection, albeit with poor specificity and with significant interpatient variability. Dr. Futterer then highlighted the evolution of DCE classification, moving from a 5-point scale for scoring in PI-RADS v1 to DCE (+) or (-) for PI-RADS v2. But, as Dr. Futterer notes, PI-RADS v2 is somewhat controversial with regards to recommendations of DCE: on the one hand recognizing that the data supporting the role of DCE is limited and the value of DCE is modest, while on the other hand advising that all MRI examinations should include DCE, describing the sequence as ‘essential’.
According to Dr. Futterer, some of the indications where DCE should absolutely be used include (i) assisting in detection of “subtle tumors” (small tumor, challenging location) that may be missed with T2W or DWI, and (ii) to aid in interpretation when the image quality of other sequences is poor. Furthermore, Dr. Futterer suggests that particularly challenging cases should also be considered for mpMRI, such as patients being assessed for disease recurrence, follow-up imaging for patients on active surveillance, and patients either pre- or post-focal therapy.
Dr. Futterer concluded by stating that there are still indications for preforming a DCE sequence, although for the majority of patients DCE imaging will not change the clinical course. Undoubtedly, head to head studies comparing outcomes of examinations with T2W+DWI vs T2W+DWI+DCE are necessary.
Presented by: Jurgen J. Futterer, University Twente, Nijmegen, Netherlands
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto
at the #EAU17 -March 24-28, 2017- London, England