Elia del Cerro

Role of 3T multiparametric magnetic resonance imaging without endorectal coil in the detection of local recurrent prostate cancer after radical prostatectomy: the radiation oncology point of view

Abstract Objective. The aims of this study were to evaluate the role of 3 tesla multiparametric magnetic resonance imaging (3TmMRI) without endorectal coil in the detection of radiographic local recurrences (rLRs) in a contemporary cohort of patients with prostate cancer who presented with biochemical recurrence after radical prostatectomy (RP) with low prostate-specific antigen (PSA) levels, and to identify clinical parameters associated with the 3TmMRI findings. Materials and methods. Between 2009 and 2013, 57 patients with biochemical recurrence of prostate cancer after RP who were considered for salvage radiation therapy (SRT) were included. 3TmMRI with T2-weighted imaging, diffusion weighted imaging (DWI) and dynamic contrast-enhanced imaging without endorectal coil was carried out in all patients before treatment. Results. In 14 out of 57 patients (24.56%) local recurrence was detected through 3TmMRI. Median pre-SRT PSA was 0.40 ng/ml (interquartile range 0.30–2.05 ng/ml). The recurrence was perianastomotic in eight out of 14 patients (57.14%) and retrovesical in six out of 14 patients (42.86%). The median size of the local recurrence was 15.2 mm (range 8.0–46.0 mm). The probability of rLR was significantly higher in patients with PSA levels above 0.5 ng/ml [adjusted odds ratio (OR) 6.25, 95% confidence interval (CI) 1.27–30.79, p = 0.02] or PSA doubling time (PSADT) over 14 months (adjusted OR 7.12, 95% CI 1.40–36.25, p = 0.01). Conclusions. This is the first study to find a significant relationship between the PSADT and the rLR through MRI. Patients with PSADT longer than 14 months or pre-SRT PSA above 0.5 ng/ml benefited most from 3TmMRI. Its routine use could have significant clinical implications for SRT.

Magnetic resonance imaging for prostate cancer before radical and salvage radiotherapy: What radiation oncologists need to know

External beam radiotherapy (EBRT) is one of the principal curative treatments for patients with prostate cancer (PCa). Risk group classification is based on prostate-specific antigen (PSA) level, Gleason score, and T-stage. After risk group determination, the treatment volume and dose are defined and androgen deprivation therapy is prescribed, if appropriate. Traditionally, imaging has played only a minor role in T-staging due to the low diagnostic accuracy of conventional imaging strategies such as transrectal ultrasound, computed tomography, and morphologic magnetic resonance imaging (MRI). As a result, a notable percentage of tumours are understaged, leading to inappropriate and imprecise EBRT. The development of multiparametric MRI (mpMRI), an imaging technique that combines morphologic studies with functional diffusion-weighted sequences and dynamic contrast-enhanced imaging, has revolutionized the diagnosis and management of PCa. As a result, mpMRI is now used in staging PCa prior to EBRT, with possible implications for both risk group classification and treatment decision-making for EBRT. mpMRI is also being used in salvage radiotherapy (SRT), the treatment of choice for patients who develop biochemical recurrence after radical prostatectomy. In the clinical context of biochemical relapse, it is essential to accurately determine the site of recurrence - pelvic (local, nodal, or bone) or distant - in order to select the optimal therapeutic management approach. Studies have demonstrated the value of mpMRI in detecting local recurrences - even in patients with low PSA levels (0.3-0.5 ng/mL) - and in diagnosing bone and nodal metastasis. The main objective of this review is to update the role of mpMRI prior to radical EBRT or SRT. We also consider future directions for the use and development of MRI in the field of radiation oncology.

Solitary Hypothalamus Triple Negative Metastasis from Luminal: A Primary Breast Carcinoma

A 49 years old woman was diagnosed of bilateral and multicentric infiltrating ductal breast carcinoma with a luminal A phenotype (Figure 1) and blastic bone metastatic spread. She had a very good response to hormonotherapy and monthly zoledronic acid without visceral spread or bone events for three years. Then she consulted because of progressively asthenia, anorexia, nausea, dizziness, orthostatic, occasional abdominal pain, increased thirst and frequent urination and altered sleep-wake cycles. On physical examination, she appeared pallid without any other remarkable finding.

Endorectal magnetic resonance imaging for risk classification of localized prostate cancer: Radiographic findings and influence on treatment decisions.

To the Editor: We appreciated the article of Liauw et al. [1] about the endorectal magnetic resonance imaging (MRI) and its influence in radiotherapeutic management. The influence of the 3 T endorectal MRI staging on the final radiotherapy (RT) treatment decision was analyzed in a total of 122 patients with prostate cancer. Briefly, in that study, the initially planned treatment was modified in 18% of patients. Surprisingly, the authors stated the following within the discussion: “There are no reports to our knowledge, which address the role of MRI on clinical decision-making from the radiation oncologists perspective.” However, our group has already published 2 studies analyzing the influence on final decisions in RT treatment of 3 T multiparametric MRI (mpMRI) without endorectal coil [2,3]. In our series, with a total of 274 patients [3], the global change in the risk groups when considering all factors, such as prostate-specific antigen levels, Gleason score, and tumor category, occurred in 32.8% of patients. Our results are comparable to an article published by Panje et al. [4] (28.7%). According to these data, we might say that at least 18% to 32% of patients with prostate cancer staged with mpMRI with or without endorectal coil could face an alteration of the final RT treatment decision. We obtained a global alteration of RT treatment in 43.8% or 52.5% of patients (depending on hormone therapy [HT] criteria for intermediate-risk patients). Other studies have shown a change in RT treatment of between 8% and 34% [5–8]. Such variability can be due to several causes previously described [3], such as factors related to MRI (magnet and coil, the use of functional sequences, expertise of the radiologist, the use of previous HT, etc.); factors related to the initial clinical staging (expertise of the clinician for the digital rectal examination/transrectal ultrasound, the use of computerized tomography scan to evaluate pelvic lymph nodes, etc.); clinical features of the cohorts of patients included in the studies; factors related to the RT treatment given in each center (doses, fractionation, target volume, HT indication, brachytherapy use, etc.); and