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PET/MRI: A One-Stop Imaging Test to Detect Prostate Cancer?

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Key Points

  • Using the mean F-18-choline target-to-background ratio, the addition of F-18-choline to multiparametric prostate MRI significantly improved the prediction of Gleason ≥ 3+4 cancers over multiparametric prostate MRI alone (AUC = 0.92; P < .001). 
  • Researchers noted about this technique, “The use of advanced imaging to inform placement of biopsy needles promises to greatly minimize the uncertainty associated with prostate cancer care.”

A University of Michigan study published by Piert et al in The Journal of Nuclear Medicine reported that the addition of molecular imaging based on F-18-choline positron-emission tomography (PET) improves the identification of significant prostate cancer over multiparametric prostate magnetic resonance imaging (MRI) alone for targeted transrectal prostate biopsies. MRI-guided biopsies already outperform standard, nontargeted biopsies. The addition of PET promises to improve targeted biopsies even further.

Morand Piert, MD, Professor of Radiology in the Division of Nuclear Medicine at the University of Michigan, Ann Arbor, points out, “Our positive results suggest that in the future, PET/MRI may become a one-stop imaging test for men with suspected but undetected prostate cancer or for patients undergoing surveillance for known low-risk prostate cancer.”

He explained, “Since prostate cancer is often multifocal and presents with multiple lesions of varying risk, it is important to identify the lesions that harbor the greatest malignant potential. Accurate identification of clinically significant cancer and avoidance of clinically insignificant cancer is the centerpiece of modern prostate cancer diagnosis.”

Study Findings

As part of an ongoing prospective clinical trial, researchers studied 36 men with rising prostate-specific antigen (PSA) to assess the value of fusion F-18–choline PET/MRI for image-guided (targeted) prostate biopsies to detect significant prostate cancer, compared to standard (nontargeted, systematic 12-core) biopsies. The biopsy procedures were performed after registration of real-time transrectal ultrasound (TRUS) and included image-guided cores plus standard cores. Histologic results were determined from standard and targeted biopsy cores, as well as prostatectomy specimens.

Fifteen subjects were ultimately identified with significant prostate cancer (Gleason ≥ 3+4), of which targeted biopsy identified 12, while standard biopsy identified only 5.

To see the PET/MRI comparison images from this study mentioned in the following paragraphs, please click here. The figure shows a Gleason 3+4 prostate cancer (arrows) as identified on T2-weighted (Fig. A) and diffusion-weighted (Fig. B) MRI, F-18-choline PET (Fig. C), as well as PET/MRI (Fig. D). A total of 52 lesions were identified by multiparametric prostate MRI (19 low, 18 intermediate, and 15 high risk), and MRI-assigned risk was a strong predictor of final pathology (area under the curve [AUC] = 0.81; P < .001). Using the mean F-18–choline target-to-background ratio, the addition of F-18–choline to multiparametric MRI significantly improved the prediction of Gleason ≥ 3+4 cancers over MRI alone (AUC = 0.92; < .001). 

The study concluded that fusion PET/MRI-TRUS image registration for targeted prostate biopsies is clinically feasible and accurate, and the addition of F-18–choline PET to multiparametric MRI improves identification of significant prostate cancer.

Dr. Piert noted, “The use of advanced imaging to inform placement of biopsy needles promises to greatly minimize the uncertainty associated with prostate cancer care. Imaging may one day be performed prior to biopsy and, if negative, no biopsy would be needed. To reach that future state, advanced imaging will need to have a superior negative-predictive value that may not be obtainable with multiparametric MRI alone.”

He added, “Although we used F-18–choline PET in this trial, it is likely that other radiotracers, which are more specific for prostate cancer—for example, those that target PSMA [prostate-specific membrane antigen]—may hold even greater promise.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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