Accurate staging of prostate carcinoma is essential for taking treatment decisions. However, pre-operative clinical staging is inaccurate. DRE and PSA can only provide an inexact indication of local extent. Addition of other parameters such as number of positive biopsies and biopsy grade improves clinical staging but is not accurate enough to predict tumour stage in the individual patient. Therefore imaging modalities such as TRUS and MR imaging are needed to increase staging accuracy. Local staging (ECE and SVI) with MRI is at least as good and potentially superior to TRUS [10, 52, 53]. The advantage of MR imaging is that both nodal, bone marrow and local staging can be done in one imaging session, limiting the number of examinations and cost.

In future research, cost-effectiveness should be an important guideline when working with these 'expensive' imaging techniques. In this respect, detection of advanced disease by imaging and thereby the prevention of an unnecessary radical prostatectomy should be weighed against the cost of imaging itself and its value to assess the stage of tumour for the individual patient. In a recent paper,

Fig. 8. Stage T3a prostate cancer. a ERC T2-weighted MR image at 1.5 T shows tumor (T) but no definite capsular penetration. b High resolution ERC image obtained at 3T shows clear extra capsular extension (arrows)

Jager et al. [54] determined the appropriate use of MR imaging for preoperative staging of prostate cancer. They performed a literature review by using the principles of evidence-based medicine and medical technology assessment. A decision analytic model was used to compare the strategy where radical prostatectomy is performed on the basis of clinical staging with the strategy where extracap-sular disease detected at MR imaging contraindicates radical prostatectomy in patients who were considered surgical candidates on the basis of clinical staging. After review of the literature, expert panel opinion did not recommend MR staging. No studies in which therapeutic efficacy was addressed were found. However, the decision analytic model indicated that the strategy including MR staging decreased costs (MR imaging, $10,568; radical prostatectomy, $11,669) and resulted in almost equal life expectancy (MR imaging, 12.59 years; radical prostatectomy, 12.60 years) and quality-adjusted life-years ([QUALYs] MR imaging, 12.53; radical prostatectomy, 12.52). Furthermore, results of sensitivity analyses demonstrated that the a

MR strategy was both more effective and less costly if the prior probability of extracapsular disease was at least 39% when considering QUALY, and 50% when considering unadjusted life expectancy. It was concluded that it is not yet conclusively determined whether preoperative MR staging is appropriate, but results of decision analysis suggest that MR staging is cost-effective for men with moderate or high prior probability of extracapsular disease.

Thus it remains very important to select appropriate patients for staging with the imaging techniques mentioned above. Finally, it should be mentioned that the role of imaging, especially MR imaging and MRS, is rapidly changing and improving and more research needs to be done to establish its definite role.

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