MRI of Prostate Cancer Introduction

Prostate cancer continues to be the leading cancer among American men, with 184,500 new cases annually [1]. It has been estimated that 39,200 men died of prostate cancer in the U.S.A. in 1998. This makes prostate cancer the second cause of cancer-related death in men [2, 3]. Furthermore, the probability of developing prostate cancer from birth to death is 20% [3]. Treatment selection is dependent on patient age and health, cancer stage and grade, morbidity and mortality of treatment, as well as patient and physician preference. The mainstay for organ-confined disease is either radical surgery or curative radiotherapy [4, 5]. This is only considered an option in the absence of seminal vesicle infiltration (SVI), extension through the prostatic capsule (extracapsular extension, ECE) or metastatic disease. Therefore, the purpose of staging is the possible detection of extraprostatic disease. Clinical staging by digital rectal examination (DRE) and prostate specific antigen (PSA) remains as yet inaccurate. Imaging modalities such as transrectal ultrasound (TRUS) and magnetic resonance (MR) imaging can be used to increase staging accuracy. This review deals with the current possibilities and limitations of MR imaging in the staging of prostate cancer.

Clinical Staging Methods

Accurate staging of prostate cancer is important because treatment decisions are mainly based on the local extent of prostate cancer (ECE, SVI) and the presence of metastatic disease (lymphatic or hematogenous). DRE is not an accurate staging method, as there are no gross characteristics that are reliable to distinguish benign from malignant nodules [6]. Furthermore, the interobserver agreement among urologists for detection of prostate cancer by DRE is only fair [7]. Data accumulated from carefully examined prostatectomy specimens revealed that DRE underestimates the local extent of cancer in 40-60% of the cases [8, 9]. PSA is the most accurate marker to screen for

* J.O. Barentsz prostate cancer, but has limited accuracy in staging because there is a substantial overlap in PSA concentrations and pathologic stages. Nevertheless, the combination of serum PSA concentration and other variables such as tumour grade, volume and clinical stage, significantly enhance the predictive value of serum PSA for the pathological stage [10, 11]. The probability of ECE, sVi and nodal involvement can be predicted by using the normo-grams of Partin [10] that are based on clinical stage, Gleason score and serum prostate specific antigen (PSA).

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