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2014, Number 3

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Anales de Radiología México 2014; 13 (3)

Prostate cancer: radiological guidelines for diagnosis and staging

Sotelo-Martínez L, Sánchez-Luna C

Language: Spanish
References: 21
Page: 230-245
PDF size: 710.58 Kb.


ABSTRACT

Objectives: discuss the usefulness of transrectal ultrasound with biopsy, describe the usefulness, indications, and findings of image studies for staging, monitoring, and reassessment of prostate cancer explaining its tumoral behavior and spread.
Clinical diagnosis: is based on the prostate-specific antigen in blood and on rectal examination, but both have suboptimal precision. A value of prostate-specific antigen in blood above 4 ng/mL is abnormal, considering that 70-80% of cases are due to benign conditions such as benign prostatic hyperplasia or prostatitis. At the time of diagnosis the most important predictors of prognosis in prostate cancer are the Gleason score and the clinical stage; the results of prostate antigen, rectal examination, and transrectal biopsy are also considered.
Image diagnosis: transrectal ultrasound is not recommended alone as an initial imaging method to diagnose prostate cancer due to its positive predictive value of 15.2%; its primary role is as a guide for transrectal biopsy, which increases the rate of detection from 36 to 84% depending on tumor size. Computed tomography is useful in detecting regional lymph nodes or distant metastasis, has some usefulness to detect extracapsular extension, and has no indication for initial diagnosis in detection of intraprostatic lesions or local staging. Magnetic resonance is the method of choice for local staging and for planning treatment; its primary role is to locate the tumor and detect extracapsular extension with between 60 and 90% accuracy. Positron emission tomography (PET/CT) is indicated in detection and localization of distant metastasis in prostate cancer refractory to hormone therapy; it has limited usefulness for primary diagnosis and staging (sensitivity 66%, specificity 81%, positive predictive value 87%, negative predictive value 55%, and accuracy 71%). 11C-acetate is used as a radiopharmaceutical in PET/CT and is indicated only in studies of patients with prostate cancer treated with radical prostatectomy, associated with an increase in the prostate antigen and suspicion of subclinical tumor recurrence.
Conclusion: transrectal ultrasound is the imaging method of first choice in patients with prostate cancer and, due to its poor diagnostic performance, is indicated only as a guide for biopsy. Resonance is the method of choice to characterize prostatic parenchyma and to locally stage prostate cancer. The weighted sequence in T1 has limited usefulness to assess the prostate in detail and is used to detect post-biopsy bleeding, evaluate the prostatic contour, the path of neurovascular bundles and as a precontrast baseline sequence. The weighted sequence in T2 is sensitive but not specific; it is recommended to combine it with at least two functional resonance techniques for an optimum characterization. 11C-acetate in the PET/CT study is indicated only in patients with prostate cancer treated with radical prostatectomy and associated with an increase in prostate-specific antigen, as long as there is a suspicion of subclinical tumor recurrence.


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