Learning Objectives
Describe prostate cancer treatment options (active surveillance, surgery, radiation, and focal therapies) and their imaging findings.
Recognize the importance of new MRI and PET techniques in the detection of recurrence after hormone, radiation, prostatectomy and focal therapies.
Understand the importance of MR imaging in surveillance after focal therapy and its role in triage and follow-up of patients who undergo active surveillance.
Biochemical recurrence (BCR) is the most clinically used endpoint for identification of treatment failure. A number of clinical nomograms are available to predict BCR, time to metastasis, and prostate cancer–specific mortality. Approximately 10% to 53% of patients undergoing primary intended curative therapy will develop BCR, depending on their preoperative risk and stage of cancer. For localized low-risk prostate cancer, the rate of BCR is as low as 9% after surgery. A first serum total PSA assay is recommended during the first 3 to 12 months after surgery or radiation treatment. When PSA is detectable following surgery, a PSA assay should be repeated 1 to 3 months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual cancer, PSA becomes undetectable by the first month after total prostatectomy. Multiparametric MRI (MP-MRI) and prostate-specific PET agents have enhanced our understanding of prostate cancer recurrence and spread. There is a significant proportion of men that can be identified with a solitary or small number of sites of disease recurrence when imaged early in the course of BCR. It is notable that prostate cancer is the second leading cause of cancer mortality among American men. The majority of these men are not dying because of initial presentation of high-stage incurable disease. Most of the men who die from prostate cancer had originally presented with disease that was thought to be clinically localized, underwent definitive primary management with curative intent, experienced treatment failure with BCR, and then their recurrent disease progressed while on non-targeted systemic therapy to become fatal. Recent imaging advances that allow identification of limited metastatic disease early in BCR rather than once the disease has become systemically advanced will be presented.
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