radiation therapy as the midpoint between PSA nadir and the first
of three consecutive rises in PSA. An alternative definition of BCR
after radiation therapy is “nadir +2 ng/mL” (Phoenix definition).
In the past, patients with BCR were often left with limited options, which included observation, empiric radiation to the prostate bed, or hormonal therapy, because of the limited ability of
conventional imaging (CT and bone scans) in detecting where
the recurrence was located. Thanks to advancements in imaging, these old approaches to BCR appear to be changing.
Approximately 50% of men who have had a radical prostatectomy with BCR have recurrent prostate cancer in the prostate
bed. Multiparametric MRI of the prostate bed utilizing an en-dorectal coil and dynamic gadolinium enhancement of the prostate bed has been shown to be highly sensitive (88%) in the
detection of recurrent prostate cancer when it occurs in the prostate bed when PSA levels after prostatectomy exceed 0.2 ng/ml.
These results enable the radiation oncologist to more confidently
target the radiation to the exact site of prostate cancer recurrence without the guessing. In addition, if prostate cancer is not
detected in the prostate bed, patients can avoid unnecessary radiation to the prostate bed that has occurred in the past.
If the multiparametric MRI of the prostate bed is negative,
many medical centers are now turning to new PE T/CT imaging
agents that are much more sensitive in detecting metastatic prostate cancer to areas outside the prostate bed such as lymph nodes
and bony structures. These new FDA-approved PET/CT imaging agents include C- 11 Choline and F- 18 Fluciclovine with several other agents undergoing FDA review, including Ga-68
PSMA, F-a8 Choline, C- 11 Acetate, and Ga-68 Bombesin.
These new PET/CT imaging agents are detecting precise locations of recurrent prostate cancer outside the prostate bed with
Radiology Is Playing a Larger Role
in Prostate Cancer Diagnosis and
Radiology is leading the way in advancing the diagnosis and treatment of biochemically recurrent prostate cancer, and ARRS is providing our membership the latest educational
activities in support of these fast-moving developments.
The diagnosis of prostate cancer has been greatly enhanced
with the recent introduction of multiparametric prostate MRI as a
complementary imaging tool in the assessment of men with an abnormal prostate specific antigen (PSA) blood test. Studies are now
confirming that the appropriate use of multiparametric MRI of the
prostate in men with an abnormal PSA result is a more accurate
approach in the diagnosis of clinically significant prostate cancers
and reduces the number of unnecessary biopsies and surgeries.
The contributions of multiparametric MRI have helped narrow down those patients who might best benefit from definitive
treatment such as robotic prostatectomy and radiation therapy.
Despite these new innovative diagnostic and therapeutic techniques, 20–50% of men who have undergone treatment (surgery
or radiation therapy) for prostate cancer go on to develop “
biochemical recurrence” (BCR) of their prostate cancer within 10
years of their treatment. BCR prostate cancer occurs when there
is reappearance of the PSA in the blood in patients who have undergone definitive therapy for their prostate cancer (radical prostatectomy or radiation therapy).
The American Urological Association (AUA) defines biochemical recurrence after a radical prostatectomy (RP) as the
presence of a PSA greater than 0.2 ng/mL measured 6–13 weeks
after RP, followed by a confirmatory test showing a persistent
PSA greater than 0.2 ng/mL. BCR indicates that the prostate
cancer has either recurred in or around the prostate bed or has
metastasized to lymph nodes or bony structures. The definition of
BCR following radiation therapy is more problematic. The AUA
and the American Society for Radiation Oncology define BCR after
2017–2018 ARRS President
The diagnosis of prostate cancer has
been greatly enhanced with the recent
introduction of multiparametric prostate
MRI as a complementary imaging tool in the
assessment of men with an abnormal prostate
specific antigen (PSA) blood test.
President's Message continues on p. 14