Multimodality imaging: prostate cancer diagnosis
and follow up by TOF-PET & MRI/MRS
F. Garibaldi – INFN Roma and ISS
- importance of ear;ly diagnosis
- PET
- MRI
- PET/MRI
- TOF-PET challenges
- choice of scintillator
- the readout
- summary and outlook
Advanced molecular imaging techniques in the detection, diagnosis, therapy,
and follow-up of prostate cancer
F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’
Advanced molecular imaging techniques in the detection, diagnosis, therapy,
and follow-up of prostate cancer
F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’
Workshop on Compton Camera
Applications to Bio-medical Imaging
Mattinata 5-7 September 2002
Frontiers in Imaging science:
high performance detectors for vascular disease (brain and heart)
imaging based on the latest developments in scintillators,
photodetectors, and solid state materials
Rome - ISS - 12,13,14 November 2006
DECEMBER 6 2006
9:00
I. Opening session (Chairman: Prof. F. Di
Silverio, University La Sapienza,Rome, ItalyProf. F.Micali,University Tor Vergata)
10:50 II. Prostate Cancer Diagnosis (Chairman: Prof. F.
Di Silverio University La
Sapienza, Rome,
Italy)
14:30 III. New techniques (Chairman: Prof. A.
Stefanini, University Pisa, A.Tubaro,
University La Sapienza, Rome, Italy)
16:20
IV. Staging (Chairman:Prof.F. Micali,University
Tor Vergata, Rome, Italy
DECEMBER 7 2006
8:30 V. Therapy and follow up (Chairman: Prof. L.
Miano, University La Sapienza, Rome, Italy)
14:30 VI. Satellite Technical Workshop on New Nuclear
Medicine Detectors For
Imaging Prostate
Cancer
Prostate Cancer Diagnosis: MRI
INCIDENCE
55/100,000 per year in Europe
9000 new cases/year in Italy
Prostate cancer is the most common cancer and
the second leading cause of cancer death in
Italian men
PROSTATE CANCER
Most common solid tumor in men over 50
PSA: Sensitivity and Specificity
Any Cancer (n.: 1225) VS
No Cancer (n: 4362 pts)
Distribuzione casi per range di PS A
PSA level
Sensitivit
y
Specificit
y
200
150
1,1 ng/ml
83,4
38,9
No K
100
1.6 ng/ml
67
58,7
50
2.1 ng/ml
52,6
72,5
0
K
<4
2.6 ng/ml
40,5
81,1
3.1 ng/ml
32,2
86,7
4.1 ng/ml
20,5
93.8
6.1 ng/ml
4,6
98,5
8.1 ng/ml
1,7
99,4
10.1
ng/ml
0,9
4 e 10
10 e 20
>20
Cutoff?

PSA remains an important prognostic markers of the
biological potential of newly diagnosed prostatic cancer and
the best marker to evaluate treatment outcome.

It will be a challenge to the medical community to change the
long- held notion that there is a “normal” PSA value at which
to recommended biopsy.

PSA proxy as Age, PSA Density, PSA velocity, Free PSA, ACTPSA, BPSA can help the physician in the decision making
process.

Future markers or tools for the early detection of clinically
significant prostate cancer and to avoid unnecessary biopsy
are strongly needed.
99,7
Thompson IM, JAMA 2005
PROSTATE CANCER
Recent INDICATIONS for BIOPSY
• Abnormal PSA level
• DRE +
false negative
BIOPSY
false positive
Not necessarily
• TRUS (hypoechoic lesion)
• normal DRE and PSA
BIOPSY
CONCLUSION
I level
II level
PSA
DRE
TRUS
BIOPSY
MRI and Spectroscopy
LA NEOPLASIA PROSTATICA
BIOPSIA PROSTATICA ECOGUIDATA
Ritenzione acuta
Ematoma
periprostatico
Ematoma perineoscrotale
Sepsi
6
4
3
2
1
Tot.
(%)
1.3
TP
(%)
1.5
TR
(%)
1.1
p
0.3
0.8
0
ns
0.3
0.8
0
ns
0.3
0
0.6
ns
5
Febbre
Difficoltà minzionali
Dolore persistente (48h)
Disuria persistente (48h)
Ematuria persistente (24h)
Microematuria (10/campo)
Leucocituria (10/campo)
Infezioni urinarie
Volume < 50 g
8 prelievi
Volume > 50 g
12 prelievi
Tot.
(%)
1
7.1
1.3
2.7
25.2
16.3
1.7
1.7
TP
(%)
0.8
7.2
2.3
1.6
26.8
15.8
1.6
2.4
TR
(%)
1.1
7
0.6
3.5
24.1
16.7
1.8
1.2
ns
p
ns
ns
ns
ns
ns
ns
ns
ns
LA NEOPLASIA PROSTATICA
ECOGRAFIA TRANSRETTALE
CON DOPPLER
Prostate Cancer Diagnosis: MRI
INCIDENCE
55/100,000 per year in Europe
9000 new cases/year in Italy
Prostate cancer is the most common cancer and
the second leading cause of cancer death in
Italian men
Prostate Cancer Diagnosis: MRI
State of Art
DRE
PSA
Normal DRE and PSA
< 4.0 ng/ml
Do not exclude prostate cancer*
Sensibility
PSA level ≤ 4.0 ng/ml 67.5 - 80%
PSA level > 4.0 ng/ml 60 - 70%
TRUS
DIAGNOSTIC PITFALLS
• 30% palpable lesions at DRE
False Positive high rate
• 20% hypoechoic lesions
are truly malignant**
EARLY DIAGNOSIS PITFALLS
*Catalona WJ, Smith DS ,Ornstein DK et al. JAMA 277: 1452-1455, 2004
**Langer JE et al. Semin Roentgenol 34: 284-294,,2004
Prostate Cancer Diagnosis: MRI
MRI: Morphologic Imaging
Sensitivity for Prostate Cancer
75 - 90%
(97% for known lesions)
low score for lesions < 5 mm
Carcinoma of the Prostate Gland: MRI Imaging with Pelvic Phased-Array Coils vs
Integrated Endorectal-Pelvic Phased-Array Coils. Radiology 1994;193:703-709
Prostate Cancer Diagnosis: MRI
MRI: Morphologic Imaging
Specificity for Prostate Cancer
55%
High false positive scores
(low intensity areas at T2 mapping)
Prostate Cancer: Effect of Postbiopsy Hemorrhage on Interpretation of MR
Images. Radiology 1995;195:385-390
Prostate Cancer
Prostate
Rectum
Single Photon:
111In-ProstaScint
Collimator
Gamma
Imager
PET:
11C-choline
11C-acetate
18F-fluorocholine
(FCH)
W. Moses LBL
Source
Image Plane
N. Clinthorne.
Michigan
1st Detector
2nd Detector
Scattered
 - Rays
S. Majewski Jefferson Lab
. Magnetic Resonance spectroscopic imaging (MRSI) provides a noninvasive invasive
method of detecting small molecular markers (metabolites) within the cytosol or in
extracellular spaces of the prostate and is performed in conjunction with high
spatial resolution (.55 x .55 mm, x 3 mm) anatomic imaging.
• Commercial packages to perform prostate MRI/MRSI in a clinical setting
are becoming available and Multi-site clinical trials of prostate MRI/MRSI
are underway.s