ACR Appropriateness Criteria ® Prostate Cancer—Pretreatment Detection, Surveillance, and Staging

Abstract

Despite the frequent statement that "most men die with prostate cancer, not of it," the reality is that prostate cancer is second only to lung cancer as a cause of death from malignancy in American men. The primary goal during baseline evaluation of prostate cancer is disease characterization, that is, establishing disease presence, extent (local and distant), and aggressiveness. Prostate cancer is usually diagnosed after the finding of a suspicious serum prostate-specific antigen level or digital rectal examination. Tissue diagnosis may be obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy. The latter requires a preliminary multiparametric MRI, which has emerged as a powerful and relatively accurate tool for the local evaluation of prostate cancer over the last few decades. Bone scintigraphy and CT are primarily used to detect bone and nodal metastases in patients found to have intermediate- or high-risk disease at biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Probing structure of normal and malignant prostate tissue before and after radiation therapy with luminal water fraction and diffusion‐weighted MRI

“…MAGNETIC RESONANCE IMAGING (MRI) is now accepted as the primary imaging method for diagnosing and T‐staging prostate cancer, for stratifying patients with prostate cancer to appropriate management options, and for their follow‐up after radical treatment . In addition, MRI is used to monitor patients deemed to have a favorable prognosis, where disease is classified as being at low risk of progression based on imaging and pathological features.…”

State‐of‐the‐art imaging techniques in the management of preoperative staging and re‐staging of prostate cancer

“…Since then, several studies have examined its accuracy in the diagnosis and staging of PCa, with considerable differences in terms of magnetic field strengths, endorectal coil and protocol study related to a variable combination of functional techniques, such as spectroscopy (magnetic resonance spectroscopy), DWI and DCE. 5,15 In 2012, the European Society of Urogenital Radiology published the first edition of the "prostate MR guidelines" in order to define the appropriate standards for carrying out and reporting the mpMRI, which combines high-resolution T2 and at least two functional techniques, mainly DWI and DCE. It requires a high-field scanner (≥1.5 T) and a combination of pelvic phased-array and endorectal coil; the latter is not an absolute requirement with 3 T. 15,16 Furthermore, with the aim of easy reporting of the data between radiologists and urologists, they developed a score (PI-RADS score) that assesses the likelihood of cancer, and its eventual degree of ECE, on a 5-point score on each MRI sequence (T2WI, DW-MRI, DCE-MRI), with a precise description of the location of the tumor.…”

“…We will take into consideration the main published guidelines that arise from the EAU, 5 the AUA, 54 the NCCN, 55 the NICE 56 and the ACR. 15 TRUS is mostly carried out with the aim of localizing the prostate gland during systemic biopsy. The EAU guideline suggest that TRUS and its derived techniques, such as 3-D and color Doppler TRUS, have no sufficient accuracy to be recommended for routine staging in PCa.…”

“…Thus, even if the EAU guideline discourages the routine use for local staging among low-risk patients, the EAU, ACR and NCCN guidelines recommend MRI in all intermediate-or high-risk patients in order to plan the surgical management. 5,15,56 The use of cross-sectional imaging techniques has very low sensitivity (<40%) for nodal staging of PCa. The EAU, AUA and ACR guidelines recommend using cross-sectional imaging techniques to assess the N stage in intermediate-and high-risk patients, 5,15,54 and the NCCN and NICE guidelines recommend CT or MRI as part of the staging work-up only in high-risk patients.…”

“…5,15,56 The use of cross-sectional imaging techniques has very low sensitivity (<40%) for nodal staging of PCa. The EAU, AUA and ACR guidelines recommend using cross-sectional imaging techniques to assess the N stage in intermediate-and high-risk patients, 5,15,54 and the NCCN and NICE guidelines recommend CT or MRI as part of the staging work-up only in high-risk patients. 55,56 The role of PET/CT in PCa staging is rapidly increasing, and several new radiotracers have been introduced with promising results.…”