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Imaging Services

Indications for Prostate MRI

  • Surgical Planning
    Benefits from endorectal coil and spectroscopy
    • Robotic-Assisted Laparoscopic Prostatectomy (RALP)
    • Intermediate risk of extracapsular extension
  • Biopsy planning (MR or ultrasound fusion)
    • Rising PSA/high PSA density & negative biopsy
  • Active Surveillance
  • Radiotherapy planning
  • Follow-up rising PSA ("biochemical failure")
    Benefits from endorectal coil and spectroscopy
    • After prostatectomy or radiotherapy
  • Benign disease

Indications for Prostate MRI by Scan Type

  • Staging (with endorectal coil, full pelvis, ± spectroscopy)
    • Surgical Planning
  • Staging (external array, full pelvis, no spectroscopy)
    • Radiotherapy planning
    • Brachytherapy planning
    • Follow-up of rising PSA after prostatectomy or radiotherapy
  • Detection (prostate only, external array only)
    • Rising PSA (or elevated PSA density) & negative biopsy
    • Biopsy planning under MR or US (in development)
  • Either Staging or Detection
    • Active Surveillance (formerly "watchful waiting")
  • Add lumbar spine to pelvis to stage bones/nodes

Prostate MRI: Biopsy Guidance

  • In the face of a rising PSA and negative biopsy, a "second look" is warranted
  • MRI can pinpoint the most suspicious area in the prostate
  • Biopsy can be done directly with MRI or with ultrasound/MRI image fusion under ultrasound guidance
  • Technique is optimized for detection, not staging

Radiation (vs. Biopsy) Planning

  • Extracapsular extension and seminal vesicle invasion are important, and often the reason surgery is deferred
  • Delineation of adjacent structures
    • Urethra and bladder
    • Rectum
    • Pelvic floor muscles and neurovascular bundles
  • Evaluates pelvic lymph nodes and bones
  • Localization of cancer in the prostate is less important, but can guide a "boost"
  • The endorectal coil distorts anatomy, complicating planning, and is omitted

Prostate MRI: Active Surveillance

  • In patients with low volume, low grade disease, MRI provides two advantages
    • Screen for missed areas suspicious for high-grade cancer
    • Baseline imaging for follow-up, to look for subtle changes

Follow-Up Rising PSA: Biochemical Failure

  • A rising PSA level after prostatectomy suggests recurrence of cancer
  • MRI has been shown to be sensitive to detect recurrent cancer
    • Surgical bed
    • Bones
    • Lymph nodes
  • MRI can also detect recurrence in the radiation therapy field
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