No one can dispute the superiority of multiparametric MRI (mpMRI) over transrectal ultrasound (TRUS) for detecting and characterizing prostate cancer (PCa) before biopsy and treatment. The past five years alone have seen a rapid accumulation of research evidence that mpMRI makes it possible to save medical dollars by avoiding unnecessary biopsies and their risks. While this makes fantastic economic sense in terms of healthcare dollars, above all it’s simply in a patient’s best interest.

In addition, mpMRI’s pictorial information about the extent and nature of an individual’s PCa facilitates treatment choice and advance planning. Will the patient be best served by a whole-gland treatment, a hemiablation (half the gland) if PCa is only on one side, a focal therapy, or Active Surveillance? Answering this depends on quality imaging and expert interpretation, while additional genomic testing and clinical factors can round out an optimum therapy decision. In short, there’s no question that mpMRI is the reigning king of prostate imaging prior to treatment.

The best imaging after treatment

Once a patient is on the other side of treatment, he commits to monitoring treatment results for the rest of his life. We don’t yet have a “silver bullet” treatment that is guaranteed to cure prostate cancer. Thus, every treatment comes with a risk (however small) of recurrence. Because there are excellent salvage treatment choices, detecting and identifying recurrence as early and accurately as possible offers the greatest hope of conquering the cancer for good.

The location and extent of any recurrence determines the appropriate salvage choice(s), so the imaging has to determine which category it falls into:

1. Is the PCa recurrence still localized in the gland or immediately adjacent prostate bed if radiation, partial gland ablation, or focal ablation was performed, or in the immediately adjacent prostate bed if prostatectomy was done? This is called local or residual recurrence.
2. Is the PCa more advanced and exists beyond the prostate bed in regional lymph nodes, nearby bone, or more distant spread? This is called advanced or metastatic disease.
3. Is the PCa both locally recurrent as well as advanced?

In these three areas, mpMRI emerges head and shoulders above other imaging modalities.

The authors of a December, 2019 article in the journal Abdominal Radiology definitively state the importance of mpMRI: “The importance of differentiating between local tumor recurrence, distant metastatic disease, and a combination of both in a patient with biochemical recurrence of prostate cancer is essential for appropriate treatment selection. Magnetic resonance imaging (MRI) is the best test for localization and characterization of locally residual or recurrent prostate cancer.”[i] (Emphasis mine) The authors are well-qualified to make this judgment, as they represent the Mayo Clinic and Duke University—two renowned prostate cancer diagnostic and treatment centers.

They emphasize that imaging experience matters greatly. The radiologist must understand the strengths of each MRI imaging sequence, or parameter, and what the findings mean in terms of post-treatment anatomy and how tumor recurrence appears after prostatectomy, radiation or focal treatment. The use of at least three imaging sequences is as valuable as in a pre-biopsy patient, but in particular they stress that dynamic contrast-enhanced (DCE) MRI is a particularly important parameter for revealing tumor activity when recurrence is suspected.

At the Sperling Prostate Center, we have long recognized the unexcelled merits of mpMRI for prostate imaging, and are proud to be at the imaging forefront in this specialty. Our services include not just first-line imaging before biopsy/treatment, and mpMRI to detect suspected recurrence, but we also provide expert second opinions on image CDs for patients whose scans were obtained at other facilities.

Multiparametric MRI has been a profound game-changer in the world of prostate cancer, and a great gift to patients by generating the very best visual portrait of PCa at any stage of detection and diagnosis. For that, mpMRI well deserves its first-place blue ribbon.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Potretzke TA, Froemming AT, Gupta RT. Post-treatment prostate MRI. Abdom Radiol (NY). 2019 Dec 2. doi: 10.1007/s00261-019-02348-x. [Epub ahead of print]