0:01

This is a 67-year-old physician.

0:04

He's got a negative physical examination

0:06

and a PSA that's hovering between 4 and 5.

0:11

And I want to focus on surveillance.

0:15

Now, I look at surveillance into

0:17

two categories or two groups.

0:20

The first group is the screening group,

0:23

where the PSA is say between 4 and 10, or

0:27

they've had negative biopsies, and you're

0:30

continuing to follow those patients serially.

0:33

With or without a finding

0:35

that's not aggressive appearing.

0:38

The second group are individuals that have cancer.

0:42

The cancer isn't high-grade, and

0:45

you're following them for that

0:46

reason, or for another related reason.

0:51

I like to break my surveillance

0:53

cases down into risk categories.

0:56

There's a three-tiered stratification system.

1:00

Low risk, intermediate risk, and high risk.

1:03

And the risk is often apportioned by PSA.

1:06

You want the PSA in the low

1:08

risk group to be under 10.

1:10

Closer to 4 would be nice, and

1:12

this patient is close to 4.

1:14

You want the physical

1:15

clinical exam to be negative.

1:17

In other words, no palpable

1:19

dominant peripheral nodules.

1:21

And this patient meets that criteria.

1:24

You want to be sure they haven't had a prior

1:26

biopsy where the Gleason score was greater than 6.

1:30

Well, he's never had a biopsy in this case.

1:33

And you want to make sure that the patient,

1:35

uh, did not have any prior biopsies or cores

1:38

where there was evidence of local invasion.

1:40

That wouldn't apply in this particular case.

1:44

Now, when you survey, in certain cases, you may

1:47

not need to use DCE MRI, especially in screens.

1:50

When you're doing broad screening programs,

1:53

DCE MRI, as shown by Kuhl and others in the

1:57

last six months published in Radiology, DCE-MRI

2:01

does not give you a detection advantage.

2:04

DCE, Dynamic Contrast-Enhanced MRI, is mostly used

2:10

for staging, for assessing lesion aggressiveness,

2:14

for looking at micrometastasis or microinvasion

2:17

of adjacent structures like the seminal vesicle.

2:22

And with a steep influx and a brisk

2:26

washout, that can give you a good idea

2:28

as to the aggressiveness of a lesion

2:30

when that curve is present.

2:34

So, let's take a look at this

2:36

physician's axial T2-weighted MR.

2:39

There is a small area of low signal intensity.

2:43

It's slightly irregular looking.

2:45

I'll scroll the whole image for you.

2:47

Slightly irregular looking.

2:49

A little bit round, but look at

2:51

these sort of speculated edges to it.

2:54

It's not bulging anything.

2:55

It's not contacting the capsule.

2:57

His 6-month prior MRI, exactly identical.

3:02

I get a PSA hovering around 4

3:03

or 5, physical exam negative.

3:06

There is a little bit of ADC map hypointensity.

3:10

There's a little bit of, not more than a

3:13

little bit, a mild diffusion restriction in

3:17

the left posterior peripheral zone, close to

3:20

the PZM medial, or peripheral zone medial,

3:25

and that has remained absolutely intact.

3:28

stable since the prior examination.

3:30

So, he has elected, as a physician with

3:32

some knowledge, to serially follow this.

3:35

Now, what might push you towards intervening?

3:39

Well, if he becomes symptomatic, if a nodule

3:42

is palpable on physical examination, if

3:45

there is a change in the morphology on the

3:48

T2-weighted image, if there is a change in

3:51

the degree of diffusion restriction.

3:54

Let's take a look at his DCE MRI and

3:56

see if there's any hypervascularity.

3:58

And the answer is, yes, there was

4:00

a little bit of hypervascularity.

4:02

Let's go right to the lesion.

4:03

Here we are.

4:04

Let's go to the first image.

4:06

And right there you can see a little bit

4:07

of enhancement corresponding to that locus.

4:11

So you could make a case either way.

4:14

For going in and intervening on

4:16

this lesion or for watching it.

4:18

He chose to watch it.

4:20

For reasons we've already discussed.

4:22

And we have his six-month prior MRI.

4:25

Which I'm going to show you in a few moments.

4:28

Now there, there have been some surveillance

4:30

criteria that have been published.

4:32

And these are known as Epstein inclusion criteria.

4:36

Although it is an older publication from 1994.

4:39

And those criteria would include

4:42

any nodules that are less than

4:46

0.2 cubic centimeters.

4:47

This one's a little bigger than that.

4:49

Let's, let's take a measure of it.

4:51

Let's see how big it is.

4:55

So it's about 8 millimeters,

4:58

so it's gonna be bigger than

4:59

0.2 cubic centimeters.

5:01

Um, if the original cancer, if you're surveying

5:04

somebody that had cancer, you want that

5:07

lesion to be less than 5 cubic centimeters.

5:11

You want the PSA density to be less than

5:13

0.01 nanograms.

5:15

And you want, if they've had

5:17

prior biopsy, wouldn't apply here,

5:18

the Gleason score to be under 7.

5:21

The number of positive cores on

5:23

any prior biopsy to be less than 3.

5:25

The volume of core positivity to be less than 50%.

5:29

And it must be clinically organ-confined.

5:33

So now let's turn our attention

5:35

to the 6-month prior examination.

5:38

Let's put it up, shall we?

5:41

So here's our 67-year-old physician 6 months ago.

5:45

And here he is now.

5:49

There is our lesion.

5:51

It is identical.

5:53

Let's make them about the same size.

5:56

It is identical in shape and overall

5:58

volume and position as it was before.

6:02

The diffusion restriction is also identical.

6:07

I won't show you the DCE

6:09

MRI, but it was identical.

6:11

So I'd like to make three points.

6:13

First, who, who is a candidate for, for screening?

6:17

I've already given you tier one criteria,

6:19

some Epstein exclusion criteria, and there are

6:24

different types of groups that we will evaluate.

6:26

Have Patients that are in this low-risk

6:28

category that have had negative biopsies.

6:32

Patients that are in this low-risk

6:33

category that don't want to have a biopsy.

6:37

Uh, patients that are at high risk

6:40

that have had prior cancer where

6:42

they haven't had a prostatectomy.

6:44

And those patients will be surveyed as well.

6:47

Now the next question, the next point is, How

6:51

frequently should you survey these individuals?

6:54

If the patient has had a negative biopsy,

6:57

I like to have my first MRI within six

6:59

months, and then yearly thereafter.

7:02

If you're just surveying somebody in the

7:04

low tier, low-risk category, who is not

7:09

excluded by Epstein exclusion criteria, then

7:12

that individual I would survey every year.

7:15

Now what about if a patient's had a

7:17

biopsy and you're going to be, you're

7:18

going to be surveying those patients?

7:20

How long should you wait?

7:22

The literature says about

7:23

approximately eight weeks.

7:26

Finally, the third point

7:27

I want to make is the why.

7:29

Why would we use surveillance?

7:32

Because it leads to less frequent

7:34

biopsies and less frequent prostatectomies

7:36

and less frequent overtreatment.

7:39

And because MRI is so good at detecting

7:42

aggressive cancer and not so good at detecting

7:45

non-aggressive or lower-grade cancers, it fits

7:48

into the surveillance strategy pretty darn well.

7:52

So again, you're looking at an example

7:55

of somebody that, He has a lowish PSA.

8:00

He has a negative physical examination.

8:03

He doesn't meet any Epstein exclusion criteria.

8:06

He's in the Tier 1 category.

8:08

He initially had a study

8:10

that shows an abnormality.

8:11

It's small in size.

8:13

It's not near the capsule.

8:15

He has chosen to be followed by

8:17

MRI rather than undergo an MRI.

8:19

A biopsy and potential prostatectomy for this

8:23

lesion, and that's exactly what we're doing.

8:26

An example of surveillance.

8:28

You've heard the who, the why, and the what.