looking ahead -what’s new in prostate cancer diagnosis docs/4 - ms... · looking ahead -what’s...
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Looking Ahead -What’s New in
Prostate Cancer Diagnosis
Mr Matt Simms
Consultant Urologist
Hull and East Yorkshire Hospitals
Incidence of Prostate Cancer at Post
-Mortem
Age at PM % Ca Prostate
<30 5%
30-39 25%
40-49 35%
50-59 45%
60-69 65%
70-79 80%
The Ten Most Common Cancers in 1984, 2007 and projected to 2030
Number of Cases, Persons, UK
Cancer Site 1984Cancer Site 2007 Cancer Site 2030
Lung 43,049Breast 45,758 Prostate 61,090
Colorectum* 29,216Lung 39,490 Colorectum* 58,176
Breast26,600
Colorectum*38,442
Breast57,442
Stomach 13,329Prostate 36,083 Lung 57,201
Prostate 11,714Uterus 15,062 Malignant Melanoma 21,824
Bladder11,629
Non-Hodgkin Lymphoma 10,928
Uterus21,443
Uterus9,112
Malignant Melanoma10,723
Non-Hodgkin Lymphoma 15,386
Pancreas 6,811Bladder 10,151 Kidney 14,815
Ovary 5,500Kidney 8,205 Bladder 14,092
Leukaemia 5,443Oesophagus 7,969 Pancreas 11,927
Diagnosing Prostate Cancer- What are
We Trying to Do?
• An efficient, cost effective diagnostic pathway
• Diagnostic pathway should be acceptable to patients
• Should avoid excess morbidity
• Should be good at detecting clinically significant prostate cancer
Benefits of A Standardised Prostate Cancer
Diagnostic Pathway Across Yorkshire and
Humber
• Opportunity to introduce high quality, safe
and efficient diagnostic pathway across the
region
• Better for patients
• Easy referral between trusts and MDTs
• May ultimately be more cost effective
Traditional Diagnostic Pathway
• Detects 80% of cancers
• Risks overdiagnosing non significant cancer
• Imaging / Staging takes place after diagnosis
• Increasing risk of Sepsis
Sepsis
• Currently up to 6% of patients develop
significant sepsis following TRUS/S Biopsy
• Incidence of Ciprofloxacin resistant coliforms
is increasing
• Associated with repeat biopsies and antibiotic
use in last 6 months
Prostate cancer: diagnosis and treatment
Issued: January 2014
Consider …….
• Multiparametric MRI for assessing T Stage
• At enrolment of Active Surveillance
• If previously negative biopsy and suspicion of
cancer
Pre Biopsy MRI
Advantages• Negates issue of post biopsy haemorrhage
• Allows for rapid disease staging (31/62!)
• Could allow accurate targeting of lesions
• Has the potential to reduce number of biopsies
Potential Disadvantages• Cost
• Wasted Resource
• Logistics
• mpMRI is a new tool
Multiparametric MRIAllows radiologists to
• See how tightly cells are packed (diffusion weighted imaging)
• Assess blood flow (dynamic contrast enhanced MRI)
• Assess chemical make-up (Spectroscopy)
Allows differentiation between benign and malignant issue
• The advantages of MP MRI are lost if it is performed too soon after biopsy
Pi-RADS score
Pi-RADS classification Definition Total score T2,DWI,DCE
1 Most probably benign 3-4
2 Probably benign 5-6
3 Indeterminate 7-9
4 Probably malignant 10-12
5 Highly suspicious of
malignancy
13-15
Roethke M, Blondin D, Schlemmer HP, Franiel T (2013) PI-RADS classification:
structured reporting for MRI of the prostate. Rofo 185:253–261
Pi-RADS
• Pi-RADS 1-2
Negative predictive score 84%
• Pi- RADS 4-5
92% sensitivity for detecting Gleason 4-5
disease
Truss Biopsy
• Sextant biopsy 60% of cancer
• 8 biopsies 75% of cancer
• 10 core specimen 78% of cancer
• 12 core specimens 90% of cancer
Fink, et al Urology 2001;58,735-739
Biopsy Types
• Standard 12 core biopsy
• Cognitive Biopsy
• MRI Fusion Biopsy
• Template transperineal biopsy
Transperineal Biopsy
MRI Fusion Biopsy
Incidence of Carbapenem Resistant Enetrobactriaecae
Worldwide Prevalance of Carbapenem
Resistant Enterobacteriaecae
Countries with High Incidence of Healthcare Associated
Carbapenem Resistant Enterobacteriaceae
• Bangladesh
• Balkans
• China
• Cyprus
• Greece
• India
• Ireland
• Italy
• Pakistan
• SE Asia
• Turkey
Sites of Healthcare
Associated
Carbopenamase
Resistant
Enterobacteriaecae
outbreaks across
UK 2010
Antibiotic Susceptibilities for Carbapenem Resistant
Enterobactriaecae
Lancet Infectious Diseases
2010 ;10:597-602
Avoiding Sepsis
Rectal Swabs – could
potentially Identify those with
resistant organisms
Rectal Cleansing with iodine
might reduce sepsis rates
Tailored Antibiotic
Usage – might prevent development
of resistant strains
Questions
• Do we feel that pre biopsy MRI is useful
(what are the barriers to implementing this)?
• How can we protect patients from
bacteraemia / sepsis from multi resistant
organisms?
• What does the ideal prostate cancer
diagnostic pathway for patients in Yorks and
Humber look like?
• Should be able to reliably detect clinically
significant prostate cancer
• Is likely to see increasing use of pre- biopsy
MRI (PROMIS Study)
• Needs more microbiological input
• Biopsies (and antibiotics) need to be tailored
to individual patients
Prostate Cancer Diagnosis in the
Future
Discussion and Questions