F. Garibaldi – INFN Roma and ISS Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS importance of ear;ly diagnosis PET MRI PET/MRI TOF-PET challenges choice of scintillator the readout summary and outlook

Advanced molecular imaging techniques in the detection, diagnosis, therapy, and follow-up of prostate cancer F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’

Frontiers in Imaging science: Advanced molecular imaging techniques in the detection, diagnosis, therapy, and follow-up of prostate cancer F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’ Workshop on Compton Camera Applications to Bio-medical Imaging Mattinata 5-7 September 2002 Frontiers in Imaging science: high performance detectors for vascular disease (brain and heart) imaging based on the latest developments in scintillators, photodetectors, and solid state materials Rome - ISS - 12,13,14 November 2006

DECEMBER 6 2006 9:00 I. Opening session (Chairman: Prof. F. Di Silverio, University La Sapienza,Rome, Italy- Prof. F.Micali,University Tor Vergata) 10:50 II. Prostate Cancer Diagnosis (Chairman: Prof. F. Di Silverio University La Sapienza, Rome, Italy) 14:30 III. New techniques (Chairman: Prof. A. Stefanini, University Pisa, A.Tubaro, University La Sapienza, Rome, Italy) 16:20 IV. Staging (Chairman:Prof.F. Micali,University Tor Vergata, Rome, Italy DECEMBER 7 2006  8:30 V. Therapy and follow up (Chairman: Prof. L. Miano, University La Sapienza, Rome, Italy) 14:30 VI. Satellite Technical Workshop on New Nuclear Medicine Detectors For Imaging Prostate Cancer

INCIDENCE 55/100,000 per year in Europe 9000 new cases/year in Italy Prostate Cancer Diagnosis: MRI INCIDENCE 55/100,000 per year in Europe 9000 new cases/year in Italy Prostate cancer is the most common cancer and the second leading cause of cancer death in Italian men

Most common solid tumor in men over 50 PROSTATE CANCER Most common solid tumor in men over 50

PSA: Sensitivity and Specificity Any Cancer (n.: 1225) VS No Cancer (n: 4362 pts) PSA level Sensitivity Specificity 1,1 ng/ml 83,4 38,9 1.6 ng/ml 67 58,7 2.1 ng/ml 52,6 72,5 2.6 ng/ml 40,5 81,1 3.1 ng/ml 32,2 86,7 4.1 ng/ml 20,5 93.8 6.1 ng/ml 4,6 98,5 8.1 ng/ml 1,7 99,4 10.1 ng/ml 0,9 99,7 Cutoff? PSA remains an important prognostic markers of the biological potential of newly diagnosed prostatic cancer and the best marker to evaluate treatment outcome. It will be a challenge to the medical community to change the long- held notion that there is a “normal” PSA value at which to recommended biopsy. PSA proxy as Age, PSA Density, PSA velocity, Free PSA, ACT-PSA, BPSA can help the physician in the decision making process. Future markers or tools for the early detection of clinically significant prostate cancer and to avoid unnecessary biopsy are strongly needed. Thompson IM, JAMA 2005

Recent INDICATIONS for BIOPSY PROSTATE CANCER Recent INDICATIONS for BIOPSY Abnormal PSA level DRE + false negative false positive BIOPSY Not necessarily BIOPSY TRUS (hypoechoic lesion) normal DRE and PSA

CONCLUSION diagnosis I level PSA DRE II level TRUS BIOPSY MRI and Spectroscopy

LA NEOPLASIA PROSTATICA BIOPSIA PROSTATICA ECOGUIDATA Volume < 50 g 8 prelievi Volume > 50 g 12 prelievi

LA NEOPLASIA PROSTATICA ECOGRAFIA TRANSRETTALE CON DOPPLER

INCIDENCE 55/100,000 per year in Europe 9000 new cases/year in Italy Prostate Cancer Diagnosis: MRI INCIDENCE 55/100,000 per year in Europe 9000 new cases/year in Italy Prostate cancer is the most common cancer and the second leading cause of cancer death in Italian men

TRUS State of Art DRE PSA EARLY DIAGNOSIS PITFALLS Prostate Cancer Diagnosis: MRI State of Art DRE Normal DRE and PSA < 4.0 ng/ml Do not exclude prostate cancer* PSA Sensibility PSA level ≤ 4.0 ng/ml 67.5 - 80% PSA level > 4.0 ng/ml 60 - 70% DIAGNOSTIC PITFALLS 30% palpable lesions at DRE False Positive high rate 20% hypoechoic lesions are truly malignant** TRUS EARLY DIAGNOSIS PITFALLS *Catalona WJ, Smith DS ,Ornstein DK et al. JAMA 277: 1452-1455, 2004 **Langer JE et al. Semin Roentgenol 34: 284-294,,2004

75 - 90% Sensitivity for Prostate Cancer (97% for known lesions) Prostate Cancer Diagnosis: MRI MRI: Morphologic Imaging Sensitivity for Prostate Cancer 75 - 90% (97% for known lesions) low score for lesions < 5 mm Carcinoma of the Prostate Gland: MRI Imaging with Pelvic Phased-Array Coils vs Integrated Endorectal-Pelvic Phased-Array Coils. Radiology 1994;193:703-709

55% Specificity for Prostate Cancer High false positive scores Prostate Cancer Diagnosis: MRI MRI: Morphologic Imaging Specificity for Prostate Cancer 55% High false positive scores (low intensity areas at T2 mapping) Prostate Cancer: Effect of Postbiopsy Hemorrhage on Interpretation of MR Images. Radiology 1995;195:385-390

Prostate Cancer

18F-fluorocholine (FCH) Prostate Rectum Collimator Gamma Imager Single Photon: 111In-ProstaScint PET: 11C-choline 11C-acetate 18F-fluorocholine (FCH) W. Moses LBL N. Clinthorne. Michigan S. Majewski Jefferson Lab

. Magnetic Resonance spectroscopic imaging (MRSI) provides a noninvasive invasive method of detecting small molecular markers (metabolites) within the cytosol or in extracellular spaces of the prostate and is performed in conjunction with high spatial resolution (.55 x .55 mm, x 3 mm) anatomic imaging. • Commercial packages to perform prostate MRI/MRSI in a clinical setting are becoming available and Multi-site clinical trials of prostate MRI/MRSI are underway.s