Radiology

Imaging recommendations were based on existing NICE guidance and regional protocols. 

Imaging recommendations can be broken down into the following categories: 

• Imaging in the primary diagnosis and staging of patients fit for radical treatment. This group is sub-divided into those with high risk of metastatic disease and those with low to moderate risk. 
• Imaging in Active Surveillance. 
• Imaging in biochemical relapse following radical treatment. 

MRI

• Offer magnetic resonance imaging (MRI) as the primary imaging investigation in suspected prostate cancer in the primary diagnosis and staging of patients fit for radical treatment. 
• Offer either bi-parametric or multi-parametric MRI depending on local availability.
• 3T MRI is the preferred option where available and will often obviate the need for contrast sequences. 
• Request card should state if a patient has hip prostheses. 
• Patients who are fit for radical treatment should go direct to MRI without the need for digital rectal examination.

MRI should be part of initial evaluation of all patients unless high risk of metastases 

Cross-sectional imaging with computed tomography (CT) (chest abdomen & pelvis)

Isotope bone scan if two of the following criteria are present 

*PSA≥20

*International Society for Urological Pathologists (ISUP) Grade group ≥3 (i.e Gleason ≥4+3), or other aggressive feature on pathology.

*Suspicion of bony metastases, T3 disease or N1 disease on MR or raised alkaline phosphatase or metastatic symptoms. 

Note: if available, Whole Body Diffusion MR can be used as additional investigation. 

Prostate-specific membrane antigen positron emission tomography (PSMA PET) for selected patients with equivocal findings on conventional imaging where PSMA will directly affect treatment. 

Intervals

NICE Guidance – At 12 to 18 months: MRI (if there is concern about clinical or prostate-specific antigen changes at any time during active surveillance, reassess with MRI).

For further information on active surveillance see the page within the CMP.

PSMA PET

• Biochemical recurrence after radical prostatectomy (PSA ≥0.2ng/mL on ≥2 consecutive samples). PSMA is particularly useful in investigating patients with low PSA values between 0.2 and 10 ng/ml. In patients with PSA>5, or rapidly rising (doubling time < 6months), PSMA should only be considered where conventional imaging has been performed and has been negative or equivocal. 
• Biochemical recurrence after radical radiotherapy/brachytherapy (PSA nadir + 2ng/ml) in patients being considered for salvage therapy following negative or equivocal conventional imaging. 

• Biochemical recurrence (PSA ≥0.2ng/ml) after surgery and salvage radiotherapy where there is intent for further salvage loco-regional therapy (e.g. salvage lymphadenectomy, nodal RT, SABR) and conventional imaging has been negative or equivocal. 

Assessing post-prostatectomy PSA relapse 

• Recommend PSMA PET as first line and consider MRI where it is felt appropriate. 

See Scottish Clinical Imaging Network (SCIN) guidance for full detail – Indications for the use of PSMA PET CT in Prostate Cancer Patients  

Key criteria to be included in reporting

• Report the results using a 5 point PI-RADS version 2.1 (best practice) or Likert scale. 
• Consider using a standardised reporting template. 
• Provide a calculation on the prostatic volume based on MRI. 
• Key images of lesions considered likely or highly likely to be cancer should be created at time of report. 

• NICE – Management of Prostate Cancer - https://cks.nice.org.uk/topics/prostate-cancer/management/management/   

• Scottish Clinical Imaging Network (SCIN) guidance - Indications for the use of PSMA PET CT in Prostate Cancer Patients [PDF only]  

• Getting it Right First Time GIRFT - Towards better diagnosis management of suspected prostate cancer.pdf [PDF only]  
  
  
• PIRADS v2 
  
  
• PRECISE  

MRI reporting pro forma