Boston Archives

Prostate Imaging Elevated By Deep Learning

Posted by Mukesh Harisinghani, MD | Mar 2022

Mukesh Harisinghani, MD, Director of Abdominal MRI at Massachusetts General Hospital and Professor of Radiology at Harvard Medical School in Boston, Massachusetts, discusses how deep learning algorithms can improve the efficiency and accuracy of prostate cancer imaging. He highlights the importance of widespread prostate cancer screening, observing that every 3 minutes, a man is diagnosed with prostate cancer, and every 17 minutes, a man dies of prostate cancer. Dr. Harisinghani notes that patients want to get a multiparametric (mp)MRI if there is a clinical suspicion of prostate cancer and, if negative, avoid a biopsy in order to prevent unnecessary intervention and avoid cost. Because this is such a widespread need and mpMRIs are relatively time-consuming, he argues there is a need to figure out how to reduce scan time and not lose accuracy. Dr. Harisinghani explains that the two main time sinks in prostate mpMRI are T2-weighted imaging and diffusion-weighted imaging (DWI). He then demonstrates how deep learning reconstruction using software like AIR Recon DL in all 3 planes leads to significant time gain for T2-weighted imaging. Dr. Harisinghani says that many might be hesitant to ‘skimp’ on DWI, since higher b value (which takes a longer time to attain) leads to better image quality. However, he argues that deep learning can reduce scan time without reducing scan quality in DWI, and presents images comparing standard DWI and Air Recon DL to show the improved quality of the latter. Dr. Harisinghani concludes that a scan time of less than 10 minutes is not necessarily just a dream if you can apply Air Recon DL to both T2 and DWI.

Standard Treatments and Global Perspective

Posted by Marc B. Garnick, MD | Jan 2022

Marc B. Garnick, MD, the Gorman Brothers Professor of Medicine at Harvard Medical School and the Beth Israel Deaconess Medical Center, summarizes recent developments in nomenclature, disease states, and standard treatments for advanced prostate cancer. Using material from a chapter he wrote for ASCO-SEP with David J. Einstein, MD, Assistant Professor of Medicine at Harvard Medical School, Dr. Garnick begins by considering the new language used to describe different states of advanced prostate cancer, including non-metastatic castrate-sensitive prostate cancer (nmCSPC), non-metastatic castrate-resistant prostate cancer (nmCRPC), metastatic castrate-sensitive prostate cancer (mCSPC), and oligometastatic prostate cancer. He then discusses new standards of care for these different states, highlighting recent research indicating the benefits of using darolutamide, enzalutamide, and apalutamide in the nmCRPC setting, and explaining how to appropriately layer and sequence therapies across disease states. He briefly looks at the role of next-generation sequencing in informing the potential benefit of PARP or PD-L1 inhibitors and touches on bone considerations in mCRPC. Dr. Garnick concludes with some comments on the global inequities of prostate cancer treatment, citing data on the significant disparity in mortality-to-incidence rate of prostate cancer in high-income countries compared to low- to middle-income countries.

Testosterone Therapy in Men with Biochemical Recurrence and Metastatic Prostate Cancer

Posted by Abraham Morgentaler, MD, FACS | Sep 2021

Abraham Morgentaler, MD, FACS, Associate Clinical Professor of Urologic Surgery at Harvard University, summarizes results from a recent study on testosterone (T) therapy for patients with biochemical recurrence and metastatic prostate cancer. He provides some background, explaining that physicians have been taught that raising testosterone in a man with prostate cancer is like “pouring gasoline on a fire,” even though approximately 20 years of evidence suggests that T therapy is safe after radical prostatectomy, after radiation therapy, in patients with prostatic intraepithelial neoplasia, and in patients on active surveillance. Dr. Morgentaler notes that his and his colleagues’ research indicates that T therapy is also safe for patients with advanced disease. He then goes over the makeup and design of the observational study, which featured 22 symptomatic men of a median age of 70.5. The median duration of T therapy was 12 months, and all patients reported symptomatic benefit from the treatment. The overall mortality was 13.6% with only one prostate cancer-specific death, and morbidity was fairly low, with no cases of pulmonary embolism, spinal cord compression or pathological fractures, and no observed rapid or precipitous progression of disease. Dr. Morgentaler highlights one 94-year-old patient’s experience, describing how this man wanted to be on testosterone because androgen deprivation made him too tired to do the things he enjoyed. After 6 weeks of T therapy, this patient’s brain was clearer, his appetite had improved, and he was exercising daily, and even though he died at age 95 after 11 months of therapy, Dr. Morgentaler emphasizes the importance of T therapy’s benefit to his quality of life in his final months. He concludes that there are men who prioritize quality of life over duration, that data contradict the idea that T therapy is dangerous for patients with prostate cancer, and that T therapy might in fact be a reasonable option for selected men with metastatic disease who refuse androgen deprivation.

The Prostate – Highlights of Prostate Cancer Advances As Covered in ASCO-SEP

Posted by Marc B. Garnick, MD | Sep 2021

Marc B. Garnick, MD, the Gorman Brothers Professor of Medicine at Harvard Medical School and the Beth Israel Deaconess Medical Center, provides a capsulated summary of key references from the ASCO Self-Evaluation Program (ASCO-SEP) 7. He also distills information of interest for practice change related to urologic oncology, particularly prostate cancer, published over the last 12-18 months. Dr. Garnick covers topics including: the emerging role and trends of MRI following elevated PSA values; the introduction of the first oral GnRH antagonist (relugolix) for endocrine management of locally advanced, biochemical recurrence or de novo metastatic castration-sensitive prostate cancer; improvements in overall survival (OS) with the addition of androgen receptor antagonists to androgen deprivation therapy; and approvals of three drugs for improving metastasis-free survival and OS in non-metastatic castration-resistant prostate cancer. Dr. Garnick then reviews ASCO, European Association of Urology (EAU), and ASTRO guidelines published during the COVID-19 pandemic and concludes by sharing data from within the ASCO-SEP chapter on genitourinary cancers that offer a global perspective on mortality disparities for prostate, bladder, kidney, testicular, and penile cancers. He finishes the presentation by pointing out a “sobering” difference in mortality-to-incidence ratios, a parameter to estimate health system performance, between high- and low-to-middle-income countries worldwide.

Current and Emerging Imaging Tools for Improving Risk Assessment and Selection of Patients for Biopsy

Posted by Clare Tempany, MB, BCh, BAO | Jun 2021

Clare Tempany, MD, the Ferenc A. Jolesz Professor of Radiology at Harvard Medical School in Boston, Massachusetts, summarizes evidence for multiparametric magnetic resonance imaging’s (mpMRI) utility in prostate cancer diagnosis, and goes over recent developments in its use. She first looks at selection criteria for biopsy and biopsy type, including history, digital rectal examination (DRE), prostate specific antigen (PSA), and imaging, arguing that mpMRI is particularly helpful in allowing patients to avoid unnecessary biopsies. Dr. Tempany then defines state-of-the art mpMRI as featuring diffusion/apparent diffusion coefficient, being T2-weighted, being IV contrast/dynamic contrast enhanced, and as being reported using the PI-RADS v2.1 assessment. She goes over the PI-RADS assessment categories, considers the findings of multiple publications backing up the value of mpMRI as compared to transurethral ultrasound (TRUS), and looks at evidence supporting guidance indicating patients with PI-RADS 3 lesions should get a biopsy. Dr. Tempany follows this up by summarizing a paper from the PI-RADS steering committee on how PI-RADS and mpMRI should be used. Suggestions include performing mpMRI in most men suspected of having clinically-significant disease, providing a safety net of monitoring for patients who decline immediate biopsy after low-likelihood MRI findings, and using a combination of systematic and targeted biopsies in biopsy-naive patients while only using targeted biopsies for patients with prior negative findings on TRUS. Dr. Tempany then notes that the AUA, EAU, and NICE guidelines all now recommend MRI before biopsy, and also observes that MRI is cost-effective if it leads to the avoidance of biopsy. She concludes by listing areas for future development, including multi-omics, molecular pathology, germline mutations, CTC/blood biomarkers, and mass spectrometry.