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Prostate cancer prevention

PROSTATE CANCER PREVENTION AT ISTITUTO RADIOLOGICO GORTAN IN TRIESTE

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Istituto Radiologico Gortan in Trieste is a radiology, ultrasound, CT and total body MRI clinic that stands out for its efficiency, for offering high-level professional services and for the quality of its instrumental examinations.

Istituto Radiologico Gortan is a specialized center for the research and study of prostate carcinoma.

In our institute we perform specific examinations for :

  • prostate cancer prevention
  • prostate health status
  • magnetic resonance imaging of the prostate
  • evaluation of PSA (Prostate Specific Antigen) values
  • Prostate hypertrophy

Magnetic resonance imaging of the prostate: a new method in the diagnosis of prostate cancer

In Italy prostate cancer is the most common form of neoplasia in the male population, representing more than 20% of all male cancers diagnosed over 50 years. In recent decades its incidence has apparently increased, in Italy as well as in Europe, especially in the over 50s since the 2000s with the introduction of the PSA (Prostate Specific Antigen) test. The spread of this test at the national level has not been homogeneous and this, along with other factors such as diet and the different intake of antioxidants, explains the existence of a North-South gradient: while in northern regions the incidence is 99.8 cases per 100,000 inhabitants per year, in the populations of Central Italy there is a 20% decrease (79.8 cases / year) and in those of the South a minus 33% (66.8 cases / year).
The gradual increase in incidence is countered by a gradual reduction in the number of deaths: in fact prostate cancer occupies the third position in the scale of cancer mortality in Italy (8% of cancer deaths), after lung and colorectal neoplasms. ISTAT data shows that the number of deaths related to prostate cancer has been continuously decreasing for about 20 years, with a reduction of 2.3-2.5% per year.

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The prevalence of the disease is therefore increasing, but the survival rate at 5 years from diagnosis is also increasing: in fact, the latter has gone from 68% in the 90s and 95s to 91% in recent years. This result is the consequence of the diagnostic anticipation following the diffusion of the PSA test and the improvement of treatments for cancer both in localized and advanced stages.

Like many other neoplasms, prostate cancer has a multifactorial etiology and represents the product of interaction between a genetic and an environmental component. The first is demonstrated by a certain degree of familiarity, by the correlation between prostate cancer and genetically determined conditions, such as Lynch Syndrome and genetic mutations of BRCA 1 and 2, and by the different incidence in the various races that sees the black one more at risk for this type of disease. The environmental component is expressed through a diet rich in calcium, exposure to carcinogens such as cadmium and dimethylhydrazine. The most important risk factor, however, remains the age: prostate cancer is in fact a neoplasm typical of men over 50 years old.

The diagnosis of prostate cancer is based on urological examination, PSA dosage, ultrasound and echo-guided biopsy. However, all these methods have limitations in sensitivity and specificity. The biopsy itself, which should be the most accurate method, has limitations: first, it is an invasive procedure as it involves a high number of samples (12-14, but in some cases even more) performed in both lobes of the prostate, second, the samples may not hit the tumor. As far as PSA is concerned, it expresses a probability of tumor presence; indicatively, values between 4-10 ng/ml corresponds
to a 25% probability while values greater than 10 ng/ml correspond to a 50% probability of neoplasm.

Magnetic resonance imaging (MRI) of the prostate allows a clear improvement in the chances of diagnosis and is a non-invasive diagnostic method.

Magnetic Resonance Imaging (MRI), thanks to the high resolution of contrast for soft tissues and the possibility of acquisitions through thin sections according to different orientations, has been used since the 80s for the study of the prostate gland and its pathological alterations, both benign and malignant. Initially, the study of the prostate was based only on an exclusively morphological approach. In more recent years, research in the field of radiology has turned to the development of techniques complementary to morphological acquisitions with the development of methods that allow the acquisition of functional information and vascularization. The set of these methods is called Multiparametric Resonance of the prostate (mpRM) which is the technique used today at an international level in Centers dealing with prostate pathology. Once the examination has been acquired with the multiparametric technique, the images are evaluated by the Radiologist according to a standardized method called PI-RADS (Prostate Imaging Reporting and Data System).

The PI-RADS (in the version that is used today) was drafted by the American College of Radiology and the European Society of Uroradiology in 2015 in order to standardize study methods, given the considerable variability in the execution and interpretation of the data collected. According to this document, it is possible, only on the basis of radiological assessment, to assign a score to the lesion, which expresses its risk of malignancy:

– PI-RADS 1 = very low risk (extremely unlikely to have clinically significant neoplasia);

– PI-RADS 2 = low risk (unlikely to have clinically significant neoplasia);

– PI-RADS 3 = intermediate risk (presence of clinically significant neoplasm is equivocal);

– PI-RADS 4 = high risk (the presence of clinically significant neoplasm is likely);

– PI-RADS 5 = very high risk (presence of clinically significant neoplasm is highly likely).

On the basis of the score obtained it will be possible to orientate towards certain subsequent options, such as a “targeted” needle biopsy on the suspected areas (in cases with PI-RADS 4 and 5); this procedure will not be necessary for cases with PI-RADS 1 and 2, while in PI-RADS 3 cases the evaluation must be collegially discussed with the Urologist who will decide the most appropriate procedure for the patient.

The mpRM examination requires a precise technique of execution and needs an advanced MRI equipment with high magnetic field intensity, equal to 1.5 Tesla or 3 Tesla.

In recent years the role and validity of multi-parametric MRI of the prostate has been and still is the subject of many scientific studies. Among these, of particular value are the results of a multicenter study published in May of this year in the authoritative New England Journal of Medicine which showed that the use of MRI before biopsy to define the risk of prostate cancer (and the possible subsequent use of “targeted” biopsy based on MRI findings) was superior to the traditional approach based on biopsy guided by ultrasound. In the same study it was also shown that in a significant number of cases the use of biopsy was avoided because the MRI findings did not show images of suspicious lesions, thus avoiding an invasive procedure.

Readings of general interest

Multiparametric MRI of the prostate, a noninvasive method for prostate cancer detection.

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