Dickinson, CL; (2015) The Integration of Magnetic Resonance Imaging in the Diagnostic and Therapeutic Pathway for Localised Prostate Cancer. Doctoral thesis , UCL (University College London).

Abstract

The current clinical pathway for localised prostate cancer firstly involves serum PSA testing, through screening programmes or ad hoc testing in highrisk or symptomatic men. If the PSA is raised, a transrectal-ultrasound guided biopsy is performed for histological diagnosis for suspected cancer. However, serum Prostate Specific Antigen (PSA) levels are inaccurate in selecting an ‘at-risk’ group for malignancy, and transrectal-ultrasound guided biopsy is a morbid procedure in which approximately 30% of men are under-diagnosed (through missing the disease) or misdiagnosed (through underestimating the true disease burden), therefore misinforming on appropriate management. A proportion of men are ‘over-diagnosed’ with low risk cancers on biopsy that may have little to no metastatic potential. The current management options of low- to intermediate-risk disease includes active surveillance with regular repeat serum PSA and biopsy tests and their inherent limitations. The alternative, which is radical treatment, may cause significant morbidity and reduce quality of life, despite considerable technical advances. An imaging test that is able to detect, characterise and localise prostate cancer may allow better diagnosis through improved risk stratification to the current standard tests, and targeted sampling of any suspicious areas, with more effective grading of disease burden. Additionally, the morbidity associated with the current therapeutic options could be reduced through the identification and targeted treatment of cancer lesions (‘focal therapy’), rather than the whole prostate. This thesis addresses the adoption of multi-parametric (mp)MRI for these diagnostic and therapeutic purposes. Whilst mpMRI has already demonstrated high accuracy rates for the detection of clinically significant prostate cancer, the current lack of standardisation of conduct and reporting has reduced comparability between studies and resulted in poor external validity. I present the rationale for the use of a new prostate mpMRI scoring system and the consensus outputs from a European expert group on standardising conduct and reporting, and their applications to date. I also present studies that apply the information obtained from mpMRI on the location and burden of clinically significant disease, to plan, conduct and follow-up focal treatment.

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