OsherMini Medical School for the...PI‐RADS scores Westphalen AC ... Post‐gad T1 Post‐gad T1...

Osher Mini Medical School for the Public

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UCSF Osher Mini Medical School for the Public

Education

Patient careResearch

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Education

Patient careResearch

Basic science research

First human studies

Clinical studies

Practice

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Westphalen AC


Lifetime riskWestphalen AC


86%

14%

Prostate Cancer (2017)

New cases (161,360)

Deaths (26,730)

Westphalen AC


Westphalen AC


Benefits

5 fewer Pca deaths

Harms

130 negative biopsies

120 positive biopsies

35 develop bladder, bowel or sexual side effects

8 complications of biopsy or treatment (i.e. sepsis, wound infection, DVT, MI, etc.)

overdiagnose

overtreat

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Westphalen AC


After treatment Treatment

After abnormal PSABefore diagnosis, i.e. biopsy

After diagnosis, i.e. biopsyBefore treatment

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After treatmentPET

TreatmentCT / bone scan / PET

After abnormal PSABefore diagnosis, i.e. biopsy

MRI

After diagnosis, i.e. biopsyBefore treatment

MRI / CT / bone scan / PET

We play a role at all stages of patient care!

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Westphalen AC


https://youtu.be/OG9SnEluQ6A

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?CT scan Ultrasound MRI

0

100

200

300

400

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600

1983 1988 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

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09/31/2017

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Our group has over 200 publications focused on MRI of prostate cancer!

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When the MRI is negative it is unlikely the patient has a bad/aggressive prostate cancer, i.e. tumor with Gleason pattern 4

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Questions:Do men with a negative MRI need a biopsy?Do men with known cancer and negative MRI need immediate treatment?

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Benefits

5 fewer Pca deaths

Slide courtesy of Dr. Peter Carroll

Harms

130 negative biopsies

120 positive biopsies

35 develop bladder, bowel or sexual side effects

8 complications of biopsy or treatment (i.e. sepsis, wound infection, DVT, MI, etc.)


Problem:Between 5 and 20% of Gleason≥4 tumors are “invisible”

Do invisible tumors impact patients’ lives?Can these tumors be followed until visible?

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31

every 3‐6 months TRUS‐guided, per protocolat 12 to 24 months

D PSA PSA PSA BPSA B

Patient A

D

PSA

PSA

BPSA B

TRUS‐guided

Patient B

?

TRUS‐guided

TRUS‐guided

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D

PSA

PSA

BPSA B

TRUS‐guided

Patient B

?

TRUS‐guided

32

Cancer is invisible

Cancer is now visible

Cancer remains invisible

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?

Flipside – bad tumors are usually very positive! PI‐RADS scores

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Questions:– Can we target these areas on biopsy to diagnose the bad cancer?

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Westphalen AC



Questions:

– Can we target only these areas?

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Questions:

– Can we treat only these areas?

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Westphalen AC


MRI trifecta

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Problem:–Variation when assigning scores– Expected rates of Gleason ≥ 4 per score not conclusively determined

UCSF is leading a study with 20 institutions and over 2000 patients from 4 continents to determine these rates and establish quality benchmarksWe are planning a study to investigate MRI‐guided focal therapy

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BiopsyActive surveillanceFocal therapy

We can also help patients and our physician colleagues to decide for definitive therapy (surgery or radiation)!

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Westphalen AC


Normal cell PCa cell

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Westphalen AC

AC PET ADC map

DWI

T2

Slide courtesy of Dr. Thomas Hope


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AC PET

AC PET

Post‐gad T1

Post‐gad T1



WB anterior MIP

Disease site 2: left internal iliac node

Disease site 1: right humerus

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S/P RP



WB anterior MIP

Disease site 1: right pelvic side wall node 1

Disease site 2: right pelvic side wall node 2

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S/P RP



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Negative CT Negative bone scan Positive PSMA



Osher Mini Medical School for the Public

OsherMini Medical School for the...PI‐RADS scores Westphalen AC ... Post‐gad T1 Post‐gad T1...

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