TRUS Prostate In general, TRUS is inaccurate for prostate cancer detection [65,67] and has a limited accuracy for staging prostate cancer [93]. Other than one retrospective study of 875 patients who demonstrated the association between imaging progression on TRUS and biopsy Gleason upgrade [94], there is lack of evidence to support TRUS in evaluating on active surveillance. TRUS-Guided Biopsy Prostate Many active surveillance programs incorporate serial PSA testing and some form of serial biopsy regimen, either in the form of 1) systemic biopsy only or 2) systemic biopsy with MRI-targeted biopsy of a suspicious lesion on MRI. Because some tumors are invisible on MRI [82] and missed by MRI-targeted biopsies [91,92], even when performing an MRI-targeted biopsy as part of active surveillance, concurrent systemic biopsies cannot be omitted at the moment. Choline PET/CT Skull Base to Mid-Thigh Choline PET, although it was approved by the FDA in 2013 for evaluating recurrence, has been widely investigated on its ability to detect nodal and distant metastases for pretreatment assessment of prostate cancer. The pooled sensitivity of choline PET/CT is low (0.57, 95% CI: 0.42-0.70) for detecting nodal metastases prior to treatment despite its high specificity (0.94, 95% CI: 0.89-0.97) in a meta-analysis of 7 studies (627 patients) [98]. Nevertheless, in patients with intermediate- and high-risk prostate cancer, choline PET/CT and PET/MRI has shown to identify more nodal and distant metastatic lesions than conventional imaging [96,98]. For example, in a study of 48 patients, choline PET/CT showed higher sensitivity (46.2% versus 69.2%) with identical specificity (92.3%) for detecting nodal metastases [99]. This in turn has shown to change in management in 33% to 71% of patients [99,100].
Pretreatment Detection Surveillance and Staging of Prostate Cancer. TRUS Prostate In general, TRUS is inaccurate for prostate cancer detection [65,67] and has a limited accuracy for staging prostate cancer [93]. Other than one retrospective study of 875 patients who demonstrated the association between imaging progression on TRUS and biopsy Gleason upgrade [94], there is lack of evidence to support TRUS in evaluating on active surveillance. TRUS-Guided Biopsy Prostate Many active surveillance programs incorporate serial PSA testing and some form of serial biopsy regimen, either in the form of 1) systemic biopsy only or 2) systemic biopsy with MRI-targeted biopsy of a suspicious lesion on MRI. Because some tumors are invisible on MRI [82] and missed by MRI-targeted biopsies [91,92], even when performing an MRI-targeted biopsy as part of active surveillance, concurrent systemic biopsies cannot be omitted at the moment. Choline PET/CT Skull Base to Mid-Thigh Choline PET, although it was approved by the FDA in 2013 for evaluating recurrence, has been widely investigated on its ability to detect nodal and distant metastases for pretreatment assessment of prostate cancer. The pooled sensitivity of choline PET/CT is low (0.57, 95% CI: 0.42-0.70) for detecting nodal metastases prior to treatment despite its high specificity (0.94, 95% CI: 0.89-0.97) in a meta-analysis of 7 studies (627 patients) [98]. Nevertheless, in patients with intermediate- and high-risk prostate cancer, choline PET/CT and PET/MRI has shown to identify more nodal and distant metastatic lesions than conventional imaging [96,98]. For example, in a study of 48 patients, choline PET/CT showed higher sensitivity (46.2% versus 69.2%) with identical specificity (92.3%) for detecting nodal metastases [99]. This in turn has shown to change in management in 33% to 71% of patients [99,100].