Magnetic resonance imaging for prostate cancer before radical and salvage radiotherapy: What radiation oncologists need to know

Abstract

External beam radiotherapy (EBRT) is one of the principal curative treatments for patients with prostate cancer (PCa). Risk group classification is based on prostate-specific antigen (PSA) level, Gleason score, and T-stage. After risk group determination, the treatment volume and dose are defined and androgen deprivation therapy is prescribed, if appropriate. Traditionally, imaging has played only a minor role in T-staging due to the low diagnostic accuracy of conventional imaging strategies such as transrectal ultrasound, computed tomography, and morphologic magnetic resonance imaging (MRI). As a result, a notable percentage of tumours are understaged, leading to inappropriate and imprecise EBRT. The development of multiparametric MRI (mpMRI), an imaging technique that combines morphologic studies with functional diffusion-weighted sequences and dynamic contrast-enhanced imaging, has revolutionized the diagnosis and management of PCa. As a result, mpMRI is now used in staging PCa prior to EBRT, with possible implications for both risk group classification and treatment decision-making for EBRT. mpMRI is also being used in salvage radiotherapy (SRT), the treatment of choice for patients who develop biochemical recurrence after radical prostatectomy. In the clinical context of biochemical relapse, it is essential to accurately determine the site of recurrence - pelvic (local, nodal, or bone) or distant - in order to select the optimal therapeutic management approach. Studies have demonstrated the value of mpMRI in detecting local recurrences - even in patients with low PSA levels (0.3-0.5 ng/mL) - and in diagnosing bone and nodal metastasis. The main objective of this review is to update the role of mpMRI prior to radical EBRT or SRT. We also consider future directions for the use and development of MRI in the field of radiation oncology.

Keywords: Prostate cancer, Staging, Radical radiotherapy, Multiparametric magnetic resonance imaging, Biochemical failure, Radical prostatectomy, Salvage radiotherapy

Core tip: Multiparametric magnetic resonance imaging (mpMRI) has revolutionized the management of prostate cancer, including external beam radiotherapy (EBRT). mpMRI has also improved local staging and recurrence detection after radical prostatectomy, even in patients with low prostate-specific antigen levels, and it has increased the accuracy of EBRT, potentially improving survival outcomes while reducing side effects. For these reasons, mpMRI is an essential tool in the evaluation and treatment of prostate cancer.