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rstanley{at}uabmc.edu
Progress in the detection, diagnosis, and management of prostate cancer has been extensive in the past two decades and has been much discussed in the general press in recent months. Advances in diagnostic imaging have played a significant role in this higher visibility. This month's issue of AJR features three important original research studies dealing with the imaging and precise staging of prostate cancer. In the article by Graser et al. [1], correlation of imaging findings with whole-mount step section histopathology is presented. Reinsberg et al. [2] combine the use of diffusion-weighted MRI and 1H MR spectroscopy to increase the accuracy in prostate cancer detection, and Wang et al. [3] show the incremental value of multiplanar cross-referencing for staging prostate cancer with endorectal MRI.
Imaging prostate cancer is difficult. The margins frequently are not well defined and the echo patterns in sonography as well as the signal intensity in MRI often are not significantly different from the surrounding nonneoplastic parenchyma. The three articles cited above offer valuable contributions to our understanding of prostate cancer imaging. The biggest challenge, of course, continues to be the management of the disease. Consider the following: The prevalence of microscopic prostate cancer in men over 60 years of age, without a clinical diagnosis of prostate cancer, is approximately 50%. But only 3% of men without a clinical diagnosis of prostate cancer are expected to eventually die from that disease. Thus, the probability that a 60-year-old man with microscopic prostate cancer will eventually die from it is less than or equal to 6% [4, 5]. The late Willet F. Whitmore, one of urology's leaders in the surgical management of prostate cancer, stated, "Is cure necessary in those in whom it may be possible? Is cure possible in those in whom it may be necessary?" [6]. He was obviously troubled by the marked variability in the biologic behavior of this neoplasm.
The prostate-specific antigen (PSA) era has brought with it the dilemma of uncertainty over what to do with the results of an elevated value. Multiple factors enter into the decision-making process: the patient's age, family risk factors, life expectancy, comorbidity, findings on digital examination, PSA doubling time, and the presence or absence of symptoms, to name a few. Even the decision whether to biopsy is not an easy one, especially if the digital examination is normal and the imaging findings are nonrevealing.
When the diagnosis is histologically established, treatment options include watchful waiting, expectant management (active surveillance), radical prostatectomy, radiation therapy, and hormonal therapy. Thus, the treatment of prostate cancer is complex. Optimal treatment will be risk-adapted to the specific characteristics of the cancer, the patient's expected longevity, as well as the personal preferences of the patient.
Why the focus on this topic in my Editor's Notebook this month? The answer is that the topic comes close to home. Within the last few months, I have been contacted by a half dozen friends seeking advice on the management of their newly diagnosed prostate cancer. As an abdominal radiologist, I have kept abreast of the disease in general. But my focus primarily has related to the imaging aspects. The complexities of the management of this ubiquitous disease have sent me to the books. And I am happy to see that progress has been made in differentiating the nonaggressive from the largely fatal forms of this neoplasm. The new variety of refinements in PSA testing related to age-specific levels, PSA densities adjusted to the volume of the prostate gland, and free to total PSA ratios will help. The mapping and identification of specific prostate cancer susceptibility genes is now on the radar screen, as well.
The studies presented in this month's issue show that we are making significant advances in the imaging aspect of this disease and that more and more research is being devoted to the topic. I am gratified to see an increasing number of submissions discussing high-quality sonography, MDCT, and MRI/MR spectroscopy studies dedicated to the better understanding of prostate cancer. I am optimistic that the appropriate screening, imaging, risk assessment, and clinical/surgical management of this complex disease will ultimately result in a reduced prostate cancer mortality rate and the elimination of unnecessary radical surgery or radiotherapy.
While I'm at it, let me also call your attention to three articles in the gastrointestinal imaging section dealing with CT colonography. The challenge for all of us in abdominal imaging is to accurately detect and precisely measure colonic polyps, and to be able to do the examination without having to subject the patients to rigorous, cathartic cleansing. Young et al. [7] discuss polyp measurement, while Gollub et al. [8] show how combining CT colonography and 18F-FDG PET may improve the detection of malignant polyps. The study by Johnson et al. [9] offers the hope of a cathartic-free method for doing reliable CT colonography. Despite the fact that I am still doing good-quality barium enemas, it is becoming apparent that well-performed CT colonography will supplant the barium examination of the colon, as a superior and considerably more inclusive technique for examining the colon and its surroundings.
Finally, in this first month of a new year and with a thought to the imaging techniques of the future, take time to read the excellent, in-depth article by Provenzale [10] on the imaging of angiogenesis. We've selected a compelling image from this article as our featured cover art for this January 2007 issue.
Our best wishes for a great 2007!
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