Multi-parametric imaging of prostate cancer - can it facilitate a paradigm shift in management?

Registered Charity No: 215869

Multi-parametric imaging of prostate cancer - can it facilitate a paradigm shift in management?

28 February 2014 Venue: The British Dental Association 5 CPD credits

BIR Annual Congress 2014 - 22-23 October, London

Welcome and thank you for coming to the ‘Multi-parametric imaging of prostate cancer can it facilitate a paradigm shift in management?’ event organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker (where supplied).

This meeting has been awarded 5 RCR category I CPD credits.

CPD certificates will be distributed by email within two weeks of the meeting once the online delegate survey has been completed.

Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/_prostate We hope you find the day interesting and enjoyable.

Dr Shonit Punwani Meeting Organiser MR SIG, BIR

We are most grateful to

for supporting this conference

Bayer HealthCare has provided sponsorship for the cost of the exhibition stand only at this meeting.

Programme

08:00 Poster display and set up 09:00 Registration and refreshments 09:30 Introduction - what is multi-parametric imaging?

Chair Dr Shonit Punwani, Senior Lecturer and

Honorary Consultant Radiologist, University College London Hospitals Session 1: Managing patients with prostate cancer - what’s our problem?

09:45 Multi-parametric prostate MRI - can it improve patient care?

Mrs Caroline Moore, Senior Clinical Researcher, University College London

Honorary Consultant Urological Surgeon, University College Hospital 10:15 What happens to patients with metastatic disease?

Dr Heather Payne, Consultant Clinical Oncologist, University College Hospital

10:45 Refreshments and poster session Session 2: Multi-parametric imaging - where are we at?

11:30 Multi-parametric prostate MRI basics

Dr Alex Kirkham, Consultant Uro-radiologist,

University College London Hospitals 12:00 Icing on the cake - histologically validated examples

Dr Clare Allen, Consultant Uro-radiologist,

University College London Hospitals 12:30 Problems with detecting metastatic disease - does nuclear

medicine have the answer?

Dr Athar Haroon, Consultant Nuclear Medicine Physician and

Radiologist, St Bartholowmew’s Hospital/University College London 13:00 Whole body MRI for metastatic prostate cancer

Professor Anwar Padhani, Consultant Radiologist and

Professor of Cancer Imaging, Mount Vernon Cancer Centre 13:30 Lunch and poster session

Session 3: Scientific session - where are we going?

Proffered paper presentations Moderators: Dr Alex Kirkham and Dr Shonit Punwani 14:30 How well does multiparametric-MRI PiRADS scoring predict

transperineal prostate biopsy outcome?

Alistair Grey, Urology Registrar, Southend University Hospital 14:40 Multiparametric magnetic resonance imaging (mpMRI) of prostate

cancer lesions – how much do we have to learn?

Tristan Barrett, Consultant Radiologist, Addenbrooke’s Hospital 14:50 Accuracy of multiparametric MRI in the diagnosis of prostate cancer

Hiba Abbas, Foundation Year 2, Wexham Park Hospital 15:00 False negative rate on pre-biopsy prostate MRI

Tristan Barrett, Consultant Radiologist, Addenbrooke’s Hospital 15:10 Diffusion-weighted imaging of prostate with VERDICT analysis

Eleftheria Panagiotaki, Postdoctoral Research Associate at CMIC,

University College London 15:20 Multi-parametric whole-body MRI for staging prostate cancer

Arash Latifoltojar, Clinical Research Fellow, University College London and

University College London Hospitals

15:30 Multi-parametric MRI followed by targeted prostate biopsy for men

with suspected prostate cancer: a clinical decision analysis

Ian Donaldson, Clinical Research Fellow, University College London 15:40

Computer assisted diagnosis of transition zone prostate cancer on multi-parametric MRI Nikolaos Dikaios, Research Associate, Centre of Medical Imaging, University College London

15:50

Can multiparametric MRI predict upgrading of TRUS biopsy results at more definitive histology?

Mohamed Abd-Alazeez, Trust Registrar in Urology, Epsom and St Helier’s University Hospital

16:00 Investigator award and closing remarks

Dr Shonit Punwani, Senior Lecturer and Honorary Consultant

Radiologist, University College London Hospitals 16:20 Close of meeting

Please remember to complete the online delegate survey using the below link: https://www.surveymonkey.com/s/_prostate Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

BIR Annual Congress 2014 - 22-23 October, London

Speaker profiles (where supplied) Mrs Caroline Moore Senior Clinical Researcher, University College London Honorary Consultant Urological Surgeon, University College Hospital Caroline Moore has been a Senior Clinical Researcher at University College London and Honorary Consultant Urological Surgeon at University College Hospital since October 2012. She trained within the London Deanery and University College London, UK. She began her MD work in 2002, was awarded her MD in ‘Photodynamic therapy for Prostate Cancer’ in 2007, and has continued her research interest in novel ways of diagnosing and treating prostate cancer since that time. Her particular interests are in the use of MRI to detect clinically significant disease, MRI-targeted biopsy, image based personalised active surveillance programmes, and focal treatment of prostate cancer. She has expertise in the set up and running of both investigator led and commercially sponsored randomised controlled studies in prostate cancer management, and the development of novel diagnostic systems.

She is an active clinical researcher and has published in the areas of MRI-targeted prostate biopsy, active surveillance and focal therapy for prostate cancer. She is involved in numerous international collaborations in prostate cancer diagnosis, active surveillance and focal therapy.

Professor Anwar Padhani Consultant Radiologist and Professor of Cancer Imaging, Mount Vernon Cancer Centre Prof. Anwar R. Padhani is an internationally recognised Oncological MRI radiologist and currently, the clinical lead in MRI and head of imaging research at the Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, London. He is Professor of Cancer Imaging at the Institute of Cancer Research, London. He is an expert in Oncologic MRI, prostate MRI and the functional evaluation of metastatic bone disease. He has pioneered a number of emerging clinical MRI applications including dynamic MRI, diffusion weighted MRI, MR spectroscopy, bone marrow fat water imaging and whole body MRI scanning.

He has a passion for teaching and has published chapters in 31 textbooks, 64 educational and scientific journal reviews and over 103 full scientific articles in peer-reviewed journals. He has edited the book Advances in Oncologic Imaging Techniques published in 2006. Prof Padhani has given over 250 invited lectures at national and international scientific and educational meetings including plenary talks on multifunctional MRI, imaging angiogenesis, early and advanced prostate imaging and diffusion imaging including whole body applications. He was the 2012 president of the International Cancer Imaging Society.

Dr Heather Payne Consultant Clinical Oncologist, University College Hospital I am a Consultant in Clinical Oncology at University College Hospital, London. I trained at St Mary’s Hospital London and after qualifying spent time working in general medicine both in London and also in Haiti where conventional medicine was mixed with voodoo practices. I returned to London to train as a Clinical Oncologist and during this time developed an interest in urological oncology. I now have a busy practice in a teaching hospital where I work within a multidisciplinary team. I am actively involved in clinical research in all these therapeutic areas and have pioneered a programme of high dose rate brachytherapy for prostate cancer. My current research interests also include hormone therapy, sensitisation of hormones and radiotherapy, predictive indices for bowel toxicity with radiotherapy, chemotherapy and quality of life and decision making for men with prostate cancer. I am Principle Investigator in a number of international multi-centre and local studies. I am a trustee of the Prostate Cancer Research Centre, Prostate UK and the chairman of the British Uro-oncology Group (BUG) I am the oncology lead for the National Prostate Cancer Audit.

Dr Shonit Punwani Senior Lecturer and Honorary Consultant Radiologist, University College London Hospital Dr Shonit Punwani is a Senior Lecturer in Oncological Imaging at University College London and Honorary Consultant Radiologist specialising in oncological radiology at University College London Hospital. He leads the 3T MR Research Facility at UCLH, developing novel MRI techniques for first-in-man oncological imaging studies. He has a specialist clinical and research interest in the application and development of local and whole- body quantitative and functional MRI methods for imaging prostate.

Abstracts (where supplied) Multi-parametric prostate MRI - can it improve patient care?

Mrs Caroline Moore The use of mpMRI for the detection and localisation of prostate cancer has expanded its use in localised disease in the last few years.

The potential for it to improve patient care is within a number of different areas:

1. Avoiding a biopsy for men with a low risk of clinically important disease

2. Targeting a biopsy for those men at higher risk of clinically important

disease

3. Monitoring on surveillance

4. Targeting treatment – focal and radical therapies Each of these will be discussed in turn, including current recommendations and opportunities for future research.

What happens to patients with metastatic disease?

Dr Heather Payne For many years the treatment options for the management of advanced prostate cancer were limited and this stage of the disease was approached with a resigned nihilism by many clinicians. The last decade has changed this attitude to one of extreme optimism as a number of new drugs have been shown to increase survival in addition to reducing symptoms and improving quality of life for men suffering with this stage of prostate cancer. The mainstay of therapy for men with advanced prostate cancer is the use of androgen-deprivation therapy.

The majority of men will have good biochemical and clinical response for several years but ultimately the cancer will progress despite castrate levels of serum testosterone (castrate-resistant prostate cancer – CRPC).

There were previously few options in this setting until 2004 when the TAX327 study demonstrated a survival benefit with the chemotherapy agent docetaxel when compared to mitoxantrone (both drugs given in combination with prednisolone). In 2010 further survival advantages were shown in addition to symptomatic benefits in phase 3 clinical trials for the hormone drug abiraterone acetate and the chemotherapy agent cabazitaxel (both in combination with prednisolone) and the antiandrogen enzalutamide when investigated in the post docetaxel setting. More recently, phase 3 trials have shown significant benefits for abiraterone, enzalutamide and the bone specific agent radium as first line of therapy for CRPC. There are many new drugs in late stage clinical trials and the treatment options are likely to increase further in the future. At the present time there is no robust data for the sequencing of these compounds.

Learning Objectives:

1. To understand the initial systemic therapy for metastatic prostate cancer 2. To be aware of the definition of castrate resistant prostate cancer 3. To have an awareness of the new drugs for castrate resistant prostate cancer (CRPC) 4. To have an awareness of the need for radiological assessment in monitoring disease response

Multi-parametric prostate MRI basics Dr Alex Kirkham We describe the main sequences used for prostate MRI and their relative utility, address the use of endorectal coils and 3T machines, discuss the reporting systems currently in use and suggest the need for minimum standards for those reporting multiparametric MRI.

Whole body MRI for metastatic prostate cancer Professor Anwar Padhani Challenges persist when assessing the presence and response of metastatic bone disease in prostate cancer patients. Current limitations can be directly ascribed to ineffective current diagnostic tools (including PSA and bone scans) which are unable to accurately predict which patient has metastatic disease, to predict who will benefit from targeted treatments and to identify who is positively benefiting early after starting treatment. Poor diagnostic tools in part contribute to limited rates and durations of response of targeted therapies. This is because of late detection of metastatic disease (larger tumor load), heterogeneity of target expression & responses are not considered by tools such as PSA and the inability to detect failure of response in a timely way impairs the progress of patients through standard therapies so they become eligible for clinical trials of emerging therapies with novel mechanisms of action.

Given that radiologic detection and treatment of asymptomatic/ mildly symptomatic mCRPC may be of clinical benefit, is it time to reconsider the central role of bone scans in directing patient management? We are now clear that planar Tc-99m BS do NOT provide robust evidence for the presence or absence of early M+ disease (+SPECT CT is better). Numerous studies show the superiority of modern imaging methods (Choline/NaF PET/CT & MRI) for detecting and assessing bone metastases at ever lower PSA levels. This talk focuses on diffusion MRI as part of whole body MRI both for detection and therapy assessment.

Patient care indications for WB-MRI in prostate cancer that will be discussed include: • High risk prostate cancer (Gl ≥8 and/or PSA >20 ng/ml) at presentation or rapid rising PSA (doubling time <12 months) in previously treated patients.

This is to replace current combine use of bone scan and abdo-pelvic CT scan • Equivocal bone scans in newly diagnosed patients • Query osteoporotic/metastatic fracture (androgen deprivation and steroids cause osteoporosis) • Known extensive spinal bony metastases (BS or CT) – to detect clinically occult spinal cord compression. Spinal MRI examinations are already recommended by NICE guidelines (2014) for this indication.

• Rule out clinically occult distant metastases in locally recurrent disease when salvage therapy is being considered (confirm M0 disease) • Detecting oligo-metastatic disease when radical local therapy is an option (create early M+ subgroup). This is to defer starting androgen blockage for as long as possible.

• To monitor response in metastatic castrate resistant patients with bone disease (particularly PSA non- or oligo-secretors), being treated with chemotherapy or novel therapies.

Key references: Wondergem M, van der Zant FM, van der Ploeg T, Knol RJ. A literature review of 18F-fluoride PET/CT and 18F-choline or 11C-choline PET/CT for detection of bone metastases in patients with prostate cancer. Nucl Med Commun. 2013;34:93545.

Yang HL, et al. Diagnosis of bone metastases: a meta-analysis comparing 18FDG PET, CT, MRI and bone scintigraphy. Eur Radiol. 2011; 21:2604-17.

Koh DM, Blackledge M, Padhani AR, Takahara T, Kwee TC, Leach MO, Collins DJ. Whole-body diffusion-weighted MRI: tips, tricks, and pitfalls. AJR Am J Roentgenol. 2012 Aug;199(2):252-62.

Lecouvet, F et al. Can Whole-body MRI with diffusion-weighted imaging replace Tc 99m bone scanning and computed tomography for single-step detection of metastases in patients with high-risk prostate cancer? Euro Urol 2012; 62:68-75 Padhani AR, Makris A, Gall P, Collins DJ, Tunariu N, de Bono JS. Therapy monitoring of skeletal metastases with whole-body diffusion MRI. J Magn Reson Imaging. 2014 Feb 10. [Epub ahead of print]

Our platinum sponsors

GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality and more affordable healthcare around the world. GE (NYSE: GE) works on things that matter - great people and technologies taking on tough challenges. From medical imaging, software and IT, patient monitoring and diagnostics to drug discovery, biopharmaceutical manufacturing technologies and performance improvement solutions, GE Healthcare helps medical professionals deliver great healthcare to their patients.

Philips is a diversified health and well-being company and a world leader in healthcare, lifestyle and lighting. Our vision is to make the world healthier and more sustainable through meaningful innovation.

We develop innovative healthcare solutions across the continuum of care, in partnership with clinicians and our customers to improve patient outcomes, provide better value, and expand access to care.

As part of this mission we are committed to fuelling a revolution in imaging solutions, designed to deliver greater collaboration and integration, increased patient focus, and improved economic value. We provide advanced imaging technologies you can count on to make confident and informed clinical decisions, while providing more efficient, more personalised care for patients.

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FORTHCOMING EVENTS Biological optimisation of radiotherapy 13 March 2014 London Paediatric body MRI course 1 April 2014 London Management and radiology - a guide to current and future management issues in radiology 2 May 2014 London Radiotherapy - meeting the current and future workforce challenges for patient care in a changing context 19 May 2014 London Molecular radiotherapy dosimetry 4 June 2014 Oxford wESSEX BRANCH MEETING 13 jUNE 2014 wINCHESTER OPTIMISATION IN CT 18 JUNE EDINBURGH EAST OF ENGLAND BRANCH MEETING: ONCOLOGY HOT TOPIcS JUNE 2014 CAMBRIDGE irmer update 29 september 2014 london Diagnostic radiology for advanced head and neck cancer planning 2 October 2014 london Optimisation in interventional radiology 10 October 2014 birmingham Linking orthopaedics and radiology II - the plain film revisited: the upper limb 16 October 2014 london

BIR Annual Congress 2014 - 22-23 October, London VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

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