Multimodale molekulare Bildgebung des Prostatakarzinoms – aktueller Stand

Zusammenfassung

Das Prostatakarzinom ist die häufigste lebensbedrohliche Tumorerkrankung des Mannes in der westlichen Hemisphäre. In Deutschland muss mit ca. 40 600 Erkrankungen jährlich gerechnet werden. Die Mortalität liegt bei ca. 10% der Erkrankten. Ziel der prätherapeutischen Diagnostik ist die möglichst exakte Bestimmung des lokalen Ausmaßes des Prostatakarzinoms bezüglich intraprostatischer Lokalisationen, Kapseldurchbruch, Samenblaseninfiltration, Infiltration der neurovaskulären Bündel und gegebenenfalls der umgebenden Organe des kleinen Beckens, die Detektion einer lokoregionären Lymphknotenmetastasierung und gegebenenfalls einer Fernmetastasierung. Eine exakte prätherapeutische Diagnostik ist deshalb wichtig, weil die verfügbaren Behandlungsstrategien in strenger Abhängigkeit vom festgestellten klinischen Stadium der Tumorerkrankung und Risikoprofil festgelegt werden müssen. Die anatomische und funktionelle molekulare Bildgebung des Prostatakarzinoms hat in den letzten Jahren erhebliche Fortschritte erzielt. Insbesondere in diagnostischen Problemfällen, z. B. bei negativer Stanzbiopsie und persistierendem Verdacht auf ein Prostatakarzinom, können die ¹¹C-/¹⁸F-Cholin PET/CT-Bildgebung und die MRT/MRS des Prostatakarzinoms häufig das Karzinom lokalisieren, die Beziehung zu den umgebenden intra- und extraprostatischen Strukturen und Organen darstellen und die eine gezielte Rebiopsie ermöglichen. Das nodale Staging des Prostatakarzinoms ist mit konventioneller Bildgebung ohne spezifische, derzeit klinisch noch nicht verfügbare lymphotrope Kontrastmittel schwierig. Besondere Fortschritte wurden in der Bildgebung des Lokalrezidivs erzielt, da dies auch schon bei deutlich <1 ng/ml PSA-Werten häufig lokalisiert werden kann. Bei dieser Fragestellung hat sich nach unseren Erfahrungen besonders die Kombination von ¹¹C-Cholin-PET/CT mit Kontrastmittel gestützter MRT bewährt. Für die Diagnostik von Skelettmetastasen hat sich ¹⁸F-Natriumfluorid-PET/CT als hoch aussagekräftig erwiesen.

Abstract

Prostate carcinoma is the most common life-threatening cancer affecting men in the western world. In Germany about 40 600 new cases have to be expected each year. The mortality is around 10%. The major goals of pretherapeutic imaging are to determine the local extent of prostate carcinoma in terms of intraprostate localisation, extracapsular extension (ECE), seminal vesicle invasion (SVI), tumour infiltration into neurovascular bundles, and if this has taken place, into surrounding tissues and organs in the small pelvis, detection of loco-regional metastases via the lymph nodes and if this so, of distant metastases. Exact pretherapeutic diagnosis and staging are essential, because the tumour treatment must be selected in strict dependence on clinical tumour stage and risk profile. Both anatomic and functional molecular imaging of prostate carcinoma have advanced significantly in recent years. When there are problems with diagnosis, e.g. when prostate punch biopsies are negative while the suspicion of prostate carcinoma persists, C-11/F-18 choline PET/CT and MRI/MRS may be helpful in localising the carcinoma, revealing how the carcinoma relates to the surrounding intra- and extraprostatic structures and organs, and making a targeted repeat biopsy possible. Lymphotropic contrast agents are highly promising for accurate nodal staging of prostate carcinoma, but are not yet available for routine clinical use. In these circumstances, the sensitivity of nodal staging with the widely available imaging modalities remains difficult. There has been particularly substantial progress in the localisation of local relapse, which can be imaged with contrast-enhanced C-11-choline PET/CT and MRI in most cases when PSA is considerably below 1 ng/ml. F-18-fluoride PET/CT has proved accurate in the diagnosis of skeletal metastases from prostate carcinoma.

Schlüsselwörter

Prostatakarzinom - Lokalrezidiv - ¹¹C-Cholin-PET/CT - molekulare Bildgebung - bildgebende Diagnostik

Key words

prostate carcinoma - local relapse - C-11-choline PET/CT - molecular imaging - MRI

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