Preoperative lymph node staging in patients with primary prostate cancer: usefulness of diffusion-weighted MR imaging at 3T-device
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1 Preoperative lymph node staging in patients with primary prostate cancer: usefulness of diffusion-weighted MR imaging at 3T-device Poster No.: C-1894 Congress: ECR 2015 Type: Scientific Exhibit Authors: S. Ortori, P. Boraschi, V. Vallini, F. Manassero, M. Gabelloni, C. Selli, C. Bartolozzi; Pisa/IT Keywords: DOI: Pelvis, Lymph nodes, Oncology, MR, MR-Diffusion/ Perfusion, Diagnostic procedure, Molecular imaging, Staging, Multidisciplinary cancer care, Pathology /ecr2015/C-1894 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12
2 Aims and objectives To evaluate the usefulness of diffusion-weighted MR imaging with multiple b values at 3 Tesla MRI for staging of pelvic lymph nodes in patients with prostate cancer candidate to radical prostatectomy and extended pelvic lymph node dissection (PLND). Methods and materials We evaluated a series of 26 patients (median age 66.3±6.9 years, range years) ( Table 1 on page 2 ) with histologically proven prostate cancer (high or intermediate risk patients, according to D'Amico risk groups) and scheduled for radical prostatectomy and PLND. All patients underwent 3T MRI of the prostate as a part of their staging workup before surgery. Exclusion criteria were the following: bone metastases, previous treatment for prostate cancer, previous/concomitant malignancy, and contraindications to MRI. After acquisition of T1- and and T2-weigthed fast spin-echo images for morphological assessment, diffusion-weighted imaging (DWI) was performed using a respiratory-triggered spin-echo echo-planar sequence (SE-EPI) with multiple b values (500, 800, 1000, 1500 sec/mm²) in all diffusion directions on the axial plane. The parameters of the DWI sequence were the following: TR ms (depending on the patient's breath), TE ms, slice width 4 mm, spacing 0.4mm, matrix 96x224, 4 averages. The DWI sequence lasted no more than 6 minutes, and the overall imaging acquisition time was no more than 30 minutes in all cases. ADC values were calculated by using dedicated software by fitting the curves obtained from the corresponding ADC figures for each b value. Fitted ADC measurements were performed at the proximal and distal externalinternal iliac and obturator bilateral nodes. The appearance of pelvic lymph nodes was also reported in terms of short axis, long-to-short axis ratio, node contours, and heterogeneity of intranodal signal intensity. For each of these parameters, a grading score system was assigned using a two-point-level score ( Table 2 on page 3 ). All patients underwent radical prostatectomy within 15 days after MRI. Lymph nodes were surgically mapped into ten different anatomic regions, including external iliac (proximal and distal), internal iliac (proximal and distal) and obturator, each on both the right and left sides. Images for this section: Page 2 of 12
3 Table 1: Demographics of the patient group. Page 3 of 12
4 Table 2: Grading score system Page 4 of 12
5 Results A total of 173 lymph nodes and 104 nodal stations were evaluated on MR imaging and histologically analyzed. Mean fitted ADC value was 0.79±0, mm 2 /s in the nodal metastatic group and 1,13±0, mm 2 /s in the nodal non-metastatic group (P<0.0001) ( Fig. 1 on page 5, Fig. 2 on page 6, Fig. 3 on page 7 ). The fitted ADC cut-off value obtained by the ROC curve analysis was mm 2 /s ( Fig. 4 on page 8 ). For each of qualitative parameters a two-point-level score was assigned. The mean grading score was 6.09±0.61 in the nodal metastatic group and 5.42±0.79 in the nodal non-metastatic group (P = 0.001). With the threshold score of 4, the lymph node station-based sensitivity, specificity, PPV and NPV and diagnostic accuracy for FSE-MRI analysis were 100%, 7.9%, 15.6%, 100% and 21.3%. For DWI analysis, they were 84.6%, 89.5%, 57.9%, 97.1% and 88.8%, respectively. Images for this section: Page 5 of 12
6 Fig. 1: An example of benign lymph node: a) T2-weighted image, b) DWI image, c) ADC map, d) grading score = 6. Page 6 of 12
7 Fig. 2: An example of metastatic lymph node: a) T2-weighted image, b) DWI image, c) ADC map, d) grading score = 7. Page 7 of 12
8 Fig. 3: An example of metastatic lymph node: a) T2-weighted image, b) DWI image, c) ADC map, d) grading score = 7. Page 8 of 12
9 Fig. 4: ROC curve analysis showed an area under the curve (AUC) of Page 9 of 12
10 Conclusion Our preliminary experience suggests that 3T DWI with multiple b values at 3T device may help distinguish benign from malignant pelvic lymph nodes in patients with prostate cancer. In particular, nodal fitted ADC measurements could represent a useful method in this differential diagnosis when using a threshold value of mm 2 /s. Since DWI only adds little imaging time to a standard prostate MRI protocol, this technique could be recommended as an additional tool for characterization of pelvic lymph nodes. However, further studies with large populations of patients are necessary to confirm the present findings. Personal information Simona Ortori, MD Department of Diagnostic and Interventional Radiology, University of Pisa Via Paradisa 2, Pisa, Italy s.ortori@libero.it Piero Boraschi, MD Department of Diagnostic and Interventional Radiology, University of Pisa Via Paradisa 2, Pisa, Italy Phone: Fax: ; p.boraschi@do.med.unipi.it Carlo Bartolozzi, MD Professor and Chairman Department of Diagnostic and Interventional Radiology, University of Pisa Via Paradisa 2, Pisa, Italy Page 10 of 12
11 References 1. Heidenreich A, Bellmunt J, Bolla M et al (2011) EAU Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis and Treatment of Clinically Localised Disease. Eur Urol 59: Briganti A, Chun FK-H, Salonia A et al (2006) Validation of a nomogram predicting the probability of lymph node invasion among patients undergoing radical prostatectomy and extended pelvic lymphadenectomy. Eur Urol 49: Briganti A (2009) How to improve the ability to detect pelvic lymph node metastases of urologic malignancies. Eur Urol 55: Baert AL, Reiser MF, Hricak H, Knauth M, Koh DM, Thoeny HC (2010) Diffusion Weighted MR imaging. Applications in the body. Springer-Verlag, Berlin Heidelberg 5. Bellin MF, Lebleu L, Meric JB et al (2003) Evaluation of retroperitoneal and pelvic lymph node metastases with MRI and MR lymphography. Abdom Imaging 28: Abdel Razek AA, Elkammary S, Elmorsy AS, Elshafey M, Elhadedy T (2011) Characterization of mediastinal lymphadenopathy with diffusion-weighted imaging. Magnetic Resonance Imaging 29: Burkhard FC, Schumacher MC, Studer UE (2006) An extended pelvic lymph node dissection should be performed in most patients if radical prostatectomy is truly indicated. Nat Clin Pract Urol 3: Tempany CM, McNeil BJ (2001) Advances in biomedical imaging. JAMA 285: Katz S, Rosen M (2006) MR imaging and MR spectroscopy in prostate cancer management. Radiol Clin North Am 44: Schumacher MC, Burkhard FC, Thalmann GN, Fleischmann A, Studer UE (2008) Good outcome for patients with few lymph node metastases after radical retropubic prostatectomy. Eur Urol 54: Harisinghani MG, Barentsz J, Hahn PF et al (2003) Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med 348: Thoeny HC, Triantafyllou M, Birkhaeuser FD et al (2009) Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusionweighted magnetic resonance imaging reliably detect pelvic lymph node metastases in normal-sized nodes of bladder and prostate cancer patients. Eur Urol 55: Roy C, Bierry G, Matau A, et al (2010) Value of diffusion-weighted imaging to detect small malignant pelvic lymph nodes at 3 T. Eur Radiol 20: Page 11 of 12
12 14. Warncke SH, Mattei A, Fuechsel FG, Z'Brun S, Krause T, Studer UE (2007) Detection rate and operating time required for gamma probe-guided sentinel lymph node resection after injection of technetium-99m nanocolloid into the prostate with and without preoperative imaging. Eur Urol 52: Giannarini G, Petralia G, Thoeny HC (2012) Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer including pelvic lymph node staging: a critical analysis of the literature. Eur Urol 61: Vinnicombe SJ, Norman AR, Nicolson V, Husband JE (1995) Normal pelvic lymph nodes: evaluation with CT after bipedal lymphangiography. Radiology 194: Page 12 of 12
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