MRI and Fusion biopsies. K Sahadevan Consultant Urologist

Transcription

1 MRI and Fusion biopsies K Sahadevan Consultant Urologist

2 MRI in Prostate Cancer Diagnosis Traditionally used for staging purposes 70 to 90% accurate detection of extra capsular disease on MRI (cornud 2002) 3T MRI, Endorectal coil, MR spectroscpy for improved staging Currently Diagnostic scan T1,T2, DWI, MRS, DCE Scoring systems Standards of technique

3 PIRADS BI-RADS for breast cancer imaging Liberman 2002 ESUR- PIRADS v1, 2012 ESUR-ACR- PIRADS v2, 2015 Hamoen 2015; Metaanalysis Sensitivity 70 to 85 NPV 58 to 95

4 PIRADS V1 vs V2 Dominant sequence T2W for TZ, DWI for PZ DCE To downgrade or upgrade PIRADS 3 in PZ No MRS New sectoral map

5 Sectoral map for reporting PIRADS 2

6 How reliable is MRI?

7 How reliable is MRI: Heterogeneity Heterogenous studies Definition of clinically sig disease UCL1: Gleason 4+3 or higher and / or CCL >6mm UCL2: Any Gleason 4 and / or CCL 4mm Epstein criteria +/- ADC <850 mm2/s Gleason score 7 Gleason score 8 PSA >10 ng/ml, PSA density >0.15, clinical stage T2b, Gleason 4 or 5, total CCL 10 mm Gleason 6 7 with 5% Gleason 4 + either 30% of cores positive or CCL >8 mm Radiologist experience Variable comparator (extended bx, TR, TP, RRP)

8 How reliable is MRI? Futterer 2015 Cancer detection rates of 44% to 87%, NPV 63 to 98% Ref pts std CSig sens spec PPv NPV fusion G fusion G7, >5% or CCL 8mm RRP Epstein

9 PROMIS Paired cohort, mpmri follwed by TRUS and template bx 576 pts TPM detected 40% clinically significant cancers (UCL1) 2% clinically significant cancers missed on MRI 27% may avoid biopsy UCL1 = Gl 4+3 +/->6mm CCL Ref sens NPV MRI TRUS 48 74

10 How reliable is MRI: vs RRP specimen Delongchamos / 137 (10%) foci of significant cancer (G7/ G6+>0.5ml) missed on mri 4% of tumour missed by targeted biopsy but detected by mri Baco pts 5%index lesions (some G6) invisible on MRI 10% index lesions missed on targetted bx Le pts, 80% index lesion detection 5% targeted bx missed index lesion MRI can identify high volume or higher grade tumours in 80-95% of the cases Branger 2016: RRP in pts with a negative MRI 17% T3, 14% Primary Gleason 4 or above, 47.5% had secondary Gleason 4 But when MRI expertly re-read, only 4% T3, 4% primary 4

11 Evasive lesions!

12 Targetted biopsies MR targetted biopsies In bore Not much literature Sensitivities 50 to 80% Expensive, time consuming Cognitive Less expensive, readily available, do need expertise Variable results but negative sensitivity up to 97% 3D Software aided

13 Fusion vs TRUS Siddiqui 2015: Fusion bx showed 30 higher incidence of high risk 17% lower incidence of low risk cases Schhots 2015 Metaanalysis approx 2000 pts Higher detection of high risk and lower detection of low risk with targetted compared to TRUS Sensitivity of MR T bx vs TRUS bx is 91 vs 74% Wegelin 2016: Systematic TRUS vs Cog Fusion, software fusion, MRI in bore No significant different between modalities, (? In bore >software fusion>cognitive) Targetted bx higher yield for clinically significant prostate cancer RCT b/w cognitive vs fusion vs in bore on going

14 Fusion Vs TRUS in RRPSiddiui JAMA

15 Issues with Fusion Radiologist Acquisition (angles, pulses, sequences etc) Interpretation (PIRADS) Urologist Registration/fusion (deformation, position) Identification Needle track/target Pathologist Inter observer variability Patient Movement, bowel prep

16 MRI Fusion: Ideal parameters Compatibility: In house US probes and with PACS Suitable for transrectal and trans perineal approaches Easy workflow and short learning curve Rigid and elastic registration Ability to use record needle track Cost!

17 MRI/TRUS fusion platforms Many european and American systems Usually with own US systems TR and TP options Slight variation in physical form Manual vs robotic arm Electromagenetic vs visual tracking

18 Validation studies

19 Uronav: Philips

20 Uronav Support for both transperineal and transrectal biopsy approaches - Ultrasound-only work flow for guided navigation without the need for pre-biopsy MR data Display of prior biopsy core locations and data from previous procedures performed with UroNav Robust, 3D gland segmentation modeling and flexibility to perform dynamic adjustments of the ultrasound segmentation boundary Elastic (deformable) and rigid registration options - On-the-fly registration adjustments

21 Biopsee

22 Biopsee Fusion with MRI Spectroscopy, dynamic MRI, PET, PET-CT, SPECT (fusion with any DICOM image type) 3D, elastography, DCE abilities Automatic 3D ultrasound image acquisition (minimum 1mm slices) Superb tools for delineating target areas and structures in any image set Stereotactic biopsy planning module for plotting exact needle paths Live stereotactic needle navigation with practical guidance tools Automatic recording of all significant data: exact biopsy coordinates, ultrasound parameters and patient data Documentation and reporting tool for follow-up

23 Artemis: Hitachi Aloka

24 Artemis Prostate mapping via needle navigation and tracking Revisit previous sample sites/overlay previous gland volumes Integrated motion compensation Automatic recording of all biopsy locations Automatic 2D to 3D image conversion

25 BK Fusion BioJet Triplane Transducer is the only urology transducer that allows you to shift between simultaneous biplane and endfire imaging modes at the touch of a button and without removing the transducer from the patient.

26 Koelis: available in US

27 Easote: Virtual navigator

28 Multiparametric US Sensitivity up to 90% PPV 50-90% NPV % CEUS Strain elastography Shear wave elastography

29 Summary MRI is good at detecting high grade, high volume CaP MRI can influence your biopsy and therapy strategy TRUS bx or MR guided bx only could miss significant CaP Experience of the operator plays a major role, standardisation and audit essential There is a role for fusion biopsy systems and TRUS bx

30 Biopsy Strategies MRI can detect high risk CaP but not all Where do you draw the line for clinically significant CaP? Do you access to a dedicated uro-radiologist? Is your finance director friendly? How much spare theatre capacity do you have? Any colleagues with interest in taking prostate cancer daignostic pathway further?

31 Diagnostic pathway strategy

32 Thank you

33 Pitfalls MR prostate reporting Panebianco 2015 Diagnostic Bilateral basal hypointense zones (moustache sign) Median posterior hypointense area at the middle third of the gland Transition zone prostate cancer versus BPH foci of stromal hyperplasia Ectopic BPH nodule Granulomatous prostatitis after intravesical instillation of BCG Hypertrophic anterior fibromuscular stroma Periprostatic venous plexus and neurovascular bundle Staging T3 versus T2 (overlapping with pitfalls in primary diagnosis: granulomatous prostatitis, periprostatic venous plexus and neurovascular bundle) Bone findings Controversial on lymph nodes Artifacts Mispositioned endorectal coil Post-biopsy changes Lymphoceles