THE ROLEOF FUSION OF MRI& ULTRASOUND

Transcription

1 THE ROLEOF FUSION OF MRI& ULTRASOUND Pierre MOZER DEPARTMENT OF UROLOGY, PITIÉ-SALPÊTRIÈRE HOSPITAL, F RANCE ISIR RESEARCH LAB, PIERRE ET MARIE CURIE UNIVERSITY, PARIS, FRANCE 1

2 PROSTATE BIOPSY ISMANDATORY Is the only definitive method to prove cancer Cornerstone for therapeutic choice: Radical treatment Focal treatment Active surveillance Blad der Pros tate Rec tum Biopsy needle US probe Can be completed with MRI images 2

3 BUT The accuracy of ultrasound-guided transrectal biopsy is debated Poor correlation between the theoretical locations of positive biopsy cores and tumor areas from radical prostatectomy specimens * 12-core protocol defined on coronal view * De Laet K and al. Predicting tumour location in radical prostatectomy specimens: same-patient comparisons of 21- sample versus sextant biopsy. BJU Int Sep;104(5):

4 CLINICAL CONTEXT WE NEED AN ACCURATE PROSTATE BIOSPIES MAPPING SYSTEM : To guide the physician during the session Reduce intra-inter physician results To record biopsies localization For quality control For new prostate biopsies session For treatment planning transfert (focal therapy) To reduce the number of cores Morbidity! (bleeding and infection) 4

5 CHALLENGES TO PROSTATE TRACKINGAND FUSION What happens when the prostate is in view of the tracking probe? Patient motion Prostate motion and deformation 5

6 CHALLENGES (2) Marcel van Herk - Netherlands Kancer Institute Amsterdam 6

7 SOLUTIONS FOR PROSTATE BIOPSIES MAPPING Transperineal biopsies with brachytherapy template : General anesthesia Increase risk of urinary retention Localization : Needle deflexion Prostate rotation during needle insertion is relatively large, unpredictable and is not taken into account* What you see outside is not what is inside * Measurement of prostate rotation during insertion of needles for brachytherapy Lagerburg V, Moerland MA, Lagendijk JJ, Battermann JJ. Radiotherapy and Oncology Déc;77(3):

8 CONCEPTS IN 3D PROSTATE MAPPING 1 «GPS» PROBE TRACKING Based on ultrasound probe position Does Not take into account : Patient motion Prostate motion and deformation 2 AUTOMATIC ORGAN TRACKING Based on organ position in image Does take into account : Patient motion Prostate motion and deformation 8

9 KOELIS3D ULTRASOUND BIOPSIES MAPPING Clinical setup and routine is unchanged Local anesthesia Live end-fire TRUS plane of the prostate At any time during the procedure, FREEZE 3D Processed by the mapping system 9

10 MOVIE 3D TRUS MAPPING 10

11 IS THATACCURATE? The organ tracking being processed from registering the prostate between 2 positions: (from 786 registrations performed on 47 patients) Prostate biopsy tracking with deformation estimation. Baumann M, Mozer P, Daanen V, Troccaz J. Medical Image Analysis May

12 LIVE VISUALFEEDBACK: DOESITMAKESENSE? YES! A study on 12-areas-hitting success rate: 12

13 LIVE VISUALFEEDBACK: DOESITMAKESENSE? A visual feedback on the system screen after every biopsy series enabled the operator to significantly improve his dexterity over time first 16 patients: median score: 7 of 10 and cumulated median core length in targets: 90mm last 16 patients: median score: 9 of 10 and cumulated median core length in targets: 121mm (+34%) P = Mapping of transrectal ultrasonographic prostate biopsies: quality control and learning curve assessment by image processing. Mozer, P., Baumann, M., Chevreau, P., Moreau-Gaudry, A., Bart, S., Renard-Penna, R., Comperat, E., Conort, P., Bitker, M.-O., Chartier-Kastler, E., Richard, F., Troccaz, J., Journal of Ultrasound in Medicine 28,

14 US & MRI FUSION Cognitive (Brain;-) Assisted with a localizer / software 14

15 CHALLENGES :: IMAGE VIZUALISATION 15

16 CHALLENGES :: IMAGE VIZUALISATION 16

17 DEVICESFOR MRI & TRUS FUSION Many sytems GE Philips Koelis Siemens Esaote SmartBx Artemis Ultrasonix 17

18 CONCEPTS IN IMAGE FUSION 1 RIGID superimposition from 3 landmarks defined in each 3D image, e.g.: Apex Median posterior Bladderneck Drawbacks: Not so easy to define the same anatomical landmarks in TRUS and in MR images. Prostate deformation between MR and US images is not taken into account 2 ELASTIC registration from 3D shapes and models Advantages: Fast 3D shape contouring Prostate deformation between MR and US images is taken into account 18

19 RIGID & NON-RIGID FUSION ILLUSTRATED MRI 3D TRUS Rigid Fusion About 10mm inaccuracy Elastic Fusion About 2-3 mm accuracy 19

20 US & MRI FUSION + RIGID Real time MRI-ultrasound image guided stereotactic prostate biopsy. Kaplan I, Oldenburg NE, Meskell P, Blake M, Church P, Holupka EJ. Magn Reson Imaging Apr;20(3):295-9.

21 ARTEMIS SYSTEM : Need for a cumbersome passive robotic arm. 2D TRUS probe used to build a 3D image -> loss of accuracy

22 NIH 2D TRUS probe + magnetic localizer. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging. Pinto PA, Chung PH, Rastinehad AR, Baccala AA Jr, Kruecker J, Benjamin CJ, Xu S, Yan P, Kadoury S, Chua C, Locklin JK, Turkbey B, Shih JH, Gates SP, Buckner C, Bratslavsky G, Linehan WM, Glossop ND, Choyke PL, Wood BJ. J Urol Oct;186(4): Epub 2011 Aug

23 NIH Patients underwent 3.0 T multiparametric magnetic resonance imaging with endorectal coil Lesions suspicious for cancer were graded according to the number of sequences suspicious for cancer as low, moderate and high 12 EXT cores 3 cores on MRI target 23

24 NIH Median prostate specific antigen was 5.8 ng/ml 90% of patients had a negative digital rectal examination. Of patients with low, moderate and high suspicion on magnetic resonance imaging 27.9%, 66.7% and 89.5% were diagnosed with cancer, respectively (p <0.0001) Magnetic resonance imaging/ultrasound fusion guided biopsy detected more cancer per core than standard 12-core transrectal ultrasound biopsy No record for cores localization 24

25 KOELISCONCEPT Image Based (Organ Tracking) for biopsies Mapping Shape Based Registration 3D + 25

26 MOVIE 2:MR/TRUS FUSION 26

27 NORMALIZEDREPORT 27

28 CLINICALOUTCOMES? From 2009 to 2012, about 600 patients had 3D biopsy mapping with Koelis system on a weekly routine basis The 100 latest cases were included in a study: 104 patients First round biopsy 85% : Normal DRE PSA = 4-20ng/ml mp-mri: One target 12 cores (Extended protocol) targeted cores on MR target Not published yet 28

29 RESULTS (1/2) At least one positive core (EXT and TAR group) # Patients EXT TAR Biopsy Biopsy (Chi2 :: p=0,7) 29

30 RESULTS (2/2) If significant cores only (> Gleason 7, length > 3mm) # Patients EXT TAR Biopsy Biopsy Median length of positive cores : EXT= 5 mm TAR= 8 mm (p <0,01) (Chi2 :: p=1) 30

31 REBIOPSY Prospective study 3 tertiary centres Toulouse (D. Portallez, B. Malavaud) Paris (F. Cornud) Paris (R. Renard-Penna) Patients with a previous history of negative transrectal ultrasound-guided biopsies mp-mri: One target with ESUR score (3 to 15) 12 cores (Extended protocol) targeted cores on MRI target Prospective evaluation of the European Society of Urogenital Radiology score for prostate cancer diagnosis on multiparametric MRI. Accepted in European Urology 31

32 REBIOPSY 129 patients Age = 64.7±6.9 years old PSA (median) = 9.6 ng/ml ( ) Prostate Volume = 51.1 cm 3 (12-192) 32

33 REBIOPSY Cancer was evidenced in 62 patients (48%) : 21 by both random systematic and targeted cores 35 only by targeted cores 6 only by random systematic cores. 5 patients : single positive core in five cancer length of 1mm (3 patients), 2mm (1 patient), 3mm (1 patient)) 1 patient two positive cores with 1 mm foci 33

34 REBIOPSY--ROC 34

35 35 REBIOPSY % of positive cores

36 SECOND LOOK December 2010 February 2011 Fully Automatic

37 TAKE-HOME MESSAGES 3D TRUS Biopsy Mapping can record biopsy cores locations, improve the sampling, bring quality control, and probably decrease intra-inter operator results. Elastic MRI/TRUS Fusion can guide biopsy cores to MR lesions to reduce the number of cores while keeping the same detection rate Such multimodality mapping can help with patient selection for treatment and treatment planning in the opening field of focal therapy Multicenter Prospective Randomized Controlled trials are needed for further proof of clinical value. 37

38 OBRIGADO! 38

39 ACCURACY Prostate biopsy tracking with deformation estimation. Baumann M, Mozer P, Daanen V, Troccaz J. Med Image Anal May