Prostate biopsy: MR imaging to the rescue

Transcription

1 Prostate biopsy: MR imaging to the rescue Poster No.: C-1855 Congress: ECR 2014 Type: Educational Exhibit Authors: N. V. V. B. Marques 1, J. Ip 1, A. Loureiro 2, J. Niza 1, M. Palmeiro 2, Keywords: DOI: M. E. M. Abreu 1, J. Venancio 2 ; 1 Lisbon/PT, 2 Lisboa/PT Genital / Reproductive system male, Urinary Tract / Bladder, Pelvis, Ultrasound, MR-Functional imaging, Biopsy, Diagnostic procedure, Neoplasia, Cancer /ecr2014/C-1855 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 Learning objectives To demonstrate the value of multiparametric MR imaging (MP-MRI) after a first negative transrectal ultrasound (TRUS) guided prostate biopsy. Page 2 of 12

3 Background Prostate cancer is the most frequent cancer diagnosed in men. It's incidence is rising, not only in parallel to the aging of the population, but also related to an earlier diagnosis, mostly dependent on the PSA screening. TRUS has a clear role in the guidance of biopsies, not so much in the screening and detection of cancer - a normal US does not rule out cancer! Some of the lesions can be isoechoic, the more infiltrative ones can be easily missed and those in the transitional zone difficult to differentiate from the background of glandular nodularity and fibrous elements found in varying proportions in benign prostatic hyperplasia. Additionally, some benign entities can also behave as hypoechoic areas at the peripheral zone, such as hyperplasia and prostatitis. MRI and its advances in functional evaluation of the prostate made it possible to detect additional suspicions lesions missed in US and, recently, with the introduction of the PI- RADS classification, a structured report with scores for individual lesions, corresponding to probabilities of significant cancer being present. Page 3 of 12

4 Findings and procedure details At our institution, we initially perform a systematic TRUS-guided 12-core biopsy and additional ones to suspicious areas. The following examples demonstrate the nonspecificity of US on some areas we have found as suspicious for cancer: In Figure 1, a 51 year old man had bilateral peripheral heterogeneity, more hypoechoic and better circumscribed on the right. The histological examination revealed foci of chronic prostatitis. In Figure 2, a 60 year old man had bilateral well circumscribed and markedly hypoechoic lesions. The histological examination revealed granulomatous prostatitis. Facing a first negative histological result and maintaining a high degree of suspicion on the presence of cancer, we have started to perform MP-MRI before the second biopsy (1.5 T, without an endorectal coil). Some examples are shown here: The next case was not a successful one. In Figure 3, a 47 year old man had a first negative TRUS-guided prostate biopsy in The MR performed at raised the question of a suspicious area in the left peripheral proximal zone. A second targeted biopsy in did not show neoplastic tissue, only hyperplastic foci. In Figure 4, a 59 year old man had a first negative biopsy in The MRI in showed a suspicious para-urethral nodule in the left transition zone. The second biopsy targeted to that area revealed a Glasgow 6 (3 + 3) adenocarcinoma. In Figure 5, a 47 year old man has a very suspicious nodule in the MP-MRI in the left transition zone. In the previous TRUS we could see cystic degeneration in the transition zone, usually seen in benign prostatic hyperplasia. Since we started to base our interpretation on the new PI-RADS classification, we began to have consistent results, but this case is so recent that and we have not yet repeated the biopsy to confirm malignancy. Page 4 of 12

5 Images for this section: Fig. 1: Sagittal and transverse TRUS of the prostate. A - hypoechoic nodule in the anterior horn of the peripheral right midgland (arrow). B - ill-defined hypoechoic area of the peripheral left midgland (arrow). The histological examination revealed foci of chronic prostatitis. Radiologia, IPOLFG - Lisbon/PT Page 5 of 12

6 Fig. 2: A - The transverse and sagittal TRUS show several well circumscribed and markedly hypoechoic lesions in the prostate peripheral zone, billaterally (arrows). B and C - Sagittal images exemplifying the core-biopsy needle path (small arrows) through different lesions. The histological examination revealed granulomatous prostatitis. Radiologia, IPOLFG - Lisbon/PT Page 6 of 12

7 Fig. 3: A - The first TRUS of the prostate wasn't able to define nodular lesions and the core-needle biopsies didn't find neoplastic tissue. B - The MP-MRI performed more than one year after raised the question of a suspicious area in the left peripheral proximal zone: hipointense nodule in T2 (top left) hyperenhancing after contrast injection (top right), showing restriction on diffusion with hyperintensity on b-1000 (bottom left) and hypointensity on the ADC map (bottom rigth). C - On the second TRUS of the prostate a nodule could be seen corresponding to the same area identified on the previous MRI. However, the targeted biopsy didn't show neoplastic tissue, only hyperplastic foci. Radiologia, IPOLFG - Lisbon/PT Page 7 of 12

8 Fig. 4: A - The first TRUS of the prostate showed a homogeneous peripheral zone and the core-needle biopsies didn't find neoplastic tissue. B - The MP-MRI performed eight months later revealed a suspicious left para-urethral transition zone nodule: hipointense in T2 (left, arrow) hyperenhancing after contrast injection (right, arrow). On A second TRUS-targeted biopsy to this nodule revealed a Glasgow 6 (3 + 3) adenocarcinoma. Radiologia, IPOLFG - Lisbon/PT Page 8 of 12

9 Fig. 5: A - The TRUS of the prostate showed a homogeneous peripheral zone and the core-needle biopsies didn't find neoplastic tissue. B - The MP-MRI performed nine months later raised showed a suspicious area in the left transition zone: hipointense in T2 (top left) hyperenhancing after contrast injection (top right), showing restriction on diffusion with hypointensity on the ADC map (bottom left) and a type II enhancemet curve (bottom right). Radiologia, IPOLFG - Lisbon/PT Page 9 of 12

10 Conclusion Although our institution is performing MP-MRI of the prostate with a 1.5T unit without an endorectal coil, we have been having positive results on the second biopsy, attesting to the indication of the MRI after a first negative TRUS-guided prostate biopsy. Page 10 of 12

11 Personal information Vasco Marques Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE Page 11 of 12

12 References Boonsirikamchai P, Choi S, Frank SJ, Ma J, Elsayes KM, Kaur H, Choi H. MR imaging of prostate cancer in radiation oncology: what radiologists need to know. RadioGraphics 2013 May; 33(3): Röthke M, Blondin D, Schlemmer HP, Franiel T. PI-RADS Classification: Structured Reporting for MRI of the Prostate. Rofo Mar; 185(3): Barentsz JO, Richenberg J, Clements R et al. ESUR prostate MR guidelines Eur Radiol. 2012; 22: Jung AJ, Westphalen AC. Imaging Prostate Cancer. Radiol Clin N Am Nov; 50(6): Page 12 of 12