Detection, Screening and. Jelle Barentsz, Radboudumc, Nijmegen, NL
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1 Detection, Screening and Staging with mpmri Jelle Barentsz, Radboudumc, Nijmegen, NL
2 NO CONFLICT OF INTEREST
3 Paradigm shift Past staging TRUS-GBx ERC, MRSI invasive Current detection agressive PCa mpmri-directed Bx multi-parametric MRI minimally invasive
4 PCa-MRI = multi-parametric MRI ANATOMY T2-Weighted Imaging (T2W) BIOLOGY Diffusion Weighed Imaging (DWI) VASCULARITY Dynamic Contrast enhanced
5 PCa-MRI = mpmri ANATOMY T2-Weighted Imaging (T2W) ANATOMY AGRESSION VASCULARITY
6
7 BIOLOGY: DWI 62 yr. PSA 12 ng/ml, 4 negative TRUS biopsies T2W DWI
8 BIOLOGY: DWI 62 yr. PSA 12 ng/ml, 4 negative TRUS biopsies T2W DWI MR-GB: Gl 4+3
9 BIOLOGY: DWI 62 yr. PSA 12 ng/ml, 4 negative TRUS biopsies T2W DWI MR-GB: Gl 4+3 Px: lager tumor
10 BIOLOGY: DWI T2W DWI Gl 3 Gl 3
11 BIOLOGY: DWI MR-GB and Prostatectomy Gl 4+3 T2W DWI Gl4 Gl 3 Gl 3
12 DETECTION
13 DETECTION: PIRADS=PROBABILITY AGRESSIVE PCA (1-5)
14 Evidence that mpmri can early detect significant PCa better than TRUS-Bx With substantial less insignificant PCa Two level 1a systematic reviews 1, 2 One level 1a prospective clinical randomised trial 3 Multiple level 1b studies 4,5 1. Schoots Eur Urol 2015, 2 Futterer Eur Urol 2015, Panebianco Urol Oncol 2015, 4. Siddiqui JAMA 2015, 5. Pokorny Eur Urol 2014
15 mp-mr-targeted-bx vs TRUS-Bx mpmri has higher detection rate of significant PCa: 91% vs 71%
16 mp-mr-targeted-bx vs TRUS-Bx More important: mpmri has lower detection rate of insignificant PCa: 44% vs 83%
17 MR-Bx vs TRUS-Bx mpmri has much better grading % 5% Undergrading of significant PCa Gold standard: prostatectomy 0 Echo-biopt TRUS-Bx MR-biopt MR-Bx Hambrock Eur Urol 2011
18 DOES mp-mri MISS SIGNIFICANT PCA?
19 YES, NO TECHNIQUE IS PERFECT WE MISS 2-11%
20 Experts in mp-mri: No = No sens spec NPV Villeirs 93% 98% 98% Thompson 96% 36% 92% Villers 90% 88% 95% Pokorny 97% 92% 97% Ahmed (PROMISE) 93% 43% 89%/75%* * 1.5T, no PI-RADS, community radiologists Villiers EJR 2011, Wang PLOS, Pokorny E Urol 2014, Thompson J Urol 2016, Ahmed Lancet 2016
21 What is best for a certain patient group? Balance: Missing significant PCa vs not finding insignificant PCa 1. Siddiqui JAMA 2015
22 What is best for a certain patient group? Balance: Missing significant PCa or not finding insignificant PCa mp-mri + additional TRUS-Bx: 103/1003 additional PCa 1. Siddiqui JAMA 2015
23 What is best for a certain patient group? Balance: Missing significant PCa or not finding insignificant PCa mp-mri + additional TRUS-Bx: 103/1003 additional PCa, 83% low risk 1 1. Siddiqui JAMA 2015
24 What is best for a certain patient group? Balance: Missing significant PCa or not finding insignificant PCa TRUS-Bx needed to detect 1 additional significant PCa - at the cost of over-diagnosis of 17 insignificant PCa 1. Siddiqui JAMA 2015
25 What is best for a certain patient group? PI-RADS: Biopsy naïve / detection:
26 What is best for a certain patient group? PI-RADS: Biopsy naïve / detection: High specificity reading
27 What is best for a certain patient group? PI-RADS: Biopsy naïve / detection: High specificity reading Post negative TRUS:
28 SCREENING?
29 Manogram : 8 minutes, no contrast! T2W axial ADC axial
30 Nijmegen study: full protocol vs screen (n=200) total screen
31 Nijmegen study: full protocol vs screen (n=200) 42/41 total screen
32 What is best for a certain patient group? PI-RADS: Biopsy naïve / detection: High specificity reading Post negative TRUS: High sensitivity reading
33 429 men with PSA > 3 ng/ml With or without prior TRUS guided biopsy (up to 4 times) Aged median 64.5 years AP-MRI identified prostate cancer in 123/429 men Bruhn, Radiology 2017
34 T-STAGING Ghent University Hospital, Belgium
35 Urologist Old situation GP referral PSA >3 ng/ml Urol Clinical tests (DRE) TRUS biopsy: - 40% missed PCa - 40% overdiagnosis - 40% aggression underestimation Urol Inaccurate Nomogram: - T stage (DRE) - Untargeted Biopsy - Unspecific PSA Urol Low risk i.m. risk High risk Urologist Advice Urol Bone scan MRI Bone scan MRI
36 PDC 110 p - okt 2017 GP PSA >3 ng/ml MDT Prostaat Diagnosis & Treatment Expertise Centre Clnical Risk (-) mpmri (+): mpmri-biopy + 37%% - 5% - 53% 4% - 5% 9% (klinisch onzeker) Low risco New Nomogram: - T-Stage (mpmri) - Targeted Biopsy - Select MDX - Advanced PSA MDT i.m. risico 28% High risico MDT MDT advice Nano-MRI 68 Ga PSMA PET-CT Nano-MRI
37 HOW GOOD ARE WE?
38 Staging accuracy
39 Staging accuracy Sensitivity 26%-100% Specificity 0%-100%
40 Staging accuracy
41 Staging accuracy Sensitivity 14%-91% Specificity 56%-100%
42 Staging accuracy
43 Staging accuracy Sensitivity 14%-90% Specificity 74%-98%
44 WHAT IS GOING WRONG?
45 Staging accuracy Sensitivity 14%-91% Specificity 56%-100% What is wrong?
46 Staging accuracy Sensitivity 14%-91% Specificity 56%-100% Large variability
47 Technical parameters *Engelbrecht, Eur Radiol 2002;12:2294
48 Diagnostic criteria ECE Focal contour bulge of capsule nearest the tumor Tumor SI within periprostatic fat Hyposignal in any periprostatic area Thickening of periprostatic veins
49 Diagnostic criteria SVI Focal hypointense luminal replacement Focal low SI in one or both seminal vesicle(s) Filling defect within root of seminal vesicles
50 HOW TO SOLVE THE PROBLEM?
51 How to solve the problem? We need: standardized diagnostic criteria
52 Diagnostic criteria Tumor growth timeline
53 Diagnostic criteria ECE Tumor clearly confined to the prostate T
54 Diagnostic criteria ECE Broad tumor contact with capsule T
55 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging T
56 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption T
57 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption T
58 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin T
59 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour T
60 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration T
61 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration Obliteration rectoprostatic angle T?
62 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration Obliteration rectoprostatic angle Measurable tumor in periprostatic fat
63 Diagnostic criteria ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration Obliteration rectoprostatic angle Measurable tumor in periprostatic fat
64 Diagnostic criteria ECE Intraprostatic Contact Minimal ECE Gross ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration Obliteration rectoprostatic angle Tumor in periprostatic fat
65 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% Pesapane, Ghent/Belgium, unpublished data
66 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Pesapane, Ghent/Belgium, unpublished data
67 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Pesapane, Ghent/Belgium, unpublished data
68 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Pesapane, Ghent/Belgium, unpublished data
69 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Unsharp prostatic margin 75,00% 11,80% Pesapane, Ghent/Belgium, unpublished data
70 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Unsharp prostatic margin 75,00% 11,80% Irregular contour 85,70% 8,80% Pesapane, Ghent/Belgium, unpublished data
71 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Unsharp prostatic margin 75,00% 11,80% Irregular contour 85,70% 8,80% PPF infiltration 87,50% 6,90% Pesapane, Ghent/Belgium, unpublished data
72 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Unsharp prostatic margin 75,00% 11,80% Irregular contour 85,70% 8,80% PPF infiltration 87,50% 6,90% RPA obliteration 100,00% 2,90% Pesapane, Ghent/Belgium, unpublished data
73 Diagnostic criteria ECE PPV Prevalence Capsular contact 51,90% 56,90% 10 mm 57,40% 26,50% 20 mm 81,30% 12,70% Capsular disruption 69,00% 18,60% Bulging 75,00% 14,70% Unsharp prostatic margin 75,00% 11,80% Irregular contour 85,70% 8,80% PPF infiltration 87,50% 6,90% RPA obliteration 100,00% 2,90% Periprostatic mass 100,00% 2,90% Pesapane, Ghent/Belgium, unpublished data
74
75 Diagnostic criteria ESUR Guidelines
76 Diagnostic criteria SVI Diffuse wall thickening
77 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening
78 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening
79 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening Intraluminal mass
80 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening Intraluminal mass
81 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening Intraluminal mass Obliteration of prostatovesicular angle
82 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening T Intraluminal mass Obliteration of prostatovesicular angle
83 Diagnostic criteria SVI Diffuse wall thickening Focal wall thickening Intraluminal mass Obliteration of prostatovesicular angle Destruction
84 Diagnostic criteria ESUR Guidelines
85 How to solve the problem? We need: standardized diagnostic criteria standardized technical parameters
86
87 Technical parameters Optimal T2-weighted MRI thin slices (preferably 3 mm) high in-plane resolution (preferably 512²) and small field of view (preferably 0.3 mm²) transverse images perpendicular to posterior prostate margin Functional imaging: mpmri De Rooij, Eur Urol 2016, Bittencourt, Radiology 2016
88 Technical parameters Optimal T2-weighted MRI thin slices (preferably 3 mm) high in-plane resolution (preferably 512²) and small field of view (preferably 0.3 mm²) transverse images perpendicular to posterior prostate margin Functional imaging: mpmri De Rooij, Eur Urol 2016, Bittencourt, Radiology 2016
89 DIAGNOSTIC THRESHOLD
90 Diagnostic threshold it3a it3b
91 Diagnostic threshold T T Slight capsular irregularity Slight capsular undulation
92 Local staging: EPE? We need: 3 Categories:
93 Local staging: EPE? We need: 3 Categories: 1. No
94 Local staging: EPE? We need: 3 Categories: 1. No 2. Possible or minimal
95 Diagnostic threshold Intraprostatic Contact Minimal ECE Gross ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin
96 Local staging: EPE? We need: 3 Categories: 1. No 2. Possible or minimal 3. Yes
97 Diagnostic threshold Intraprostatic Contact Minimal ECE Gross ECE Broad tumor contact with capsule Smooth capsular bulging Capsular SI disruption Unsharp margin Irregular contour Periprostatic fat infiltration Obliteration rectoprostatic angle Tumor in periprostatic fat
98 Local staging: mpmri Accuracy 74% 1,2 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
99 Local staging: mpmri Accuracy 74% 1,2 27% influence of surgical plan 2,3 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
100 Local staging: mpmri Accuracy 74% 1,2 27% influence of surgical plan 2,3 60% more NSS (appropriateness 91%) 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
101 Local staging: mpmri Accuracy 74% 1,2 27% influence of surgical plan 2,3 60% more NSS (appropriateness 91%) 40% more non-nss 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
102 Local staging: mpmri Accuracy 74% 1,2 27% influence of surgical plan 2,3 60% more NSS (appropriateness 91%) 40% more non-nss NSS: 0% positive margins 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
103 Local staging: mpmri Accuracy 74% 1,2 27% influence of surgical plan 2,3 60% more NSS (appropriateness 91%) 40% more non-nss NSS: 0% positive margins non-nss: 7% positive margins 1. Somford J Urol 2013, 2. Park, J Urol 2014, 3. McClure, Radiology 2012
104 TAKE HOME MESSAGES
105 Take home messages For staging, use MRI to assess capsular perforation and/or seminal vesicle invasion Technical standardization needed Reporting standardization needed
106 Not all radiologists can do it well!
107 Diagnostic threshold A doubtful MRI should not change the therapy plan
108 Diagnostic threshold A doubtful MRI should not change the therapy plan Talk to the surgeon: active surveillance good option? broader margin at site of potential ECE more R0!
109 And,.
110 mpmri shows the agressive tumor, but..
111 mpmri shows the agressive tumor, but.. Raise your finger to the Radiologist When he is wrong!
112 Stimulate Radiologists to work on certification
113 And,. non-radiologists need to learn PI-RADS and staging as well.
114 Jelle
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