Multi-parametric MR imaging in Problems: TRUS Bx Low Risk Prostate Cancer Important cancers are missed Jelle Barentsz Clinically insignificant cancers are identified by Prostate MR Center of Excellence chance Department of Radiology Radboud University Nijmegen Medical Center The Netherlands 36-46% undergrading of Gleason score j.barentsz@rad.umcn.nl Objectives Learning Objectives Clinical questions in PCa How to decrease the number of biopsy cores and increase the yield? Can mp-mri show the exact location of the (most) aggressive part of the tumor? 1. Improve localization & detection 2. Determine aggression 3. Improve local staging 4. Detect nodal metastases 5. Detect recurrences 1
Clinical questions in PCa Localization/detection 1. Improve localization & detection 2. Determine aggression 3. Improve local staging 4. Detect nodal metastases 5. Detect recurrences Futterer, Radiol 2006 multi-parametric MRI > anatomic MRI Patient 62 y, PSA 28 8x negative TRUS Bx (96 cores) Patient 62 y: Your diagnosis? 1.7 cm line normal 2
Patient 62 y Multi-parametric detection MRI (30 min, no ERC) T2-w anatomy DWI (b800) ADC DCE - MRI TRUSor MRguidance? 1.7 cm line Next step? my view! c. Hambrock MR-guided biopsy: patient 62 y Multi-modality MR-guided biopsy in tumor detection Gleason score 4+3 Hambrock J Urol 2010 3
c. Cornud, France c. Cornud, France Clinical questions in PCa Dogs and Prostate 1. Improve detection & localization 2. Determine aggression 3. Improve local staging 4. Detect small nodal metastases 5. Detect recurrences / follow up What is the association betweeen dogs and prostate cancers? 4
Dogs and Prostate Dogs and Prostate Benign Intermediate aggressive c. T. Hambrock Gleason 3 c. T. Hambrock Gleason 4 Dogs and Prostate DWI: ADC-value vs Gleason score Highly aggressive Pearson Correlation r = 0.73 p < 0.01 c. T. Hambrock Gleason 5 Hambrock, Radiology 2011, Alvares, Radiology, in press, Itou JMRI 2011 5
Two Patient Cohorts 33 MR-GB Patients Multimodality MRI-Localization MR-GB towards darkest part on ADC-map 64 TRUS-GB Patients 10-Core TRUS biopsy (Siemens, Trio Tim) TRUS-Bx & MR-Bx vs Prostatectomy Biopsy Gleason Prostatectomy Gleason Hambrock 2010 SCBTMR Lauterbur Award TRUS-Bx & MR-Bx vs Prostatectomy TRUS-Bx & MR-Bx vs Prostatectomy Undergrading Undergrading 5% P < 0.001 46% 46% Hambrock 2010 SCBTMR Lauterbur Award Hambrock 2010 SCBTMR Lauterbur Award 6
Improved localization and determination of aggression Improved localization and determination of aggression Active Surveillance Active Surveillance Screening? Screening? Focal therapy Focal therapy AS: exclusion of high grade tumors T2-w + MRSI Sens for Gl 4+3: 93% Spec for Gl 4+3: 98% NPV: for Gl 4+3: 98% G. Villiers: RSNA 2010 Villers et al. J Urol December 2006 Tumour vol 0.2cc 0.5cc Sensitivity 77% 90% Specificity 91% 88% PPV 86% 77% NPV 85% 95% 7
AS (PRIAS) protocol AS (PRIAS) protocol Year 1 2 3 4 Year 1 2 3 4 Month 0 3 6 9 12 15 18 21 24 30 36 42 48 Month 0 3 6 9 12 15 18 21 24 30 36 42 48 PSA-test PSA-test DRE DRE Biopsy Biopsy Clinical Evaluation Clinical Evaluation MRI MRI Patients MR-indicated patient exclusions 7/25 (28%) MR-GB: Gleason grade 4-5 2 nd cancer location 1 V V 2 V 3 V 4 V 5 V 6 V 7 V Hoeks, RSNA 2010 Stage T3a: ECE Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5% Candidate for Active Surveillance 6 x 4 x 6 mm (0.14 cc) 8
Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5% Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5% all 5 biopsy cores 80%, Gleason 8 DWI DCE with extension in periprostatic fat (T3a) Patient exclusion Improved localization and determination of aggression Active Surveillance Screening? Focal laser therapy ERSPC: Goteborg trial: Learning Objectives however at high cost: biopsies, overdiagnosis do not use PSA alone apply risk modifiers identify indolent disease develop better markers Rationale screening mortality reduction: 31% mortality reduction: 44% Hanley J Med Screen 2010: : mortality reduction: 50-60 60% 9
Rationale screening Learning Objectives Screening Learning Objectives ERSPC: Goteborg trial: however at high cost: biopsies, overdiagnosis do not use PSA alone apply risk modifiers identify indolent disease develop better markers mortality reduction: 31% mortality reduction: 44% Hanley J Med Screen 2010: : mortality reduction: 50-60% ERSPC: Goteborg trial: however at a high cost: do not use PSA alone apply risk modifiers identify indolent disease develop better markers mortality reduction: 31% mortality reduction: 44% Hanley J Med Screen 2010: : mortality reduction: 50-60% add mp-mri mp-mri MRI will miss MRI >>PCa3 Clinical questions in PCa Patient 48 y, sexually active; PSA 9 Gl 4+3; DRE T1 1. Improve detection & localization 2. Determine aggression 3. Improve local staging 4. Detect small nodal metastases 5. Detect recurrences 3T ERC only when detecting minimal ECE is important: (se 87% sp 96%) 10
ECE 2 mm close to NVB: min. T3a, R- DTI: position of PCa to NVB T c. H. Morales, S. Verma, Cincinnati, USA Clinical questions in PCa 1. Improve detection & localization 2. Determine aggression 3. Improve local staging 4. Detect nodal metastases 5. Detect recurrences Are we there? 11
Yes we Scan! even in non-academia at 1.5T without ERC T2WI ADC (900) But we need Awareness and knowledge of MRI of: DCE DWI b800 Radiologists, Urologists, Radiation Oncologists, Patients c. John Feller, Palm Desert Awareness and knowledge of: Radiologists, Urologists, Radiation Oncologists, Patients We need Standardized Protocols: simple and good 1. Detection / recurrence protocol (20-30 min, - ERC) - Guidelines for: * standardized protocols: simple, good, fast 2. Staging protocol (45-55 55 min, +/-ERC ERC) 3. Bone & node protocol (20-35 min, - ERC) 12
Awareness and knowledge of: Radiologists, Urologists, Radiation Oncologists, Patients - Guidelines for: We need Score T2W Classification System (Pi-RADS) Criteria 1 Uniform high signal intensity or heterogeneous transitional zone adenoma with well-defined margins 2 Linear or geographic areas of lower SI on T2W images 3 Intermediate appearances not in categories 1/2 or 3/4 4 Discrete, homogenous low signal focus/mass confined to the prostate 5 Discrete, homogeneous low signal intensity focus with extra-capsular extension /invasive behaviour or mass effect on the capsule (bulging) Score DWI Criteria 1 No reduction in ADC compared to normal glandular tissue. No increase in signal on any high b-value image ( b1000) 2 Diffuse, hyper intensity on b1000 image with low ADC; No focal features - linear, triangular or geographical features allowed 3 Intermediate appearances not in categories 1/2 or 3/4 4 Focal area(s) of reduced ADC but iso-intense signal intensity on high b-value images ( b1000) 5 Focal area/mass of hyper intensity on the high b-value images ( b1000) with reduced ADC * structured reporting (Pi-RADS) Score DCE Criteria 1 Type 1 enhancement curve 2 Type 2 enhancement curve 3 Type 3 enhancement curve +1 For focal enhancing lesion with curve type 2 or 3 +1 For asymmetric lesion r lesion at an unusual place with curve shape 2 or 3 Score MRSI Criteria 1 Citrate peak exceeds choline peak >2 times 2 Citrate peak exceeds choline peak >1-2 times 3 Choline peak equals citrate peak 4 Choline peak exceeds citrate peak >1-2 times 5 Choline peak exceeds citrate peak >2 times DCE: 5/5 DWI: 5/5 Structured Analysis workstation 5 point scale: Pi-RADS Structured Reporting DWI: 5/5 T2W: 5/5 DCE: 5/5 MRSI: 2/5 13
We need also - availability - education - certification - multi-center trials - sub-specialization specialization in PCa? Multi-parametric MRI shows where PCa is, it s aggression, and if it grows outside the prostate This will decrease the number of needle cores, and improve its yield MRI opens the way to tailored (minimal invasive) therapy, which reduces side-effectseffects Thank you for your attention 14