MultiMulti--parametric MR imaging in parametric MR … · Classification System (Pi -RADS) Score T2W Criteria 1 Uniform high signal intensity or heterogeneous transitional zone adenoma

BarentszBarentsz 22--44--20112011

11

Jelle Barentsz

Prostate MR Center of Excellence

Department of RadiologyRadboud University Nijmegen Medical CenterThe Netherlands

[email protected]

MultiMulti--parametric MR imaging in parametric MR imaging in Low Risk Prostate CancerLow Risk Prostate Cancer

•• Important Important cancers are cancers are missedmissed

•• Clinically Clinically insignificant insignificant cancers are identified by cancers are identified by chancechance

•• 3636-- 46% 46% undergradingundergrading of of Gleason scoreGleason score

Problems: TRUS Bx

Learning Objectives

•• How to How to decrease decrease the the number number of of biopsy biopsy cores cores and and increase increase the the yieldyield ??

•• Can Can mpmp--MRI MRI show the exact show the exact location location of the (most) of the (most) aggressive aggressive part of the part of the tumortumor ??

Objectives Clinical questions in PCa

1. Improve localization & detection

2. Determine aggression

3. Improve local staging

4. Detect nodal metastases

5. Detect recurrences







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Clinical questions in PCa











Futterer, Radiol 2006

multi-parametric MRI > anatomic MRI

Localization/detection

Patient 62 y, PSA 288x negative TRUS Bx (96 cores)

Patient 62 y: Your diagnosis?

normalnormal

1.7 cm line1.7 cm line


33

Patient 62 yMultiMulti--parametric parametric “detection” “detection” MRIMRI (30 min(30 min, no ERC), no ERC)

T2T2--w w anatomyanatomy DWI (b800) ADCDWI (b800) ADC DCE DCE -- MRIMRI

Next step ?1.7 cm line1.7 cm line

c. Hambrock

TRUS-or

MR-guidance ?

“my view!”

MR-guided biopsy: patient 62 y

Gleason score 4+3 Hambrock J Urol 2010

Multi-modality MR-guided biopsyin tumor detection


44

c. Cornud, France c. Cornud, France


1. Improve detection & localization



4. Detect small nodal metastases

5. Detect recurrences / follow up





5. Detect recurrences / follow up

WhatWhat is the is the associationassociation betweeenbetweeendogsdogs and and prostate prostate cancerscancers ??

WhatWhat is the is the associationassociation betweeenbetweeendogsdogs and and prostate prostate cancerscancers ??

Dogs and Prostate


55

BenignBenignBenignBenign

Gleason 3

Dogs and Prostate

c. T. Hambrock

IntermediateIntermediate aggressiveaggressiveIntermediateIntermediate aggressiveaggressive

Gleason 4c. T. Hambrock

Dogs and Prostate

c. T. Hambrock Gleason 5

Dogs and Prostate

HighlyHighly aggressiveaggressiveHighlyHighly aggressiveaggressive

Pearson Pearson CorrelationCorrelation

r = r = 0.73 0.73

p <p < 0.010.01

Hambrock, Radiology 2011,

Alvares, Radiology, in press, Itou JMRI 2011

DWI: ADC-value vs Gleason score


66

Two Patient Cohorts

3333 MRMR--GB GB PatientsPatients

•• MultimodalityMultimodality MRIMRI--LocalizationLocalization•• MRMR--GB GB towardstowards darkestdarkest part part onon ADCADC--mapmap

(Siemens, Trio Tim)

64 64 TRUSTRUS--GB GB PatientsPatients

•• 1010--CoreCore TRUS TRUS biopsybiopsy

Biopsy Gleason ↔Prostatectomy Gleason

TRUS-Bx & MR-Bx vs Prostatectomy

Hambrock 2010 SCBTMR “Lauterbur Award”

Undergrading

46%



Undergrading

5%



46%

P < 0.001


77

Improved localization and determination of aggression

→ Active Surveillance

→ Screening ?

→ Focal therapy


→ Screening ?

→ Focal therapy



→ Screening?

→ Focal therapy


→ Screening?

→ Focal therapy

AS: exclusion of high grade tumors

T2T2--w w + + MRSIMRSI

SensSens for for GlGl ≥4+3≥4+3: : 93%93%

Spec Spec for for GlGl ≥4+3: ≥4+3: 98%98%

NPV: NPV: forfor GlGl ≥4+3: ≥4+3: 98%98%

GG. Villiers: . Villiers: RSNA 2010RSNA 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%


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AS (PRIAS) protocol

Year 1 2 3 4

Month 0 3 6 9 12 15 18 21 24 30 36 42 48

PSA-test � � � � � � � � � � � � �

DRE � � � � � � �

Biopsy � � �

Clinical

Evaluation � � � � � � �

MRI

AS (PRIAS) protocol

Year 1 2 3 4

Month 0 3 6 9 12 15 18 21 24 30 36 42 48

PSA-test � � � � � � � � � � � � �

DRE � � � � � � �

Biopsy � � �

Clinical

Evaluation � � � � � � �

MRI

Patients MR-indicated patient exclusions

7/25

(28%)MR-GB:Gleason grade 4-5

2nd cancerlocation

Stage T3a:ECE

1 V V

2 V

3 V

4 V

5 V

6 V

7 V

Hoeks, RSNA 2010

Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5%Candidate for Candidate for Active SurveillanceActive Surveillance

6 x 4 x 6 mm (0.14 cc)


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Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5%

DWIDWI DCEDCE

Case: 69 y. PSA 6.7, T1, Gl. 3+3, 1/9 cores 5%

all all 5 5 biopsy cores biopsy cores 80%, Gleason 880%, Gleason 8

with extension in with extension in periprostatic fat (periprostatic fat (T3a)T3a)

→ Patient exclusion



→ Screening ?

→ Focal laser therapy


→ Screening ?

→ Focal laser therapy

Learning Objectives

however at however at high high cost: biopsies, overdiagnosiscost: biopsies, overdiagnosis•• do not use PSA alonedo not use PSA alone•• apply risk modifiersapply risk modifiers•• identify indolent diseaseidentify indolent disease•• develop better markers develop better markers

Rationale screening

ERSPCERSPC: : mortality mortality reduction: reduction: 3131%%GoteborgGoteborg trialtrial : : mortality mortality reduction: reduction: 4444%%Hanley Hanley J Med Screen 2010J Med Screen 2010 : mortality reduction: : mortality reduction: 5050--6060%%


1010

Learning Objectives

however at however at high high cost: cost: biopsies, overdiagnosisbiopsies, overdiagnosis•• do do notnot use use PSA alonePSA alone•• apply apply risk modifiersrisk modifiers•• identify indolent identify indolent diseasedisease•• develop develop better markers better markers

Rationale screening

ERSPC: ERSPC: mortality mortality reduction: 31%reduction: 31%Goteborg trial: Goteborg trial: mortality mortality reduction: 44reduction: 44%%Hanley Hanley J Med Screen 2010J Med Screen 2010 : mortality reduction: 50: mortality reduction: 50--60%60%

Learning Objectives

however at a high cost:however at a high cost:•• do not use PSA alonedo not use PSA alone add mpadd mp--MRIMRI•• apply risk modifiersapply risk modifiers mpmp--MRIMRI•• identify indolent diseaseidentify indolent disease MRI MRI will misswill miss•• develop better markers develop better markers MRI MRI >>PCa3>>PCa3

Screening

ERSPC: ERSPC: mortality mortality reduction: 31%reduction: 31%Goteborg trial: Goteborg trial: mortality mortality reduction: 44reduction: 44%%Hanley Hanley J Med Screen 2010J Med Screen 2010 : mortality reduction: 50: mortality reduction: 50--60%60%












Patient 48 y, sexually active; PSA 9Gl 4+3; DRE T1

3T 3T ERC ERC only when only when detecting minimal detecting minimal ECE is important:ECE is important:

(se (se 87% 87% spsp 9696%%) )

3T 3T ERC ERC only when only when detecting minimal detecting minimal ECE is important:ECE is important:

(se (se 87% 87% spsp 9696%%) )


1111

ECE 2 mm close to NVB: min. T3a, R-

TT

DTI: position of PCa to NVB

c. H. Morales, S. Verma, Cincinnati, USA












Are we there?Are we there?


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c. John Feller, Palm Desert

“Yes we Scan!” even in non-academia at 1.5T without ERC

DCE DWI b800

ADC (900)T2WIT2WIBut we need

Awareness and knowledge Awareness and knowledge of MRI of:of MRI of:

RadiologistsRadiologists ,, UrologistsUrologists , , Radiation OncologistsRadiation Oncologists ,, PatientsPatients

We need

Awareness and knowledge Awareness and knowledge of:of:

RadiologistsRadiologists, , UrologistsUrologists, , Radiation Oncologists, PatientsRadiation Oncologists, Patients

-- GuidelinesGuidelines forfor::

** standardizedstandardized protocolsprotocols::simple,simple, good,good, fastfast

Standardized Protocols:simple and good

1.1. Detection / recurrenceDetection / recurrence protocol protocol (20(20--30 30 min, min, -- ERCERC))

2. 2. Staging Staging protocol protocol (45(45--55 55 min, min, +/+/--ERCERC))

3.3. Bone & node Bone & node protocol protocol (20(20--35 35 min, min, -- ERCERC))


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We needAwareness and knowledge Awareness and knowledge of:of:

Radiologists, Urologists, Radiologists, Urologists, Radiation Oncologists, PatientsRadiation Oncologists, Patients

-- GuidelinesGuidelines forfor::

** structuredstructured reportingreporting(Pi(Pi--RADS)RADS)

Classification System (Pi -RADS)Score T2W 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

Score DCE Criteria

1 Type 1 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

Structured Analysis workstationStructured Analysis workstation

••5 5 point point scale: scale: PiPi--RADSRADS

T2W: 5/5T2W: 5/5

DWI: 5/5DWI: 5/5DCE: 5/5DCE: 5/5

MRSI: MRSI: 22/5/5

DWI: 5/5DWI: 5/5

DCE: 5/5DCE: 5/5

Structured Reporting


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We need also

-- availabilityavailability-- educationeducation

-- certificationcertification

-- multimulti--center trialscenter trials-- subsub--specialization specialization in in PCa?PCa?

•• MultiMulti--parametric parametric MRI MRI shows shows wherewhere PCaPCa isis, , it’s it’s aggressionaggression , and if , and if it growsit grows outsideoutside the the prostateprostate

•• MRI opens MRI opens the way to the way to tailored tailored (minimal invasive) (minimal invasive) therapy, which therapy, which reduces sidereduces side--effectseffects

•• This will This will decreasedecrease the the numbernumber of needle of needle corescores ,,andand improve improve itsits yieldyield

Thank you for your attention

Documents

MultiMulti--parametric MR imaging in parametric MR … · Classification System (Pi -RADS) Score T2W Criteria 1 Uniform high signal intensity or heterogeneous transitional zone adenoma