advances in prostate learning objectives mr · pdf filedjavan j urol (2001); roehl j urol...

BarentszBarentsz 22--44--20112011

11

Jelle Barentsz

Prostate MR Center of Excellence

Department of RadiologyRadboud University Nijmegen Medicaal CenterThe Netherlands

[email protected]

Advances in Prostate Advances in Prostate MR imagingMR imaging Learning Objectives

•• to show theto show the potentialpotential of of new new MRMRI I developments developments in in PCaPCa

•• to illustrate this from a to illustrate this from a clinicalclinical((radiation oncologyradiation oncology ) perspective) perspective

Learning Objectives

Learning ObjectivesMulti-parametic MRI

1. High resolution 1. High resolution T2T2WI: WI: anatomyanatomy

2. 2. DDiffusioniffusion WWeightedeighted IImaging: maging: functionfunction

3. 3. HHydrogenydrogen MRMR--SSpectroscopy: pectroscopy: functionfunction

4.4. DDynamic ynamic CContrast ontrast EEnhanced:nhanced: functionfunction

T2WI MRI: anatomy


22

MRI: high soft tissue contrast Delineation of CTV:CT > MRI

CT Image MR Image

c. Villiers

Delineation of CTVAdditional Use of MRI

•• Smaller Smaller CTV (6.5%CTV (6.5%--34%)34%)

•• InterInter--observer variability observer variability ↓↓ (~63%)(~63%) at: at: -- Apex : Apex : ↓ ↓ ↓ ↓↓ ↓ ↓ ↓-- Base : Base : ↓ ↓↓ ↓-- SV : SV : ↓↓-- MidMid--gland : gland : -- RoachRoach IJROPB 1996, IJROPB 1996,

RashRash IJROPB 1999, IJROPB 1999, VilliersVilliers, , StrahlentherStrahlenther OnkoOnko 20062006

PCa, hematoma, fibrosis, prostatitis: low SI

MR-anatomy of PCa


33

Patient 57 y, PSA 7; TRUS Bx: negative

1. 1. nnormalormal2. 2. BPHBPH3. 3. prostatitisprostatitis4. 4. ventralventral TZTZ tumortumor

YourYour diagnosis?diagnosis?

T2WI: PCa anatomy

“Erased Charcoal drawing sign”

T2WI: PCa anatomy

BPH: organised chaosBPH: organised chaos

• prostatectomy vs radiotherapy• decrease R+• nerve sparing• local therapy

• prostatectomy vs radiotherapy• decrease R+• nerve sparing• local therapy

T2WI: Local Staging

3T ERC:3T ERC:se se 87% 87% spsp 96%96%

3T ERC:3T ERC:se se 87% 87% spsp 96%96%

Futterer, Invest Radiol 2006, Heijmink, Radiology 20 07


44

DWI:DWI: PCaPCa restrictedrestricted HH 22O O movementmovement

Multi-parametric MRI: DWI

Tightly packed cellular tissueTightly packed cellular tissueOrganised Organised galandulargalandular tissuetissue

Specificity, aggression!

Pearson Pearson CorrelationCorrelation

r = r = 0.73 0.73

p <p < 0.010.01

DWI: ADC-value versus Gleason score

HambrockHambrock, Radiology, in press, Radiology, in press

AlvaresAlvares, Radiology, in press , Radiology, in press

DWI: ADC-value vs Gleason score Multi-parametric MRI: DCE

DCE MRI: DCE MRI: PCaPCa increasedincreased vascularvascular permeabilitypermeability

SensitivitySensitivity!!


55

Creatine

Creatine

Creatine

Creatine

CitrateCitrateCitrateCitrate

0.37 / 0.37 / 0.640.64

Cho + Cho + Cr Cr ↑↑CitCit

Metabolite Metabolite ratioratio

MR Spectroscopy MR Spectroscopy

For Ferrari drivers only?

You need EXPERIENCE how to drive

MR Spectroscopy

•• PSAPSA: : non non specificspecific marker : marker :

>4 >4 ngng/L: /L: senssens.: 80%, .: 80%, specspec.: 36%.: 36%

Djavan J Urol (2001); Roehl J Urol (2002); Pepe Uro l (2007), Schroeder JNCI (1998) Djavan J Urol (2001); Roehl J Urol (2002); Pepe Uro l (2007), Schroeder JNCI (1998)

Clinical Problems

•• DRE DRE is is notnot sensitivesensitive

-- senssens.: 37%.: 37%,, specspec.: 91%.: 91%


66

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

•• Important Important cancers are cancers are incorrectly incorrectly classified as classified as unimportant unimportant or areor are missedmissed

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

Problems: TRUS Problems: TRUS BxBx Be aware! Be aware! EU Urologists are getting thereEU Urologists are getting there

Sciarra, European Urology 2011Sciarra, European Urology 2011

IntraprostaticIntraprostatic LocalizationLocalization AccuracyAccuracy::

T2T2--w : w : 70%70%

DWIDWI--MRI: MRI: 86%86%

HH--MRS: MRS: 81%81%

DCEDCE-- MRI: MRI: 85%85%

Jager AJR 1996; Scheidler Radiol 1999Jager AJR 1996; Scheidler Radiol 1999

Haider AJR 2007; Miao Eur J Rad 2007Haider AJR 2007; Miao Eur J Rad 2007

Futterer Radiol 2006, Reinsberg AJR 2007Futterer Radiol 2006, Reinsberg AJR 2007

Ito Br J Radiol 2003, Futterer Radiol 2006Ito Br J Radiol 2003, Futterer Radiol 2006

Multi- modality MRI: MR-guided biopsy

Gleason score 4+3


77

• After ≥2 - biopsies: TRUS is + in 5-19% • After ≥2 - biopsies: TRUS is + in 5-19%

• with MR ~ 4 cores instead of ~ 12• with MR ~ 4 cores instead of ~ 12

• 93% (37/40) clinically significant tumors• 93% (37/40) clinically significant tumors

• MR-guided biopsy of TSR: + in 59% (40/68) • MR-guided biopsy of TSR: + in 59% (40/68)

3T MR-biopsy (n=68)

• 57% anterior tumors • 57% anterior tumors

Hambrock, J Urol 2010

Learning ObjectivesWhat is beyond the horizon?

1.1. ImprovementImprovement of of mpmp--MR MR directeddirectedbiopsybiopsy techniquestechniques

2. 2. AActive ctive SSurveillance, urveillance, ScreeningScreening

3. Will 3. Will mpmp--MRI MRI replacereplace Gleason?Gleason?

4. 4. FocalFocal therapytherapy

5. 5. NodesNodes: : nanonano--particlesparticles + + DWIDWI

Learning ObjectivesWhat is beyond the horizon?What is beyond the horizon?


2. Active Surveillance, Screening2. Active Surveillance, Screening

3. Will 3. Will mpmp--MRI MRI replace Gleason?replace Gleason?


5. Nodes: 5. Nodes: nanonano--particles particles + + DWIDWI

Learning ObjectivesWhat is beyond the horizon?What is beyond the horizon?



3. Will 3. Will mpMRImpMRI replacereplace GleasonGleason??


5. 5. NodesNodes: : nanonano--particlesparticles + DWI+ DWI


88

Biopsy with TRUS - mp-MRI fusion

with with TRUS TRUS –– MR MR ((ADCmap) ADCmap) fusionfusionwith with TRUS TRUS –– MR MR ((ADCmap) ADCmap) fusionfusion

Hit the most aggressive lesion

Learning ObjectivesFuture Potential

•• MRMR--robotrobot with MR guided with MR guided remote remote controlcontrol

Case: 59 y.o., PSA 10, 3x negative TRUS sessionsCase: 59 y.o., PSA 10, 3x negative TRUS sessions

DCEDCEDWIDWIT2T2--weightedweighted

First, diagnostic sessionFirst, diagnostic session

TSR 2TSR 2

MR-robot


99


1010

Perform biopsyPerform biopsy

HistopathologyHistopathologyGleason Gleason 4+34+3


1.1. Improvement of Improvement of mpmp--MRMR--directed directed biopsy techniquesbiopsy techniques




5. 5. NodesNodes: : nanonano--particlesparticles + DWI+ DWI

PZ PZ PCaPCa withwith focalfocal“hot spot” “hot spot” (Gl (Gl 4+34+3))


1111

Focal therapy

- Focal laser ablation

- HDR Brachytherapy / DIL IMRT



DWI with b values 0, 50, 600 ADC map showing restricted diffusion

Focal therapy

c. J. Feller, Palm Springs USA

Treatment temperature map Irreversible damage estimate

Laser Doses

Treatment #1177s @ 8.00W

Visible Damage10mm by 12mm

Animation – not in real-time

Focal therapy


Damage Estimate

Irreversible damage estimate Post-treatment MRIT2 Pre-treatment Image

Axial Images

Thermal AblationTarget Area

Laser Fiber Trajectory

Prostate Capsule

Focal therapy



1212

Focal therapy





Marker fusion CT- MRI

inaccuracy < 1 mminaccuracy < 1 mmat at peripheryperiphery of prostateof prostate

Huisman Radiology 2005

f-MR-based DIL IMRT Planning

van Lin IJROBP 2006IMRT: Partial boost to 90 Gy


1.1. Improvement of Improvement of mpmp--MRMR--directed directed biopsy techniquesbiopsy techniques




5. Nodes: 5. Nodes: nanonano--particles particles + + DWIDWI


1313

Pathway of spread

MRL detected in 41% patients Positive nodes outside routine PLND

Heesakkers et al Radiology 2009

SVIDetecting Nodal metastasis

in PCa

• Imaging (CT, MRI etc)- Less invasive- Inaccurate size

criterion

• Surgery (PLND)- Invasive, costly- Limited in coverage

• Imaging (CT, MRI etc)- Less invasive- Inaccurate size

criterion

• Surgery (PLND)- Invasive, costly- Limited in coverage

Vincent van GoghVincent van GoghSorrowing old manSorrowing old man

FeFe--nanoparticlesnanoparticles(20 nm)(20 nm)

FerumoxtranFerumoxtran--1010

(Combidex/Sinerem(Combidex/Sinerem))

FeFe--nanoparticlesnanoparticles(20 nm)(20 nm)

FerumoxtranFerumoxtran--1010

(Combidex/Sinerem(Combidex/Sinerem))

PatientPatient--toto--patientpatient correlationcorrelation (n=375)(n=375)CTCT MRL MRL

accuracyaccuracy 86% 86% → → 9191%%specificityspecificity 97%97% →→ 9393%%sensitivitysensitivity 34% 34% →→ 9393%%NPVNPV 89% 89% →→ 9797%%

ProbabilityProbability of of correct diagnosiscorrect diagnosis : : MRL MRL 91%91%PLND + CT PLND + CT 89%89%

Dutch study: 13 centres

Heesakkers et al Lancet Oncology 2008


1414

PSA ≥PSA ≥0.2 0.2 ngng/ml /ml 6 w. postop. + 6 w. postop. + 1 1 higher higher value, or a single PSA value, or a single PSA ≥≥0.5 0.5 ngng/ml; /ml; no bone no bone metastasesmetastases

•• 72% 72% (47/65) ≥1 (47/65) ≥1 ⊕⊕ node, node, 66/275/275 nodes >1 cmnodes >1 cm•• 6262% % had ≥had ≥1 1 ⊕⊕ node node with with low PSA low PSA ((<1.0<1.0))•• 77%77% and and 61%61% ≥≥1 1 ⊕⊕ node in regions node in regions not in CTV not in CTV for elective for elective

pelvic irradiation pelvic irradiation by the by the RTOGRTOG

Post Px recurrence: MRLMeijer, IJROPB in preparation

4. Many nodes are 4. Many nodes are not in CTVnot in CTV

Nodal Roach Formula: Low PPV

Deserno, IJROPB 2010

IMRT planning

• Accurate mapping of positive MRL nodes for IMRT has the potential:

- to reduce toxicity in normal tissue

- allows higher doseson the positive nodes

• Accurate mapping of positive MRL nodes for IMRT has the potential:

- to reduce toxicity in normal tissue

- allows higher doseson the positive nodes

IJROPB 2010IJROPB 2010


1515

Case

•• 60 60 yryr; ; initialinitial PSAPSA 66; ; GleasonGleason 4+34+3

•• DecDec 2005: Da Vinci 2005: Da Vinci PxPx: : T3B N1 T3B N1 MxMx R+ R+ •• FebFeb 2006: PSA 2006: PSA 0.220.22

WhatWhat treatmenttreatment: : hormonalhormonal palliativepalliativewholewhole pelvicpelvic radiationradiationparapara--aorticaortic nodesnodes??

March 2005 Combidex/Sinerem MRI

Case

•• MarchMarch 20052005 Combidex/Sinerem MRI: Combidex/Sinerem MRI:

•• 6 6 positivepositive pelvicpelvic nodesnodes

→ ADT + → ADT + 4D4D--IGIG--IMRTIMRT: : dosedose paintingpainting

Case 1Case 1

c M Dattoli


1616

Case

•• PSAPSA: : Nov 06:Nov 06: 0.00060.0006Apr 07:Apr 07: 0.0030.003

July 07: Stop ADTJuly 07: Stop ADT

•• PSAPSA:: AugAug 07:07: <0.01*<0.01*MarchMarch 08:08: <0.003<0.003MarchMarch 09:09: <0.003<0.003MarchMarch 10:10: <0.01*<0.01*

Combidex/Sinerem MRI November 2009

Due to approval Due to approval problems, problems, development development of of CombidexCombidexis is discontinueddiscontinued

But

But there is hope: DWI? Ferumoxytol? P904?

DWI helps to findbone and nodal metas

Future: Future: ferumoxytolferumoxytol: WIP: WIP24 24 hrshrs post post ferumoxytolferumoxytol24 24 hrshrs post Combidexpost Combidex

CTACTA post post ferumoxytolferumoxytol post post ferumoxytolferumoxytol + + GdGd

c. S Bravo, Orlandoc. S Bravo, Orlando


1717

•• Bone: Bone: DWI DWI MRI of MRI of pelvis pelvis & & spinespine•• Bone: Bone: DWI DWI MRI of MRI of pelvis pelvis & & spinespine

PSA Relapse: Imaging Protocol

•• Nodes: Nodes: Nanoparticle MRI (n.a.)Nanoparticle MRI (n.a.)DWI MRI of pelvis & spineDWI MRI of pelvis & spine

•• Nodes: Nodes: Nanoparticle MRI (n.a.)Nanoparticle MRI (n.a.)DWI MRI of pelvis & spineDWI MRI of pelvis & spine

•• Local: Local: DCEDCE-- and DWI MRI and DWI MRI •• Local: Local: DCEDCE-- and DWI MRI and DWI MRI

Learning ObjectivesPost-Brachy, PSA recurrence (1.8)

Post-Brachy, PSA recurrence

bone + X: bone + X: se 63% sp 64%se 63% sp 64%bone + X: bone + X: se 63% sp 64%se 63% sp 64% MRI: MRI: se 100% sp 88%se 100% sp 88%MRI: MRI: se 100% sp 88%se 100% sp 88%

Spine and pelvis is enough Lecouvet JCO 2007

Post-Brachy, PSA recurrence


1818

• Bone: DWI MRI of pelvis & spine• Bone: DWI MRI of pelvis & spine


• Nodes: Nanoparticle MRI (n.a.)DWI MRI of pelvis & spine


• Local: DCE- and DWI MRI • Local: DCE- and DWI MRI

StephensonStephenson nomogramnomogram accurately predicted accurately predicted ⊕⊕ MRL result MRL result →can be used to →can be used to identify patients identify patients

for pelvic radiationfor pelvic radiationbutbut

We need We need better imaging better imaging to to decrease the CTVdecrease the CTV

Post Post PxPx recurrencerecurrence: MRL: MRLMeijer,Meijer, IJROPBIJROPB inin preparationpreparation

Meijer, IJROPB Meijer, IJROPB 20102010

Future: MRL or 11C Choline PET/CT?

MRL• 151 positive nodes in 23/29 patients

mean size 4.9 mm*

11C Choline PET/CT• 34 positive nodes in 13/29 patients

mean size 8.4 mm*

MRL• 151 positive nodes in 23/29 patients

mean size 4.9 mm*

11C Choline PET/CT• 34 positive nodes in 13/29 patients

mean size 8.4 mm*

* p<0.001 more and smaller nodes detected

Future: MRL or 11C Choline PET/CT?


1919

USPIOUSPIO--MRIMRIUSPIOUSPIO--MRIMRI Choline PET/CTCholine PET/CTCholine PET/CTCholine PET/CT

Negative PET/CT: post-RP (T3b N0 M0)

• Bone: DWI MRI of pelvis & spine• Bone: DWI MRI of pelvis & spine




• Local: DCE- and DWI MRI • Local: DCE- and DWI MRI

post Pxpost Px DCE MRI!DCE MRI!

T2T2--w w DCE KDCE K transtrans

Local post radiotherapy Local post radiotherapy recurrence: DCErecurrence: DCE-- MRIMRI


2020

•• MRI MRI is the best technique to show the is the best technique to show the prostate and its tumor localization and prostate and its tumor localization and aggressionaggression

•• MRI MRI is the best technique to show the is the best technique to show the prostate and its tumor localization and prostate and its tumor localization and aggressionaggression

Take home messages

•• MRI MRI is a superior technique in showing is a superior technique in showing small small nodal nodal and bone and bone metastatesmetastates

•• MRI MRI is a superior technique in showing is a superior technique in showing small small nodal nodal and bone and bone metastatesmetastates

•• integration of Rth and MRI still needs a integration of Rth and MRI still needs a lot of lot of research research but offers but offers great potentialgreat potential

•• integration of Rth and MRI still needs a integration of Rth and MRI still needs a lot of lot of research research but offers but offers great potentialgreat potential

Thank you for your attention

Bomers, Debats, Fütterer, Bomers, Debats, Fütterer, Hambrock, Huisman, Hambrock, Huisman, Heijmink, Heerschap, Heijmink, Heerschap, Hoeks, Scheenen, Yakar.Hoeks, Scheenen, Yakar.

HulsbergenHulsbergen, van Lin, , van Lin, van Oort, Witjes, Dattolivan Oort, Witjes, Dattoli

advances in prostate learning objectives mr · pdf filedjavan j urol (2001); roehl j urol...

Documents