multiparametric (mp) mr: prostate fusion...
TRANSCRIPT
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12-13 Janeiro 2018
MULTIPARAMETRIC (Mp) MR: Prostate fusion biopsies
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Adalgisa Guerra
Imagiology Department
Hospital da Luz
MULTIPARAMETRIC (Mp) MR: Prostate fusion biopsies
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How can multiparametric MRI change the management ofprostate biopsy?
What technique should be used to sample mpMRI detected
lesions?
What is the performance of mpMRI-PB (TB) compared with
systematic TRUS-PB (SB)?
Take home Messages
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Functional MRI
Advanced MRI tools for clinical practice
FUNCTIONAL MRI Biological property depicted
Diffusion DWI (BIOLOGY) Cellular density
Espectroscopy MRS (MOLECULAR) Cell membrane turnover/tissues
Dynamic Contrast Enhancement
DCE(VASCULARITY)Blood flow and vascular permeability
The Biophysical basis of Multiparametric Magnetic Resonance Imaging (mp-MRI)
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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Guidelines for MRI interpretation on PCa
PI-RADS version 1
PI-RADS: Prostate Imaging Repport And Data System
2012 2015 2018
Eur Radiol (2012) 22:746–757
DOI 10.1007/s00330-011-2377-y
Score 1 Clinically significant disease highly unlikely to be present
Score 2 Clinically significant cancer unlikely to be present
Score 3 The presence of clinically significant cancer is equivocal
Score 4 Clinically significant cancer likely to be present
Score 5 Clinically significant disease highly likely to be present
PI-RADS version 2
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
PI-RADS version 3
or V2 improvment?
PIRADS V2 + “Risk
factors”
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T2
ADC
DCE
PI-RADS: Prostate Imaging Repport And Data System
PIRADS V2
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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T2
ADC
DCE
PI-RADS: Prostate Imaging Repport And Data System
PIRADS V2
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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How can multiparametric MRI change the management of prostate biopsy?
Conclusion (1º question)
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
• Protect Study• Over-diagnosis and over treatment of low risk disease , resulting from
the TRUS biopsy approach, has minimal patient survival benefits.
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How can multiparametric MRI change the management of prostate biopsy?
Conclusion (1º question)
mp MRI • provides good detection of aggressive cancers. NPV 90% for exclusion CSD
(clinically significant disease)
• Reduce the number of men over diagnosed with low risk disease
• It can localize suspicious areas and improve detection of clinical significant Pca at biopsy
• In the repeat biopsy setting• Detection of CSD (clinically significant disease) 35-50% in men with prior
negative biopsies
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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How can multiparametric MRI change the management of prostate biopsy?
Conclusion (1º question)
• MRI can be used to avoid prostate systematic biopsy ?
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
mp MRI • provides good detection of aggressive cancers. NPV 95% for exclusion CSD
(clinically significant disease)
• Reduce the number of men over diagnosed with low risk disease
• It can localize suspicious areas and improve detection of clinical significant Pca at biopsy
• In the repeat biopsy setting• Detection of CSD (clinically significant disease) 35-50% in men with prior
negative biopsies
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MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
• It is possible to miss smaller volume high-grade disease
• MRI can be used to avoid prostate systematic biopsy ?
OBJECTIVE:
To systematically review the literature
assessing the negative predictive value (NPV)
of mpMRI in patients with a suspicion of PCa
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How can multiparametric MRI change the management of prostate biopsy?
Conclusions (1º question)
• MRI can be used to avoid prostate systematic biopsy ?
It depends:• on the pre-MRI risk-stratification of patients
• “low risk” avoiding biopsy might be possible if negative mpMRI (PI-RADS<3)
• “High risk” mp MRI and SB• For focal therapy (fused plus systematic whole-gland template biopsy
• mp MRI provides good detection of aggressive cancers
• It can localize suspicious areas and improve detection of clinical significant Pcaat biopsy
• In the repeat biopsy setting• In biopsy-naïve patients ??
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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MRI Guided Biopsy/Target biopsy
Definition:
Guidance during Method of assistance used by the
operator in directing the biopsy needle at a target
originally identified on MRI.
Biopsy technique carried out within the MRI
scanner: In Bore Biopsy
Cognitive registration (without MRI/TRUS
software fusion: mental fusion)
Software Registration: The target identified on
MRI is registered to a real-time biopsy US by
using a software that overlays the images:
MRI/TRUS fusion;
Caroline Moore et al. EUROPEAN UROLOGY 64 (2013) 544–552
What technique should be used to sample mpMRI detected lesions?
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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MRI Guided Biopsy : MR scanner: \
In Bore Biopsy
How can mp-MRI change the management of prostate cancer?
MULTIPARAMETRIC MRI: mp-MRI
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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PSA >10 ng/dl and 2 X Negative TRUS Biopsies
MRI Guided Biopsy :
Cognitive Fusion Registration
How can mp-MRI change the management of prostate cancer?
MULTIPARAMETRIC MRI: mp-MRI
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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MRI Guided Biopsy :
How can mp-MRI change the management of prostate cancer?
MULTIPARAMETRIC MRI: mp-MRI
Software US/MRI Fusion Registration
• Deformable (elastic) registration
• 3D mapping fusion
• Navigation
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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MRI Guided Biopsy :
How can mp-MRI change the management of prostate cancer?
MULTIPARAMETRIC MRI: mp-MRI
Software US/MRI Fusion Registration
• Deformable (elastic) registration
• Live 3D mapping fusion
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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MRI Guided Biopsy :
How can mp-MRI change the management of prostate cancer?
MULTIPARAMETRIC MRI: mp-MRI
Software US/MRI Fusion Registration
• Active surveillence
• Second look reconnects previous sessions to the current exam
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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What technique should be used to sample mpMRI detected lesions?
It depends…Not every patient needs to undergo in- bore-PB or software fusion PB.
Large, aggressive lesions can often be detected through TRUS-PB when
mpMRI images are either reviewed or fused, and can therefore be adequately
sampled.
Conclusion (2º question)
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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What is the performance of mpMRI-PB (TB) compared with systematic TRUS-PB (SB)?
Target Biopsy (TB) vs Systematic biopsy (SB)
2017
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
Conclusion:
Using MP-MRI as a triage test:
• reduce the problem of unnecessary
biopsies in men who have a low risk
• improve the detection of clinically signifi
cant cancers.
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What is the performance of mpMRI-PB (TB) compared with systematic TRUS-PB (SB)?
Target Biopsy (TB) vs Systematic biopsy (SB)
ongoing …
2025 pts
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
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Imaging biomarkers: Radiomics (Quantitative imaging data)
“radiophenotypes” : correlate to and complement existing validated clinical and genomic risk
stratification biomarkers
Future …
MULTIPARAMETRIC (Mp) MRI in the diagnosis of PCa
Translational Cancer Research, Vol 5, No 4 August 2016
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How can multiparametric MRI change the management ofprostate biopsy?
Excellent tumor visibility
MRI-targeted TRUS-guided biopsies
What technique should be used to sample mpMRI detected
lesions?
It depends: Lesion size, operator experience...
Targeting MRI lesion clearly increases the detection rates of both
transrectal and transperineal biopsy techniques
What is the performance of mpMRI-PB compared with
systematic TRUS-PB?
• Increase the detection of high grade and reduce the detection of
insignificant tumours
• mpMRI should be performed before biopsy naive patients...But SB
should not be ommited (never if focal therapy is a tratment
choice).
Take home Messages
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Take home Messages
Costs
• If we can maximize the accuracy of identifying clinicallysignificant lesions, the costs of overtreatment can be reducewhile improving quality of life for the patients
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Hotel Tryp, Costa de Caparica - Portugal * 12 e 13 de janeiro de 2018