Staging of Prostate Cancer: Current role of MRI and

Staging of Prostate Cancer: Current role of MRI and
PET and their influence on treatment decision making
12.9.2012
Timo Joensuu, MD, PhD
Chief Executive Medical Director
Adjunct Professor, Specialist in Medical Oncology and Radiotherapy
12.9.2012
www.docrates.com
Prostate biopsies
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Transrectal US-guided sextant (dex 1-6, sin 7-12)
Does not find the existing ca in 10-38%
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Problematic locations apex, anterior and lateral parts
Saturation biopsies
Transperineal biopsies
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3D-ULTRA SOUND
1 mm slices
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”Central
Prostate”
Central Zone
Transition
Zone
Periferique Zone
Bonecamp etal. RadioGraphics 2011;31:677703
Prostate
Cancer grows outside prostate
MRI show with endorectal coil
Where the tumor is
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”Note the symmetric homogeneous
muscular stroma layer in the posterior
prostate base!”
A
Nuisance in Prostate Diagnostics
B
The caudal tip of each seminal vesicle joins the
corresponding deferent duct to form the ejaculatory duct,
which is enveloped in a thick low signal intensity
muscular coat and traverses the central zone to
terminate at the veru montanum.
C
Periferiq Zone Flattens
Due to Central hypertrophy
Prostatic capsule continuous internally with the stromal septa subdividing the
glandular peripheral zone. Capsule only less distinct at the prostatic apex and
base
Stromal hypertrophy
Glandular hypertrophy
Prostate-ca
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It is located in glandular part
70% in periferc zone, 30% centrally
85% multifocal
”The dominant focus” determines mans fate and that
localization should be fined by MRI
Multiparametric MRI
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T2 SE sag, ax ja cor
T1 SE ax
Diffusion images
Dynamic imaging with contrast enhancement
Spectroscopy
Endorectal coil with 1.5 T
Prostate-ca in T2-images
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Signal in Perif. Zone is normally clear
The Signal of Ca is scanty
Decreased signal also in
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Prostatitis
Scars
Atrophy
After Radiotherapy
Hormone therapy
Cancer in Central part is difficult to see
Vain tämä ryhmä prostata ca-potilaista
soveltuu radikaalileikkaukseen, minkä takia
on keskeistä selvittää, rajoittuuko kasvain
kapselin sisäpuolelle
Infiltration of the capsule (T3)
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Asymmetry in Neurovaskular bundle
Capsule swelling
Blocked Rectoprostatic angle
Tumor/capsule contact >10 mm
Discontinuation of Capsule
Retracted Capsule
Irregular or spiculated Capsule
Diffusion
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Based on movement of water in tissues (Brownian
motion)
Different diffusion weighning (b=50, 400 ja 800)
The movemnet is restricted by high cell density -> in
cancer the signal will increase with diffusionimaging
Calculated from 3 directions of ortogonal images
”apparent diffusion coefficient” i.e. ADC, expressed
by parametric image
Reduced signal is black in ADC-images
ADC-value can be calculted quantitatively
Diffusion weighted
imaging = DWI
b=50
b=400
b=800
ADC map
ADC
0.49x10 e-3
mme2/s
75-old. 9/2011 Gleason 3+4, PSA 20/18% prostata ca, Finasteridi, PSA
15
Some examples
Nocturia. PSA 27/11%. Gleason 10, 90%
ADC 0.68x10 e-3
mme2/s
FluoroCholine-PETCT
55-old PSA 4.4 in 5/2011,
PSA 5.8 in 11/2011. TPR
Some tenderness on right
side
In Biopsy GS 9 (4+5) on right.
ADC 0.69x10
e-3 mme2/s
”Spectry in right.
Normal spectroscopy on left.
61-ol without symptoms PSA >30. Radiology thought that the
man has GS 9 but it was GS 8 (4+4)
ADC 0.47x10
e-3 mme2/s
PSA 22, without symptoms, both lobes hard
ADC 0.67x10E -3
mmE2/s
Gleason 8
patologic
PSA 22, molemmat lohkot kiinteät palpaatiossa, oireeton
ADC 0.67x10E -3
mmE2/s
Gleason 8 biopsioista
Normaali!
patologic
60-year old, PSA- 17-30 with 5 times Transrectal biopsies
Focus Found in anterior apex!
T2 SE
tra
ADCvalue
0.75x10e3 mm e2/s
T2 SE
cor
Gd,
subtr.
Dynamic CE washout
Typical choline peak
60-vuotiaan tuomarin PSA-taso nousi 7 kk:ssa 4->7. Ortopediystävä
lähetti MK:een.
PAD: Gleason 7 (4x3) kaikista oik. puolen
näytteistä
56-year old PSA 2004 = 5, 2005 PSA 6-7.4. Biopsies negat 4
times and PSA increased up to 10. In transperineal biopsy GS 7
(3+4)
Detection and Localization of Prostate Cancers Using
Multiparametric Magnetic Resonance Imaging
Bratan et al. RSNA 2011
Luokitus
Gleason
Koko (vol
cc)
0.05-0.5 cc
0.5-2 cc
>2 cc
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27-37%
42-51%
67-83%
7
61-64%
80-83%
96%
>8
100%
100%
100%
Ca:n detektio ja lokalisointi
DW-MRI>T2 SE = DCE-MRI>MRSI
Ca:n agressiivisuuden arviointi
DW-MRI=MRSI>T2 SE>DCE-MRI
Indications for MRI
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Before second biopsy
Before radical operation
High risk disease
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Increasing PSA, High PSA, High GS (7, 8-10), most of
biopsies are +, clinically T3, symptoms
Learning Curve
Cyclotron
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Cyclotron
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Chemical processing of the tracer in GMP laboratory
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Quality Control
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18F-Choline PET-CT
Left lobe
Bladder
Seminal Vesicle
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Primary PSA 45. GS 6.
Ca in left lobe 1999
LHRH + RT LNs 45 gy; P 69
PSA relapse (5,1); Where?
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PET-CT
CT
PET-CT
BONE METASTASEs
CAN BE SEEN IN PET-CT
NOT IN plain CT
PET
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NAF PET-TT
LUUSTOKARTTA
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Bone scan
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SPET-TT
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FLUORIDI-PET
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