Prostate MRI Wolfgang Picker Aleris Cancer center

Prostate MRI
Wolfgang Picker
Aleris Cancer center
Oslo
Todays problems
Unpresis and late diagnostics
Overtreatement of low grade cancer!!
Too late diagnostic and unsufficient
treatememt results of aggressive
disease
Distinguishing Lethal from
Nonlethal Disease
The Overarching Problem in Clinical
Management of Prostate Cancer
Challenges in Clinical Prostate Cancer : The Role of Imaging;
Kelloff et al for The Prostate Cancer Imaging Group;
AJR: 192; June 2009
Goal
Less overtreatment of low grade
diasease
Early and more aggressive
therapy of high grade diasease
Insidence
2006, American cancer society
MRI
1. Detection of cancer
2. Active surveilance
3. Pre op staging
4. Recurrent disease
Patients examined
900
800
700
600
500
400
300
200
100
0
2007 SIV
2008 SIV
2009 SIV
2010 SIV
2011
2012 ALERIS
All you need is 1,5 T and a
good MRI tech
2,5 mm , Pixel 0,9 mm
Slice Thickness !!
T2
ADC 3mm
ADC 6mm
3D FSE with 1 mm resolution!
3 mm TSE
Vista 1/05 mm
Aleris MRI protocol
• Staging
• Screening
– 3D T2 whole pelvis
– 3D T1 Lumbar spine + pelvis
– Prostate:
•
•
•
•
Diff ADC: B 100,450,800
Diff B 1500
2D T2 FSE
T1 FS perfusion
– Prostate:
•
•
•
•
Diff ADC: B 100,450,800
Diff B 1500
2D T2 FSE
2D T1 FSE
T1/T2
Anatomy
– Extraprostatic extenstion,
– Lymfnodes,
– Bone metastases
Low signal in the periferal zone
•
•
•
•
•
•
•
Blood
Prostatitis
Scar
Radiotherapy
Cryotherapy
Hormon therapy
Tumor
H
H
MR
Functional sekvences
DWI
Perfusion
Spektroskopi
Perfusion MRI – detection
Wash in
Wash out
Choi et al. Functional MR Omaging of Prostate Cancer. Radiographics 2007;27:63-77
DWI detection and tumor grading
• ADC:
T2
0,93 +- 0,11 for cancer
1.72 +- 0,35 for periferal zone
1,46 +- 0,16 for transitional zone
Dif
ADC
50
220
Prostate cancer: The clinical value of diffusion-weightet imaging and dynamik MR imaging
in combinationwith T2-weightet imaging; Tanimoto et al.; Journal of magnetic resonance imaging 25: 146-152 (2007)
ADC is a robust quantitative
parameter
18.10.07
10.04.08
Gleason Pattern
1+2
2
2+3
3
4
ADC has a correlation to Gleason score
5
Diffusion/T2 MRI Score
Number of negative biopsi
post MRI
Number of positive patients/Gleasson score
post MRI
Rising PSA. What now?
The truth about PSA
US guidet biopsi samples 0,05 % of the
prostate volume
PSA 18 neg. biopsi before MRI
MR T4
Biopsi before MRI shows 1 mm tumor focus in
2 biopsies
PSA 10
Biopsi 2x i 2008 , DRE suspect nodule right
side, negative results
MR screening T3A, T4 apex right side ?
PSA 4,7 positiv family history, Biopsi
before MRI neg
Problem: biopsi after MRI !
12.02.07
Biopsi after 1. MRI negative
10.12.08
Biopsi after 2. MRI Gleason 3+4
Positiv MR
negativ biopsi post MR
Pasient journal: ….. PSA controll…!!??!!
MRI / Ultrasound soft fusion
Koelis urostation
MRI / Ultrasound soft fusion
Koelis urostation
Koelis urostation
Staging
before
Treatment!
PSA 2.97 after surgery
FACBC PET shows bone met
MRI vs. Scintigrafi
MRI modified therapy by finding
• 66 consecutive patients with a high-risk prostate
cancer profile who underwent MRI of the spine and
pelvis
in addition to ain
standard
sequential
imaging
metastases
about
a
third
of
workup. The imaging workup included technetium99m bone scintigraphy, targeted x-rays in patients
with inconclusive bone scans, and on-request MRI in
patients
with inconclusive
scans and
x-rays
almost
half ofbone
those
with
• They found that MRI alone was more sensitive
(100%) than the combination of the other tests
(63%). MRI's specificity (88%) also topped the
combination of theimaging.
other tests (64%).
patients considered negative and
inconclusive results by standard
(J Clin Oncol 2007;25[22]:3281-3287).
MRI 3D T1 and T2 FSE with 1mm resolution
Lymfnode and Bone Met
The future of Prostatecancer
treatment
Earlier + more presise diagnostics
More Active surveillance and local treatement
Earlier diagnosis and treatment of highly
aggressive cancer
The future for Prostate cancer diagnostics
MRI is the key!
• MRI rutinely before all invasive diagnostics
• Diagnostic is done in prostate centers that
consider the whole diagnostic chain
• Target biopsy replaces systematic biopsy
• MRI replaces bone scint
• MRI is a key modality in AS
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