multiparametric (mp) mr: prostate fusion...

12-13 Janeiro 2018

MULTIPARAMETRIC (Mp) MR: Prostate fusion biopsies

Adalgisa Guerra

Imagiology Department

Hospital da Luz

MULTIPARAMETRIC (Mp) MR: Prostate fusion biopsies

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

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

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


PI-RADS version 3

or V2 improvment?

PIRADS V2 + “Risk

factors”

T2

ADC

DCE

PI-RADS: Prostate Imaging Repport And Data System

PIRADS V2


How can multiparametric MRI change the management of prostate biopsy?

Conclusion (1º question)


• Protect Study• Over-diagnosis and over treatment of low risk disease , resulting from

the TRUS biopsy approach, has minimal patient survival benefits.



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




• MRI can be used to avoid prostate systematic biopsy ?


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


• It is possible to miss smaller volume high-grade disease


OBJECTIVE:

To systematically review the literature

assessing the negative predictive value (NPV)

of mpMRI in patients with a suspicion of PCa


Conclusions (1º question)


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 ??


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?


MRI Guided Biopsy : MR scanner: \

In Bore Biopsy

How can mp-MRI change the management of prostate cancer?

MULTIPARAMETRIC MRI: mp-MRI


PSA >10 ng/dl and 2 X Negative TRUS Biopsies

MRI Guided Biopsy :

Cognitive Fusion Registration




MRI Guided Biopsy :



Software US/MRI Fusion Registration

• Deformable (elastic) registration

• 3D mapping fusion

• Navigation


MRI Guided Biopsy :




• Deformable (elastic) registration

• Live 3D mapping fusion


MRI Guided Biopsy :




• Active surveillence

• Second look reconnects previous sessions to the current exam


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.



What is the performance of mpMRI-PB (TB) compared with systematic TRUS-PB (SB)?

Target Biopsy (TB) vs Systematic biopsy (SB)

2017


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.

What is the performance of mpMRI-PB (TB) compared with systematic TRUS-PB (SB)?

Target Biopsy (TB) vs Systematic biopsy (SB)

ongoing …

2025 pts


Imaging biomarkers: Radiomics (Quantitative imaging data)

“radiophenotypes” : correlate to and complement existing validated clinical and genomic risk

stratification biomarkers

Future …


Translational Cancer Research, Vol 5, No 4 August 2016

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

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

Hotel Tryp, Costa de Caparica - Portugal * 12 e 13 de janeiro de 2018

multiparametric (mp) mr: prostate fusion...

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