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 • • • • Transrectal US-guided sextant (dex 1-6, sin 7-12) Does not find the existing ca in 10-38% • Problematic locations apex, anterior and lateral parts Saturation biopsies Transperineal biopsies 12.9.2012 www.docrates.com 3D-ULTRA SOUND 1 mm slices 4 12.9.2012 ”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 6 12.9.2012 www.docrates.com ”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 • • • • 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 • • • • • • 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 • • • • Signal in Perif. Zone is normally clear The Signal of Ca is scanty Decreased signal also in • • • • • 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) • • • • • • • Asymmetry in Neurovaskular bundle Capsule swelling Blocked Rectoprostatic angle Tumor/capsule contact >10 mm Discontinuation of Capsule Retracted Capsule Irregular or spiculated Capsule Diffusion • • • • • • 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 6 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 • • • • Before second biopsy Before radical operation High risk disease • Increasing PSA, High PSA, High GS (7, 8-10), most of biopsies are +, clinically T3, symptoms Learning Curve Cyclotron 53 12.9.2012 www.docrates.com Cyclotron 54 12.9.2012 www.docrates.com Chemical processing of the tracer in GMP laboratory 55 12.9.2012 www.docrates.com Quality Control 56 12.9.2012 www.docrates.com 18F-Choline PET-CT Left lobe Bladder Seminal Vesicle 57 12.9.2012 www.docrates.com Primary PSA 45. GS 6. Ca in left lobe 1999 LHRH + RT LNs 45 gy; P 69 PSA relapse (5,1); Where? 58 12.9.2012 www.docrates.com PET-CT CT PET-CT BONE METASTASEs CAN BE SEEN IN PET-CT NOT IN plain CT PET 12.9.2012 www.docrates.com NAF PET-TT LUUSTOKARTTA 61 12.9.2012 www.docrates.com Bone scan 62 12.9.2012 SPET-TT www.docrates.com FLUORIDI-PET