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