Evaluation and Targeting No More Blind Biopsies. Previous Negative Biopsies Active Surveillance Focal Therapy. Icahn School of Medicine at Mount Sinai

Icahn School of Medicine at Mount Sinai Art Rastinehad D.O Director, Focal Therapy and  Interventional Urologic Oncology Associate Prof. of Urology a...
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Icahn School of Medicine at Mount Sinai

Art Rastinehad D.O Director, Focal Therapy and  Interventional Urologic Oncology Associate Prof. of Urology and Radiology www.interventionalurology.com

• Evaluation and Targeting • No More Blind Biopsies • Previous Negative Biopsies • Active Surveillance • Focal Therapy

• How is it clinically used  today? • Most urologists use it to  guide needle Biopsies

• Few look for areas  suspicious for cancer Wein et. al. Campbell-Walsh Urology. 9th ed. 2007:Philadephia, PA

• Garbage ‘IN ’ Garbage ‘OUT’

1. MR Imaging Quality 2. Pre‐Biopsy Setup MR Review Segmentation / Targeting

3. Procedure Technique

4. Post Procedure  Review Video Outcome and Pathology

• 3 Components – MR Imaging – Combines US and MRI Images • Surface Rendering

– Targeting • Tracking

• Combine the benefits of one imaging modality  with another • MRI and US • Guide, Track , and Record Biopsies in 3D space

• 1.5 Tesla versus 3 Tesla • What sequences are  obtained? • Endo Rectal Coil versus  no Coil – What do you put in the  coil balloon

• Type of surface coil – # channels per surface  area?

• When to obtain the  MRI? – Hemorrhagic Artifact (8  weeks)

• Fluoronert, Barium, Air • De‐mineralized water

• ANATOMIC – Triplane (sagittal, axial and coronal) T2W MRI

• FUNCTIONAL – Diffusion Weighted (DWI) – Dynamic Contrast enhanced (DCE) MRI (T1) – MR Spectroscopy

T2

DCE

ADC

Sagittal

Axial                    Coronal

• Evaluates the Brownian motion of free water within tissue • Tissue diffusion is restricted •increased cellularity •the water path is interrupted by cell membranes. •Prostate Cancer

• B Values? – How does this impact your ADC map? – What kind of B values are used • 0‐750 five equal divisions • 0, 800, 1000, 1500, 2000 • Possibly remove the 0 B value for improved ADC maps

– Does the results of ADC map correlate with  pathology?

• Comparison of signal intensities with and  without DWI taking into account the  ‐1/b  value – Creates a Ratio that is then graphed • ADC = log slope of the line of the signal values ratio

– ADC Maps  • decrease T2 shine through  • Possibly increase cancer detection with b‐values > 1000  to 2000* *AJR Am J Roentgenol. 2010 Jan;194(1):W33-7.

DWI MRI

ADC b=0

s/mm2 b = 188 s/mm2

b = 375 s/mm2

b = 563 s/mm2

b = 750 s/mm2

Turkbey, Rastinehad, Pinto et al. Radiology 2011

Gleason Pattern 3

Less Restricted

Gleason Pattern 4

Gleason Pattern 5

Restricted

Free Motion of Water

• Evaluates the VASCULARITY of tumors • Prostate cancers usually show early and rapid enhancement, early washout

JAMA. 2015 Jan 27;313(4):390-7.

• Level 1 Evidence

– MR US Targeted Biopsy outperforms 12 core – Detects 30% more high risk cancer • 17% less low grade disease

– Accuracy (WMH) • 77% Targeted vs 53% Std Biopsy

Urol Oncology Sept 201

77% + MRI

STD BX + CaP 36% MRI Neg MRI + SAT Bx 29% Gleason 6

+ MRI + CaP 87%

- Bx 28%

+ CaP 93%

Elevated  PSA NO BIOPSY

Standard 12 core  US Guided Biopsy 

33‐45% of Men  Negative MRI

67% MRI Clinically  Significant Images

Department of Radiology and Urology Mt. Sinai School of Medicine

What a Urologist Needs to Know

Art Rastinehad D.O Director, Focal Therapy and Interventional Urologic Oncology Assistant Prof. of Urology and Radiology

100% Men Biopsied

• Location Description: – (Peripheral / Central Gland / Anterior Fibromusclar Stroma) – Location: Apex / Mid / Base • NIH Zone: Slice# range: Series X images 11‐16, Center: Image 15. Size (Transverse, AP, CC):  • T2:                              ( SQS Score) / (PI‐RADS) Diffusion/ADC:         ( SQS Score) / (PI‐RADS)  Enhancement:         ( SQS Score) / (PI‐RADS)  Adjacent capsule:    ( SQS Score) / (PI‐RADS) • Overall 5 point Risk Stratification: 1‐5

Simplified Qualitative Scoring System (SQS) T2 Low Signal Intensity (SI) Focal  Positive (+1) Defect (PZ) Erased Charcoal (CG)

No Pathologic  Enhancement

No EPE

Negative (0)

no SI defect

No focal Defects

Any Size

T2 Wedge / Thin Band / Diffuse

> 0.2 

DWI/ADC DCE Neg b‐2000 and No Type III Focal enhancement

Suspicion Score 2

b‐2000 Positive or Type III Focal Enhancement

4 3 4 3 4 5 4

b‐2000 Positive or Type III Focal Enhancement Wedge / Thin Band / Diffuse

> 0.5 3

EPE

3 Focal Lesion

> 0.5   0.2 4 Any Size Transition Zone / Anterior Fibromuscular Stroma SQS Score Size (cc) T2  0.5  1.0

4

Mild Enhancement

Low SI Band, Wedge (PZ)

3.5

3.5

EPE Bulge, Loss of well  defined Border

Mild    (+0.5)

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