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Transcript of 1. mpMR of the Prostate mpMR of the Prostate Change of Paradigm in the Diagnosis and Therapy of P-Ca...
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mpMR of the ProstateChange of Paradigm in the Diagnosis and Therapy of P-Ca
Beat Porcellini, Institut für Radiologie und Zentrum für Urologie, Klinik Hirslanden Zürich
6. Interdisziplinäres Prostatakarzinomsymposium St.Gallen 5.Nov. 2015
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Elevated PSA (prostate specific antigene)Pathologic DRE (dig. rectal examination)
TRUS (transrectal ultrasound + biopsy)
The Urologist’s Way
Positive Negative
Therapy Follow Up PSA + TRUS
etc
etc, etc, etc....
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Van Gogh – Heulender alter Man
The Urologist’s Way
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The Radiologist’s WayElevated PSA (prostate specific antigene)Pathologic DRE (dig. rectal examination)
Positive Negative (ca 50%)
Image guided Biopsy H.N.
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mpMRI of the Prostate
1.5 T
Nicola Tesla 1856 - 1943
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mpMRI of the Prostate
3.0 T
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mpMRI of the Prostate
Endorectal Coil
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Jelle BarentszDept. of Uroradiology
UMC St.Radboud UniversityNijmegen / NL
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7 biopsies 2002-2008TUR-P 2009 (40g)PSA 9.0
3T without + 3T with EC
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7 biopsies 2002-2008TUR-P 2009 (40g)PSA 9.0
Gleason 4+3=7b
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Why missed by TRUS biopsies?
1.7 cm line
The Urologist’s Way
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MR Guided Biopsy Device – Invivo (Philips)
Hambrock Invest. Radiol (2008)
MR-guided Biopsy
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MR-guided Biopsy
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Most aggressive Part of Tumor
Representativity?
MR-guided Biopsy
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MR-guided Biopsy
Gleason 4+4=8
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MR-guided Biopsy
Gleason 3+3=6rechts (TRUS)
Gleason 4+4=8
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mpMRI of the Prostate
St.n. TUR-P 2012Gl. 6
PSA 1.6
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mpMRI of the Prostate 3.0 T2011 PSA 7.2 2012 PSA 5.2 2013 PSA 12.0 Bx - 2014 PSA 24.0
Gleason 3+4
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mpMRI and MR-guided Biopsy
- mpMRI: 4 - 5 Pat/d over 4500 Pat. since 2006
- MR guided Biopsies: 6 - 8 Pat/w (incl Artemis and Koëlis) over 1200 Pat. since 2009
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Korrelation MRI-Befund zu Pathologie Präparat
Radiologie Pathologie
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PI-RADS
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mpMRI of the ProstatePIRADS
1. High Resolution T22. High Resolution Diffusion3. Dynamic Contrast Agent
4. Proton Spectroskopy
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mpMRI of the ProstatePIRADS V2
1. High Resolution Diff High Resolution T22. High Resolution T2 High Resolution Diff
(Dynamic Contrast Agent)
PZ TZ
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TRUS verpasst Ca; typischerweise anterior gelegene Karzinome(auch mit Saturationsbiopsie wird dieser grosse Befund verpasst!)
Signifikanter Tumor
Insignifikanter Tumor
MRI gezielte Biopsie
MRI gezielte Biopsie• verbesserte Detektionsrate• weniger Biopsien
TRUS Biopsie
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MRI; keine gezielte Biopsie
Klinik:-PSA erhöht-MRI Prostata ohne relevante Pathologie-Keine gezielte Biopsie
Histo:-TRUS-Biopsie: 3 mm Infiltrat eines Gleason 3+3=6 Karzinomes in 1 von 12 Stanzen
Signifikanter Tumor (keiner)
Insignifikanter Tumor (ja)
MRI gezielte Biopsie• verbesserte Detektionsrate• weniger Biopsien
TRUS Biopsie
negative Selektion durch TRUS:→ Diagnostik insignifikanter Tumore
positive Selektion durch MRI: → insignifikante Tumore sind nicht darstellbar→ keine Biopsie
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Das multiparametrische MRI (mpMRI) der Prostata in der Primärdiagnostik: Senkung der Rate insignifikanter Tumore?
- Die gezielte Biopsie vermindert die Diagnose eines low risk–Prostatakarzinomes um 89.4% gegenüber der TRUS-Biopsie
- Die gezielte Biopsie erhöht die Diagnose eines intermediate u. high risk–Prostatakarzinomes um 17.7% gegenüber der TRUS-Biopsie
(Lit: Pokorny MR et al. Prospective Study of Diagnostic Accuracy Comparing Prostata Cancer Detection by Transrectal Ultrasound-Guided Biopsy versus Magnetic Resonance (MR) Imaging with Subsequent MR-Guided Biopsiy in Men without previous Prostate Biopsis. Eur Urol. 2014Jul;66(1):22-9
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Less insignificant tumors by initial diagnostic mpMRI of prostateJ.-L. Fehr, B. Porcellini et al., Zentrum für Urologie , Institut für Radiologie, Klinik Hirslanden Zürich
Studie:MRI-Selektion:
- mpMRI der Prostata in der Primärdiagnostik mit nachfolgend gezielter Biopsie (MRI-gezielt/Koëlis/Artemis)
- Ausschlusskriterium:Keine vorgängige Prostatakarzinomdiagnose durch TRUS-Biopsie
Ziel: Evaluation aller Prostatektomie-Präparate in Bezug auf signifikante/insignifikante Tumore (Übertherapie); n = 170 (radikale Prostatektomie-Präparate)
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Resultate
Kalkulierte Rate der Übertherapie: 5 % bis 46 %, (Loeb S et al. Overdiagnosis and Overtreatment of Prostate Cancer. Eur Urol, 2014: 65: 1046-55)
Less insignificant tumors by initial diagnostic mpMRI of prostateJ.-L. Fehr, B. Porcellini et al., Zentrum für Urologie , Institut für Radiologie, Klinik Hirslanden Zürich
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Weitere Vorteile des mp MRI
Cave
• zuverlässigere Führung und Information des Patienten• Planung im Hinblick auf eine Da Vinci Prostatektomie (Landkarte)
• bevorzugte Lokalisation der Schnellschnittuntersuchung• Planung des Ausmasses einer Gefässnervenschonung
• Zusätzliche Sicherheit für Patienten in der Active Surveillance• Das mpMRI ersetzt (bei uns) die Rebiopsie in der Active Surveillance weitgehend
(MRI-Surveillance)• MRI-Verlaufskontrolle bei pathologischem PSA (MRI Surveillance)
• verpasste intermediate/high risk Tumore in ca. 3 - 5%• Vom Overtreatment zum Undertreatment?
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Die randomisierte (mehrfach)TRUS-Biopsie beinhaltet eine negative Selektion durch Zufallsbefunde; in unserem Zentrum wurde die TRUS Biopsie zur primären Diagnostik des Prostatakarzinomes entsprechend durch die gezielte Biopsie ersetzt.
Das multiparametrische MRI (mpMRI) der Prostata in der Primärdiagnostik: Senkung der Rate insignifikanter Tumore?
Positiver Nebeneffekt:- geringe Rekrutierung an Active Surveillance-Patienten- ca 50% weniger Prostatabiopsien
The End of Overtreatment? - Yes ! (Undertreatment?).
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HERZLICHEN DANKTHANK YOU VERY MUCHMERCI BEAUCOUP
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