UMC St Radboud, Innovatieve imaging biedt grote kansen voor betere iagnostiek en therapeutische producten
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UMC St Radboud, Innovatieve imaging biedt grote kansen voor betere iagnostiek en therapeutische producten

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Jelle Barentsz, UMC St Radboud, Health Valley Event 2010

Jelle Barentsz, UMC St Radboud, Health Valley Event 2010

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  • In conclusion:
  • So, problem for current nodal imagines is that ordinal CT and MRI rely on inaccurate size criterion. And an invasive surgery is limited in coverage of nodes.
  • The focus of our work is to improve the diagnostic performance of the radiologist. One way is to increase the objective evaluation of PK-parameters. The CAD program using a dedicated prostate hanging protocol, with in the 3 views on top axial T2-w images as background and pharmacokinetic paramater maps as foreground. The 3 views at the bottom show the sagittal and coronal view as well as the pre-contrast T1-w volume. Distribution of the CAD output trained database

UMC St Radboud, Innovatieve imaging biedt grote kansen voor betere iagnostiek en therapeutische producten UMC St Radboud, Innovatieve imaging biedt grote kansen voor betere iagnostiek en therapeutische producten Presentation Transcript

  • J. O. Barentsz Hoofd-wetenschap Radiologie RUNMC Innovatieve imaging biedt grote kansen voor betere diagnostiek- en therapeutische produkten , [email_address]
  • Missie
    • Patiënt helpen door wetenschappelijk onderzoek: verbetering radiologische diagnostiek
    • Bench-to-clinic-to-population : translationeel onderzoek
    • Betere diagnose -> effectievere therapie
  • Focus
    • Richting:
      • Ontwikkelingen vanuit de kliniek
      • Inzichten vanuit fundamenteel onderzoek
    • Niches opzoeken
    • Mogelijkheden om ons heen benutten
  • Focus: kanker (RUCO)
    • Prostaat : 1/6 mannen
    • Borst kanker: 1/8 vrouwen
    • Dikke darm kanker
    • Hoofd-hals tumoren
  • Learning Objectives Multi-modality MRI 1. High resolution T2-w .: anatomy 2. D iffusion W eighted I maging: function 3. H ydrogen MR-S pectroscopy: function 4. D ynamic C ontrast E nhanced: function
  • Learning Objectives Multi-modality MRI: anatomy 1 mm
    • Brownian movement of water
    • DWI: cell density, extracellular space , tortuosity, integrity of cellular membranes & extent of glandular tissues
    Multi-modality MRI: DWI Tightly packed cellular tissue Organised glandular tissue Well organised tissue
  • DWI: PCa restricted H 2 O movement Multi-modality MRI: function
  • MRS: PCa Choline/Citrate ratio ↑ Multi-modality MRI: function
  • Multi-modality MRI: vascularity DCE MRI: PCa increased vascular permeability
  • Clinical questions in PCa
    • 1. Determine aggression
    • 2. Improve detection & localization
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
  • Clinical questions in PCa
    • 1. Determine aggression
    • 2. Improve detection & localization
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
    • What is the association betweeen dogs and prostate cancers ?
    Dogs and Prostate
    • Benign
    Gleason 3 Dogs and Prostate c. T. Hambrock
    • Intermediate aggressive
    Gleason 4 c. T. Hambrock Dogs and Prostate
  • c. T. Hambrock Gleason 5 Dogs and Prostate Highly aggressive
  • At random TRUS prostate biopsies -> 64% accuracy to predict true GS Narain et al. Prostate 2001; Antumes et al. Arch Path Lab Med 2008 Gleason Score (GS) generally used predictor of aggressivity HOWEVER Clinical problem Therefore using TRUS biopsy GS can result in inappropriate therapy
  • Pearson Correlation r = 0.73 p < 0.01 DWI: Non-invasive aggression determination Hambrock Radiology accepted p.r.
  • DWI: ADC-value versus Gleason score
  • Clinical questions in PCa
    • 1. Determine aggression
    • 2. Improve detection & localization
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
    Introduction localization aggression local nodes recurrence/FU
  • 70 yr: 5 x neg. biopsies ( 30 cores) PSA 33 ng/ml Case Next step ?
  • Localization: saturation biospy? I ntroduction Local Nodes Fusion
  • 70 yr: 6 x neg. biopsies ( 54 cores) PSA 33 ng/ml Case Next step ? Saturation biopsy (24 cores)
  • Case MR Guided biopsy
  • 3T MR-biopsy Manual biopsy gun and confirmation scan of correct needle position
  • 3T MR-biopsy Highly aggressive cancer (4+4)
  • MRGB vs multi-session TRUS 3T MR guided biopsy
  • Multi-modality MR imaging - guiding biopsy with MRI-TRUS fusion Accurate Tissue Sampling by
  • Hit the most aggressive lesion with TRUS – MR ( ADCmap) fusion
  • Learning Objectives MR-robot with guided remote control? MR-guided biopsy MIRIAM Project
  • Improved Localization -> Focal therapy
    • 1. IMRT dominant prostatic lesion
    • 2. HD-Brachy
    • 3. Cryotherapy
    • 4. Thermo ablation
    • 5. High Frequency US ablation
  • IMRT : high dosis to DIL van Lin IJROBP 2006 IMRT: Partial boost to 90 Gy
  • Clinical questions in PCa
    • 1. Determine aggression
    • 2. Improve detection & localization
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
  • 3T ERC-MRI: 2 mm close to NVB T
  • Clinical questions in PCa
    • 1. Determine aggression
    • 2. Improve detection & localization
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
  • Detecting nodal metastasis: some challenges
    • Imaging (CT, MRI , PET)
      • Less invasive
      • Inaccurate size criterion
      • Size limitation
    • Surgery (PLND)
      • Invasive, costly
      • Limited in coverage
    Vincent van Gogh Sorrowing old man
  • Nanoparticle Contrast (Combidex / Sinerem) MR Lymphography MRL Nodal involvement
  • USPIO
  • pre -USPIO n m p ost-USPIO
  • Patient-to-patient correlation (n=375) MD CT MRL accuracy 86% -> 91 % specificity 97% -> 93 % sensitivity 34% -> 93% NPV 89% -> 97 % Probability of correct diagnosis : MRL 91% Surgery + CT 89% Dutch study: 13 centres Heesakkers, Lancet Oncology 2008
  • IMRT planning
    • Accurate mapping of
    • positive MRL nodes
    • for IMRT has the
    • potential:
      • to reduce toxicity in normal tissue
      • allows higher doses
      • on the positive nodes
  • Case
    • 60 yr; initial PSA 6 ; Gleason 4+3
    • Dec 2005: Da Vinci Px: T3B N1 Mx R+
    • Feb 2006: PSA 0.22
    • Do weneed to treat both areas ?
    • March 2005 Combidex/Sinerem MRI:
  • Case
  •  
  • Case
    • 60 yr; initial PSA 6 ; Gleason 4+5
    • Dec 2005: Da Vinci Px: T3BN1Mx
    • Feb 2006: PSA 0.22
    • March 2005 Combidex/Sinerem MRI:
    • -> ADT + 4D-IG-IMRT
  • Case 1
  • Case
    • PSA : Nov 06: 0.0006
    • Apr 07: 0.003
    • July 07: Stop ADT
    • PSA : Aug 07: <0.01*
    • March 08: <0.003
    • March 09: <0.003
    • March 09: <0.01*
    Combidex/Sinerem MRI November 2009
  • Case March 2006 November 2009
  • Case 1
  • Clinical questions in PCa
    • 1. Improve detection & localization
    • 2. Determine aggression
    • 3. Improve local staging
    • 4. Detect small nodal metastases
    • 5. Detect recurrences / follow up
  • Bone involvement
    • Plain film and CT show bone
    • destruction
    • Scintgraphy shows increased bone
    • metabolism
    MRI shows bone marrow itself
  • bone scan: se 46% sp 32% bs+X: se 63% sp 64% MRI: se 100% sp 88% Bone scan, PET/CT, or MRI? Lecouvet JCO 2007 T1-w. MRI DWI-MR
  • Computers: Visualize MR images Pharmacokinetic analysis MRS analysis Structured reporting CAD
  • CADx – Computer aided diagnosis
  • Samenwerking (met Industrie)
    • MR-geleide Robot (U-Twente)
    • Minimaal invasieve behandelingen
    • Contrast middelen (Magnamedics)
    • C omputer A ssisted D iagnosis (Meavis)
  • Innovaties van Beeldvorming
    • Maakt PCa screening mogelijk:
    • - MRI als PSA ↑
    • Spoort meest agressieve PCa op
    • -> optimale behandeling
    • Toont exact de uitbreiding buiten
    • prostaat aan -> optimale behandeling
    Confectiewerk: “behandeling op maat!”
  • Implementatie van Zorgverbetering
    • U niversitair P rostaatkanker
    • S neldiagnostiek en
    • B ehandeladvies C entrum
    Topdiagnose en advies < 1 week
  • Vragen? Wetenschap blijft Teamwork: Debats, Fütterer, Hambrock, Heerschap, Heijmink, Hoeks, Huisman, Litjes, Scheenen, Vos, Yakar, Witjes, van Oort, van Lin, Hulsbergen UT, RUNMC, XiVent Medical Demcom, Siemens Magnamedics