What are the problems with transrectal biopsies of the prostate for prostate ...
20150317-Handbook-Full 24 pages version
1. Samuel Aronson, M.D.
a small handbook for patients and curious doctors
From PSA Screening
Magnetic Resonance Imaging
Accurate Diagnosis and Treatment
Prostate Cancer Imaging
A Remarkable Achievement
To
2. 2
can you imagine being treated
for a high fever, racking cough and
pneumonia without a chest x-ray ?
can you imagine being diagnosed or
treated for prostate cancer
without your doctor being able to see it ?
that is what we were doing
finally, the prostate can be seen
in anatomic and functional detail with
prostate MRI
3. 3
Introduction
Welcome to the new world of accurate diagnosis and
treatment of prostate cancer with Prostate MRI.
It has taken a number of years, and many scientist and
clinicians worldwide to develop Prostate MRI for clinical
use.
The current practice of PSA Screening, Trans Rectal
Ultrasound (TRUS) random biopsy are inaccurate and
misses many of the aggressive prostate cancers that cause
serious illness.
Random biopsies frequently diagnose the numerous
not-aggressive cancers that are slow growing and cause no
harm. Many men with not-aggressive cancers have
undergone what we now know is unnecessary treatment.
TRUS/MRI fusion targeted prostate biopsy can diagnose
the aggressive cancers at the initial biopsy session avoiding
repeat biopsy sessions (target practice) and biopsy
complications.
With MRI there is a decrease in over diagnosis and over
treatment of the not-aggressive cancers. The aggressive
cancers are diagnosed earlier with greater opportunity for
cure.
When prostate cancers are diagnosed the MRI Images are
key for monitoring men on active surveillance and for
treatment selection, planning and evaluation.
TRUS biopsies are performed randomly
Random biopsies are inaccurate
Lucky Strike
5. 5
Prostate MRI is a Major
Advancement in Prostate Cancer
Diagnosis, Treatment,
Research, and Knowledge
nodule peripheral zone
rectum
sector 4p, 0.9 cc
Mr. MRI Machine
Prostate MRI T2w image
transition zone
a
b
52 years, PSA 1.1 4.7, over 3 years, PSAD 0.12
DRE- no nodule
6. 6
First
you need to know
some facts about
Prostate Cancer
PSA, PSA Density
Prostate Cancer
Risk Assessment
7. 7
Prostate Cancers Are
Not-Aggressive or Aggressive
Most Prostate Cancers are Not-Aggressive
Common, frequent and small
Men die with it, not from it (very slow growing)
Biologically inactive
visualized on MRI
Most older men have not-aggressive cancers
Some Prostate Cancers are Aggressive
Less frequent and larger
Grow faster
Biologically active
on MRI
8. 8
PSA (Prostate Specific Antigen)
A good misused test with a bad reputation
PSA Density
A more accurate use of PSA
PSA indicates Benign Prostate Hypertrophy
(BPH), Prostate Infection, Urinary Tract
Manipulation and Cancer
Prostates grows with age (BPH)
PSA usually goes up with age
Baseline PSA age 30, men at high risk
age 40, men with cancer concern
PSA Progression is faster and higher with
aggressive cancers
PSA - 4ug/l upper limit of normal is incorrect
PSA - less than 4 ug/l
aggressive cancers can be present
PSA - over 4 ug/l mostly caused by BPH
When used wisely PSA is a good cancer predictor
PSA Density is doubly better than PSA as a cancer
predictor
PSA Density is PSA divided by prostate volume
obtained from TRUS or MRI
9. 9
PCRA (Prostate Cancer Risk Assessment)
Determines which men are candidates for a MRI
men at high risk of prostate cancer
Less than 70 years
More than 10 year life expectancy
(prostate cancers are very slow growing)
Family – genetic history of Prostate Cancer
Men of African origin
Prostate nodule on finger rectal exam (DRE)
PSA Progression faster than expected
PSA increase in men on Avodart, Proscar,
and Testosterone
PSA more than 10
PSAD more than 0.15
Abnormal Prostate Cancer Predictors and
Calculators
Previous diagnosis of prostate cancer
10. 10
all men at risk of prostate cancer need
to be investigated
some men investigated benefit from
an MRI
not all men who have an MRI require
a biopsy
11. 11
Prostate MRI
What Can It Really Do?
MRI Accurately Visualizes, Characterizes and Stages
Prostate Cancer Nodules
Visualizes:
Number of nodules
Sector location within the prostate
Nodule volume
Capsule invasion
Cancer outside the prostate
Characterizes:
Likelihood of Cancer
3 parameters score (T2w, DWI/ADC, DCE)
Cancer aggressiveness
Stages:
Cancer outside the prostate –adjacent,
seminal vesicles, bones and nodes
Prostate MRI is 90 % accurate in finding
aggressive prostate cancer nodules
12. 12
How Does It Do It?
parameters characterize prostate nodules
T2w
T2 Weighted Images – detailed anatomy
DWI/ADC
Diffusion Weighted Images/Apparent Diffusion
Coefficient - cellular density (restriction of
water diffusion among cancer cells)
DCE Dynamic Contrast Enhancement
mini angiogram, new micro tumor blood vessels
3
T2w roadmap
DWI/ADC traffic congestion
DCE new arterial construction
14. 14
The MRI Report
Patient Data - risk assessment, previous biopsy
Initial (Reference) MRI, Previous MRI
Prostate Volume
PSA, PSA Density
Visualizes:
Nodule(s) location in 27 sectors
Nodule size
Capsule invasion
Cancer outside the prostate
Other pelvic organs (bowel,
bladder, large arteries, hernia)
Characterizes:
3 Parameters - T2w, DWI/ADC, DCE –5 point Score
Highly likely no aggressive cancer
Likely no aggressive cancer
Unsure
Likely aggressive cancer
Highly likely aggressive cancer
Tumor Stage (cancer outside the prostate) - adjacent,
seminal vessels, bones, nodes
Comparison to previous MRI
Radiologist MRI Summary
Diagnosis MRI - indicates the need for biopsy when
clinically warranted
Monitoring MRI – identifies the likelyhood of residual
or recurrent cancer after treatment
15. 15
The significance of a nodule
imaged on MRI…
depends on
Patient’s Prostate Cancer Risk Assessment profile
(age, life expectancy, Family-Genetic history, race, major illnesses,
chemical-medication exposure, voiding symptoms, previous biopsy,
prostate cancer predictors ; urologic exam, DRE; urinalysis, culture,
renal function, PSA, PSAD; TRUS findings; and other factors to consider)
Experience of the Radiologist and Urologist
Nodule(s) Size and Location (27 sectors)
3 Parameter Score
Capsule invasion
Cancer outside the prostate
27 Prostate Sectors
Rt Lt
16. 16
Prostate MRI
Selects
For Diagnosis
Which sector to target the biopsy
The patients not requiring biopsy, instead
monitor
When Cancer
Treatment type, planning and evaluation
Treatment Options
Pre Programmed Follow Up – MRI monitoring men
at high risk, no cancer diagnosed
Active Surveillance – MRI monitoring diagnosed not-
aggressive untreated cancers
Surgery, Radiation, Focal Therapy, Medical
Oncology and Combinations
17. 17
TRUS Prostate Biopsy
bladder
prostate
Trans rectal ultrasound
probe
3D imaged
guidance system
TRUS/MRI Fusion Targeted Biopsy
a
b
rectal probe
Prostate biopsy performed only when clinically warranted
20. 20
Prostate MRI: A Team Effort
Radiologists interprets the MRI, identifies
the aggressive cancer nodules,
indicates which men to biopsy
Urologist use the MRI to select which
men to biopsy, where in the
prostate to target the biopsy,
and in treatment decisions
Pathologists provides the tissue proof
of the presence of cancer
21. 21
From PSA Screening
To
Prostate Cancer Imaging
inaccurate to accurate
Thorough Prostate Cancer Risk Assessment
(including PSA)
MRI selects men for biopsy
MRI best performed before initial biopsy
session (before biopsy artefact)
TRUS/MRI fusion targeted biopsy
Aggressive cancers diagnosed at the initial
biopsy session (greater opportunity for cure)
Decreased numbers of biopsy sessions and
fewer complications
Decreased over diagnosis and over
treatment of not-aggressive cancers
MRI image guided
diagnosis and treatment decisions
MRI image evaluation for residual or
recurrent cancer after treatment
22. 22
cancer nodule
T2w
DWI ADC
DCEnormal MRI
sector 11p12p, 1.3 cc, score 5
An Advanced Complex
Technology
41 years, African American, PSA 4.5, PSAD 0.1
DRE- no nodule
53 years, PSA 0.3 6.8, over 5 years, PSAD 0.18
DRE- nodule left prostate
23. 23
Prostate MRI is a
remarkable achievement
It is an advanced complex technology which
is time consuming to learn, perform,
interpret, and implement
It provides accuracy in prostate cancer
management that was inaccurate without
detailed imaging
It is becoming the basis for prostate cancer
diagnosis, treatment selection and planning
It is key for patients at risk of prostate
cancer, on active surveillance and monitoring
after treatment
Prostate MRI is a major advancement in
prostate cancer care, knowledge and
research
Concerned About
PSA, Prostate Cancer ?
Think Prostate MRI
