J.  O. Barentsz Hoofd-wetenschap Radiologie RUNMC Innovatieve imaging biedt grote kansen voor betere diagnostiek- en thera...
Missie <ul><li>Patiënt helpen  door wetenschappelijk onderzoek:  verbetering  radiologische  diagnostiek </li></ul><ul><li...
Focus <ul><li>Richting:  </li></ul><ul><ul><li>Ontwikkelingen vanuit de  kliniek </li></ul></ul><ul><ul><li>Inzichten vanu...
Focus: kanker (RUCO) <ul><li>Prostaat :  1/6  mannen </li></ul><ul><li>Borst  kanker:  1/8  vrouwen </li></ul><ul><li>Dikk...
Learning Objectives Multi-modality MRI 1. High resolution  T2-w .:  anatomy 2.  D iffusion   W eighted   I maging:  functi...
Learning Objectives Multi-modality MRI: anatomy 1 mm
<ul><li>Brownian  movement of water </li></ul><ul><li>DWI:  cell  density, extracellular  space , tortuosity,  integrity o...
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 <ul><li>1.  Determine  aggression </li></ul><ul><li>2.  Improve  detection & localization  </li>...
Clinical questions in PCa <ul><li>1.  Determine  aggression </li></ul><ul><li>2. Improve detection & localization  </li></...
<ul><li>What is the association betweeen  dogs  and  prostate cancers ? </li></ul>Dogs and Prostate
<ul><li>Benign </li></ul>Gleason 3 Dogs and Prostate c. T. Hambrock
<ul><li>Intermediate aggressive </li></ul>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. A...
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 <ul><li>1.  Determine aggression </li></ul><ul><li>2.  Improve  detection & localization  </li><...
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 <ul><li>1.  IMRT  dominant prostatic lesion </li></ul><ul><li>2.  HD-Brachy </li><...
IMRT : high dosis to DIL van Lin IJROBP 2006 IMRT: Partial boost to 90 Gy
Clinical questions in PCa <ul><li>1.  Determine aggression </li></ul><ul><li>2.  Improve detection & localization  </li></...
3T ERC-MRI: 2 mm close to NVB T
Clinical questions in PCa <ul><li>1.  Determine aggression </li></ul><ul><li>2.  Improve detection & localization  </li></...
Detecting nodal metastasis: some challenges <ul><li>Imaging (CT, MRI , PET) </li></ul><ul><ul><li>Less invasive </li></ul>...
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...
IMRT planning <ul><li>Accurate  mapping  of  </li></ul><ul><li>positive MRL  nodes  </li></ul><ul><li>for  IMRT  has the  ...
Case  <ul><li>60 yr; initial PSA  6 ; Gleason  4+3 </li></ul><ul><li>Dec 2005: Da Vinci Px:  T3B N1 Mx R+  </li></ul><ul><...
Case
 
Case  <ul><li>60 yr; initial PSA  6 ; Gleason  4+5 </li></ul><ul><li>Dec 2005: Da Vinci Px:  T3BN1Mx  </li></ul><ul><li>Fe...
Case 1
Case  <ul><li>PSA :  Nov 06: 0.0006 </li></ul><ul><li>Apr  07: 0.003 </li></ul><ul><li>  July 07:  Stop ADT </li></ul><ul>...
Case  March 2006   November 2009
Case 1
Clinical questions in PCa <ul><li>1.  Improve detection & localization  </li></ul><ul><li>2.  Determine aggression </li></...
Bone involvement <ul><li>Plain film and CT show  bone  </li></ul><ul><li>destruction  </li></ul><ul><li>Scintgraphy shows ...
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 ...
Computers: Visualize MR images Pharmacokinetic analysis MRS analysis Structured reporting CAD
CADx – Computer aided diagnosis
Samenwerking (met Industrie) <ul><li>MR-geleide  Robot  (U-Twente) </li></ul><ul><li>Minimaal invasieve  behandelingen   <...
Innovaties van Beeldvorming <ul><li>Maakt  PCa screening  mogelijk: </li></ul><ul><li>- MRI als  PSA   ↑ </li></ul><ul><li...
Implementatie van Zorgverbetering <ul><li>U niversitair  P rostaatkanker  </li></ul><ul><li>S neldiagnostiek en  </li></ul...
Vragen? Wetenschap blijft Teamwork: Debats, Fütterer, Hambrock, Heerschap, Heijmink, Hoeks, Huisman, Litjes, Scheenen, Vos...
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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

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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

    1. 1. J. O. Barentsz Hoofd-wetenschap Radiologie RUNMC Innovatieve imaging biedt grote kansen voor betere diagnostiek- en therapeutische produkten , [email_address]
    2. 2. Missie <ul><li>Patiënt helpen door wetenschappelijk onderzoek: verbetering radiologische diagnostiek </li></ul><ul><li>Bench-to-clinic-to-population : translationeel onderzoek </li></ul><ul><li>Betere diagnose -> effectievere therapie </li></ul>
    3. 3. Focus <ul><li>Richting: </li></ul><ul><ul><li>Ontwikkelingen vanuit de kliniek </li></ul></ul><ul><ul><li>Inzichten vanuit fundamenteel onderzoek </li></ul></ul><ul><li>Niches opzoeken </li></ul><ul><li>Mogelijkheden om ons heen benutten </li></ul>
    4. 4. Focus: kanker (RUCO) <ul><li>Prostaat : 1/6 mannen </li></ul><ul><li>Borst kanker: 1/8 vrouwen </li></ul><ul><li>Dikke darm kanker </li></ul><ul><li>Hoofd-hals tumoren </li></ul>
    5. 5. 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
    6. 6. Learning Objectives Multi-modality MRI: anatomy 1 mm
    7. 7. <ul><li>Brownian movement of water </li></ul><ul><li>DWI: cell density, extracellular space , tortuosity, integrity of cellular membranes & extent of glandular tissues </li></ul>Multi-modality MRI: DWI Tightly packed cellular tissue Organised glandular tissue Well organised tissue
    8. 8. DWI: PCa restricted H 2 O movement Multi-modality MRI: function
    9. 9. MRS: PCa Choline/Citrate ratio ↑ Multi-modality MRI: function
    10. 10. Multi-modality MRI: vascularity DCE MRI: PCa increased vascular permeability
    11. 11. Clinical questions in PCa <ul><li>1. Determine aggression </li></ul><ul><li>2. Improve detection & localization </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>
    12. 12. Clinical questions in PCa <ul><li>1. Determine aggression </li></ul><ul><li>2. Improve detection & localization </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>
    13. 13. <ul><li>What is the association betweeen dogs and prostate cancers ? </li></ul>Dogs and Prostate
    14. 14. <ul><li>Benign </li></ul>Gleason 3 Dogs and Prostate c. T. Hambrock
    15. 15. <ul><li>Intermediate aggressive </li></ul>Gleason 4 c. T. Hambrock Dogs and Prostate
    16. 16. c. T. Hambrock Gleason 5 Dogs and Prostate Highly aggressive
    17. 17. 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
    18. 18. Pearson Correlation r = 0.73 p < 0.01 DWI: Non-invasive aggression determination Hambrock Radiology accepted p.r.
    19. 19. DWI: ADC-value versus Gleason score
    20. 20. Clinical questions in PCa <ul><li>1. Determine aggression </li></ul><ul><li>2. Improve detection & localization </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>Introduction localization aggression local nodes recurrence/FU
    21. 21. 70 yr: 5 x neg. biopsies ( 30 cores) PSA 33 ng/ml Case Next step ?
    22. 22. Localization: saturation biospy? I ntroduction Local Nodes Fusion
    23. 23. 70 yr: 6 x neg. biopsies ( 54 cores) PSA 33 ng/ml Case Next step ? Saturation biopsy (24 cores)
    24. 24. Case MR Guided biopsy
    25. 25. 3T MR-biopsy Manual biopsy gun and confirmation scan of correct needle position
    26. 26. 3T MR-biopsy Highly aggressive cancer (4+4)
    27. 27. MRGB vs multi-session TRUS 3T MR guided biopsy
    28. 28. Multi-modality MR imaging - guiding biopsy with MRI-TRUS fusion Accurate Tissue Sampling by
    29. 29. Hit the most aggressive lesion with TRUS – MR ( ADCmap) fusion
    30. 30. Learning Objectives MR-robot with guided remote control? MR-guided biopsy MIRIAM Project
    31. 31. Improved Localization -> Focal therapy <ul><li>1. IMRT dominant prostatic lesion </li></ul><ul><li>2. HD-Brachy </li></ul><ul><li>3. Cryotherapy </li></ul><ul><li>4. Thermo ablation </li></ul><ul><li>5. High Frequency US ablation </li></ul>
    32. 32. IMRT : high dosis to DIL van Lin IJROBP 2006 IMRT: Partial boost to 90 Gy
    33. 33. Clinical questions in PCa <ul><li>1. Determine aggression </li></ul><ul><li>2. Improve detection & localization </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>
    34. 34. 3T ERC-MRI: 2 mm close to NVB T
    35. 35. Clinical questions in PCa <ul><li>1. Determine aggression </li></ul><ul><li>2. Improve detection & localization </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>
    36. 36. Detecting nodal metastasis: some challenges <ul><li>Imaging (CT, MRI , PET) </li></ul><ul><ul><li>Less invasive </li></ul></ul><ul><ul><li>Inaccurate size criterion </li></ul></ul><ul><ul><li>Size limitation </li></ul></ul><ul><li>Surgery (PLND) </li></ul><ul><ul><li>Invasive, costly </li></ul></ul><ul><ul><li>Limited in coverage </li></ul></ul>Vincent van Gogh Sorrowing old man
    37. 37. Nanoparticle Contrast (Combidex / Sinerem) MR Lymphography MRL Nodal involvement
    38. 38. USPIO
    39. 39. pre -USPIO n m p ost-USPIO
    40. 40. 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
    41. 41. IMRT planning <ul><li>Accurate mapping of </li></ul><ul><li>positive MRL nodes </li></ul><ul><li>for IMRT has the </li></ul><ul><li>potential: </li></ul><ul><ul><li>to reduce toxicity in normal tissue </li></ul></ul><ul><ul><li>allows higher doses </li></ul></ul><ul><ul><li>on the positive nodes </li></ul></ul>
    42. 42. Case <ul><li>60 yr; initial PSA 6 ; Gleason 4+3 </li></ul><ul><li>Dec 2005: Da Vinci Px: T3B N1 Mx R+ </li></ul><ul><li>Feb 2006: PSA 0.22 </li></ul><ul><li>Do weneed to treat both areas ? </li></ul><ul><li>March 2005 Combidex/Sinerem MRI: </li></ul>
    43. 43. Case
    44. 45. Case <ul><li>60 yr; initial PSA 6 ; Gleason 4+5 </li></ul><ul><li>Dec 2005: Da Vinci Px: T3BN1Mx </li></ul><ul><li>Feb 2006: PSA 0.22 </li></ul><ul><li>March 2005 Combidex/Sinerem MRI: </li></ul><ul><li>-> ADT + 4D-IG-IMRT </li></ul>
    45. 46. Case 1
    46. 47. Case <ul><li>PSA : Nov 06: 0.0006 </li></ul><ul><li>Apr 07: 0.003 </li></ul><ul><li> July 07: Stop ADT </li></ul><ul><li>PSA : Aug 07: <0.01* </li></ul><ul><li>March 08: <0.003 </li></ul><ul><li>March 09: <0.003 </li></ul><ul><li>March 09: <0.01* </li></ul>Combidex/Sinerem MRI November 2009
    47. 48. Case March 2006 November 2009
    48. 49. Case 1
    49. 50. Clinical questions in PCa <ul><li>1. Improve detection & localization </li></ul><ul><li>2. Determine aggression </li></ul><ul><li>3. Improve local staging </li></ul><ul><li>4. Detect small nodal metastases </li></ul><ul><li>5. Detect recurrences / follow up </li></ul>
    50. 51. Bone involvement <ul><li>Plain film and CT show bone </li></ul><ul><li>destruction </li></ul><ul><li>Scintgraphy shows increased bone </li></ul><ul><li>metabolism </li></ul>MRI shows bone marrow itself
    51. 52. 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
    52. 53. Computers: Visualize MR images Pharmacokinetic analysis MRS analysis Structured reporting CAD
    53. 54. CADx – Computer aided diagnosis
    54. 55. Samenwerking (met Industrie) <ul><li>MR-geleide Robot (U-Twente) </li></ul><ul><li>Minimaal invasieve behandelingen </li></ul><ul><li>Contrast middelen (Magnamedics) </li></ul><ul><li>C omputer A ssisted D iagnosis (Meavis) </li></ul>
    55. 56. Innovaties van Beeldvorming <ul><li>Maakt PCa screening mogelijk: </li></ul><ul><li>- MRI als PSA ↑ </li></ul><ul><li>Spoort meest agressieve PCa op </li></ul><ul><li>-> optimale behandeling </li></ul><ul><li>Toont exact de uitbreiding buiten </li></ul><ul><li>prostaat aan -> optimale behandeling </li></ul>Confectiewerk: “behandeling op maat!”
    56. 57. Implementatie van Zorgverbetering <ul><li>U niversitair P rostaatkanker </li></ul><ul><li>S neldiagnostiek en </li></ul><ul><li>B ehandeladvies C entrum </li></ul>Topdiagnose en advies < 1 week
    57. 58. 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  

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