多參數(shù)磁共振成像在前列腺癌診斷和主動監(jiān)測中的應(yīng)用課件

1、多參數(shù)MR在前列腺診斷和主動監(jiān)測中的應(yīng)用MR imaging of prostate gland2Start Here:PZ or TZ?PZTZ1235411235412354DCE-DWI1-4DCE+DWI 5PI-RADS v2, 201420032016Clinical applications of prostate MRIInitial diagnosisTumor detectionLocalization CharacterizationRisk stratificationLocoregional stagingGuide for biopsySurveillanceGui

2、de for surgery, focal therapy and radiation therapyAssessment of suspected recurrence3Excessive variation in the performance, interpretation, and reporting of prostate MRI examsPI-RADS2007 AdMeTech foundation International prostate MRI working gorup2010 ESUR working group of prostate MR2011 ESUR dev

3、elops PI-RADS v1ACR, ESUR & AdMeTech join forces2012 PI-RADS v1 published (Eur Radiol 2012; 22:746-7572014PI-RADS v2 announcedOutline SECTION I Clinical Considerations and Technical SpecificationsSECTION II Normal Anatomy and Benign FindingsSECTION III Assessment and ReportingSECTION IV Multiparamet

4、ric MRI (mpMRI)SECTION V Staging5Initiation of PI-RADSPromote global standardizationDiminish variation in AcquisitionInterpretationReportingA “l(fā)iving” document that will evolve as clinical experience and scientific data accrue6PIRADS v2 needs to be tested and validated forspecific research and clini

5、cal applicationsPurpose of PIRADSEstablish minimum acceptable technical parameters for prostate mpMRISimplify and standardize the terminology and content of radiology reportsDevelop assessment categories that summarize levels of suspicion or risk and can be used to select patients for biopsies and m

6、anagement (e.g., observation strategy vs. immediate intervention)7Facilitate the use of MRI data for targeted biopsyProstate Imaging and Reporting and Data System: Version 2Outline SECTION I Clinical Considerations and Technical SpecificationsSECTION II Normal Anatomy and Benign FindingsSECTION III

7、Assessment and ReportingSECTION IV Multiparametric MRI (mpMRI)SECTION V Staging9Scan protocol常規(guī)序列方向范圍層厚采集參數(shù)層面內(nèi)分辨率其他要求T1WI軸位前列腺+精囊腺T2WI軸位矢狀位冠狀位前列腺+精囊腺FOV：12-20 cm3mm無間距0.7 mm （相位編碼方向） 0.4 mm（頻率編碼方向）DWI/ADC軸位前列腺+精囊腺FOV：16-22 cm4mm無間距TE: 90 ms, TR: 3000 ms2.5 mm 高b值1400sec/mm2重建ADC圖，計算ADC值DCE軸位前列腺+精囊腺3

8、mm無間距TR: 100ms, TE: 7 (including 3+4 with prominent but not predominant Gleason 4 component), and/or Volume 0.5cc, and/or Extraprostatic extension (EPE)13PIRADS v2 Assessment CategoriesPIRADS 1 Very low (clinically significant cancer is highly unlikely to be present)PIRADS 2 Low (clinically signific

9、ant cancer is unlikely to be present)PIRADS 3 Intermediate (the presence of clinically significant cancer is equivocal)PIRADS 4 High (clinically significant cancer is likely to be present)PIRADS 5 Very high (clinically significant cancer is highly likely to be present)14Start Here:PZ or TZ?PZTZ12354

10、DWIT2WI1235412354DCE-DWI1-4DCE+DWI 5Multi-parametric imagingReportingMeasurement of the Prostate GlandMapping LesionsMeasurement of LesionsCaveats for Overall Assessment17Outline SECTION I Clinical Considerations and Technical SpecificationsSECTION II Normal Anatomy and Benign FindingsSECTION III As

11、sessment and ReportingSECTION IV Multiparametric MRI (mpMRI)SECTION V Staging18Section V: Staging19Imaging features used to assess for EPE Asymmetry or invasion of the neurovascular bundlesBulging prostatic contourIrregular or spiculated marginObliteration of the rectoprostatic angleTumorcapsule int

12、erface of greater than 1.0 cmBreach of the capsule20The apex of the prostate should be carefully inspected.Seminal vesicle invasion Demonstration of direct tumor extension from the base of the prostate into and around the seminal vesicleFocal or diffuse low T2WI signal intensityAbnormal contrast enh

13、ancement within and/or along the seminal vesicleRestricted diffusion, obliteration of the angle between the base of the prostate and the seminal vesicle21Lymph node metastasis 8mm in short axis Nodal groups that should be evaluated Common femoralObturatorExternal iliacInternal iliac Common iliacPara

14、rectalPresacralParacavalParaaortic22Structured report of Prostate MRRID 10312磁共振成像Magnetic resonance imagingMagneticam resonatur imaginationeDie Magnetresonanztomographie磁気共鳴- imagerie par rsonance magntique La resonancia magnticaLa risonanza magnetica23Start Here:PZ or TZ?PZTZ12354DWIT2WI1235412354

15、By PI-RADS v2 logicRADLex ID臨床評估影像所見診斷除外前列腺臨床顯著癌已確診前列腺癌，擬行術(shù)前分期其他臨床評估影像所見外周帶及移行帶1、4、5分信號單一2、3分信號可能性多默認(rèn)信號，可自行修改1-2分：整體描述3-5分：病灶描述影像所見診斷除外前列腺臨床顯著癌2. 已確診前列腺癌，擬行術(shù)前分期Management of prostate cancer based on mpMRIRecent articles reporting the role of mpMRI in prostate biopsyRecent studies of the role of mpMR

16、I in determining active surveillance eligibilityRecent studies of the role of mpMRI in high-risk prostate cancerRecent studies of the role of mpMRI in detecting local recurrence after radical prostatectomyLiteratureNICE Guidelines, UK 2014ESUR/ACR Guidelines 2012/2014Vache T et al, Radiology 2014de

17、Rooij M et al. AJR 2014Willis SR et al BMJ Open 201435mpMRI has performance characteristics to help manage patients with suspected or proven prostate cancersAbility to “rule in” and “rule out” disease depends on the mpMRI approach, image quality, reading system & reporter expertiseCancer detection a

18、bility is dependent on the anatomic location, tumor volume and aggressivenessmpMRI detected lesions are not always malignant; biopsy is always needed. Rule out rule in performance!Clinical utility of mpMRI is an interdependent function between target disease prevalence & test performance36What is th

19、e MRI target?“clinically significant cancer”A tumor that poses a significant risk to health depends onAggressiveness of the tumorLife expectancy (period of risk)Definition debated: often usedIndex tumor volume 0.5 ml and/orGleason pattern 4 or 5 and/orExtra-capsular disease (ECE/SVI)37Significantins

20、ignificant38Each component of mpMRI is helpful fordetecting clinically significant cancer39Sequences FunctionT2WI (& T1WI)Anatomy, tissue density, gland formation, fibrosisDWIExtent of gland formation, cellular density, necrosis and perfusion. Correlates with volume & grade.MRSMembrane turnover/ener

21、getics and replacement of normal glandular tissues. Correlates with volume & grade.DCEBlood flow and vascular permeability.May correlate with grade.Targted biopsy/ RxMR guided and/or directedSuspicionKnown cancerRisk categoryUnknownLowIntermediateHighPathologicstatus-Abnormal PSA & normal DRE;-Abnor

22、mal DRE & normal PSA;-Persistently raised PSA and 1negative TRUS biopsyPSA 20 ng/mL, orGleason score 810, orclinical stage T2cProblems ofcategorization50% have cancer dependingon above group; substantialproportion having significantdiseaseProstatectomy data suggestsa substantial proportionhave highe

23、r grade disease(miss-classified)Heterogeneous group with awide incidence of biochemicalrelapse & numerous curativetherapy optionsLocal staging accuracyDetection of metastaticdisease4041SuspicionKnown cancerRisk categoryUnknownLowIntermediateHighRole of MRI inmanagementTo identify location ofsuspicio

24、us clinically significantlesion(s) to enableappropriately directed biopsy-To confirm truly low riskdisease so as to allow activesurveillance to be undertaken-To identify location of non-low risk disease to enablerepeat biopsy & Rx-Stage cancers to enable curative surgery with nerve sparing-If initia

25、l AS is considered,then it is important not to underestimate tumor grade/volume/stage-For EBRT, the presence ofunfavorable disease affectsduration of adjuvanthormonal Rx-For focal therapy, indexlesion localization is needed-For surgery, accurate stagingto enable curative treatmentwith negative margi

26、ns &nerve sparing if possible-To detect extensiveECE/SVI that wouldpreclude radical surgerywith negative margins-To detect nodal andbone metastases42SuspicionKnown cancerRisk categoryUnknownLowIntermediateHighType of MRILesion detection &localization with T2WI, DWI DCE-MRI-Lesion detection &localiza

27、tion with DWIand DCE-MRI- MRSI for low ADC lesions to assess aggressiveness-Staging with high specificityECE/SVI criteria-Lesion detection &localization with DWI andDCE-MRI- MRSI for low ADC lesions to assess aggressiveness-Staging with multi-planar T2WI,DWI DCE-MRI for ECE/SVI-Accurate local stagin

28、gand pelvic nodalassessments-Bone scan + CT abdomenor WB-MRIKey questions on performance formpMRI/PI-RADS in suspected cancer1.Ability of mpMRI for detecting (rule in) clinically significant disease & thereby directing appropriate patient management2.NPV of mpMRI for ruling out clinically significan

29、t disease thus enabling avoidance of biopsy & thereby reduce over-diagnosis43Assessing the literature about the utility of mpMRI to rule “in” or “out” diseasempMRI method for data acquisition and analysis should be clearly defined (acceptable)Definition of clinically significant disease should be cl

30、earPrevalence of cancer & significant cancer should match what is expected in daily practiceStandard of reference should reliably inform on true pathologic status (particularly NPV), short of a prostatectomy (100% prevalence!); i.e., adequate biopsy core sampling; the more cores, the betterPatient/w

31、hole prostate level analysisPPV & NPV more important than test “accuracy” statistics44Accuracy of mpMRI for prostatecancer detection: meta-analysis45de Rooij M, et al. Accuracy of multiparametric MRI for prostate cancer detection: a meta-analysis. AJRAm J Roentgenol. 2014; 202(2):343-51.46The best s

32、tudy on the utility of mpMRI torule “in” or “out” disease347 patients 177 1st biopsy170 previous negative TRUS biopsyPSA 9.8 ng/mL (10.5-104); prostate volume 48.7 mL (9-180)Prebiopsy mpMRI3T, No ERC, T2W/DWI/DCE, 2 readersconsensus47Kuru TH, et al. Critical evaluation of magnetic resonance imaging

33、targeted, transrectal ultrasound guidedtransperineal fusion biopsy for detection of prostate cancer. J Urol 2013; 190:1380-1386The best study on the utility of mpMRI torule “in” or “out” diseasempMRI assessments (3 scale) - not PI-RADSNo suspicious lesions (n=94)Intermediate (n=149)Suspicious (n=104

34、)Transperineal; US guided saturation biopsies (median 24(12-36) targeted MRI/US fusion biopsy (median 4 (2-6)Patient level analysis on ability to detect significant cancers (NCCN criteria)48Kuru TH, et al. Critical evaluation of magnetic resonance imaging targeted, transrectal ultrasound guidedtrans

35、perineal fusion biopsy for detection of prostate cancer. J Urol 2013; 190:1380-1386“Rule in” disease abilityCancer prevalence200 of 347 men (58%)147 (42%) clinically significant53 low risk49No suspicious group (n=94)cancer in 14 (15%); 11 significantIntermediate group (n=149)cancer in 100 (67%); 70

36、significantSuspicious group (n=104)cancer in 86 (83%); 66 significant50Implication: 40% of times this patient may NOT have clinically significant disease (NCCN criteria)5180 yr, Gleason 3+3; 30% cores RT and 10% cores LT. On AS 3 yrs. PSA rising from 5 to 13 ng/mlImplication: 12% of times this patie

37、nt may have clinically significant disease (NCCN criteria)52PSA 5.3ng/ml; TRUS- small foci of Gleason 3+3 plus prostatitis in PZ; for active surveillanceFollow 1yr, post antibiotics53PSA 5.9ng/ml; enlarging anterior gland tumor with decreased enhancement in PZ. Needs targeted biopsy of the anterior

38、TZ mass.Multiparametric MRI followed by targeted prostate biopsy for men with suspected prostate cancer: a clinical decision analysis54Multiparametric MRI followed by targeted prostate biopsy for men with suspected prostate cancer: a clinical decision analysis. BMJ Open. 2014 Jun 15;4(6):e004895.55S

39、ubjects at risk (variable prevalence of significant disease)Persistent suspicion: saturation and/or full template BxSystematic TRUS biopsyClinical follow- upTherapy-ve-ve+ve+veProportion of patients in different groups depends on prevalence of target condition, and specificity and accuracy of biopsy

40、 methodsCurrent management pathway for investigating patients with suspected cancer does NOT incorporate mpMRIPI-RADS 1-356Subjects at risk (variable prevalence of significant disease)Diagnostic mPMRISaturation and/or full template BxSystematic TRUS targeted Bx for allClinical follow- upTherapy-ve-v

41、e+ve+vePI-RADS 4-5-ve-Greater precision of determining tumor grade & volume (risk stratification)-Potential increased rates of detection of significant diseaseProposed pathway incorporating mpMRI for suspected cancer (most conservative)PI-RADS 357Subjects at risk (variable prevalence of significant

42、disease)Diagnostic mPMRISaturation and/or full template BxSystematic TRUS targeted Bx for PI-RADS 3-5Clinical follow- upTherapy-ve-ve+ve+vePI-RADS 4-5-veAlternate pathway incorporating mpMRI for suspected cancer (next most conservative)-Greater precision of determining tumor grade & volume (risk str

43、atification)-Potential increased rates of detection of significant disease-Potential reduction in diagnosis of indolent disease (reduces over-diagnosis & over treatment-Reduce number of patients undergoing biopsyPI-RADS 1-2PI-RADS 3-5PI-RADS 3: Systematic TRUS targeted Bx PI-RADS 4-5: targeted Bx on

44、lyPI-RADS 358Subjects at risk (variable prevalence of significant disease)Diagnostic mPMRISaturation and/or full template BxClinical follow- upTherapy-ve-ve+ve+vePI-RADS 4-5-veAlternate pathway incorporating mpMRI for suspected cancer (least conservative)-Greater precision of determining tumor grade & volume (risk stratification)-Potential increased rates of detection of significant disease-Potential reduction in diagnosis of indolent disease (reduces over-diagnosis & over treatment-Reduce number of pati