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MRI Guided Prostate Biopsy
Harm-‐Jan van Klaveren Jordy Oudhuizen
Tom van Slingerland 17-‐04-‐2014
Contents
• Prostate Carcinoma • Current Examina9ons • MRI Guided • Risks/Follow-‐up Care • Gleason Score • TRUS/MRI Fusion
Prostate Carcinoma
• 22% of all male cancer pa9ents • >65 years: 6,87 out of 1000 males • 15-‐64 jaar: 0,60 out of 1000 males
Risks for prostate ca. development
• Age – >65 years
• Hormone regula9on – Testosteron
• Hereditary – 50-‐100% more change
• Food – Calcium and dairy products
Characteris9cs
• 95% consists of Adenocarcinoma’s
• Slow rate of development
• Painless Complica9ons
Cause for examina9on • Metastasis in bone 9ssue (Pelvis/Spine) • Dysfunc9on of the prostate
– Difficult urina9on – Urine dripping – Weak flow – More frequent urina9on
Current Examina9ons
• Clinical • Urologic • Ultrasound • TRUS (transrectal ultrasound)
Clinical Examina9on
• Rectal toucher – Irregulari9es – Asymmetrical prostate – Lumps
• Blood examina9on – PSA (Prostare Specific An9gen)
Urologic examina9on
• Rectal toucher – PCA3-‐ / urine examina9on
Urologic Examina9on
• PCA-‐3 has a superficial detec9on. Medical imaging and biopsy show accurate loca9on, nature and malignity of the cancer. Prostate cancer oden excists of various Gleason Grades, therefore precise determina9ons is important . See the Gleason Grades slide for more informa9on.
TRUS
• Transrectal Ultrasound
TRUS Biopsy
• Randomised TRUS Biopsy • Consists of 12 biopsies
MRI Guided
Prepera9ons before examina9on
• An9bio9cs-‐ Ciproxin(500 mg). Addi9onal dose when: – Endocardi9s (a inflamma9on of the inner heart lining) – Gene9c abnomali9es of the heart – Cadiomyopathy
• Food is not allowed 4 hours prior
• Ejacula9on is not allowed 4 days prior • Pauze An9-‐clofng medica9on:
– Acenocoumarol Sintrom mi9s® – Fenprocoumon Marcoumar®
Contra-‐indica9ons
• Common MRI contra-‐indica9ons • INR >2
MRI sequences prior to MRI-‐biopsy • T1 • T2 TSE • Diffusion (DWI) • Dynamic Post Gadolinium T1 • Post Gadolinium T1 3D
MRI sequences prior to MRI-‐biopsy
• Ader administering Gadolinium a dynamic T1 sequence will take place. Prostate carcinoma’s characterise themselfes with rapid vascularias9on and distribu9on of contrast fluid. Difference is seen in the wash-‐out of the cancer.
• The SPC (space) will be performed next. Isometric voxels allow
mul9planar reconstruc9ons showing the loca9on of the cancer.
MRI sequences
• T1 • T2 TSE
MRI sequences
• Diffusion
MRI sequences
• Post Gadolinium T1 • Post Gadolinium T1 3D
Prostate biopsy by MRI • Prepera9ons • Placing needle guide
Prostate biopsy by MRI(2)
• Localisers • T2 trufi • T2_TSE sag+tra • DYNA CAD
Prostate biopsy by MRI(2)
• First, localisers will be preformed • Second, a sagital T2 TRUFI sequence will provide a more accurate
overview for planning the following sequences. • Ader the T2 TRUFI a sagimal and axial Turbospin Echo will be
preformed. These sequences will be sent to DynaCad for accurate calcula9ons on needle placement.
• The probe will be put in place and every movement of the neelde
will be followed by two SPACE sequences (axial, sagimal) for showing the loca9on and direc9on of the needle.
• Biopsies will be taken, ader every sample (x2) a SPACE squence
with needle in place will be preformed to determine the loca9on of the needle.
Prostate biopsy by MRI(2) • Probe placement • Take sample • T2_tra follow-‐up
Prostate biopsy by MRI
Advantages MRI biopsy
• High accuracy when taking samples – Abnomal9es well visible in rela9on to TRUS
Advantages MRI biopsy
• Bemer Contrast-‐/Spa9al resolu9on • Less Biopsies • Less False nega9ves • Less risk for complica9ons • Extra certainty for the pa9ent with a persistent PSA and false
nega9ve TRUS
Disadvantages MRI biopsy
• Ar9facts • Claustrofobic pa9ents • Common contraindica9ons
Risks
• Infec9on (acute bacterial prosta99s) – More likely with previous unknown prosta9ts
• Bleeding in urethra of bladder • Rectal Bleeding
Follow-‐up Care
• Hospitalisa9on not necessary
• No ac9vi9es and 48 hours no cycling
• Possible temperature rise
• Possible Bloodloss – Small bleeding 2 weeks – Reproduc9on system up to 4 weeks possible
Gleason Score
• Determines the malignity of the prostate cancer
Gleason Score
• The Gleason Score is build from two Gleason Grades. The first Gleason Grade is given to the most appearing type of tumor. The second Gleason Score is given to the second most appearing type of tumor.
• Gleason Score = Gleason Grade type tumor 1 + Gleason Grade type tumor 2
Future
• TRUS/MRI fusion imaging
TRUS/MRI Fusion
• Increase in detec9on of mostly anterior and central situated prostate ca’s. Current random-‐biopsy methods foresees in detec9on of mostly dorsal situated cancers in the periferal zone.
• Decrease in the detec9on of indolent lowgrade prostate ca’s. These
lowgrade ca’s don’t metastasise oden en cause herefore no death. These lowgrade ca’s are less visible on MRI-‐images and biopsy of these ca’s is not nessecary. Due to accurate biopsy, histological differenta9on of the hetrogene ca’s will be more accurate.
• Decrease in number of samples. Aimed biopsies apply to 2 samples,
where randomised-‐biopsies apply to 10-‐12 biopsies.