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BACKGROUND AND OBJECTIVE: Magnetic resonance imaging (MRI) can detect recurrences after focal therapy for prostate cancer but there is no robust guidance regarding its use. Our objective was to produce consensus recommendations on MRI acquisition, interpretation, and reporting after focal therapy. METHODS: A systematic review was performed in July 2022 to develop consensus statements. A two-round consensus exercise was then performed, with a consensus meeting in January 2023, during which 329 statements were scored by 23 panellists from Europe and North America spanning urology, radiology, and pathology with experience across eight focal therapy modalities. Using RAND Corporation/University of California-Los Angeles methodology, the Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy (TARGET) were based on consensus for statements scored with agreement or disagreement. KEY FINDINGS AND LIMITATIONS: In total, 73 studies were included in the review. All 20 studies (100%) reporting suspicious imaging features cited focal contrast enhancement as suspicious for cancer recurrence. Of 31 studies reporting MRI assessment criteria, the Prostate Imaging-Reporting and Data System (PI-RADS) score was the scheme used most often (20 studies; 65%), followed by a 5-point Likert score (six studies; 19%). For the consensus exercise, consensus for statements scored with agreement or disagreement increased from 227 of 295 statements (76.9%) in round one to 270 of 329 statements (82.1%) in round two. Key recommendations include performing routine MRI at 12 mo using a multiparametric protocol compliant with PI-RADS version 2.1 standards. PI-RADS category scores for assessing recurrence within the ablation zone should be avoided. An alternative 5-point scoring system is presented that includes a major dynamic contrast enhancement (DCE) sequence and joint minor diffusion-weighted imaging and T2-weighted sequences. For the DCE sequence, focal nodular strong early enhancement was the most suspicious imaging finding. A structured minimum reporting data set and minimum reporting standards for studies detailing MRI data after focal therapy are presented. CONCLUSIONS AND CLINICAL IMPLICATIONS: The TARGET consensus recommendations may improve MRI acquisition, interpretation, and reporting after focal therapy for prostate cancer and provide minimum standards for study reporting. PATIENT SUMMARY: Magnetic resonance imaging (MRI) scans can detect recurrent of prostate cancer after focal treatments, but there is a lack of guidance on MRI use for this purpose. We report new expert recommendations that may improve practice.
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Imagen por Resonancia Magnética , Neoplasias de la Próstata , Humanos , Masculino , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/terapia , Imagen por Resonancia Magnética/normas , Próstata/diagnóstico por imagen , Próstata/patología , Consenso , Internacionalidad , Recurrencia Local de Neoplasia/diagnóstico por imagen , Guías de Práctica Clínica como AsuntoRESUMEN
Patients with localized recurrent prostate cancer (PCa) are eligible for androgen-deprivation therapy, salvage radical prostatectomy (RP) or radiation therapy. These treatments are associated with serious side-effects, illustrating the need for alternative local treatment options with lower morbidity rates. All patients who underwent magnetic resonance imaging (MRI)-guided salvage focal cryoablation (SFC) with localized recurrent PCa between 2011-2021 (n = 114) were included. Two subgroups were formed: patients without (n = 99) and with prior RP (n = 15). We assessed the recurrence- (RFS) and treatment-free survival (TFS), measured from date of treatment to date of recurrence or initiation of additional salvage treatment, using Kaplan-Meier plots. Complications were reported using the Clavien-Dindo (CD) scale. Overall 1-year and 5-year RFS were 76.0% and 25.1%, and overall 1-year and 5-year TFS were 91.5% and 58.2%, respectively. Patients without prior RP showed a significantly higher 1-year (78.5% vs. 52.5%) and 5-year RFS (28.1% vs. 0.0%; p = 0.03), and a trend towards a higher 1-year (92.6% vs. 79.0%) and 5-year TFS (60.2% vs. 23.0%; p = 0.10) compared to those with prior RP. A total of 46 complications occurred in 37 patients, and the overall complication rate was 32.4% (37/114 patients). The majority (41/46; 89.1%) of complications were minor (CD 1-2). Overall (31.3 vs. 40.0%) and major (3.0 vs. 13.3%) complication rates were lower in patients without compared to those with prior RP, respectively. MRI-guided SFC is an effective and safe therapy for patients with recurrent PCa, and has proved to delay and potentially prevent the initiation of salvage treatments. Patients with locally recurrent PCa after prior RP had an increased risk of recurrence, a shortened time to additional treatment, and more complications compared to those without prior RP, which should be considered when selecting patients for SFC.
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PURPOSE OF REVIEW: Minimal invasive procedures, including targeted biopsy (TB) and focal therapy (FT), are increasingly used in diagnosis and treatment of localized prostate cancer. Here, we review the current role of these procedures, from a perspective of an interventional radiologist. RECENT FINDINGS: TB is an established part of current guidelines for diagnosis of PCa. Several modalities of FT are gaining prevalence in recent years, as a tissue-preserving alternative for definitive treatment of localized PCa. FT is currently at early research stages, offered to selected patients in clinical trials settings. TB and FT are minimally invasive procedures used by multidisciplinary teams for diagnosis and treatment of localized PCa.
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Neoplasias de la Próstata , Masculino , Humanos , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/terapia , Biopsia , Radiólogos , Procedimientos Quirúrgicos Mínimamente InvasivosRESUMEN
Magnetic resonance imaging (MRI)-guided therapy for prostate cancer (PCa) aims to reduce the treatment-associated comorbidity of existing radical treatment, including radical prostatectomy and radiotherapy. Although active surveillance has been used as a conservative method to reduce overtreatment, there is a growing demand for less morbidity and personalized (focal) treatment. The development of multiparametric MRI was of real importance in improving the detection, localization and staging of PCa. Moreover, MRI has been useful for lesion targeting within the prostate, as it is used in the guidance of prostate biopsies, by means of cognitive registration, MRI-ultrasound fusion guidance or direct in-bore MRI-guidance. With regard to PCa therapies, MRI is used for precise probe placement into the lesion and to accurately monitor the treatment in real-time. Moreover, advances in MR-compatible thermal ablation allow for noninvasive real-time temperature mapping during treatment. In this review, we present an overview of the current status of MRI-guided therapies in PCa, focusing on cryoablation, focal laser ablation, high intensity focused ultrasound and transurethral ultrasound ablation. We explain the important role of MRI in the evaluation of the completeness of the ablation and during follow-up. Finally, we will discuss the challenges and future development inherent to these new technologies.
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CONTEXT: Focal therapy is a promising, minimally invasive strategy to selectively treat localized prostate cancer. A previous systematic review indicated that there is growing evidence for favorable functional outcomes, but that oncological effectiveness was yet to be defined. OBJECTIVE: To assess the effectiveness of focal therapy in patients with localized prostate cancer in terms of functional and oncological outcomes. EVIDENCE ACQUISITION: PubMed, Embase, and The Cochrane Library were searched for studies between October 2015 and December 31, 2020. In addition, the research stages were acquired according to the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) recommendations. Ongoing studies were identified through clinical trial registries. EVIDENCE SYNTHESIS: Seventy-two studies were identified exploring eight different sources of energy to deliver focal therapy in 5827 patients. Twenty-seven studies reported on high-intensity focused ultrasound (HIFU), nine studies on irreversible electroporation, 11 on cryoablation, eight on focal laser ablation and focal brachytherapy, seven on photodynamic therapy (PDT), two on radiofrequency ablation, and one on prostatic artery embolization. The majority of studies were prospective development stage 2a studies (n = 357). PDT and HIFU, both in stage 3, showed promising results. Overall, HIFU studies reported a median of 95% pad-free patients and a median of 85% patients with no clinically significant cancer (CSC) in the treated area. For PDT, no changes in continence were reported and a median of 90% of patients were without CSC. Both treatments were well tolerated. CONCLUSIONS: Over the past 5 yr, focal therapy has been studied for eight different energy sources, mostly in single-arm stage 2 studies. Although a first randomized controlled trial in focal therapy has been performed, more high-quality evaluations are needed, preferably via multicenter randomized controlled trials with long-term follow-up and predefined assessment of oncological and functional outcomes and health-related quality-of-life measures. PATIENT SUMMARY: Focal treatment (FT) of prostate cancer has potential, considering that it has less impact on continence and potency than radical treatment. Our systematic review indicates that despite the method being studied extensively over the past half decade, the majority of studies remain in an early research stage. The techniques high-intensity focused ultrasound and photodynamic therapy have shown most progression toward advanced research stages and show favorable results. However, more high-quality evidence is required before FT can become available as a standard treatment.
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Embolización Terapéutica , Hiperplasia Prostática , Neoplasias de la Próstata , Humanos , Masculino , Estudios Multicéntricos como Asunto , Estudios Prospectivos , Próstata/cirugía , Hiperplasia Prostática/terapia , Neoplasias de la Próstata/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate safety, quality of life (QoL), and local cancer control after focal salvage MR imaging-guided cryoablation in patients with local recurrence of prostate cancer (PCa) after radiotherapy. MATERIALS AND METHODS: A retrospective, single-center study was performed in 62 patients with radiorecurrent PCa who underwent MR imaging-guided cryoablation since May 2011 with a follow-up ≥12 months in December 2017. Rates and descriptions of adverse events were reported. Ablation complications were classified according to the Clavien and SIR systems. Validated questionnaires were used to observe functional outcomes and QoL before therapy and 6 and 12 months after therapy. Cancer control was defined as no biochemical failure according to Phoenix criteria and no other clinical evidence for local or metastatic disease. RESULTS: All procedures were technically feasible. The number of complications requiring major therapy (Clavien grade 3b/4 or SIR grade D/E/F) was low (2 [3.2%] and 1 [1.6%], respectively). After 12 months, the International Consultation of Incontinence Questionnaire-Short Form (P < .001) and 5-item International Index of Erectile Function (P = .001) scores became significantly worse, indicating increased symptoms of incontinence and diminished erectile function, without compromising QoL. Six patients developed metastases within 6 months. After 12 months, 36 patients (63%) were disease-free. CONCLUSIONS: Focal salvage MR imaging-guided cryoablation is safe and is associated with a high technical success rate, preservation of QoL, and local PCa control. This treatment can be a reasonable alternative to salvage radical prostatectomy in properly selected patients with low morbidity and preservation of QoL; however, longer follow-up is needed.
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Criocirugía , Imagen por Resonancia Magnética Intervencional , Recurrencia Local de Neoplasia , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Terapia Recuperativa , Anciano , Toma de Decisiones Clínicas , Criocirugía/efectos adversos , Supervivencia sin Enfermedad , Humanos , Imagen por Resonancia Magnética Intervencional/efectos adversos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Selección de Paciente , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Calidad de Vida , Estudios Retrospectivos , Terapia Recuperativa/efectos adversos , Factores de TiempoRESUMEN
BACKGROUND: The Prostate Imaging Reporting and Data System (PI-RADS) is the most commonly used scoring system in prostate magnetic resonance imaging (MRI). One of the available techniques to target suspicious lesions is direct in-bore MRI-guided biopsy (MRGB). OBJECTIVE: To report on the experience and results of MRGB in a large cohort of patients with lesions classified as equivocal (PI-RADS 3), likely (PI-RADS 4), or highly likely (PI-RADS 5) to be clinically significant (cs) prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: We retrospectively included 1057 patients having MRGB, between January 2012 and September 2016, of lesions classified as PI-RADS≥3 on multiparametric MRI. Biopsy-naïve patients, patients with prior negative systematic transrectal ultrasound-guided biopsy, and patients in active surveillance were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome measurement is the detection rate of csPCa. Descriptive statistics and chi-square tests were used to calculate the differences in proportions. We considered a Gleason score of ≥3+4 as csPCa. RESULTS AND LIMITATIONS: PCa was diagnosed in 35% (55/156), 60% (223/373), and 91% (479/528), and csPCa in 17% (26/156), 34% (128/373), and 67% (352/528) of patients with PI-RADS 3, 4, and 5 lesions, respectively. Follow-up of patients with negative biopsy findings resulted in csPCa in 1.7% (5/300) after a median period of 41 (interquartile range 25-50) mo. The evaluation of prostate-specific antigen density (PSAD) to predict csPCa resulted in 42% of patients with a PI-RADS 3 lesion who could avoid biopsy in case a PSAD of ≥ 0.15ng/ml/ml would be used. In 6% (95% confidence interval, 2-15), csPCa would then be missed. The study is limited because of its retrospective character. CONCLUSIONS: MRGB in lesions scored PI-RADS≥3 yields high detection rates of csPCa in daily clinical practice in cases with previous negative biopsy. PATIENT SUMMARY: In daily clinical practice, direct in-bore magnetic resonance imaging-guided biopsy of suspicious lesions reported according to the Prostate Imaging Reporting and Data System yields high detection rates of clinically significant prostate cancer.
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OBJECTIVES: To evaluate iceball margins after magnetic resonance (MR)-guided focal salvage prostate cryoablation and determine the correlation with local outcome. METHODS: A retrospective review was performed on 47 patients that underwent percutaneous MR-guided focal cryoablation for biopsy-proven locally recurrent prostate cancer after primary radiotherapy. Preprocedural diagnostic and intraprocedural MR images were analysed to derive three-directional iceball margins. Local tumour progression after cryoablation was defined as evident tumour recurrence on follow-up MRI, positive MR-guided biopsy or biochemical failure without radiological evidence of metastatic disease. RESULTS: Mean iceball margins were 8.9 mm (range -7.1 to 16.2), 10.1 mm (range 1.1-20.3) and 12.5 mm (range -1.5 to 22.2) in anteroposterior, left-right and craniocaudal direction respectively. Iceball margins were significantly smaller for tumours that were larger (P = .008) or located in the posterior gland (P = .047). Significantly improved local progression-free survival at 1 year post focal cryoablation was seen between patients with iceball margin >10 mm (100%), 5-10 mm (84%) and <5 mm (15%) (P < .001). CONCLUSIONS: Iceball margins appear to correlate with local outcome following MR-guided focal salvage prostate cryoablation. Our initial data suggest that freezing should be applied at minimum 5 mm beyond the border of an MR-visible recurrent prostate tumour for successful ablation, with a wider margin appearing desirable. KEY POINTS: ⢠Shortest iceball margin most often occurred in anteroposterior direction ⢠Margins were smaller in tumours that were larger or posteriorly located ⢠Minimum iceball margin was a predictor of early local tumour progression ⢠A minimum 5-mm margin seems required for effective cryoablation of recurrent PCa.
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Criocirugía/métodos , Imagen por Resonancia Magnética , Recurrencia Local de Neoplasia/cirugía , Neoplasias de la Próstata/cirugía , Terapia Recuperativa/métodos , Anciano , Biopsia , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/patología , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Estudios RetrospectivosRESUMEN
PURPOSE: To correlate treatment effects of MRI-guided focal laser ablation in patients with prostate cancer with imaging using prostatectomy as standard of reference. METHODS: This phase I study was approved by the Institutional Review Board. Three weeks prior to prostatectomy, five patients with histopathologically proven, low/intermediate grade prostate cancer underwent transrectal MRI-guided focal laser ablation. Per patient, only one ablation was performed to investigate the effect of ablation on the tissue rather than the effectiveness of ablation. Ablation was continuously monitored with real-time MR temperature mapping, and damage-estimation maps were computed. A post-ablation high-resolution T1-weighted contrast-enhanced sequence was acquired. Ablation volumes were contoured and measured on histopathology specimens (with a shrinkage factor of 1.15), T1-weighted contrast-enhanced images, and damage-estimation maps, and were compared. RESULTS: A significant volume correlation was seen between the ablation zone on T1-weighted contrast-enhanced images and the whole-mount histopathology section (r = 0.94, p = 0.018). The damage-estimation maps and histopathology specimen showed a correlation of r = 0.33 (p = 0.583). On histopathology, the homogeneous necrotic area was surrounded by a reactive transition zone (1-5 mm) zone, showing neovascularisation, and an increased mitotic index, indicating increased tumor activity. CONCLUSIONS: The actual ablation zone was better indicated by T1-weighted contrast-enhanced than by damage-estimation maps. Histopathology results highlight the importance of complete tumor ablation with a safety margin.
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Terapia por Láser/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Anciano , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Cirugía Asistida por ComputadorRESUMEN
OBJECTIVE: The purpose of this article is to identify histopathologically proven prostate cancer locations using MRI followed by MRI-guided biopsy in patients with elevated prostate-specific antigen (PSA) levels and at least one negative transrectal ultrasound (TRUS)-guided biopsy session. Our hypothesis is that in this patient group most cancers are located in the anterior portion of the prostate. This may have implications for the biopsy strategy regarding the location of sampling. MATERIALS AND METHODS: This retrospective study consisted of 872 consecutive men who had undergone MRI-guided prostate biopsy. Inclusion criteria were PSA level greater than or equal to 4 ng/mL, one or more negative TRUS-guided biopsy session, the presence of suspicious lesions on previous multiparametric MRI, and prostate cancer histopathologically proven by MRI-guided biopsy. Thereafter, the location of intermediate- or high-risk cancers and cancers with a maximum cancer core length of 6 mm or longer were determined. The proportion of cancer locations was compared using a chi-square test. One-way ANOVA analyses were performed to compare patient characteristics. RESULTS: Results were presented on both a patient and lesion basis because a single patient can have multiple lesions. In total, 176 of 872 patients met the inclusion criteria. Prostate cancer was detected in 202 of 277 (73%) suspicious lesions. In total, 76% of patients had cancer of the transition zone and anterior fibromuscular stroma. Peripheral zone cancers were found in 30% of the patients, and 6% had cancers in both zones. In 70% of cases (141/202; 95%, CI, 63-76%), lesions were located anteriorly; this included 75% (132/176; 95%, CI, 69-81%) of patients. Intermediate- or high-risk prostate cancer was found in 93% (128/138; 95%, CI, 88-96%) of patients. Of these patients, 73% (94/128; 95%, CI, 66-81%) had anterior involvement. Cancers with a maximum cancer core length of 6 mm or more were more likely to be located in the anterior part of the prostate than were cancers with a core length of less than 6 mm (66% vs 6%). Most cancers 58% (102/176; 95% CI, 51-65%) were found in the mid prostate. Anterior involvement of prostate cancer detected by MRI-guided biopsy was statistically significantly (p = 0.04) higher in patients with two or more negative TRUS-guided biopsy sessions (79%) than in those with one negative TRUS-guided biopsy session (55%). CONCLUSION: Anterior involvement was high (76%) in patients with an elevated PSA level and one or more negative TRUS-guided biopsy session, and the majority of these cancers (93%) were intermediate or high risk.
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Biopsia Guiada por Imagen , Imagen por Resonancia Magnética/métodos , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/diagnóstico , Anciano , Biomarcadores de Tumor/sangre , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Ultrasonografía IntervencionalRESUMEN
PURPOSE: To correlate T1-weighted (T1w) magnetic resonance (MR) image contrast around a cryoablation iceball with temperature in a phantom study and to compare this to its in vivo appearance during MR-guided focal cryoablation of prostate cancer. METHODS: A MR-compatible cryoneedle was inserted into identical gel phantoms (n = 3) on a 1.5 T MR system. Two fiber-optic temperature sensors were placed parallel to the needle. A fast 3D T1w gradient echo (GRE) sequence (TR/TE/FA = 4.81/1.98/6°) was used to monitor iceball progression. Normalized signal intensity (SI) was correlated with temperature. The same T1w sequence was used during MR-guided prostate cryoablation in ten consecutive patients at the authors' institution. In vivo findings were quantitatively compared to the phantom data. RESULTS: In the phantom study, the cryoablation iceball appeared in the T1w MR images as a sharply delineated signal void. A 2.2 ± 0.2 mm wide hyperintense rim directly surrounded the iceball at cooled but nonfreezing temperatures (<20 °C) in the gel. Normalized SI was maximum at 8.4 ± 2.4 °C, showing a 35.6%-43.0% (mean 40.5%) increase with respect to baseline before cooling. In the clinical procedures, the same image contrast was observed in vivo in all patients. In vivo, width of the hyperintense rim was 1.6 ± 0.6 mm. Normalized SI increases with respect to nontreated prostate ranged 28.4%-55.6% (mean 36.8%). On quantitative analysis, normalized SI changes along a linear region of interest from surrounding tissue onto the iceball center were similar between the patients and phantom setting (root mean square difference 0.06). CONCLUSIONS: The hyperintense rim around the iceball in fast T1w GRE images corresponded to cooled but nonfreezing temperatures (<20 °C) proximal to the frozen zone. The same image contrast was observed both in a phantom study as well as in vivo in the human prostate during cryotherapy. Potentially, monitoring of this rim could be useful in order to maintain a safe margin from at-risk tissues during MR-guided prostate cryoablation procedures.
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Criocirugía/instrumentación , Crioterapia/instrumentación , Imagen por Resonancia Magnética/métodos , Fantasmas de Imagen , Neoplasias de la Próstata/radioterapia , Medios de Contraste/química , Criocirugía/métodos , Crioterapia/métodos , Tecnología de Fibra Óptica , Geles/química , Humanos , Hielo , Procesamiento de Imagen Asistido por Computador/métodos , Masculino , Agujas , Neoplasias de la Próstata/patología , TemperaturaRESUMEN
The purpose of this paper is to introduce and describe the Prostate Imaging and Reporting Archiving Data System (PI-RADS). For every single parameter the PI-RADS scoring system will be explained and magnetic resonance imaging (MRI) examples will be given. In the end two patient cases are presented to explain the overall interpretation score in multiparametric imaging.
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Bancos de Muestras Biológicas , Imagen por Resonancia Magnética/normas , Próstata/patología , Proyectos de Investigación , Medios de Contraste , Imagen de Difusión por Resonancia Magnética , Humanos , Masculino , Estándares de ReferenciaRESUMEN
Laser interstitial thermotherapy (LITT) is a relatively new focal therapy technique for the ablation of localized prostate cancer. In this study, for the first time, we are integrating ex vivo pathology and magnetic resonance imaging (MRI) to assess the imaging characteristics of prostate cancer and treatment changes following LITT. Via a unique clinical trial, which gave us the availability of ex vivo histology and pre- and post-LITT MRIs, (1) we investigated the imaging characteristics of treatment effects and residual disease, and (2) evaluated treatment-induced feature changes in the ablated area relative to the residual disease. First, a pathologist annotated the ablated area and the residual disease on the ex vivo histology. Subsequently, we transferred the annotations to the post-LITT MRI using a semi-automatic elastic registration. The pre- and post-LITT MRIs were registered and features were extracted. A scoring metric based on the change in median pre- and post-LITT feature values was introduced, which allowed us to identify the most treatment responsive features. Our results show that (1) image characteristics for treatment effects and residual disease are different, and (2) the change of feature values between pre- and post-LITT MRIs can be a quantitative biomarker for treatment response. Finally, using feature change improved discrimination between the residual disease and treatment effects.
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OBJECTIVES: The objective of this study was to evaluate the apparent diffusion coefficient (ADC) of diffusion-weighted magnetic resonance (MR) imaging for the differentiation of transition zone cancer from non-cancerous transition zone with and without prostatitis and for the differentiation of transition zone cancer Gleason grade (GG) using MR-guided biopsy specimens as a reference standard. MATERIALS AND METHODS: From consecutive MR-guided prostate biopsies (2008-2012) in our referral center, we retrospectively included patients from whom diffusion-weighted MR imaging ADC values were acquired during MR-guided biopsy and whose biopsy cores had a (cancer) core length 10 mm or greater and originated from the transition zone. Two radiologists, who were blinded to the ADC data, annotated regions of interest on biopsy sampling locations of MR-guided biopsy confirmation scans in consensus. Median ADC (mADC) of the regions of interest was related to histopathology outcome in MR-guided biopsy core specimens. Mixed model analysis was used to evaluate mADC differences between 7 histopathology categories predefined as MR-guided biopsy core specimens with primary and secondary GG 4-5 (I), primary GG 4-5 secondary GG 2-3 (II), primary GG 2-3 secondary GG 4-5 (III) and primary and secondary GG 2-3 cancer (IV), and noncancerous tissue without (V) or with degree 1 (VI) or degree 2 prostatitis (VII). Diagnostic accuracy was evaluated using areas under the receiver operating characteristic (AUC) curve. RESULTS: Fifty-two patients with 87 cancer-containing biopsy cores and 53 patients with 101 non-cancerous biopsy cores were included. Significant mean mADC differences were present between cancers (mean mADC, 0.77-0.86 × 10 mm/s) and noncancerous transition zone without (1.12 × 10 mm/s) and with degree 1 to 2 prostatitis (1.05-1.12 × 10 mm/s; P < 0.0001-0.05). Exceptions were mixed primary and secondary GG cancers versus a degree 2 of prostatitis (P = 0.06-0.09). No significant differences were found between subcategories of primary and secondary GG cancers (P = 0.17-0.91) and between a degree 1 and 2 prostatitis and non-cancerous transition zone without prostatitis (P = 0.48-0.94).The mADC had an AUC of 0.84 to differentiate cancer versus non-cancerous transition zone. AUCs of 0.84 and 0.56 were found for mADC to differentiate prostatitis from cancer and from non-cancerous transition zone. The mADC had an AUC of 0.62 to differentiate a primary GG 4 versus GG 3 cancer. CONCLUSIONS: The mADC values can differentiate transition zone cancer from non-cancerous transition zone and from a degree 1, and from most cases of a degree 2 prostatitis. However, because of substantial overlap, mADC has a moderate accuracy to differentiate between different primary and secondary GG subcategories and cannot be used to differentiate non-cancerous transition zone from degrees 1 to 2 of prostatitis. Diffusion-weighted imaging ADC may therefore contribute in the detection of transition zone cancers; however, as a single functional MR imaging technique, diffusion-weighted imaging has a moderate diagnostic accuracy in separating higher from lower GG transition zone cancers and in differentiating prostatitis from non-cancerous transition zone.
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Imagen de Difusión por Resonancia Magnética/métodos , Biopsia Guiada por Imagen/métodos , Próstata/patología , Neoplasias de la Próstata/patología , Anciano , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Método Simple CiegoRESUMEN
PURPOSE: To assess the feasibility of magnetic resonance (MR) imaging-guided focal cryoablation in patients with locally recurrent prostate cancer after radiation therapy. MATERIALS AND METHODS: This was a prospective study, and informed consent was obtained from all patients. Ten consecutive patients with histopathologically proved recurrent prostate cancer after radiation therapy, without evidence of distant metastases, were treated while under general anesthesia in a 1.5-T MR unit. A urethral warmer was inserted. Cryoneedles were transperineally inserted under real-time MR imaging. Then, a rectal warmer was inserted. Ice ball growth was continuously monitored under MR imaging guidance. Two freeze-thaw cycles were performed. Follow-up consisted of a visit to the urologist, measurement of prostate-specific antigen level, and multiparametric MR imaging at 3, 6, and 12 months. Potential complications were recorded. RESULTS: All patients were successfully treated. In one patient, the urethral warmer could not be inserted and the procedure was cancelled. Two months later, the procedure was successfully repeated. Another patient had urinary retention. Follow-up data were available for all patients. A local recurrence or remnant tumor was found in two patients after 6 months and in another patient after 12 months. These three patients underwent successful retreatment with MR imaging-guided focal cryoablation. CONCLUSION: MR imaging-guided focal cryoablation of recurrent prostate cancer after radiation therapy is feasible and safe. Initial results are promising; however, longer follow-up is needed and more patients must be studied.
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Criocirugía/métodos , Imagen por Resonancia Magnética Intervencional , Recurrencia Local de Neoplasia/cirugía , Neoplasias de la Próstata/cirugía , Anciano , Terapia Combinada , Estudios de Factibilidad , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/radioterapia , Estudios Prospectivos , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/radioterapia , Resultado del TratamientoRESUMEN
OBJECTIVE: The purpose of this article is to evaluate MRI-guided therapies and to investigate their feasibility for focal therapy in prostate cancer patients. Relevant articles were retrieved using the PubMed online search engine. CONCLUSION: Currently, MRI-guided laser ablation and MRI-guided focused ultrasound are the most promising options for focal treatment of the prostate in patients with prostate cancer. Other techniques-that is, cryosurgery, microwave ablation, and radiofrequency ablation-are, for several and different reasons, less suitable for MRI-guided focal therapy of the prostate.
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Ultrasonido Enfocado de Alta Intensidad de Ablación , Terapia por Láser , Imagen por Resonancia Magnética Intervencional , Neoplasias de la Próstata/terapia , Braquiterapia , Ablación por Catéter , Criocirugía , Humanos , Masculino , Microondas/uso terapéutico , Neoplasias de la Próstata/cirugíaRESUMEN
BACKGROUND: Patients with elevated prostate-specific antigen (PSA) and one or more previous negative transrectal ultrasound (TRUS) biopsy sessions are subject to diagnostic uncertainty due to TRUS-biopsy undersampling. Magnetic resonance (MR)-guided biopsy (MRGB) has shown high prostate cancer (PCa)-detection rates in studies with limited patient numbers. OBJECTIVE: Determine the detection rate of (clinically significant) PCa for MRGB of cancer-suspicious regions (CSRs) on 3-T multiparametric MR imaging (MP-MRI) in patients with elevated PSA and one or more negative TRUS-biopsy sessions. DESIGN, SETTING, AND PARTICIPANTS: Of 844 patients who underwent 3-T MP-MRI in our referral centre between March 2008 and February 2011, 438 consecutive patients with a PSA >4.0 ng/ml and one negative TRUS-biopsy session or more were included. MRGB was performed in 265 patients. Exclusion criteria were existent PCa, endorectal coil use, and MP-MRI for indications other than cancer detection. INTERVENTION: Patients underwent MRGB of MP-MRI CSRs. MEASUREMENTS: (Clinically significant) MRGB cancer-detection rates were determined. Clinically significant cancer was defined by accepted (i.a. Epstein and d'Amico) criteria based on PSA, Gleason score, stage, and tumour volume. Follow-up PSA and histopathology were collected. Sensitivity analysis was performed for patients with MP-MRI CSRs without MRGB. RESULTS AND LIMITATIONS: In a total of 117 patients, cancer was detected with MRGB (n=108) or after negative MRGB (n=9). PCa was detected in 108 of 438 patients (25%) and in 41% (108 of 265) of MRGB patients. The majority of detected cancers (87%) were clinically significant. Clinically significant cancers were detected in seven of nine (78%) negative MRGB patients in whom PCa was detected during follow-up. Sensitivity analysis resulted in increased cancer detection (47-56%). Complications occurred in 0.2% of patients (5 of 265). CONCLUSIONS: In patients with elevated PSA and one or more negative TRUS-biopsy sessions, MRGB of MP-MRI CSRs had a PCa-detection rate of 41%. The majority of detected cancers were clinically significant (87%).
Asunto(s)
Biopsia Guiada por Imagen/métodos , Calicreínas/sangre , Imagen por Resonancia Magnética Intervencional , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/diagnóstico , Ultrasonografía Intervencional , Anciano , Distribución de Chi-Cuadrado , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Clasificación del Tumor , Estadificación de Neoplasias , Países Bajos , Valor Predictivo de las Pruebas , Pronóstico , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Derivación y Consulta , Estudios Retrospectivos , Sensibilidad y Especificidad , Carga Tumoral , Regulación hacia ArribaRESUMEN
OBJECTIVES: To evaluate the accuracy and speed of a novel robotic technique as an aid to perform magnetic resonance image (MRI)-guided prostate biopsies on patients with cancer suspicious regions. METHODS: A pneumatic controlled MR-compatible manipulator with 5 degrees of freedom was developed in-house to guide biopsies under real-time imaging. From 13 consecutive biopsy procedures, the targeting error, biopsy error and target displacement were calculated to evaluate the accuracy. The time was recorded to evaluate manipulation and procedure time. RESULTS: The robotic and manual techniques demonstrated comparable results regarding mean targeting error (5.7 vs 5.8 mm, respectively) and mean target displacement (6.6 vs 6.0 mm, respectively). The mean biopsy error was larger (6.5 vs 4.4 mm) when using the robotic technique, although not significant. Mean procedure and manipulation time were 76 min and 6 min, respectively using the robotic technique and 61 and 8 min with the manual technique. CONCLUSIONS: Although comparable results regarding accuracy and speed were found, the extended technical effort of the robotic technique make the manual technique - currently - more suitable to perform MRI-guided biopsies. Furthermore, this study provided a better insight in displacement of the target during in vivo biopsy procedures.
Asunto(s)
Biopsia con Aguja/métodos , Imagen por Resonancia Magnética/métodos , Neoplasias de la Próstata/cirugía , Biopsia/métodos , Imagen de Difusión por Resonancia Magnética/métodos , Diseño de Equipo , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Próstata/cirugía , Antígeno Prostático Específico/biosíntesis , Reproducibilidad de los Resultados , Robótica , Cirugía Asistida por Computador/métodos , Procedimientos Quirúrgicos Urológicos/métodosRESUMEN
Multiparametric magnetic resonance imaging (MRI) has the potential of being the ideal prostate cancer (PCa) assessment tool. Information gathered with multiparametric MRI can serve therapy choice, guidance of interventions, and treatments. The purpose of this review is to discuss the potential role of multiparametric MRI in focal therapy with respect to patient selection and directing (robot-guided) biopsies and intensity-modulated radiation therapy (IMRT). Multiparametric MRI is a versatile and promising technique. It appears to be the best available imaging technique at the moment in localizing, staging (primary as well as recurrent disease, and local as well as distant disease), determining aggressiveness, and volume of PCa. However, larger study populations in multicenter settings have to confirm these promising results. However, before such studies can be performed more research is needed in order to achieve standardized imaging protocols.