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Magnetic Resonance Therapy: The Prostate program

Magnetic Resonance Therapy: The Prostate program. Clare Tempany MD Director, MRT Program leader & Core Leader. Prostate cancer: Scope of the problem. 1.5 million prostate biopsies per year 25 million men have had at least one negative biopsy 2003- 220,900 New cases were diagnosed

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Magnetic Resonance Therapy: The Prostate program

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  1. Magnetic Resonance Therapy: The Prostate program Clare Tempany MD Director, MRT Program leader & Core Leader

  2. Prostate cancer: Scope of the problem • 1.5 million prostate biopsies per year • 25 million men have had at least one negative biopsy • 2003- 220,900 New cases were diagnosed • 2015- 450,000 New cases will be diagnosed • Approx 4-8% disease specific mortality rate • How will we improve diagnosis and treat all these patients? • Ideally • Non-invasive, low cost, effective therapy • Imaging Dx and Rx

  3. Staging/Treatment prostate cancer • T1/T2 intra-glandular tumors • Treatment-goal-local cure • Radical prostatectomy • XRT • Implant • Watchful waiting • T3 Extra-glandular • Through capsule • Into seminal vesicles • Treatment-Radiation+/- Total androgen suppression

  4. BWH prostate program: Milestones • 1991 Prostate MR Imaging (CT-BWH) • Urology (Jerome Richie)/Med Onc (Phil Kantoff) • 1994 New collaboration • Prostate imaging/ Radiation Oncology collaboration began. (Anthony D’Amico /CT) • CALGB trial • Schering Oncology grant • 1997 MRT brachytherapy program • 1999 1st NIH R01 grant (AG R01 19513) • 8/05 427 men treated

  5. MR Appearance: Normal prostate Axial T2W Sag T2W CG PZ E COIL

  6. Prostate MR image interpretation • Tumor • T2W/T1W image: Low signal • Capsule • Neurovascular Bundles • Seminal vesicles • Nodes • Bones

  7. Focal right sided tumor with ECP Sag T2W Axial T2W PZ PZ CG Tumor Tumor

  8. Clinical problems: rx of prostate Ca • Inc Clinical Cases • QOL issues • Morbidity • IGT • MR/TRUS • Image quality • IGT Neurosurgery program 1.5T normal prostate 0.5T normal prostate 1997 state of the art

  9. MR guided prostate interventions • Two major clinical programs • Diagnostic biopsy • I-125 interstitial implant Brachytherapy/ Cancer treatment • Pre intervention imaging-State of the art • 1.5T endorectal coil MRI • Open 0.5T MRT system- GE medical • Procedure guided with real time MR • Plan • Guide • Monitor

  10. MR IMAGE Prostate cancer imaging and Brachytherapy program • Pre clinical testing, feasibility testing and Clinical trial, designed and established by Drs D’Amico & Tempany • 1997 First patient treated in MRT (GE Signa SP 0.5T) • Pt selection criteria- T1C, PSA<10, GG< 3+4 • Ecoil- no extra-glandular disease TREATMENT PLANNING NEEDLE PLACEMENT

  11. Contouring PZ, urethra and rectum Axial T2W image Treatment plan

  12. Needle Placement Additional Needles Necessary? Needle Insertion Next Needle Yes Yes RT Imaging Cor,Sag,Ax Radio logic Evaluation Dosimetric Evaluation Place Seeds No No Dose Evaluation Plan Modification Reposition Needle Feedbacks: Anatomic Geometric Dosimetric

  13. Brachytherapy planning Software* * US PATENT OFFICE Radiation seed implant method and apparatus. JCR098-01pA: 2001, Nov 1.

  14. MR-guided prostate biopsy program TARGET • Clinical need • TRUS high false negative • MR Bx Target +Sextant/octant • Need target validation method • Need ‘free-hand’ or Robot assisted approach 3D-Slicer adapted for prostate procedures and target definition, trajectory planning and guidance

  15. Pre-biopsy MR imaging Define any targets T2W Contrast MRSI LSDI T2 maps Biopsy Open MRT Transperineal Targeted sampling Systematic sampling (Sextant/Octant) Site specific pathology MR guided biopsy protocol

  16. MRI/MRSI : Data Summary Cancer Overlaid Citrate Choline Images Normal Overlaid Choline/Citrate image Up to 1024 Prostate spectra Data from UCSF Kurhanewicz et al

  17. Multi-parametric and multi- modal data problem

  18. [11C] Choline PET/MRI FUSION MRI PET Courtesy of J. Czernin, MD Ahmanson Biological Imaging Center, David Geffen School of Medicine at UCLA

  19. Prostate IGT Research projects • Registration & Segmentation • Multi-modal image display • Seed definition-seed based dosimetry • Clinical outcomes • Cancer diagnosis, control, toxicity and QOL • Target definition • Multi-parametric data analysis and summation • Optimized biopsy • Davatzikos et al-mathematical statistical model • Robotic assist device /closed bore systems • Fichtinger, Burdette et al • MRg Prostate cancer FUS • Hynynen et al

  20. IGT requires dynamic imaging to monitor delivery: Rapid image processing & registration Interfractional Motion from Serial CT – Movement AP ~1cm* Courtesy of Andrew Zitman MD (MGH)

  21. Recent case: Rising PSA 4 years after brachytherapy

  22. MR/MRSI guided biopsy & Rx Adenocarcinoma Anterior TZ

  23. MR guided brachytherapy: Clinical validation / outcomes • Outcomes. Albert* et al Cancer (2003) • Grade 3 rectal bleeding 8% vs. 30% (combined) • 4yr freedom from Radiation cystitis: 100 vs. 95% • No urethral strictures or TURP to date • Cancer control D’Amico et al (2003) • 93% 5 yr PSA control, similar to a surgically managed population over the same time frame • QOL: Szot* et al RSNA 2004 • Significant improvement over US in both GU and sexual function * R25 training grant fellows

  24. Non-invasive Focused ultrasound surgery High intensity FUS first proposed by Lele in 1962 • Sound waves heat tissue through molecular vibration • Delay due to lack of targeting, guidance and temperature monitoring • Tested in animals-nude mouse model- Vaezy S et al • Feasible for treating Breast Fibroadenomas-Hynenen K, et al • Feasible for treating uterine Leiomyomas-Tempany et al

  25. Future directions; MR guided Focused Ultrasound Surgery for Prostate cancer* FUS THERMO-COAGULATION Real time MR thermometry necrosis *R01: CA-109246-01 A1 Tempany

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