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Multiparametric MRI of Prostrate

May 14 | 1:30 PM

Prostate cancer is the second most common cancer in men and the fifth leading cause of cancer deaths in men. This underlines the importance of early detection, accurate staging, and appropriate treatment. Prostate imaging-Reporting and Data System (PI-RADS) is currently used to indicate the probability of the presence of a clinically significant cancer for each lesion in the prostate. In this session by Dr. Sneha A. Kini, she will talk about how Multiparametric MRI combines high-resolution anatomic imaging with functional and physiologic evaluation to detect prostate cancer, with excellent results. Register now for this interesting session by IRIA, Kerala.

[Music] so hi everyone good evening i welcome you all on the behalf of matrix team and today we are gathered here for a very interesting session by ira kerala and dr avni would be introducing the speaker and the topic so handing over to dr rasmi please doctor yes uh so thank you so much dr thanvi and welcome everybody on behalf of carolia i welcome you all for the session we from kerala ria have been having this recurrent regularly we have been having these academic sessions which i'm sure all the students and all the other consultants that are also finding useful so in the similar manner with our regular routine we are proceeding we have this amazing session for today so we all know that prostate mri is something that is uh coming up in work a lot these days because uh there was a time when we used to follow a blinded path we used to follow the psa and the dre examination and a blinded biopsy which used to guide the treatment so now uh people have started understanding how imaging is going to play a role but if we have to be helpful in that we have to be knowing exactly how we are going to play a role and what is exactly to be done we have to know the systematic manner that we have to approach it and also what is the exact uh stratifying mechanism or the pattern and for that we have an amazing speaker with us she has already been with us earlier also and she's an amazing teacher dr sneha a guinea i welcome you dr sneha she is she has got a gold medal in md following which she has done her dnb she has also done her visiting fellowship in abdominal radiology at massachusetts general hospital and harvard medical school boston usa currently she's working as an assistant professor at lokmania tiltman's quality horse medical college and general hospital the seon hospital at mumbai her areas of interest include abdominal radiology neuroimaging breast imaging and future imaging she has over 20 publications to her credit both in national and international reputed index journals and she has multiple presentations at various international conferences including likes like harassing me and he has ecr she has even won awards for the same and she has written quite a few book chapters so that itself tells us that we are uh you know looking out for something very impressive so over to you dr smith for the session thank you dr akni for this uh kind introduction and thank you very much for giving me this opportunity to speak on multi-parametric mri of prostate thank you very much so without any further ado i will start the session uh on multi-parametric mri of prostate so prostate cancer is the second most common cancer in men and the fifth leading cause of cancer deaths in men so this itself underlines the importance of early detection accurate staging and appropriate treatment the imaging modalities that are available with us for evaluating prostate cancer our first trust that is transfectable ultrasound which has low accuracy for detection of prostate cancer with relatively poor accuracy for local staging the most important indication is guidance for prostate biopsy then is computed tomography that is the ct scan however ct does not demonstrate the zonal anatomy of the prostate well and neither the uh prostate cancer well it may be used for nodal and distal metastasis the most important imaging modality available for evaluating project cancer is multi-parametric prostate mr which we are going to discuss today what are the indications of multi-parametric prostate emma first to see if there is a cancer now the patient comes to you with elevated serum total psa levels and other bio biochemical markers with abnormal tre findings so mr is highly sensitive modality to pick up prostate cancer but the specificity is a little lower because there are many other benign etiologies or entities which may sometimes mimic prostate cancer then the patient comes to you with negative prior trust guided biopsies that is the patient has high psa level has undergone trust guided biopsy which has come out to be negative for malignancy in this situation an mr may be done to look out for any focus of cancer in the prostate when the clinical suspicion is high next indication is to look to look for how far has it locally spread in a known case of prostate cancer since this dictates the management in these cases so what is the protocol that we use for imaging prostate first we take action t1 meter non-fat suppressed uh sequence then we go ahead with t2-weighted non-fat suppressed uh sequence in small using a small fov this is done in actual plane and at least one orthogonal plane that is the title or kernel however in our institute we take all three planes then we go on to diffusion weighted imaging according to the pirates committee a high b value diffusion is recommended with a b value of at least 1400 seconds per meter square uh the next sequence is a dynamic contrast enhanced imaging that is dcemra this is a 3d t1 weighted fastpoint gradient echo mr sequence uh the 3d image sets are obtained sequentially for at least two minutes with optimal temporal resolution being less than or equal to 15 seconds the injection rate is 2 to 3 cc per seconds starting with continuous image data acquisition now mr spectroscopy may or may not be done few centers still do it if you don't a large fov actual t2-weighted image and then a delayed post-contrast image of the pelvis is taken uh if you find some neural metastasis in this then then an abdominal screening is also done now when we say multi-parametric mri this implies uh these three sequences that is t2 weighted uh images diffusion weighted imaging and dynamic contrast enhanced imaging on which most of the evaluation of prostate cancer is based now before we go on to see how prostate cancer looks let us see first a little on the prostate anatomy because describing the location of the tumor and the tumor itself requires a prior knowledge of prostate and atom now prostate zonal anatomy prostate is divided into different zones uh first is the peripheral zone which is present posteriorly and inferior laterally and comprises approximately 70 to 80 percent of the glandular tissue then is the central zone surrounding the ejaculatory tox which contributes approximately 20 percent of the glandular tissue then is the transition zone surrounding the urethra proximal to the virumentarium which contains approximately five percent of the glandular tissue and then is the anterior fibromuscular stroma here now this is the societal uh section of where you're seeing this is the peripheral zone central zone posterior superiorly this is the transition zone and this is the anterior fibromuscular stroke now this is the mr anatomy which is uh best delineated on t2 weighted small fob images now this is the peripheral zone that is laterally and posteriorly which appears hyperintense on t2-weighted images uh transitions one which surrounds the prosthetic urethra then this is the subtitle uh section uh corresponds to the anatomy's image that we just saw this is the anterior fibromuscular stoma this is the prosthetic urethra surrounding which is the transitional zone these are the ejaculatory ducts seminal vesicle and this is the peripheral zone again this is the peripheral zone appearing hyperintense on t2 and the central zone which appears as wedge-shaped t2 hypointense areas in the posterior superior aspect of the prostate near the base of the prostate so this should not be confused with a prostate malignancy this is a normal central zone uh for description uh purposes prostate is divided into three parts upper one third is the base of the prostate near the neck of the platter middle one third is called as the mid land and low one third is called as the apex of the prostate so let us start with the different sequences that we uh take for prostate mr first as we discussed in the t1 meter images now zonal anatomy of the prostate is not well appreciated on t1 weighted sequences they are primarily used to determine the presence of hemorrhage within the prostate and seminal vesicles post biopsy okay now there is something called as the mr hemorrhage exclusion sign now normal prostate paragraph produces citrate now citric is thought to be an anticoagulant while prostate cancer comprises of non-functioning cells and hence does not produce or produces very little citrate so when a post biopsy hemorrhage is present the area of the tumor appears hypo intense as compared to the normal prosthetic parenchyma which may show hemorrhage and appears hyperintense on t1 so this is called as the mr hemorrhage exclusion sign then we go on to t2 weighted images which are extremely important to evaluate proceed cancer and we look out uh actively for any suspicious lesion on t2 now prostate cancers normally appear uh hypo intense on t2-weighted images okay as we saw the peripheral zone appears hyperintense so the pz tumors that is the peripheral zone tumors usually appear as circumscribed homogeneous moderately high points focus or masses as in this case you are seeing a mass in the right prosthetic lobe extending into the transitional zone here which is uh hypo intense on t2 similar hypo intense areas are also noted in the peripheral zone in this image where the arrows are pointing then we go on to the transitional phone now transition prostate cancers appear uh or occur predominantly in older age group but in these patients even the transitional zone shows changes of benign prosthetic hypoplasia the bph nodules can also appear hypo intense on t2 so how do we differentiate these tumors from bps nodules now bph nodules as we see in this case these are pph nodes okay so they so show very sharp models so with a pencil we can almost like draw the margins of the dph nodes while these tumors are non-circumscribed homogeneous moderately hypointense lesions which are classically called as erased charcoal or smudgy fingerprint of lorenz shows speculated margins or lenticular shape absence of a complete hypointense capsule which we see in the bps truman nodules and sugmeshu invasion of prosthetic urethra peripheral zone or anterior fibromuscular stroma as in this case uh the next that we discuss is the diffusion weighted imaging now we usually use high p value images which utilizes a b value of more than or equal to 1400 seconds per meter square now this increases the conspicuity of tumors adjacent to or invading the anterior fibromuscular stroma or in a subcapsular location at the apex or the base of the gland now usually we do qualitative visual assessment that is the primary method to assess adc but sometimes quantitative assessment of abc may be done wherever you measure the adc values and a threshold of approximately 750 to 900 is used which uh tentatively 800 which may assist differentiation between benign and malignant prostate tissues with adc values below the threshold correlating with clinically significant cancers now this is the diffusion weighted imaging of pz tumors this was the case that we just saw the hypointense lesion in the prostate you can see how markedly hyperintense the lesion appears on high b value diffusion and how markedly high o intensity it appears on the adc values on the adc maps this is again the teaser tumor that we saw which appears markedly hyperintensive diffusion and mark really high points on adc maps now persistence of hyper intensity on highway value images may sometimes be used to differentiate these tumors from stromal pph nodules which we saw which may also appear high intense on t2 weighted images next sequence is dynamic contrast enhanced imaging now dce is termed to be positive when there is enhancement that is focal and earlier or even contemporaneous the to the enhancement of adjacent normal prosthetic tissues and it usually corresponds to a suspicious finding on t2 and or diffusion weighted images now positive enhancement in a lesion is termed when the enhancement occurs within 10 seconds of the appearance of the injected galilean contrast in the femoral arteries okay so it now the contrast has appeared in the femoral arteries so beyond that within 10 seconds of the enhancement occurs then it is called as the early enhancement uh now how do we assess the pc mri uh images usually we use direct visual assessment the uh even subtracted subtraction techniques may be used when there is post biopsy hemorrhage that is already present in the prostate or seminal vesicles semi-quantitative methods are used that is called as curve typing which are even used in other organs but in prostate there is great heterogeneity enhancement characteristic of prostate cancers and specific curve types are not usually used another quantitative approach is the use of compartmental pharmac kinetic modeling time constant for the rate of contrast at washing which is called as k trans and washer that is kep but para steering committee believes that there is currently insufficient uh peer-reviewed published data or expert consensus to support routine adoption of this method of analysis for clinical use so commonly we use this direct visual assessment of dcami now again that's the same case that we saw state to high point translation in peripheral zone now this is how early enhanced early or positive dce looks that the enhancement is focal and early earlier than the adjacent normal prostate running then this is positive dc mr then is mr spectroscopy now mr spectroscopy of prostate requires use of multivoxel volume selection techniques which is called as press or point resource spectroscopy sequence now in that a grid of multiple spectroscopic voxels can be collected at the same time allowing coverage of the entire prostate and what you get are metabolic maps and you can press on each voxel to see the spectrum of that voxel okay so an increase in the choline to citrate ratio or choline press creatinine is to citrus ratio is used as a marker of malignancy in prostate cancer and increases the specificity of diagnosis however it is most reliable in the peripheral zone so these are this is how the metabolic marks look like so this is a multivoxel prostate spectroscopy and you get these metabolic maps now if you press on one vox cell then you will get a larger magnified view of the spectrum of that voxel and you will get the values of these ratios in the prostate uh next we use mri for local staging of prostate cancer now how do you assess extra prostatic spread or extra crampola spray if there is breach of the capsule with evidence of direct tumor extension if there is bladder wall invasion obliteration of the recto prosthetic angle or symmetry or invasion of the neurovascular bundles a bulging prosthetic contour an irregular or speculated margin and a tumor is to capsule interface or greater than one centimeter is actually you can just say suspicious of extra prostate spread now let us see a few cases in this case you can see that there is frank extension of the tumor beyond the capsule so there is breach of the capsule with evidence of direct tumor extension next there is bulging of the prostatic contour here you can see that there is a bulge here and the tumor is to capsule interface is more than one centimeter again here there is this margin has become indistinct and speculative and the tumor capsule interface is more than one centimeter which is suspicious of extra prosthetic spread now neurovascular bundles are around the prostate are seen at five o'clock and seven o'clock positions now this is the tumor extension into the right neurovascular bundle which is suggestive of extra prostatic spread next you have to see for seminal vesicle invasion because it upstages the disease uh how do you say that on mri if there is focal or diffuse low t2 weighted signal intensity and or abnormal contrast enhancement within or along the seminal vesicle if there is restricted diffusion if there is obliterate obliteration of the angle between the base of the prostate and the seminal vesicle or there is demonstration of direct tumor extension from the base of the prostate into and around the seminal vesicle then you have to say there is involvement of seminal vesicle or there is invasion of the several species let us see a few cases here uh this was the case of ca pro state and you can see how there is diffuse load to weighted signal intensity within the di uh right similar vesicle which is indicator of seminal vesicle invasion then in this case there is demonstration of direct tumor there is a tumor in the prostate which is directly extending into the left seminal recipe again in this case you can see that there is a large prostate cancer which is actually extending into bilateral seminal vesicles there are multiple neural metastasis also in this image you can see that there is frank invasion of the uh of the bladder okay now once you have evaluated all these sequences and you have picked up the lesions or suspicious lesions based on their morphology and signal intensity then you have to give pirate score for each lesion that you have picked up now what is pirates pirates is prostate imaging reporting and data system and the latest version is 2.1 so it uses a 5 point scale based on the probability that a combination of the multi-parametric mri findings on t2 diffusion and dce correlates with the presence of a clinically significant cancer for each lesion in the prostate gland that you have picked up so from scale of one to five periods one suggests clinically significant cancer is highly unlikely to be present two pyrites two suggest clinically significant cancer is unlikely to be present parasites suggest the presence of a clinically significant cancer is equivocal pirates 4 suggests that a clinically significant cancer is likely to be present and 5 suggests clinically significant cancer is highly likely to be present so how do you assess the pyrite score for the lesions okay so now you have seen how to evaluate these sequences now let us see how to score them on these sequences so now pirates committee has put up the scoring system in their document okay so now based uh so if the lesion is seen in the peripheral zone then on the t2 weighted images that is given a score either from one to five based on uh whether the lesion is circumscribed or not circumscribed whether the lesion is homogeneous or heterogenous whether it choose moderate or mild hypointensity and the size of the lesion and whether there is extra prosthetic spread or the lesion shows invasive behavior so based on all these points you have to give a score to the lesion in the peripheral zone on t2 weighted images now similarly if the lesion is in transitional zone it is again given a score on t2 based on similar characteristics like whether it is circumscribed or non-circumscribed whether it is mildly or moderately high uh high points the size of the lesion or whether there is extra prostate spread or not okay so based on this again a score is given on t2 then we go on to diffusion so whether the uh the lesion appears mildly moderately or markedly hyperintense on high b value diffusion and high pointers on the adc you give the score on diffusion weighted images then you go to dce now you say whether the dc is positive or whether it is negative positive dc is said when the enhancement is focused and earlier or contemporaneous with the enhancement of adjacent normal prosthetic parenchyma then you say that the dc is positive so now you have got this course on t2 diffusion and dc whether the dc is positive or negative for each region okay there is something called as dominant sequence now what is the concept so for the peripheral zone diffusion weighted imaging is the primary data mining sequence or the dominant technique thus if the diffusion weighted score is 4 for the peripheral notation and t2 score is 2 the final assessment category would be four that is the diffusion score will determine the ultimate pyrites assessment category for a peripheral zone lesion similarly uh for a transitional zone region t2 weighted uh sequence is the primary determining sequence so if the t2 score is 4 and the diffusion score is 2 then the paradise assessment category should be 4. so the t2 score for the transitional zone determines the final parrot's assessment category so this is how you determine the assessment category as we saw in the peripheral zone the diffusion method uh imaging determines the pirates category let the t2 at its core v anything on dce comes into picture when the diffusion score is 3 and in that if the dc is positive then you give pirates 4 as 4 and the dc is negative then you give a pirate score as 3 so this is the role of dce then you go on to transitional zone in that as we saw t2 is the primary determining sequence and then uh dc does not have any role and diffusion in if the t2 is if the t2 score is three and the diffusion score is less than or equal to four you give a pi rise of three and the diffusion is five then you give a paradise of four so this is how you determine the final pirates assessment category for each lesion in the prostate now once you have decided the pirates assessment category you have decided you have assessed the lesions how do you communicate to the clinicians or other radiologists now this is a segmentation model adapted from european consensus meeting and asu prostate mri guidelines so this is a standardized reporting format and aids in precise localization since prostate cancer is usually multifocal so it employs 39 sectors or regions 36 for the prostate two for the seminal vesicles and one for the external urethral sphincter now up to four findings with pyrites assessment category of three four or five may each be assigned on the sector map like this and the index for the dominant intra prosthetic lesion should be identified the index lesion is the one with the highest finance assessment category if the highest pirates assessment category is assigned to two or more lesions the index region should be the one that shows extra prostatic spread then we assess any visible abnormal lymph nodes so the detection of abnormal lymph nodes on mri is currently limited to size that is a short axis more than 10 millimeters morphology and shape and enhancement pattern that is rounded heterogeneously enhancing nodes others are considered to be positive or metastatic now this is how metastatic nodes will look like or as we saw in that is la or enlarged lobulated heterogeneous signal intensity and these uh heterogeneously enhancing nodes are considered to be metastatic now when you see such large lymph nodes it is prudent to get an abdominal screening to look for retroperitoneal lymphadenopathy which upstages the disease then uh you have to evaluate if there are any cautious metastases that are seen in the uh covered fov so uh prostate metastasis as you know appear our sclerotic metastasis now these are this was a very small uh metastatic lesion that was picked up in the uh pubic bone which shows heterogeneous post contrast enhancement now this were uh again multiple oceans metastasis were picked up which are hypo intense on t1 weighted images no hyperintense on t2 fat suppressed images and show heterogeneous post contrast enhancement so these were again osha's metastasis thus multi-parametric prostate iman is excellent for detecting prostate cancer with high sensitivity the most important sequences are t2 weighted sequences fusion weighted imaging and dynamic contrast enhanced imaging local staging you have to assess for extra capsular spread and adjacent organ infiltration including the seminal vesicle infiltration you have to give pirates assistant category for each lesion and you have to evaluate pelvic nodal and cautious metastasis in the covered field thank you very much i'll end my talk here each and every part was covered and was really really very useful actually i couldn't come in the beginning i was hearing after your two or three uh slides it was really wonderful each each and every uh images you showed was very very very good thank you so much for this wonderful talk thank you thank you very much ma'am thank you so much for this opportunity thank you thank you dr sneha and actually you took it in a step-by-step manner like you know covering like how you can eurovascular bender this is where it is so this is how it's going to appear and it went in a very systematic way so it's very easy for us to process when we start reporting on our own uh just one thing that i wanted to ask you is many times when we start doing we realize that post biopsy especially for the post biopsy patients you did mention that t1 is a place where which helps you in picking up the hemorrhage but sometimes we even then end up getting cases which you know you see the maybe you see the neurovascular bundle which are kind of uh hazy yeah or you see this the capsule is very thick so what do you do in such cases to determine you know whether it is because of the biopsy or not actually uh see many times what happens is if a biopsy has been done and at that site the biopsy has come out to be negative the pirates committee says that the likelihood of a clinically significant cancer being at that site is less likely okay so the local staging as you said is definitely affected in um look uh post biopsy cases but uh the combination of this multiparametric mr that is t2 even diffusion and dce definitely helps in delineating prostate cancers post biopsy so i have honestly not faced a lot of trouble in post biopsy cases if you combine all these three like diffusion and uh uh dc and sometimes in these cases so actually as i said local staging may uh be a little difficult but picking up a prostate cancer i guess should be fine if you use all these three sequences together so any uh recommendations for maybe suggesting an imaging re-imaging in a short while or does it not hold good then pardon i didn't get it no do you think it would be uh would it be recommend should you be recommending a re-imaging after say a month or two would you or would you know actually uh according to pirates committee they have said that an ideal uh duration between a biopsy and an mri is six weeks they say that uh the changes remain even after that but six weeks is the ideal interval between a biopsy and a prostate mri so if it is feasible then that much interval has to be kept but many times what happens is you know asking the patient to wait for six weeks is a little uh yeah so that is where you can go ahead but if there is some discrepancy or some doubt then six weeks is the interval which is recommended to be kept between a uh prostate biopsy and a prostate mri okay another thing i had in mind is you did mention about mr spectroscopy but do you do it routinely for all the cases the mass spectroscopy uh actually that is not really recommended but in our center yes we are doing mr spectroscopy for uh routinely but it is uh absolutely not uh mandatory to do now pirates recommends that it may or may not be done according to the uh the center like whether or not they are comfortable whether the software is available or not but if you are not doing a mask spectroscopy that it is perfectly okay if some centers are not having the uh the software or anything for uh the multiboxes proceed spectro then you can just like based on t2 diffusion and dc is perfectly enough to uh report a prostate mr and give a pirates category okay so that was because like you mentioned already it's not there in all the centers so that was one of my concerns even we don't do it routinely maybe i think we have done it only once or twice when we have had these you know difficult to make decisions kind of yes that's the only time we have done it actually one of our students had a thesis so that's right that's how you do it routinely yeah yeah most of the interests don't have the software for uh and regarding the curve do you think you should be using a dynamic curve uh is there any rule for it personally no not really we do a visual direct visual assessment only like uh even the pi s doesn't really recommend a semi-quantitative method like they have seen that it is extremely heterogeneous like uh sometimes even uh like what um routinely or uh is expected that the tumor will wash in and wash out but you know sometimes we have seen that the tumors can retain contrast also so it is very heterogeneous and so they don't really recommend a curve typing in prostate okay fine so that was really nice doctors neha and you sorted quite a few of my doubts also thank you so much i don't see a lot of questions or rather any questions in the q a section i think that's because you made everything so clear crystal clear for everyone thank you thank you so much thank you so much we really hope we'll have you with us again so uh once again i would like to thank you dr sneha for this amazing session it's been very clear things have been really made very easy and simple for us i'm sure all of us will be able to start practicing prostate mri after this talk and i thank kerala array for always persistently you know continuing with academics it's always there it's in the forefront of all of our activities [Music] and president even our secretary dr jose they've always been leading us from the front so thank you so much for that dr ramesha who is always guiding us supporting us dr vedu sir and we have an excellent team of academic coordinators who are diligently you know making sure that these things keep happening and dr vini sir leads all of us in that and i thank all of our academic coordinators and i thank our netflix team for such a wonderful platform dr pandi especially and all the audience for being with us supporting us consistently so thank you so much for this thank you thank you very much good night all of you yeah yeah all right so thank you once again again and good night thank you good night yeah good night thank you thank you for attending the session yeah

BEING ATTENDED BY

Dr. Sasikanth Reddy & 357 others

SPEAKERS

dr. Sneha A Kini

Dr. Sneha A Kini

M.B.B.S., M.D. (Gold Medalist), D.N.B., Visiting fellowship in Abdominal Radiology at Massachusetts General Hospital and Harvard Medical School, Boston, U.S.A. Assistant Professor, Lokmanya Tilak Mu...

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dr. Avni Skandhan

Dr. Avni Skandhan

Lead Consultant and Head of Radiology & Quality Chief, Aster MIMS Kottakal

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dr. Sneha A Kini

Dr. Sneha A Kini

M.B.B.S., M.D. (Gold Medalist), D.N.B., Visit...

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dr. Avni Skandhan

Dr. Avni Skandhan

Lead Consultant and Head of Radiology & Quali...

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