Fusion prostatic biopsy

Fusion prostatic biopsy

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  Mohammad Ihmeidan PGY5
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  • MRI isan effective way to visualize prostate tumors. • Multiparametic MRI combines anatomic, diffusion- weighted (DWI), and dynamic contrast-enhanced (DCE) imaging • Anatomic imaging provides the highest spatial resolution images in which tumors appear as low-signal intensity areas in T2-weighted images.
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  • DWI measuresdifferences in the random Brownian motion of water, or diffusion, which is more rapid in the normal gland than in tumors because of the high cellularity of tumors. • DCE MRI takes advantage of differences in the vascularity of tumors and normal tissue. Due to angiogenesis, vascularity is higher in tumors than in surrounding tissue, resulting in higher rates of uptake and washout of contrast material. • A recent meta-analysis indicated that multiparametric MRI has an estimated sensitivity of 0.74 (95% CI, 0.66–0.81), specificity of 0.88 (95% CI, 0.82–0.92).
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  • With theadvent of advanced imaging techniques and image-guided biopsy for the detection of prostate cancer (PCa), the concept of fusion biosy gained popularity.
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  • Fusion :t heprocess of joining two or more things together to form a single entity
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  • The mainthree approaches to TB include • 1-cognitive fusion (COG-TB) • 2-software-based fusion (FUS-TB) 3-in-bore or in-gantry TB (IB-TB).
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  • The simplestway of integrating MRI information into TRUS guided biopsies. • If a radiologist reports lesions on a sector map with a suspicious lesion, an experienced urologist may guide the needle exactly into this area. • Cognitive approach has some limitations , most importantly the large rotational differences between the prostate MRI and TRUS orientations that make targeted biopsy difficult for operators even experienced surgeon.
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  • MR/US Fusion-GuidedProstate Biopsy • MR/US fusion-guided biopsy depends on the creation of a 3D image of the prostate gland that shows the location, size, and shape of a suspected tumor. • This image is created from an MRI performed prior to the biopsy procedure • During procedure, the stored MR image is uploaded into a dedicated device that aligns it with real-time US • The urologist can then direct the biopsy tool to sample the suspected tumor.
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  • The MR/USfusion-guided biopsy device records the precise location of the biopsy site. • Subsequent sampling of the same site can be obtained at a later date with an accuracy of within 1–2 mm.
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  • Several softwareplatforms using a transrectal or perineal approach are available on the market. • Good tool for active surveillance . • Repeat biopsies under active surveillance may be guided more precisely to initially positive areas, which can increase the safety of such protocols. • Could be used in ablative procedures (eg, high-intensity focused ultrasound therapy, cryotherapy. With fusion biopsies it is possible to create an accurate 3D model of cancer areas of the prostate and to transfer this model to appropriate treatment systems.
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  • Results forthe largest MRI/TRUS fusion biopsy cohort of 1003 men were published by Siddiqui et al in 2015. • The primary study objective was to compare MRI/TRUS fusion and standard biopsy approaches for detection of high-risk PC (Gleason score 4 + 3); a secondary endpoint was detection of low-risk PC (Gleason score 3 + 3 or low-volume 3 + 4). • In comparison to standard biopsy, fusion biopsy detected 30% more high-risk cancers and 17% fewer low-risk cancers.
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  • mpMRI informationcan be used to guide biopsies directly in the MRI gantry . • Special nonferromagnetic guiding systems are necessary for this sophisticated technique. • Different systems with different biopsy approaches are currently available on the market. • In 2011, Roethke et al reported results for in-magnet biopsies in patients with previous negative results. The detection rate was significantly higher than the rate for TRUS-guided biopsies in that settings.
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  • While IB-TBmight have the potential to be the most precise target strategy as it does not require ultrasound image fusion and lesions are directly targeted on MRI,some authours argue that CDR is similar to other fusion strategies.
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  • Has somelimitations IB-TB is expensive and time-consuming, requiring an MRI suite and MRI-compatible equipment and supplies, as well as the expertise to use them. • Approximately 15% of csPCa are invisible on MRI, and therefore will not be detected on IB-TB . • In addition, Systematic Bx, which may improve CDR when combined with TB, cannot be performed during IB- TB. • Given these limitations, some authors advocate the use of IB-TB specifically for very small lesions, and/or repeat biopsy when clinical suspicion is high but prior TB are
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  • Visual-estimation maybe the most straightforward choice for larger, diffuse lesions. • In-bore used in selected cases for men with ongoing suspicion of cancer despite negative visual-estimation or image-fusion biopsy.
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  • A questionurologists face every day is whether they should only take biopsies from MRI-suspicious lesions? • The answer is mostly NO , as mapping biopsies supplemented with targeted biopsy remain the gold standard for tumor detection.
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  • It isnot yet known whether the use of targeted biopsies will affect the clinical outcomes of patients diagnosed with prostate cancer. • However, the current method of systematic biopsy, in which as many as 12 cores may be sampled, can lead to overdetection of small indolent tumors and may underdetect clinically significant tumors. • Up to 50% of tumors detected by this method may not be clinically relevant; and although many patients undergo active • surveillance, some will undergo prostate cancer treatment unnecessarily.
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  • At thesame time, 28,000 men die from prostate cancer each year in the US and these numbers might decrease if more high-risk cancers were accurately detected at an earlier stage. • Further studies are necessary to discover if MR/US fusion- guided biopsies will improve the ability to categorize the risk of tumor growth and, on this basis, reserve aggressive treatment for patients at intermediate to high risk while avoiding treatment in patients at low risk. • For men with apparently low-risk prostate cancer who are considering active surveillance, MR/US fusion-guided biopsy can be useful in detecting higher risk clinically significant disease that was undetected by the initial biopsy, identifying men in whom active treatment is more appropriate. Further study is needed to establish these suggestions.
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  Thank You
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  • 1-Kuru, T.H., Herden, J., Zugor, V., Akbarov, I., Pfister, D., Porres, D., & Heidenreich, A. (2016). How to Perform Image-guided Prostate Biopsy: In-bore and Fusion Approaches. European Urology Focus, 2(2), 151–153. doi:10.1016/j.euf.2016.03.016 • 2-Visual-estimation (cognitive), image-fusion (software) and in-bore targeted prostate biopsy: is there an optimal approach? Christopher C Khoo, Martin J Connor and Hashim U Ahmed • 3-MR/US Fusion Imaging as an Aid to Prostate Biopsy/radiology rounds/2016-14-1 • 4-Comparative Effectiveness of Techniques in Targeted • Prostate Biopsy Dordaneh Sugano 1 , Masatomo Kaneko 1,2, Wesley Yip 1 , Amir H Lebastchi 1, Giovanni E. Cacciamani 1 and Andre Luis Abreu 1,*