Download Tempany

Magnetic Resonance Therapy:
The Prostate program
Clare Tempany MD
©2005 Surgical Planning Laboratory, ARR
Director, MRT Program leader & Core Leader
Slide 1
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
©2005 Surgical Planning Laboratory, ARR
Slide 2
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
©2005 Surgical Planning Laboratory, ARR
Slide 3
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
©2005 Surgical Planning Laboratory, ARR
Slide 4
MR Appearance: Normal prostate
Axial T2W
Sag T2W
CG
PZ
E COIL
©2005 Surgical Planning Laboratory, ARR
Slide 5
Prostate MR image interpretation
• Tumor
– T2W/T1W image: Low signal
•
•
•
•
•
Capsule
Neurovascular Bundles
Seminal vesicles
Nodes
Bones
©2005 Surgical Planning Laboratory, ARR
Slide 6
Focal right sided tumor with ECP
Sag T2W
Axial T2W
Tumor
PZ
CG
PZ
Tumor
©2005 Surgical Planning Laboratory, ARR
Slide 7
Clinical problems: rx of prostate Ca
1.5T normal prostate 0.5T normal prostate •Inc Clinical Cases
•QOL issues
•Morbidity
•IGT
• MR/TRUS
•Image quality
•IGT Neurosurgery
program
1997 state of the art
©2005 Surgical Planning Laboratory, ARR
Slide 8
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
©2005 Surgical Planning Laboratory, ARR
Slide 9
MR
IMAGE
Prostate cancer imaging
and Brachytherapy
program
Pre
clinical testing,
feasibility testing and
Clinical trial, designed and
established by Drs
D’Amico & Tempany
TREATMENT PLANNING
NEEDLE PLACEMENT
PZ
1997
First patient treated
in MRT (GE Signa SP 0.5T)
Pt
Urethra
selection criteria-
T1C, PSA<10,
Ant Rect
GG< 3+4
0%
50%
100%
Ecoil©2005 Surgical Planning Laboratory, ARR
no extra-glandular disease
Slide 10
Contouring PZ, urethra and rectum
Axial T2W image
©2005 Surgical Planning Laboratory, ARR
Treatment plan
Slide 11
Needle Placement
Additional Needles Necessary?
Needle
Insertion
Next Needle
Yes
RT Imaging
Cor,Sag,Ax
Radio logic
Evaluation
No
Reposition
Needle
Yes
Dosimetric
Evaluation
No
Place
Seeds
Dose Evaluation
Plan Modification
Feedbacks: Anatomic
Geometric
Dosimetric
©2005 Surgical Planning Laboratory, ARR
Slide 12
Brachytherapy planning Software*
©2005 Surgical Planning Laboratory, ARR
* US PATENT OFFICE
Slide
Radiation seed implant method and apparatus. JCR098-01pA: 2001, Nov
1. 13
MR-guided prostate biopsy program
– Clinical need
• TRUS high false negative
• MR Bx Target +Sextant/octant
TARGET
– Need target validation method
– Need ‘free-hand’ or Robot
assisted approach
3D-Slicer adapted for prostate
procedures and target definition,
trajectory planning and guidance
©2005 Surgical Planning Laboratory, ARR
Slide 14
MR guided biopsy protocol
• Pre-biopsy
• MR imaging
• Define any targets
– T2W
– Contrast
– MRSI
– LSDI
– T2 maps
©2005 Surgical Planning Laboratory, ARR
• Biopsy
• Open MRT
• Transperineal
• Targeted
sampling
• Systematic
sampling
(Sextant/Octant)
• Site specific
pathology
Slide 15
MRI/MRSI : Data Summary
Cancer
Overlaid
Citrate
Choline
Images
Normal
Up to
1024
Prostate
spectra
Overlaid
Choline/Citrate
©2005
Surgical Planning Laboratory, ARR
image
Slide 16
Data from UCSF Kurhanewicz et al
Multi-parametric and
multi- modal data problem
©2005 Surgical Planning Laboratory, ARR
Slide 17
[11C] Choline PET/MRI
FUSION
MRI
PET
Courtesy of J. Czernin, MD Ahmanson Biological Imaging
Center, David Geffen School of Medicine at UCLA
©2005 Surgical Planning Laboratory, ARR
Slide 18
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
©2005 Surgical Planning Laboratory, ARR
Slide 19
IGT requires dynamic imaging to monitor
delivery: Rapid image processing & registration
Interfractional Motion from Serial CT – Movement AP ~1cm*
©2005 Surgical Planning Laboratory, ARR
Courtesy of Andrew Zitman MD (MGH)
Slide 20
Recent case: Rising PSA 4 years after
brachytherapy
©2005 Surgical Planning Laboratory, ARR
Slide 21
MR/MRSI guided
biopsy & Rx
Adenocarcinoma
Anterior TZ
©2005 Surgical Planning Laboratory, ARR
Slide 22
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
©2005 Surgical Planning Laboratory, ARR
Slide 23
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 modelVaezy S et al
– Feasible for treating Breast
Fibroadenomas-Hynenen K, et al
– Feasible for treating uterine
Leiomyomas-Tempany et al
©2005 Surgical Planning Laboratory, ARR
Slide 24
Future directions; MR guided Focused
Ultrasound Surgery for Prostate cancer*
FUS THERMO-COAGULATION
Real time
MR thermometry
*R01: CA-109246-01 A1 Tempany
©2005 Surgical Planning Laboratory, ARR
necrosis
Slide 25