21 Post Treatment Recurrence

Post-Treatment Recurrence: Overview

In this next section of the program, we're gonna hear about post-treatment recurrence.

There'll be three different brief talks by Dr. Kora, Dr. Ani and Dr. Verma.

The first speaker is going to be Dr. Kora.

Application of Multiparametric MRI in Post-Treatment Recurrence: Dr. Kora

I'm going to continue on the application of Multiparametric MRI in the context of post-treatment recurrence and the role of MRI in this clinical setting.

I'm going to discuss the risk of prostate cancer recurrence, post radical prostatectomy.

So I'm going to focus mainly on the postoperative course, and then review the multiparametric MRI findings in the recurrence of prostate cancer.

So the clinical suspicion of local recurrence, post radical prostatectomy is based on biochemical failure.

However, we need to remember that biochemical failure is not synonymous with local recurrence in the prostatic bed.

Persistently elevated PSA can be due to residual glandular tissue, and that is something that MRI can really help us in terms of detection.

The recurrence after a radical prostatectomy happens in about 50% of high risk patients, and in about 10% of low risk patients.

We need to remember that the absence of the capsule at the apex, and the fact that during the surgical management, there is a need to preserve the urethral sphincter and neurovascular bundles, are the main reasons for high incidence for local recurrence.

And of course, these are important strategic steps in the surgery to maintain quality of life.

So, what are the risks of local recurrence after radical prostatectomy?

So, biochemical failure is defined by two consecutive values of serum PSA above 0.2, and there is a higher risk of local recurrence if PSA is detectable after one year.

If the PSA velocity is below 0.75.

If PSA doubling time is above six months, if negative lymph nodes were found after RRP, when there was no seminal vesicle invasion.

However, where there were positive margins and typically Gleason scores below seven, the risk of systemic relapse, however, is associated with PSA detection before one year PSA velocity higher than that in the other risk group above 0.5 PSA doubling time less than six months when there are positive lymph nodes, seminal vesicle invasion, and higher Gleason score lesions.

So with the current therapies, such as IRTs and image guided radiation therapies, there is a potential to target the recurrence.

And therefore there is an opportunity for imaging to contribute to very specific treatment planning.

Therefore, accurate identification of local recurrence improves the chance of effective treatment and of course, long-term oncologic control.

And both multiparametric MRI and PET imaging have been shown to be successful in the early detection of recurrence.

However, there are several known limitations of PET imaging for detection of small lesions.

As we know, PET has limited spatial resolution.

MRI has on the other side a very good spatial resolution, and when we also apply an endorectal coil, as you've heard before, and also we benefit from superior contrast resolution and great anatomical detail that can be detected on prostate MRI.

There are new tracers in PET world.

And with the increasing application of PET MRI, perhaps the advantages of the two modalities can be combined and we are to see some ongoing trials and the results from those.

So how can MRI contribute to detection of disease in the prostatic bed?

We are going to use the multiparametric approach, as we've already discussed.

We're going to look at the morphologic imaging performed with high spatial resolution T2-weighted imaging.

We are going to look at the dynamic contrast enhanced imaging of the prostatic bed and application of the diffusion weighted imaging of the prostatic bed.

And the goal is to distinguish between the local regional recurrence and the perhaps small amount of residual glandular tissue that can happen.

And it does happen more frequently after radical prostatectomy with the robotics approach and specifically when surgeons start utilizing this technique in their practice.

And it's going to be important to differentiate residual or recurrent tissue from cancer from the scar or fibrosis.

And of course, granulation tissue in the postoperative setting is another potential tissue that we should be able to characterize.

It has been shown that the aggressiveness of the recurrent tumor can perhaps be elucidated with the diffusion weighted imaging.

So what are the imaging findings on T2-weighted imaging?

We may see lobulated nodule like, or plaque like soft tissue in the prostatectomy bed.

Some of these may be palpated by digital rectal exam.

Most of them are not palpated.

And there's opportunity for MRI to identify the prostate cancer tissue.

We will be looking at T2-weighted imaging findings of being slightly hyperintense to surrounding muscles.

I'll show you example in a moment.

We will be looking at very classic location at the vesicourethral anastomosis around the urinary bladder.

And at the level of the membranous urethra and pelvic floor, there are some rare sites of recurrence, such as in the rectovesical space between the bladder and the rectum, within the retained seminal vesicles, and also at the anterior and lateral surgical margins at the prostatectomy bed, and that may involve or abut levator ani muscles I mentioned already, scar and fibrosis that are present at the prostatectomy bed.

And there are slightly different signal characteristics at the scar tissue where we typically see, not a nodule like an intermediate bright signal, but low spiculated a dark signal on T2-weighted imaging.

And also, granulation tissue can have intermediate signal characteristics and actually can be a mimicker of recurrence in the anastomotic resection site.

So let's look at this case.

One, we have patient post radical prostatectomy where you can appreciate on axial T2-weighted image, there is this intermediate tissue nodule, which has signal intensity higher of surrounding muscles and obturator muscles.

And you can see there is the bladder neck distension on the right side, tumor recurrence on the left side, on the sagittal, I'm sorry, on the coronal view.

You can appreciate again, this distinct nodule intermediate to signal.

So this is what we are going to look at.

Again, soft tissue nodule, slightly higher signal than that of muscles.

And this presents like a mass little nodule 3D space occupying structure on diffusion, I'm sorry, on dynamic contrast enhanced MRI, which is considered the most significant sequence in the search for the recurrent prostate cancer.

We are going to be able to distinguish viable tumor, which should enhance from postoperative changes, which may enhance at a different rate than the cancer.

When you heard a lot about the pattern of cancer enhancement yesterday, and that certainly applies also to recurrent tumor, we know that the recurrent prostate cancer is going to enhance quickly and avidly.

So these are the specific imaging findings that we are going to be looking for at the level of T2 identified nodularity.

On the other hand, when we have postoperative scar, typically there may be no enhancement or there is a slow fibrous tissue delayed enhancement that can help us differentiating the two.

It's important to understand that some periprostatic vascular structures, and Dr. Hader alluded to this yesterday, also may mimic enhancing tissue.

And certainly in the post prostatectomy bed, when there is distortion of what we expect to be the normal anatomy, some of these vessels can really be causing some false positives.

Important to review again, multiplanar imaging to define the course of the vessels.

So we already saw the T2-weighted imaging demonstrating the nodule in the RP bed.

And then we add this very early post contrast enhance image from the DCE sequence here, where you can identify clearly enhancement of this recurrence.

Also in, when it comes to diffusion weighted imaging, it has been demonstrated that the aggressiveness of local recurrence, not only for detection purposes, but also for the assessment of the local tumor aggressiveness, ADC can play an important role in a quantitative fashion, not only in the qualitative fashion where we detect the restriction, the impeded diffusion in the recurrent tumor.

So in the study from Europe, they actually illustrated that the glandular remnants have sort of a normal range in their setting, in their clinical practice when it comes to the ADC values over 1300 or 1.3 depending on the units that you use.

And then you can see the high grade recurrence will have a very significantly lower ADC values.

So you can see cancer essentially below 1000 and above 1300.

The normal range of ADC values, of course, diffusion in a postoperative setting has some challenges because of the surgical clips and background noise and we can have some distortion.

So in this case that I show you T2 post contrast imaging before, now you can see on the ADC map and high B value, which can be quite helpful.

You can see that there is corresponding bright signal within the nodule with the decreased ADC values.

And there is evidence that demonstrates that giving contrast is really very important.

And in this setting of post radical prostatectomy patients, when you can see in this study on an unenhanced study, the accuracy was below 70% when the contrast was injected, the accuracy for detection was above 85%.

This was a retrospective study.

However, there was a prospective study of a larger cohort, which had two group of patients with a smaller and a larger size of lesions.

And they use the biopsy reference in the smaller lesion size cohort.

And they use the PSA reduction after radiation therapy as a reference in the larger cohort.

And you can see that actually the accuracy was pretty high for both groups when the dynamic contrast enhanced imaging was utilized.

And an example, I'll just run through few examples of the post radical prostatectomy recurrence patient who had RP then had follow up of external beam radiation and steroid treatment.

His PSA maintained elevated and was rising.

And you can see there is nodule on the left side right there to this level.

You can see very avid enhancement and also ADC reduction.

And this tumor was also extending along the bladder wall.

Patient was treated and you can see post-treatment, we can follow this patient with reduction of the size.

This patient had the RP and six months after RP had PSA that started rising.

You can see on the sagittal image that fusiform intermediate signal nodularity, sometimes it blends in with the tissue such as here, but after contrast, you have no difficulty identifying this tumor recurrence that you can see.

This patient is post RP 12 months. Similar scenario.

PSA is rising on sagittal image.

You can see there is a nodularity right there, more posterior between the bladder and the rectum.

And you can see this nodule avid enhancement ring like enhancement.

And of course, we can do the multiparametric imaging setting.

We can do the color mapping of the DCE perfusion.

And that can actually be a helpful sort of a screening sequence where we can look at the post contrast and then go backwards to look at the T2-weighted imaging for better morphologic assessment.

This patient had radical prostatectomy with robotics approach, then had palpable nodule.

And the question was, was there residual tissue after robotic surgery or was there local cancer recurrence?

So with PSA of 6.8, you can see we do the post RRP imaging where there is a lot of tissue that looks like almost normal prostate, except for of course, BPH.

And this patient in the surgical specimen had prostate seminal vesicles.

So you wonder what's going on.

And there is a large portion of retained.

And then growing BPH nodularity with this heterogeneity on ADC mapping within the nodule.

This was followed with biopsy and turned out not to be a cancer.

Turned out to be a residual glandular tissue with big BPH nodule.

This is patient who had transurethral resection and then external beam radiation therapy.

You can see a lot of abnormality around this bladder neck interface with the urethral junction.

You can see some tissue there.

You can't tell is it right or left, what's going on until you perform the diffusion weighted imaging.

ADC very distinctively focal positive on the right side Contrast really helps you very much in this setting.

And this important imaging for contribution of the ADC and DCE to local recurrence.

This patient happened to had PFO before distorted portion of the gland, again, intermediate signal.

You can see how high B value and post contrast imaging really contributes to confirmation of this recurrence.

And perhaps at this point, I will turn the floor for other topics including the post-radiation therapy recurrence that Dr. Claire Tamani is going to discuss with you. Thank you.

Post-Treatment Recurrence After Radiation Therapy: Dr. Claire Tamani

I'll continue the discussion of post-treatment recurrence and focus primarily on radiation therapy, but others as well.

So first of all, what modalities do we have to image these patients?

As we've heard a lot about MRI and we'll continue to hear more about MRI, CT scan can play a role, of course, in looking at more advanced disease when we're interested in lymph node disease and maybe lung and liver metastasis, which occur rarely, but can happen in less than 10% of people with advanced prostate cancer.

But primarily today, I think we're focusing more on the local recurrence because those are the ones that obviously can go to salvage therapies.

The nuclear medicine test, of course, the bone scan is obviously very good for assessing bone metastasis, as we know.

And that's, again, in the more advanced people, a word or two about PSMA, which is a PSMA nuclear medicine test, which is done in many centers around the country.

It's not done much in Boston, I have to say, but it is very useful in the biochemical failure patient and biochemical failure, of course, means that the PSA is abnormal and out of the expected range after therapy, FDG has no role.

And then as we've also heard, there are exciting new tracers in PET that are coming.

So looking at the initial staging, I think one of the most important things for us is, once a prostate has been removed, is to review the prostatectomy pathological report and determine the margin status before you start to interpret a post prostatectomy MRI.

It's very important to know was there any tumor residual tumor left behind at the time of prostate cancer removal?

The gland removal and one of the most common places for this to occur will be right here, as in this patient who didn't go to surgery because of the MRI findings of extracapsular penetration right here down deep below the external sphincter.

But that the level of the sphincter or the apex is the most common place for local recurrences you've already seen, nicely illustrated.

So do look at the original tumor and determine the stage of it.

And if you have imaging preoperatively, go back and look at that.

See how much tumor was present prior to surgery or prior to treatment.

Always try if you can, in your system, in the PACS and EMR is so much better now than it used to be.

We are able to obtain the preoperative studies and so assessing the initial tumor, and I like this one because it was just a nice illustration of a very advanced case, which didn't go to surgery, but illustrates that nice organized chaos and blurred charcoal sign that we discussed so much yesterday, where you can see this very large central tumor in comparison to what is our, what our encapsulated BPH nodules here.

So this is the benign portion of the tumor of the prostate in the front, and then you can really see how big in advance this is and invading seminal vesicles bilaterally.

So look at those again.

And then, as you can see, this is clearly a Gleason eight cancer with restricted diffusion, very nicely seen.

So really, the patients will present with rising PSAs, and your job is to localize the recurrence, the site of disease in a radical prostatectomy.

Patients, you know, the PSA should stay at zero for the rest of the man's life in any raise or rise in PSA is important to assess.

And the really, the importance for directing therapy is to determine is it a local recurrence or is it systemic throughout the body?

'cause obviously there'll be different treatments At our center, we do three T imaging with the endorectal coil in all of these patients still, I believe it's very important, again, after radical prostatectomy, to try to find these small nodules.

But excellent images without the coil can also be used.

We just happen to have this thing with the coil in our place.

Always look at the, look at all of the edges of the examination and enhancing nodule as you've already heard.

And then the, the criteria here, one thing that's important, and I think it's been mentioned before as well, is what is the definition of biochemical failure in the radiation therapy patient?

The Phoenix criteria has been defined now as being the standard.

We revised ASTRO criteria.

This is a rise of two in the PSA above the nadir, which is the lowest point it gets to after treatment, is now considered to be the definition for failure after radiation with or without hormones.

And so MRI is very helpful for that.

Spectroscopy does play a role in some of these patients, and it's been nicely illustrated by Sauna yesterday.

It's a useful tool, I think, in biochemical recurrence and disease.

And spectroscopy has, as John Kitz and many others in the past, been useful to demonstrate atrophy recurrence in cancer disease.

These colors are not showing up as well as they might, but I think you get the general idea.

We've used spectroscopy in the past more so than today.

But this is a classical example of a patient who presented after localized brachytherapy to the posterior peripheral zone who presented with this ill-defined abnormality on T2.

I don't think one would call it on T2 because as you know, the radiation will induce generalized low signal intensity throughout the prostate on a T2 image after any form of radiation.

So spectroscopy was abnormal in these three voxels here up across the front at the 12 o'clock location in the famous anterior location, which you're now getting familiar with a common site of prostate cancer, post radical prostatectomy with the robotics.

I think in the early days we were seeing cases like this.

We rarely see this now, thank goodness, but here's a man who presented six months out from radical with a robotic prostatectomy.

And you can see coming from the top down towards the apex, seminal vesicles here, normal bladder here, bladder coming into a soft tissue abnormality in the prostatectomy bed.

And then this mass unfortunately gets even bigger here, where we have a significant amount of residual prostate left behind.

And this patient, of course, had a positive surgical margin as well.

And so the report on the pathology was particularly helpful.

We didn't have the preoperative imaging in this case, but this was a significant localized mass.

And the importance is obviously to find that characterize it, measure it, provide three dimensional volumetric assessment of it so that salvage radiation therapy can be delivered into this area.

And the radiation therapy will be done either with external beam or localized salvage brachytherapy, both associated with fairly significant toxicities, unfortunately.

But that is the current treatment after, again, radical prostatectomy, very similar to what Kasha showed you.

The contrast enhanced dynamic images are very helpful and really show the enhancing masses.

And here's an example of a patient who's being followed for active surveillance.

And this isn't postoperative treatment, but is obviously an active treatment.

And I think, again, we have to look and see what these patients who are on treatment, are they getting worse or are they getting better?

Is the, is the not better?

Is the disease stable or is it not?

And so we're gonna see two studies in this patient where in originally in two, excuse me, in 2009, he presented with a PSA of four biopsy Gleason three plus three, and then his PSA went up over a significant period of time from oh nine to 11 to 6.2.

And you can see here, and I think we've seen cases like this already this weekend, where you can see at 2009 on the left side and then 2011 on the right side, the diffusion weighted images are extremely helpful for looking for individual lesion change over time.

And you can see here this lesion certainly went from being mildly restricted to a significantly restricted lesion right here, which is obviously even extending upwards towards the seminal vesicle.

And this was classified as a PI-RADS four.

And this, this may even be five, I guess if we measured it correctly, I think it might even be bigger than a 1.5.

But the biopsy here showing significant Gleason change and this patient went on to surgery and the surgery confirmed that lesion and it was confined to the prostate.

And as we can see, it was a significant PI-RADS five lesion, with a large volume tumor that had really advanced.

So the interval change is very important.

Now, after brachytherapy, when the seeds are in place in the prostate, there's a lot of concern about how, what sequences and how we should be looking at these images because you'll have local artifacts from the seeds.

It's very variable from patient to patient.

First of all, there's no standard number of seeds that get implanted in a given gland.

It's dependent on the volume of the gland.

Many of these are whole gland implants, some of them are subtotal implants.

So it's quite variable, but we just use the standard MP three sequences, again, T2 diffusion and dynamic contrast.

And you can see in this patient really without much effort on the T2 images, we clearly have tumor invading the seminal vesicle that was not there preoperatively, you can see it in the coronal plane.

You can see the radiation seeds here nicely, not distorting the image.

And then avid enhancement with the gadolinium after injection of contrast.

And so this was an advanced case and this is another one where there are more seeds and it's a little bit more complex and a little bit more difficult to interpret.

And you can see the density of seeds here.

These are all these little black dots or all the individual I 125 radiation sources implanted into the prostate.

And you can see that there's significant changes on the T two weighted images as we go down this way.

And then if you look across the top here, you see the ADC abnormality and then the dynamic contrast abnormality.

And if I click all the little red circles will show you where we believed the tumor was.

And I think, again, disorganized chaos, that smudged charcoal sign really can work even in the post-radiation patient on the T two weighted images, this is clearly a fairly significant recurrence.

And one of the tips I have on these patients is look in the places where there are no seeds, obviously, if there are no seeds there, that's an area of prostate that hasn't been treated.

And that will be the area most likely where the, where the local tumor will recur if it is a low indeed local.

So in this case, we reported that out, it's a low T2 in the area of the paucity of seeds.

And ADC was at 800 patients dynamic, DCE demonstrated a type three curve.

And we call this a right focal tumor of intermediate grade.

And this is another example of the same thing in a different patient, six weeks out after radiation, we do standardly image patients at six weeks to look at the volume of the prostate and to look and assess where the seeds are located.

And you can see here that they're somewhat peripherally located.

The placement of these seeds is not always perfect and they will end up in different places, and that's rather important occasionally for toxicity issues.

And that's essentially why we do some of these.

But you can see there's a significant area of no seeds in the middle of this prostate.

And then six months later, the PSA had passed the Phoenix criteria and was rising above nadir.

And again, the same sort of story, look at the T2 images.

That smudge sign is again there, the blurred charcoal, disorganized chaos.

And you can see a corresponding abnormality on the diffusion image here, classical example of localized and clinically significant prostate in a post radiated patient.

And lemme see if I can keep going.

So this man is a radical prostatectomy 72-year-old man.

He came in with a rising PSA and he had this CT scan.

And I will caution you when you're reading CTs, as we many of you also do in your practice, in post radical prostatectomy patients look at it as particularly if you're lucky, like they were in this case where you're doing it at the arterial phase of injection on CT, look for an enhancing nodule, which can be, this one was actually missed at the time, but we'll show you the MRIs in a minute.

But I think you can see that there is clearly an enhancing nodule in the prostatectomy bed.

The corresponding MRI shows without doubt a mass, very similar to the case Kasha just showed us on the opposite side from hers.

But you can see a T2 abnormality here, abutting the bladder neck as it comes down to the anastomotic site.

And then on the diffusion is this high signal, and then on the ADC restricted.

So these small nodules, you will see them occasionally on CT.

So be careful and look there as well.

This is just gonna show you what the red circles where everything is, again, more of the same.

I mean, it's a repetitive story, but it's just nice to keep showing these.

You can see clearly the focal abnormality in this man.

And he was presenting to us in 2004, excuse me, 2014.

You could see that mass clearly on the T twos.

You can see it here on the diffusion images anteriorly.

And my reason for showing this case is that when we went back and looked at his original MRI from 2005, which was done before we introduced diffusion imaging, I think it's fairly subtle, but it really is there.

It was missed at the time because we weren't very aware.

And I think looking back at a lot of things I've done in the past, some of these anterior lesions escaped our perception in the early days.

And there really is a focal abnormality there in retrospect that was there at baseline.

And that's the one of course that is present now in 2014 and will be treated for salvage radiation.

So I'm gonna end a little bit early to give Sadhna some time, but I wanted to just get through the, the local recurrence issues.

And I think you've seen how we can play a role in radiation therapy patients just as well as we can in the postoperative patient and remember applying the same criteria.

And the T twos will, the caveat being they will be interfered with by radiation, but as you can see, really can be very helpful as well.

Thank you very much.

Post-Treatment Recurrence After Focal Therapy: Dr. Verma

I'm gonna finish up the talk with focal therapy that's being done.

This is very exciting and new changes that are occurring in prostate cancer treatment.

And my talk's gonna be most on the recurrence after focal therapy.

So as we've already discussed earlier about Claire and Kasha, that our role is to localize this recurrence.

And this becomes even more complicated with focal therapy because now we may or may not have half or all of the gland, as I'll show you some cases.

So obviously if there's nothing there, then we just observe or if there's tissue there recurrence than we have to go on to salvage treatment.

So that's our role in focal therapeutic recurrence, just like in any other treatment.

So on T1 weighted images we look at non enhancing low intensity regions, and then on post contrast we'll look at for enhancement.

So again, for focal therapy or any therapy of the prostate dynamic contrast is the dominant sequence to see if there's recurrence.

And of course, diffusion can be helpful.

And if that doesn't help and the patient has renal insufficiency, you may consider spectroscopy.

But anyway, dynamic contrast is most commonly used.

So as Claire's already mentioned, that in radiation, the ASTRO criteria, which is definition of PSA failure three consecutive times, and then they went on to redefine it as the Phoenix criteria, which is the lowest PSA nadir plus two nanograms per ml of rise is used in focal therapy as there is nothing that's defined for focal therapy.

Most of the people doing focal therapy use this typical radiation therapy kind of definition for biochemical recurrence.

So protocol and T2 we use a coil and you can use a 1.5 or three Tesla, but staging is important here, I feel, because often these recurrence patients do may have lymph nodes, et cetera.

So I do do a staging type of pre exam to evaluate those.

Now, as you can imagine, in general focal, you know, prostate is multifocal, et cetera.

So there are hurdles just to the focal therapy issue.

So accurate risk stratification is key, and obviously cancer must be correctly identified and then precisely ablated.

But that's not the case these days because as I'll show you, focal therapies is quite a wide range of treatments.

There are no standard criteria, defined tumor persistence or progression, and no standardized tools to follow up schedules to monitor patients after focal therapy.

That makes my talk real easy.

But unfortunately, you know, that's the way these days.

So this is the biochemical failure definition.

And given the lack of evidence of standardized definitions, people either do biopsies or image at different points after focal therapies.

And this is the other problem.

So true focal therapy obviously is this where you go and precisely ablate the lesion, but there's this form where they ablate the entire, the half of the gland, or they could do 75% of the gland.

And I really don't know how this is focal therapy, but that this is considered focal therapy as well.

So that's where we are right now.

So obviously with these type of treatments, you get high rate of complications reported after current focal therapies, whether it be HIFU or cryosurgery cryotherapy, and you get in precise treatment targeting and monitoring.

And that leads to unintended injuries of the rectum and neurovascular bundles worse than if they just had the prostate removed in many cases.

So this is going to be something that's evolving and it's definitely in the very early stages right now.

Patient has to also agree to be have careful and frequent follow up of all.

So this is an example of a patient who had multifocal tumor, and as you can see that he underwent cryotherapy.

And the gland, you know, if you go from posterior to anterior is only the transition zone somewhat is visible, but the entire gland was taken.

I mean, he did have extensive, he had the entire right side and the left mid gland and his PSA was, you know, nadir was 0.5 and it began to rise.

This recurrent, you can see this focal T2 weighted image, you see this nodule, but really you wouldn't be able to call that unless you had some diffusion sequences.

And DCE contrast, which enhanced right here and on B 2000, even though you don't see the, you know, the, a lot of artifact, it really lights up.

So this was recurrence.

This, these are images given to me by Hash from the UCL group, and they've done a lot of HIFU and have follow up.

And this actually shows this big lesion on DCE that a week after HIFU hemi ablation, and then as you go on six months later, it starts to retract.

And so these are the kind of things we may see as we follow these patients.

And not only that it retract, but a small amount of normal tissue will also enhance.

So that's something we have to be careful as we follow this with post contrast, if we see a little bit of enhancement adjacent to a lesion of ablation.

This is a patient from Cincinnati who had, who flew to Puerto Vallarta and got his hemi ablation done using the HIFU treatment.

And we don't have his pre-op exam, so I don't know initially we had how much disease he had, but they ablated the entire gland.

And you can see the peripheral zone on the right, the transition zone, but there's really nothing on the left side.

So the entire left side was gone.

But then he the PSA dropped and then started to rise where they wanted to get an MRI.

And on the T2 weighted images, can't tell much, but you know, and I almost wish I didn't see this on the functional sequences, but there's actually when you look at more closely on the high resolution T2, there is a little bit of a darker high intense, somewhat not circumscribed nodule that is low ADC and focal enhances.

So they did a fusion biopsy and this was Gleason 3+3, which you know, he's just elected to follow and we've had three year follow up on him.

So what about this?

Well, this is the complete near total gland.

He had bilateral disease.

Again you see there's hardly any gland there, but then you, when you, when they come in, do functional sequences, it lights up on both ADC, sometimes on ADC as well, and then the DCE, so they all look the same, but so DCE is the main sequence we use for locally recurrent disease, whether it be from radiation, HIFU, cryo, et cetera.

This is an example given to me by Andy.

And this is after photodynamic therapy or vascular targeted photodynamic treatment.

This is somewhat of a science fiction type treatment where they use foil.

And there's actually a good article by Dr. Hader in radiology on this.

So this this was a hemi ablation treatment with then you don't see much of the left gland and after Hemi ablation, and this was in 2010 and they started have rising PSA and then when you, when they followed with DCE further down, if you go, you know, it enhances focal recurrence.

So this, as you see over and over these lesions, any treatment they have when there's recurrence, they look all the same.

So whether it be post prostatectomy radiation, and now in focal therapy, the enhancement's gonna occur, focal in that area, you know, where there's focal tissue on T2.

Now we really would like focal therapy to be more focal therapy, precisely precise ablation.

They are few ways we can do that through MR guided and Claire's got a nice talk on that, but I'll just show a few examples that actually showing how focal focal treatment that can be useful for recurrence.

So not just to see recurrence after focal, you know, this was for cryoablation or other treatments they had and then they had recurrence again.

And how these devices can be helpful to treat those as well.

So for instance, this is a patient who had cryoablation and then came back with this focal nodule that has low ADC and dark bright on high B value exam.

His PSA was rising, this was local recurrence.

He opted for laser MR guided laser treatment and went to Desert Medical Imaging where they treated this.

And you can see the focal area that's been treated.

So you can, it becomes a dark hole basically around where the treatment is and no matter which treatment they do, and I'll show you a couple other examples, this is form, this focal boost was done on this patient.

And so but he had recurrence.

So there's on T2, you can't tell anything on ADC, there's focal restricted area that lights up on the B 1500 and his PSA was rising.

And then he also chose to go to Desert Medical Imaging and got his treatment done there.

But all these patients have this, you know, basically no enhancement initially, and then you can follow 'em.

There's really no rules. Some people follow 'em six months or so.

This is something that they're doing.

MR Guided HIFU in Israel, some image given to me by these folks.

And again, this was, this lesion is being treated and you can see that basically it creates a big circular defect.

This is from Jurgen and they do focal MR guided cryo treatments.

And this is a nice example where a 64-year-old man who had radiation treatment in 2007, he had a PSA rise in 2010.

And MRI showed the focal recurrence in the right peripheral zone.

And they treated this using focal cryoablation.

And then again, just like the other treatments, it just creates a big black hole.

And this is focal cryoablation 2011, and then he starts to have rise in PSA again.

So you got an MR again, and then there's enhancement, this blue arrow showing area of focal recurrence after cryoablation using MRI.

So this is a nice example where you can go back and so there's if we have nice imaging, we can not only treat the initial tumor followed up and then perhaps re-treated there, there's really no end as opposed to the salvage radiation, et cetera, if they get initial radiation treatments.

This is an example in the Mayer group was doing a lot of these laser treatments for focal recurrence and this is David Woodland's case where enhancing tumor in the left mid gland, and again, they put the ice ball and then basically it creates a big hole just like any other treatments.

And there's no enhancement in that treatment.

So no matter what the treatments are, they usually, you know, they'll create a basic void of tissue.

The goal, our goal is to follow these and see if there's any focal enhancement, nodular enhancement and for recurrence obviously.

So but I think there's image does offer improved accuracy and detection of these recurrence, especially for focal treatment because PSA may or may or may not work as well.

And however, further work is needed for understanding and formation of new and location of recurrent disease and have some idea on PSA surveillance.

Thank you.