18 In-bore & MR US Fusion

Overview of Experience with MR Biopsies

I'm gonna summarize a little bit on both.

I do the inor MR biopsy using transrectal approach,
and I've also have experience
with three different fusion systems.

A little bit on both,
but I think a lot has already been covered.

I'm gonna give more case examples.

The Need for Change in Biopsy Practices

Obviously you see today that,
if we don't change the way things are done,
it's not gonna make difference.

If we keep doing these tra blind biopsies,
it doesn't help if we can obviously target.

Things have changed that come a long way.

It used to be a novelty to do these procedures.

And really now I hear from a lot of practices calling,
saying they wanna learn prostate MR
because the urologists wanna do the biopsy,
using a fusing fusion technique.

Things have come a long way.

It's gonna be routine, it's very routine already, and,
and you'll see in your practices as you go along,
that it's gonna be very commonplace.

It's obviously rapid area of evolution.

Cognitive and Fusion Approaches

I'm not gonna go into these because everybody's already
discussed the cognitive approach where you're friendly,
urologist calls you and you go in the OR
or wherever they're doing the biopsy
and triangulate the lesion in your mind and biopsy.

Or you can do these either direct inbo
or fusion protocol a little bit.

I use a diagnostic approach for these.

I do a lot of my cases are staging.
'cause when I tell the urologist I'm just wanna do
detection, they're like, well, I wanna know the stage.

And so since the insurance companies only pay once I end up doing
a staging exam initially.

So I do do a diagnostics staging scan.

You could use either 1.5 or three Tesla,
and I do use indirect coil because of that reason.

But only on the first on the follow ups have stopped
using the INAL coil and a MULTIPARAMETRIC approach.

In-Bore Biopsies and Detection Rates

Now in in board biopsies,
they've obviously shown an improved detection rates.

In most studies, at least one negative trust guided biopsy,
or in many, two or more prior negative biopsies.

The detection rates rates were much higher
with the targeted biopsy.

And this is one of the studies, this is one
of the earlier studies, but a large number
of patients from NYIMA that showed in patients
who've had multiple negative transrectal ultrasound biopsies.

So the blue correlates with two negative biopsies,
and the red is three or,
and then the green was the MR guided biopsy.

So you can see in all the PSAs here,
actually it did much better except
in the very large volume.

And these corresponded to very 65 cc are
above prostate glands,
where it was still better, but not as much.
'cause these patients have already been sampled enough.

And probably the PSA et cetera was related
to their volume of disease.

MR Guided Biopsy Process

So the MR guided biopsy, I the start out
with the diagnostic multiparametric mr.

And then you use combination of couple
of functional sequences for the transrectal approach.

And you've seen this a couple of times today.

This is the biopsy device,
and here's the guide needle that's attached.

So the guide needle is put in trans rectally,
and then this device is connected to it.

And then you can see these planning sequence
sequences while you're doing the biopsy.

The needle guide is directed towards the lesion.

And then the guidance sequences are performed.

And this is these are the parameters on the biopsy device
calibration and et cetera that can help you.

And you do this all outside the scanner
and make adjustments as needed
and do oblique axial and sagittal planes.

The software assists the needle placement,
providing automated adjustment parameters for the needle.

Nowadays, we even have longer needles.

So the anterior lesions are not a problem to obtain.

Initially, we weren't able to get in very far.

Anteriorly of the gland was very large.

And after acquiring a biopsy specimen, you can do a
verification scan where you actually image
with a needle in place.

And so obviously this approach is the most precise.

And here's showing you
that you know exactly where you went in.

The prep is similar to traditional trust biopsy.

It can take a few minutes.

If you take several targets, I try to limit to two.

But sometimes there are just no an MR scan,
just like anything else, you just have no control.

If certain sequence doesn't work out
or the patient moves, you have to readjust things.

So you'd have to kind of take into account at least an our
time to do these, even though it may take much less.

And if it's just one
or two targets, now with if you've done enough,
it'll take about 35 to 40 minutes.

Total, obviously you do reduce number of core so
that you're only targeting specific lesions.

Case Examples of In-Bore Biopsies

And as you show you some examples,
here's a 61-year-old pastor who came from Michigan
with a rising PSA, he'd been to several states,
already had negative multiple biopsies.

So his story started in 2005
where his PSA was 5.3
and he went on to 2008, at which point he'd had multiple cores and they were all negative.

So he comes in and he gets this scan,
and this is a T two weighted image.

So if you look at it here, peripheral zone,
you see something here, not quite sure,
but this peripheral zone here looks good.

And if you look around here,
there's just too much, it's just too dark.

It's not very low T two,
but there's definitely something that you would look
that's asymmetric on the left side.

And so on this, on py rads, you could give this T two.

I noticed there was a little bit
of a nodule here.

So I actually gave this a T two,
I would give this a four.

But you know, if you didn't,
you could give this a three as well.

And so if you go on on diffusion, there's a
there's a nodule that you see.

And on perfusion was very positive too.

And this was a on a high B 2000 was bright,
so this would be a would be a four on on py rads,
it's a one centimeter lesion.

So because it's not one and a half centimeter.

And so to because I'm the last speaker,
and I feel like you've been sitting
all day listening too hard.

I thought I would introduce some humor.

So I call these, and you've seen plenty of these today,
these anterior lesions, the mc hammer lesion
because the urologist can't touch the stone.

Alright, so this guy, by the way, it had five,
five negative biopsies and estimated cords of 51 cores.

Of course when we did the biopsy,
we can see that precisely where the needle is,
nice.

This was a Gleason seven.

He underwent a radical prostatectomy
and hopefully blessed me as well.

So anyway, the guy who was rising PSA negative biopsy,
and this is a another big prostate with a large
low T two area here, very high superiorly.

I mean, they could biopsy I don't know how many,
they had already had 60 core negatives.

They could continue and they'll never get this
because this is so superior.

And these are the kind of iceberg type
lesions, which you're never gonna get.

And this is low T two and so on.

Rads, this is a fairly significant mass,
and this would be close to one
and a half, give up T two, pyres five.

This is a transition zone.

So T two is gonna be the dominant sequence here.

And on a DC, this is fairly low.

This was bright on on height, so this would be a pyres five,
all the way on diffusion as well.

And then this was biopsied
and this was Gleason eight disease.

So targeted biopsies are necessary,
especially in these patients who've had negative,
multiple negative biopsies.

There's really no reason to continue
to do multiple transrectal biopsies
because we have ways to do better now.

Ultrasound Fusion Biopsy

Switching gears now into more into fu the ultrasound fusion.

This is a time.

So we've had a couple of different systems.

I think both Dan
and Peter explained most
of the tech technical issues with them.

I'm gonna just show some examples.

This is a patient who had who rising PSA,
he had negative trust biopsy and underwent fusion biopsy.

But on the mr, you see on T two,
this is very mildly hyperintense.

On T two, the rads here would be about three.

On on a DC, you do see low A D C,
but this was not bright on the high B 2000.

So again, this would be kind of a three lesion.

And since this is peripheral zone, and
this is the diffusion predominance here,
this was RAD C this was biopsied, and this was Gleason six.

Follow-Up on Active Surveillance

He came back, so he got followed.

The next year we do yearly MRIs on some of these patients.

One of the urologists likes to do every two years.

There are no guidelines as to how you follow these,
but most of the urologists in my practice follow these
yearly on active surveillance.

So there was no change in 2011.

He comes back in 2000 13, I guess.

In 11 and 12, there's no change In 13, he,
this nodule is now a little bit more discreet.

Now, here on on T two, this is a peripheral zone nodule.

This is discrete, this would be a four.

And a DC is dark.

This was now bright on the high B 2000.

And so this becomes a py rads form.

He did get a biopsy, a fusion biopsy.

And then this was a seven.

Fusion Biopsy Process

So in terms of fusion biopsies themselves,
I'll just show, so you know, you've seen how this, all
of them require segmentations.

There there are many different systems available.

I use particular Artemis,
but this one, they all require some sort of,
you have to do the segmentation first.

And so here, as Dan also showed you,
you do the the volume segmentation in all,
I do it in three planes.

You can just do it in two and then it'll
propagate all the way through.

It'll also then you can then go on to mark the regions of interest
and it gives you a nice 3D volume there.

And then you can mark lesions that are suspicious,
that you think are suspicious.

So there's a lesion, the peripheral zone,
and then there's another lesion.

You know, you can I mark up to three.

I try to keep it even on fusion biopsies, not
to go crazy and do too many lesions
because again, we're assessing clinically significant
disease and it'll give you a nice 3D volume.

So and that's what sent the
the T two and that's sent to the urologists.

Monitoring Post-Prostate Cancer Treatment

What about monitoring past prostate cancer?

What about biopsies in those patients?

Again, any recurrence cases, post-treatment,
surgery or radiation,
and they have rising PSA,
you know, we can
we can localize and biopsy those using these,
any of these techniques.

The MR protocol, I keep it the same since it's simple.

I continue to use contrast.

And of course, if you've noticed today,
recurrence cases, contrast is very important.

But so I do use DC in all all the post treated patients.

Example of Post-Treatment Recurrence

So here's an example of a patient who had,
he's 57-year-old who had least in seven disease originally in the left base.

And this is not on mr, you can see the the seeds nicely
that cause this kind of a zipper kind of artifact.

And in two then he started having rising PSA went up to eight,
at which time he had mr.

And if you just look at T two weighted images, you
there's really no way to know.

But knowing
that he had seven disease in his left base originally,
always recurrence usually will occur in the site.

Originally it was, and
and sure enough, there's a little
asymmetry on the left side.

And if you look at the functional sequences,
they corroborate here, even the this spectroscopy,
but diffusion here was positive as well.

And then DCE, so this is a post-treatment recurrence.

This was biopsied
and this turned out to be Gleason seven,
again, three plus four.

Comparison of In-Gantry MR and Fusion Techniques

So in general, in gantry mr, it's most precise.

You can you have the needle in there, you can image it.

However, as everyone has mentioned,
it's longer cumbersome
and MR time is a issue until you get you know, do enough
of them to go faster in them.

But again, there's someti some things
that you cannot control, such as patient motion, et cetera.

Fusion is faster.

Traditional urologists are used to it,
but there is a true misregistration potential.

And so that's where you have to really keep in mind
and use your mr.

And using this PY rads will be very useful
because it'll help you assess the
clinically significant disease.

So if you think something is pyres four or five
and it comes out negative on one of fusion biopsies,
you need to think about it again and
and follow these patients or re-biopsy.

And I'll I have re-biopsied some of these patients.
'cause initially when we were, I started the fusion biopsy
systems, we were actually doing it in the OR
because we were using this electromagnetic system
that would stop working in the middle, et cetera.

And it was fairly involved.

Now they've become so sophisticated
that the throughput is very fast.

But again, you have
to keep in mind the misregistration potential.

So I mean there are two different ways you have
to register and both have limits limitations, of course.

Obviously you can get the target confirmation best in
the tar direct MR biopsy.

The fusion is accurate to two to three millimeters.

You can do multiple lesions and
and do them you know,
including the traditional sextant biopsies
as we do in our in our practice.

Local anesthesia.

I actually use no anesthesia for my direct MR biopsy.

I've never acquired it.

And it's worked out well.

I mean, I really have, I do use the lidocaine gel when I put
the the when I use for the core.

It's up to 15 minutes per target, so it can be timely.

Example of Targeting Based on ADC

Now this is an example, highly suspicious lesion
with heterogeneous a DC restriction.

Now you'll you know, you can target on both
of these system, but let me show you this example.

So here's a page 49-year-old physics professor
with elevated PSA and he had two negative biopsies
and of course he, this is the typical mc hammer lesion.

He's got this big lesion anteriorly.

And when you look at the A DC though,
you see some dark areas and not so dark areas.

And this is as many studies have shown
that the A DC correlates with Gleason grades.

Certainly you wanna put your needle here, not there
because when these regions were sampled this a
you know, a DC of seven 80 corresponded
to a different Gleason than the a DC of 1100.

So we have control over how we biopsy
and it's important that if you were to do this
say in a fusion biopsy system and you it was negative
and you are really thinking PY rads four
or five, you need to go back and work on that.

So based on MR results, this was
the higher Gleason grade was seen in this
a DC of seven 80 of course.

Choosing the Right Biopsy Technique

So which biopsy f technique to use it,
it really depends on your referral base.

That's what it comes down to.

Urologists do like the fusion systems,
however, if they're discordant results,
E either using your traditional you know,
when we first did cognitive or Mr.
Trusts fusion, you have to go back and re-biopsy 'em
and resources, I mean, if your department's willing
to purchase one or the other.

But again, the one thing I would like you
to take back from all of these biopsy talks is
that high index of suspicion for pirates four and five.

If those results are negative,
we need to do something about them.

Thank you.