Magnetic Resonance Therapy: The Prostate program

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Magnetic Resonance Therapy The Prostate program

• Clare Tempany MD
• Director, MRT Program leader Core Leader

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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

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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

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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 DAmico /CT)
• CALGB trial
• Schering Oncology grant
• 1997 MRT brachytherapy program
• 1999 1st NIH R01 grant (AG R01 19513)
• 8/05 427 men treated

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MR Appearance Normal prostate
Axial T2W
Sag T2W
CG
PZ
E COIL
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Prostate MR image interpretation

• Tumor
• T2W/T1W image Low signal
• Capsule
• Neurovascular Bundles
• Seminal vesicles
• Nodes
• Bones

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Focal right sided tumor with ECP
Sag T2W
Axial T2W
PZ
PZ
CG
Tumor
Tumor
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Clinical problems rx of prostate Ca

• Inc Clinical Cases
• QOL issues
• Morbidity
• IGT
• MR/TRUS
• Image quality
• IGT Neurosurgery program

1.5T normal prostate
0.5T normal prostate
1997 state of the art
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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

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Prostate cancer imaging and Brachytherapy
program
MR IMAGE

• Pre clinical testing, feasibility testing and
  Clinical trial, designed and established by Drs
  DAmico Tempany
• 1997 First patient treated in MRT (GE Signa SP
  0.5T)
• Pt selection criteria-
• T1C, PSAlt10,
• GGlt 34
• Ecoil- no extra-glandular disease

TREATMENT PLANNING
NEEDLE PLACEMENT
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Contouring PZ, urethra and rectum
Axial T2W image Treatment plan
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Needle Placement
Additional Needles Necessary?
Needle Insertion
Next Needle
Yes
Yes
RT Imaging Cor,Sag,Ax
Radio logic Evaluation
Dosimetric Evaluation
Place Seeds
No
No
Dose Evaluation Plan Modification
Reposition Needle
Feedbacks Anatomic Geometric Dosimetric
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Brachytherapy planning Software
US PATENT OFFICE Radiation seed implant method
and apparatus. JCR098-01pA 2001, Nov 1.
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MR-guided prostate biopsy program

• Clinical need
• TRUS high false negative
• MR Bx Target Sextant/octant
• Need target validation method
• Need free-hand or Robot assisted approach

TARGET
3D-Slicer adapted for prostate procedures and
target definition, trajectory planning and
guidance
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MR guided biopsy protocol

• Pre-biopsy
• MR imaging
• Define any targets
• T2W
• Contrast
• MRSI
• LSDI
• T2 maps

• Biopsy
• Open MRT
• Transperineal
• Targeted sampling
• Systematic sampling (Sextant/Octant)
• Site specific pathology

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MRI/MRSI Data Summary
Up to 1024 Prostate spectra
Data from UCSF Kurhanewicz et al
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Multi-parametric and multi- modal data problem
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11C Choline PET/MRI
FUSION
MRI
PET
Courtesy of J. Czernin, MD Ahmanson Biological
Imaging Center, David Geffen School of Medicine
at UCLA
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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

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Interfractional Motion from Serial CT Movement
AP 1cm
IGT requires dynamic imaging to monitor delivery
Rapid image processing registration
Courtesy of Andrew Zitman MD (MGH)
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Recent case Rising PSA 4 years after
brachytherapy
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MR/MRSI guided biopsy Rx
Adenocarcinoma Anterior TZ
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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 DAmico 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
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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 model- Vaezy S et al
• Feasible for treating Breast Fibroadenomas-Hynenen
  K, et al
• Feasible for treating uterine Leiomyomas-Tempany
  et al

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Future directions MR guided Focused Ultrasound
Surgery for Prostate cancer
FUS THERMO-COAGULATION
Real time MR thermometry
necrosis
R01 CA-109246-01 A1 Tempany