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MR guided prostate biopsy in 65-year-old male

Case Study
Schoth, Felix, M.D. RWTH Aachen University Hospital Germany
Weibrecht, Martin, PhD Philips Healthcare Germany

Patient history

A 65-year-old male presented with PSA level.

Previous biopsies and histoscanning were negative. One 12-core biopsy at age 63 (PSA 5.33, free PSA 0.35, ratio 0.07) and one 24-core biopsy at age 64 (PSA increased to 10.11) did not demonstrate abnormalities. When PSA level remained high (6.5 ng/ml at age 65), patient was referred to Urology department of UH Aachen. Histoscanning was performed but did not demonstrate suspect lesions.

MR examination

Diagnostic MR is performed after fasting (>6h) and clyster to inhibit peristaltic motion. The Endorectal and SENSE Cardiac coils are used. The Endorectal coil is applied after DRE (digital rectal examination) and filled with Micropaque to reduce artifacts at the coil-tissue boundary. The exam is based on the ExamCard by Pete Choyke, MD of NIH-NCI
MR sequences used are:
1. Survey
2. T2 TSE sagittal (3 mm slice, recon 0.27 mm in-plane)
3. T2 TSE axial (3 mm slice, 0.27 mm in-plane)
4. 3D_PRESS
5. T2 TSE coronal
6. WIP SSh_DWI
7. T1 TSE axial
8. DCE (100 time points, 1/s)

Interventional MR is done after obtaining informed consent. One day before intervention antibiotic therapy of 6 days duration is started. Fasting (>6h) before intervention, clyster, buscopan to inhibit peristaltic motion.
The SENSE Flex-L coil is used. With this coil it easier to position patient than with the Flex-M coil and it provides better SNR for large patients. After postioning coils, DRE is done to locate the prostate and place the needle sleeve of DynaTRIM.
The MR sequences used are again based on the same ExamCard. The procedure is:
1. Survey
2. T2 TSE sagittal
3. Calibrate DynaCAD with actual needle sleeve
4. T2 TSE axial to locate lesion
5. Biopsy planning using DynaCAD and adjust the device
6. Survey to plan verification scan
7. T2 TSE Verification scan (along main axisx of needle sleeve
8. Correct needle sleeve position if necessary (and verify)
9. Perform biopsy (2 samples per location)
10. Continue at 5. for next suspicious lesion


1. Left apical lesion (established tumor site):

Diagnostic exam results

 T2w axial MRI T2w sagittal MRI of same lesion
T2w axial MRI
T2w sagittal MRI of same lesion
A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were
 Diagnostic MR data analysis
Diagnostic MR data analysis

A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were recorded during a diagnostic MRI using an endorectal coil. Also,an suspect time series was found in the diagnostic scan in this location.

Interventional MR

 T2w axial MRI with SENSE Flex-L at intervention
T2w axial MRI with SENSE Flex-L at intervention
A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were
 Biopsy planning screen
Biopsy planning screen

The suspicious region was located on the anatomical pre-biopsy scan in the interventional session and targeted as shown on image.

2. Right median lesion:

Diagnostic MR

 T2w axial MRI sagittal T2w MRI of second lesion
T2w axial MRI
sagittal T2w MRI of second lesion
A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were
 Diagnostic MR data analysis
Diagnostic MR data analysis
A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were

Interventional MR

 T2w axial MRI at intervention
T2w axial MRI at intervention
A suspect T2 hypointense area apical in the left peripheral zone can be delineated in the axial T2-weighted image and sagittal T2 weighted image. Together with the DCE study these images were
 Biopsy planning screen
Biopsy planning screen

Within the transition zone a high contrast enhancement could be detected as shown on image, while no suspected areas were visible on the T2 weighted axial and sagittal scans during a diagnostic MRI, which was performed using an endorectal coil and 6-channel SENSE cardiac. This region was re-identified on the anatomical pre-biopsy scan in the interventional session and targeted as shown on image. The histological examination did not confirm a prostate cancer in the site.


Diagnosis

This biopsy revealed a Gleason score 3+4 prostate carcinoma. A second, right median lesion was also biopsied, which resulted in findings negative for cancer but indicative for chronic prostatitis. The patient will undergo prostatectomy.

Clinical impact of MR image guided prostate biopsy:

The lesion was clearly visualized with Achieva 3.0T. With the advent of MR guidance, prostate biopsy is easier for both patients and physicians, which helps to correctly biopsy the lesion and characterize it.


Related reading:



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Case Study
Achieva 3.0T
Release 2.5, Release 2.6, Release 3.2
Quasar, Quasar Dual
biopsy, Body, prostate, Prostate, Spectroscopy
 

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