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MR image guided prostate biopsy in 73-year-old male

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

MR image guided prostate biopsy in 73-year-old male with suspected prostate cancer

Patient history

A 73-year-old male with PSA level rising for 5 years, even after short drop following Finasterid therapy. Previous TRUS biopsies were negative.

When PSA level reached 12. ng/ml at age 70, a TRUS guided 12-core biopsy was performed. Findings included prostatitis and hyperplasia but no prostate cancer. Half a year of Finasterid therapy reduced PSA to 3.9. Another TRUS biopsy with 14 cores provided the same findings as before, i.e. no confirmation of prostate cancer. Subsequently, the PSA level continuously increased to 27.8 ng/ml at age 73 despite continued Finasterid therapy.

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 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 and clyster to inhibit peristaltic motion.
The SENSE Flex-L coil is used. With this coil its easier to position patient than with the Flex-M coil and the Flex-L 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

Diagnostic exam results

 T2-weighted axial T2-weighted coronal
T2-weighted axial
T2-weighted coronal
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,
 Diagnostic MRI data analysis
Diagnostic MRI data analysis

Diagnostic MR images show a suspicious T2-hypointense area in the right apical peripheral zone of the prostate.


MR-guided biopsy procedure

 T2-weighted axial
T2-weighted axial
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,
 Biopsy planning screen
Biopsy planning screen

The biopsy procedure again starts with an anatomic scan to visualize the right apical lesion (marked in image). The biopsy planning screen provides the settings for the biopsy device and the pre-calculated position of the biopsy needle overlaid on the anatomical scans.

Diagnosis

A Gleason score 3+4 prostate carcinoma was diagnosed from this biopsy. Findings from other biopsied lesions were negative for cancer, some showed prostatitis. In the follow-up, histology of pelvic lymphadenectomy revealed lymph node involvement despite negative abdominal CT. The proposed treatment was external beam radiation therapy.

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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Jul 4, 2011

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

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