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Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis - PET - MRI - PET/MRI - TOF-PET challenges - choice of scintillator - the readout - summary and outlook
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Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Mar 27, 2015

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Page 1: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET &

MRI/MRSF. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis

- PET

- MRI

- PET/MRI

- TOF-PET challenges

- choice of scintillator

- the readout

- summary and outlook

Page 2: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Advanced molecular imaging techniques in the detection, diagnosis, therapy, and follow-up of prostate cancer

F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’

Page 3: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Advanced molecular imaging techniques in the detection, diagnosis, therapy, and follow-up of prostate cancer

F. Garibaldi, Italian National Insitute of Health and INFN Rome1, gr. Sanita’

Workshop on Compton Camera Applications to Bio-medical

Imaging

Mattinata 5-7 September 2002

Frontiers in Imaging science: high performance detectors for vascular disease (brain and heart) imaging based on the latest developments in scintillators, photodetectors, and solid state materials

Rome - ISS - 12,13,14 November 2006

Page 4: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

DECEMBER 6 2006

9:00 I. Opening session (Chairman: Prof. F. Di Silverio, University La Sapienza,Rome, Italy-Prof. F.Micali,University Tor Vergata)

10:50 II. Prostate Cancer Diagnosis (Chairman: Prof. F. Di Silverio University La Sapienza, Rome, Italy)

14:30 III. New techniques (Chairman: Prof. A. Stefanini, University Pisa, A.Tubaro, University La Sapienza, Rome, Italy)

16:20 IV. Staging (Chairman:Prof.F. Micali,University Tor Vergata, Rome, Italy

DECEMBER 7 2006

 8:30 V. Therapy and follow up (Chairman: Prof. L. Miano, University La Sapienza, Rome, Italy)

14:30 VI. Satellite Technical Workshop on New Nuclear Medicine Detectors For Imaging Prostate Cancer

Page 5: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

55/100,000 55/100,000 per year in Europe per year in Europe

90009000 new cases/year in Italynew cases/year in Italy

Prostate cancer is the Prostate cancer is the most common cancermost common cancer and andthe the second leading causesecond leading cause of cancer death in of cancer death in

Italian menItalian men

INCIDENCEProstate Cancer Diagnosis: Prostate Cancer Diagnosis: MRIMRI

Page 6: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Most common solid tumor in men over 50

PROSTATE CANCER

Page 7: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

PSA levelSensitivit

ySpecificit

y

1,1 ng/ml 83,4 38,9

1.6 ng/ml 67 58,7

2.1 ng/ml 52,6 72,5

2.6 ng/ml 40,5 81,1

3.1 ng/ml 32,2 86,7

4.1 ng/ml 20,5 93.8

6.1 ng/ml 4,6 98,5

8.1 ng/ml 1,7 99,4

10.1 ng/ml

0,9 99,7

Any Cancer (n.: 1225) VSAny Cancer (n.: 1225) VSNo Cancer (n: 4362 pts)No Cancer (n: 4362 pts)

Thompson IM, JAMA 2005

PSA: Sensitivity and Specificity

0

50

100

150

200

<4 4 e 10 10 e 20 >20

Distribuzione casi per range di PSA

No K

K

PSA remains an important prognostic markers of the biological potential of newly diagnosed prostatic cancer and the best marker to evaluate treatment outcome.

It will be a challenge to the medical community to change the long- held notion that there is a “normal” PSA value at which to recommended biopsy.

PSA proxy as Age, PSA Density, PSA velocity, Free PSA, ACT-PSA, BPSA can help the physician in the decision making process.

Future markers or tools for the early detection of clinically significant prostate cancer and to avoid unnecessary biopsy are strongly needed.

Cutoff?

Page 8: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Recent INDICATIONS for BIOPSY

• Abnormal PSA level

• DRE + false negative

false positive

BIOPSY

• TRUS (hypoechoic lesion)

• normal DRE and PSA

Not necessarily

BIOPSY

PROSTATE CANCER

Page 9: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

PSA

DRE TRUS

CONCLUSION

I level

II level

BIOPSY

MRI and Spectroscopy

Page 10: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

BIOPSIA PROSTATICA ECOGUIDATABIOPSIA PROSTATICA ECOGUIDATA

1234 56

LA NEOPLASIA PROSTATICA

Volume < 50 g8 prelievi

Volume > 50 g12 prelievi

Tot.(%)

TP(%)

TR(%)

p≤

Ritenzione acuta 1.3 1.5 1.1 ns

Ematomaperiprostatico

0.3 0.8 0 ns

Ematoma perineo-scrotale

0.3 0.8 0 ns

Sepsi 0.3 0 0.6 ns

Tot. (%)

TP (%)

TR (%)

p≤

Febbre 1 0.8 1.1 ns Difficoltà minzionali 7.1 7.2 7 ns Dolore persistente (>48h) 1.3 2.3 0.6 ns Disuria persistente (>48h) 2.7 1.6 3.5 ns Ematuria persistente (>24h) 25.2 26.8 24.1 ns Microematuria (>10/campo) 16.3 15.8 16.7 ns Leucocituria (>10/campo) 1.7 1.6 1.8 ns Infezioni urinarie 1.7 2.4 1.2 ns

Page 11: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

ECOGRAFIA TRANSRETTALEECOGRAFIA TRANSRETTALECON DOPPLERCON DOPPLER

LA NEOPLASIA PROSTATICA

Page 12: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

55/100,000 55/100,000 per year in Europe per year in Europe

90009000 new cases/year in Italynew cases/year in Italy

Prostate cancer is the Prostate cancer is the most common cancermost common cancer and andthe the second leading causesecond leading cause of cancer death in of cancer death in

Italian menItalian men

INCIDENCEProstate Cancer Diagnosis: Prostate Cancer Diagnosis: MRIMRI

Page 13: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

State of Art

*Catalona WJ, Smith DS ,Ornstein DK et al. JAMA 277: 1452-1455, 2004**Langer JE et al. Semin Roentgenol 34: 284-294,,2004

DRE

PSASensibility

PSA level ≤ 4.0 ng/ml 67.5 - 80% PSA level > 4.0 ng/ml 60 - 70%

TRUS

Normal DRE and PSA

< 4.0 ng/ml

Do not exclude prostate cancer*

DIAGNOSTIC PITFALLS• 30% palpable lesions at DRE

False Positive high rate• 20% hypoechoic lesions

are truly malignant**

EARLY DIAGNOSIS PITFALLS EARLY DIAGNOSIS PITFALLS

Prostate Cancer Diagnosis: MRI

Page 14: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

MRI: Morphologic Imaging

75 - 90% (97% for known lesions)

low score for lesions < 5 mm Carcinoma of the Prostate Gland: MRI Imaging with Pelvic Phased-Array Coils vs Integrated Endorectal-Pelvic Phased-Array Coils. Radiology 1994;193:703-709

Prostate Cancer Diagnosis: MRI

Sensitivity for Prostate Cancer

Page 15: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

55% High false positive scores

(low intensity areas at T2 mapping)

Prostate Cancer: Effect of Postbiopsy Hemorrhage on Interpretation of MR Images. Radiology 1995;195:385-390

Prostate Cancer Diagnosis: MRI

MRI: Morphologic Imaging

Specificity for Prostate Cancer

Page 16: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -

Prostate Cancer

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Single Photon:111In-ProstaScint

PET:11C-choline11C-acetate18F-fluorocholine (FCH)

Prostate

Rectum

Collimator

GammaImager

Source

Image Plane

1st Detector

2nd DetectorScatteredγ - Rays

S. Majewski Jefferson Lab

W. Moses LBL

N. Clinthorne. Michigan

Page 37: Multimodality imaging: prostate cancer diagnosis and follow up by TOF-PET & MRI/MRS F. Garibaldi – INFN Roma and ISS - importance of ear;ly diagnosis -
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. Magnetic Resonance spectroscopic imaging (MRSI) provides a noninvasive invasivemethod of detecting small molecular markers (metabolites) within the cytosol or in extracellular spaces of the prostate and is performed in conjunction with high spatial resolution (.55 x .55 mm, x 3 mm) anatomic imaging.

• Commercial packages to perform prostate MRI/MRSI in a clinical settingare becoming available and Multi-site clinical trials of prostate MRI/MRSIare underway.s