ROLE OF DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING

IN EVALUATION OF PROSTATE CANCER

DR. SHUBHAMOY GANTAITDNB TRAINEE(RADIODIAGNOSIS)RGCI&RC

GUIDEDR. S.AVINASH RAOSR. CONSULTANT(RADIOLOGY)RGCI&RC

Prostate cancer is the 2nd most common cancer in men accounting for 15% of all cancers diagnosed in men.

It is the 5th leading cause of cancer related deaths in men(6.6% of total men deaths).

Sixteen percent males(one in six) will develop prostate cancer in their lifetime.

The prevalence of prostate cancer increases with age.It is seen that 34% of men in 5th decade and 70% of men in 8th decade has histopathologic evidence of prostate cancer.

ZONAL ANATOMY OF MCNEAL1.Periurethral2.Transitional3.Central4.Peripheral

It contains a fibromuscular stroma in the anterior portion.It has no true capsule but an outer band of fibromuscular tissue existoutside peripheral zone mainly seen as dark area in posteriorand posterolateral aspect in T2WI

Neurovascular structures are present in posterolateral portion in5 ‘0 clock and 7’0 clock position bilaterally which send theirpenetrating branches near base and apex.These are potential sites for tumour extension.

These are potential sites for tumour extension.95% prostate cancers are adenocarcinomas of which 70% prostate cancers arise in peripheral zone,25% in transitional zone and 5% in central zone.Transitional zone is a potential location of benign hypertrophy of prostate gland.

On T2WI the normal peripheral zone has homogenous high signal intensity and the central gland has variable amounts of intermediate signal intensity.In prostate cancer the high signal intensity of peripheral zone is replaced by low signal intensity which is readily identified by trained observation.

DWI is based on the principle of brownian motion of water molecules. It is sensitive to diffusion as well as capillary perfusion of water . It is measured by Apparent Diffusion Coefficient (ADC). In proliferating cells there is an increased cellulardensity and corresponding decrease in amount of the intra and extra cellular space available ,leading to a reduction in ADC value. Malignant lesions have lowerADC values (20%-40%)than benign or normal prostatic tissue.So cancerous prostate tissue can be identified by visual inspection of the ADC mapping on the regions of interest by lower ADC values.

Extraglandular extension is identified by several observations like1.Assymetry and envelopement of neurovascular bundle2. Obliteration of rectoprostatic angle3.Irregular spiculated margin4.Low signal intensity in adjacent organs like seminal vesicle ,bladder etc.5.Pelvic lymph node involvement in T2WI.

According to Woodfield CA ,Tung GA et al DWI may help differentiate between low-risk (Gleason score, 6) and intermediate-risk (Gleason score, 7) prostate cancer and between low-risk (Gleason score, 6) and high-risk (Gleason score > 7) prostate cancer. There is an inverse relationship between the ADC and the percentage of tumor involvement on prostate core biopsies.

Ren J ,Huan Y et al has stated that Diffusion-weighted imaging and ADCs for thenormal central gland, PZ, prostate cyst, BPH nodules, and Prostate CA demonstrate significant differences, and those can be used in the diagnosis and differential diagnosis of the diseases of prostate.

Noha Md AbdelMaboud et al has concluded that the addition of ADC map and DWI to T2WI provide significantly more accurate results for prostate cancerdetection and staging. Hiroo Kajihara , Yoshiku Hayashida has studied 43 lesions in 23 patients where

6 observers identified 11-22 lesions in T2WI and 20-31 lesions in T2WI+DWIcombined and concluded that addition of DWI improves detectability of prostate cancer.

AIMS AND OBJECTIVES

PRIMARY OBJECTIVE

1.TO EVALUATE SUSPECTED CASES OF CA PROSTATE WITH DWI AND CORRELATE IT WITH HISTOLOGY

SECONDARY OBJECTIVE

1.TO EVALUATE SUSPECTED CASES OF CA PROSTATE WITH T2WI AND CORRELATE IT WITH HISTOLOGY

2. TO COMBINE THE FINDINGS OF T2WI AND DWI AND SEE WHETHER THIS MULTIPARAMETRIC APPROACH INCREASES THE SENSITIVITY AND SPECIFICITY OF PROSTATE CANCER DETECTION

MATERIALS & METHODSPLACE OF THE STUDY: RGCI & RC

SAMPLE SIZE : 100 PATIENTS AGED BETWEEN 40 AND 80 YRS.INCLUSION CRITERIA : CLINICALLY SUSPECTED CASES WITH 1.BLOOD PSA > 4 ng /ml 2.HARD PROSTATE ON DRE.

EXCLUSION CRITERIA : 1. PRIOR PROSTATIC BIOPSY WITHIN 12 WEEKS 2.PRIOR SURGICAL , HORMONAL, RADIATION THERAPY. 3.AGE < 40 YRS.DATA COLLECTION : BETWEEN JUNE 2015 AND DECEMBER 2016

MRI PROTOCOL : ALL EXAMINATIONS WILL BE PERFORMED USING INSTITUTIONAL 1.5 TESLA MRI UNIT BY SURFACE AND ENDORECTAL COIL .AXIAL , CORONAL , SAGGITALTHIN SECTION HIGH RESOLUTION T2WI THROUGH PROSTATE AND SEMINAL VESICLES HAS TO BE PERFORMED.BASED ON T2WI , DWI WILL BE OBTAINED IN AXIAL ORIENTATION THROUGH PROSTATE.ADC MAPS WILL BE GENERATED BY CALCULATING THE ADC VALUE IN EACH PIXEL OF EACH SLICE.

STATISTICAL ANALYSIS

TO CORRELATE

1. T2WI FINDINGS WITH HISTOLOGY2. DWI FINDINGS WITH HISTOLOGY3. COMBINED (T2WI+DWI) FINDINGS WITH HISTOLOGY4. TO STAGE PROSTATE CANCER BASED ON T2WI+DWI FINDINGS IN TNM SYSTEM AND CORRELATE IT WITH STAGING BASED ON OPERATIVE AND HISTOLOGICAL FINDINGS.

TNM CLASSIFICATION OF PROSTATE CANCER

T2A- TUMOUR IN LESS THAN HALF OF ONE LOBET2B- TUMOUR IN MORE THAN HALF OF ONE LOBET2C- TUMOUR IN BOTH LOBES BUT WITHIN PROSTATIC CAPSULET3A- EXTRACAPSULAR EXTENSION T3B - SEMINAL VESICAL INVASIONT4 - LYMPH NODE INVASION, URINARY BLADDER INVASION ,AND/ORBONE METASTASIS.

CASE RECORD FORM

A. NAME OF THE PATIENT B. AGE

C. CHIEF COMPLAINTS WITH DURATION

D. CLINICAL FINDINGS

E. BLOOD PSA LEVEL

F. OTHER INVESTIGATION FINDINGS

G. T2WI MRI FINDINGS H. DWI FINDINGS

I. STAGING BASED ON T2WI+DWI FINDINGS

J. HISTOPATHOLOGICAL DIAGNOSIS

K. STAGING BASED ON HISTOLOGY AND OPERATIVE FINDINGS

L. FINAL IMPRESSION

Informed Consent Form  Title of the Project: ROLE OF DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING IN EVALUATION OF PROSTATE CANCER Name of the Principal Investigator Dr. SHUBHAMOY GANTAIT Tel. No. 9560257936 I have received the information sheet on the above study and have read and / or understood the written information. I have been given the chance to discuss the study and ask questions. I consent to take part in the study and I am aware that my participation is voluntary. I understand that I may withdraw at any time without this affecting my future care. I understand that the information collected about me from my participation in this research and sections of any of my medical notes may be looked at by responsible persons (ethics committee members / regulatory authorities). I give access to these individuals to have access to my records. I understand I will receive a copy of the patient information sheet and the informed consent form. ___________________________ _________________ Signature / Thumb Impression of subject Date of signature ______________________________ Name of the subject in capitals _______________________________________ _________________ Signature of the person conducting the Date of Signature informed consent discussion _________________________________________ Name of the person conducting the Informed consent discussion in capitals

Patient Information Sheet  Title: ROLE OF DIFFUSION WEIGHTED IMAGING IN EVALUATION OF PROSTATE CANCER Introduction: You are being invited to take part in a research study. Before you decide it is important for you to understand why the study is being done and what it will involve. Please take time to read the following information carefully and discuss it with friends, relatives and your treating physician/ family doctor if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part. The following statement describes the purpose, procedures, benefits and risks of the study and your right to withdraw from the study at any point of time.  Purpose: This study involves research to compare the usefulness of a new functional MRI sequence DWI when used along with morphological imaging i.e. T2WI for detection and staging of prostate cancer . The study is looking for a minimum of 100 patients. Benefits: No monetary benefit will be given to you. We cannot and do not guarantee or promise that you will receive any benefits from the study. However, in case any abnormalities are detected, the same shall help your treating doctor in planning for further treatment accordingly.   Confidentiality: All information collected about you during the course of the study will be kept strictly confidential. The information from this study , if published in scientific journals or presented at scientific meetings, will not reveal your identity. . Contact for additional information: At any time during or after the study, you can obtain further information about the study from:- DR. SHUBHAMOY GANTAITDEPARTMENT OF RADIOLOGY, RGCI&RC, ROHINI, NEW DELHI 110085

Ethical Clearance Certificate  Subject : Reference Thesis/ Protocol submitted by Dr. Shubhamoy Gantait, 1st year DNB Resident(Radio-diagnosis),Department of Radiodiagnosis and Imaging, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi.   Project Titled: ROLE OF DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING IN EVALUATION OF PROSTATE CANCER   Status: Applied for The study will be conducted after receiving the Ethical clearance from the Institutional Ethics Committee. Date: Dr SHUBHAMOY GANTAITDNB-Trainee, RGCI & RC

EXPECTED OUTCOME

1.DIFFUSION WEIGHTED MR IMAGING IS HIGHLY SENSITIVE AND SPECIFIC IN DETECTION OF PROSTATE CARCINOMA.2.COMBINED T2WI+DWI FINDINGS INCREASES THE OVERALL SENSITIVITY AND SPECIFICITY OF DETECTION AND STAGING OF PROSTATE CARCINOMA BY MULTIPARAMETRIC APPROACH.

FINANCIAL IMPLICATION THE PRESENT STUDY HAS NO FINANCIAL REQUIREMENT AS THE INVESTIGATIONS CARRIED OUT ARE PART OF THE NORMAL PROTOCOLAND NO FUNDINGS ARE SOUGHT FROM ANY AGENCY.