1. Declaration of Relevant Financial Interests or Relationships Speaker Name: J. Tokuda I have no relevant financial interest or relationship to disclose with regard to the subject matter of this presentation.

2. Preliminary Accuracy Evaluation of 3T MRI-guided Transperineal Prostate Biopsy with Grid Template J. Tokuda 1, K. Tuncali 1, I. Iordachita 2, S-E. Song 1, A. Fedorov 1, S. Oguro 1, A. Lasso 3, F. M. Fennessy 1, Y. Tang 1, C. M. Tempany 1, N. Hata 1 1 Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA 2 The Johns Hopkins University, Baltimore, MD, USA 3 School of Computing, Queen’s University, Kingston, ON, Canada Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761

3. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Introduction

4. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 MRI-guided Prostate Biopsy Alternative to conventional Transrectal ultrasound (TRUS)-guided biopsy – Better delineation of prostate and substructures – For patients with rising PSA level and negative TRUS- guided biopsies Approaches – Transperineal biopsy in 0.5 T open MRI [1] – Transrectal biopsy in 1.5 – 3T closed- bore MRI with supporting devices [2, 3] [1] D’Amico AV et al., J Urol, 2000; 164(2):385-387 [2] Susil RC, et al. Magn Reson Med 2004;52(3):683-687. [3] Hambrock T, et al. Invest Radiol 2008;43(10):686-694.6.

5. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 MRI-guided Prostate Biopsy Transperineal Prostate Biopsy in 3 T MRI? – Superior image quality to 1.5 T MRI – Better approach for lesions in central gland – Suitable for patients who are unable to have: TRUS / MRI with endorectal coil transrectal guiding device Needs for supporting devices / software for transperineal prostate biopsy in 3T MRI – Wide-bore (70 cm) 3T MRI

6. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Objectives Development of device/software to support transperineal prostate biopsy guided by wide- bore 3T MRI – Prostate intervention table – Template calibration using fiducial frame – Navigation software Feasibility study: targeting accuracy evaluation – Preliminary evaluation in first 5 patients in ongoing clinical study

7. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Materials and Methods

8. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Prostate Intervention Table Supporting a patient in lithotomy position (A) Base board (B) Leg support (C) Stationary frame (D) Template (plexiglas) (E) “Z-frame” (A) (B) (C), (D) (E) (D) (B)

9. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Template Calibration Calibration by Z-shaped fiducial (Z-frame) – Automatic estimation of position and orientation of Z- frame from cross-sectional image – 3D FLASH (Matrix: 256x256x20, FOV: 16cm) Z-frame Template

10. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Navigation Software 3D Slicer [4] with ProstateNav Plug-in module [5] – Registration of pre- and intra-procedural images using B-Spline deformable registration – Target planning – Template calibration – Hole selection – Confirmation [4] http://www.slicer.org/ [5] Tokuda J, et al. Comput Med Imaging Graph, 2010; 34(1):3-8

11. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Workflow Initial setup > Adjust leg holders Drape / cleaning Stationary frame Template and Z-frame > Adjust template position > Template registration Needle Insertion

12. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Workflow Initial setup > Adjust leg holders Drape / cleaning Stationary frame Template and Z-frame > Adjust template position > Template registration Needle Insertion

13. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Workflow Initial setup > Adjust leg holders Drape / cleaning Stationary frame Template and Z-frame > Adjust template position > Template registration Needle Insertion

14. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Workflow Initial setup > Adjust leg holders Drape / cleaning Stationary frame Template and Z-frame > Adjust template position > Template registration Needle Insertion

15. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Workflow Initial setup > Adjust leg holders Drape / cleaning Stationary frame Template and Z-frame > Adjust template position > Template registration Needle Insertion

16. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Clinical Study Core biopsy needle – 18G / diamond-shaped tip * Imaging – Tumor identification with preprocedural MRI ** (T2w, DWI, DCE-MRI) with endorectal coil *** – Planning with intraprocedural T2w MRI (2D TSE) **** – Confirmation image (2D FISP) **** *MRI Bio Gun, E-Z-EM, Westbury, NY **Signa HDx 15.0 (3T), GE Healthcare, Waukesha, WI ***MEDRAD eCoil, MEDRAD Inc., Warrendale, PA ****MAGNETOM Verio 3T VB17, Siemens AG, Erlangen, Germany

17. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Targeting Accuracy Evaluation First 5 patients (age: 57 – 73) 2D root mean square error (RMS) between: – Center of needle artifact on confirmation image – Planned target No consideration of error in depth direction Sampling 20 mm core along needle axis

18. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Results

19. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Real-time MRI of Needle Insertion * 5 times faster than actual speed

20. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Results in 5 Cases 2D targeting error: 4.9 mm All cases successfully completed – Mean number of target locations: 4 / case – Mean number of cores: 7 / case – Mean time of procedure: 107 ± 15 min. Case #12345 # of target locations23546 # of cores468611 Targeting error (mm)5.16.02.57.53.9 Duration of procedure (min)10510011090130

21. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Discussion and Conclusion

22. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Discussions and Conclusions Targeting error is less than the error in MRI- guided prostate biopsy in 0.5 T open MRI (6.5 mm) [6] Possible error sources: – Miscalibration of the template – Gap between holes on the template (5 mm) – Needle bending MRI-guided prostate biopsy in wide-bore 3T MRI using prostate intervention table and 3D Slicer was feasible [6] Blumenfeld P., et al. J Magn Reson Imaging 2007; 26(3):688-694

23. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Related Presentations (Oral) 53: Tuncali K, et al. 3T MRI-guided ransperineal Targeted Prostate Biopsy: Clinical Feasibility, Safety, and Early Results. Session:Prostate Cancer @ Room 518 ‐ A ‐ C Date/Time:Monday, May 9, 12:48-13:00 (E-poster) 3055: Fedorov A, et al. Hierarchical Image Registration for Improved Sampling during 3T MRI-guided Transperineal Targeted Prostate Biopsy Date/Time:Thursday, May 12, 13:30-15:30 Presentation:14:30-15:00 (Poster) : Franco F, et al. Correaltion of Histology from MR-guided Transperineal Prostate biopsy with Multiparametric MR Imaging: A Feasibility Study. Session: Prostate Cancer (Clinical Studies) Date/Time: Tuesday, May 10, 13:30-15:30

24. ISMRM 2011 Tokuda et al : Accuracy of 3T MRI-guided Prostate Biopsy 3761 Acknowledgements This work is supported by R01CA111288, P41RR019703, P01CA067165, U01CA151261, and U54EB005149 from NIH. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Authors thank Angela Kanan, Nancy Trane, Colleen Huether, and other nurses and MR technicians for their help.