1. Performance Characteristics of mpMRI at Centers of Excellence Peter Choyke, MD National Cancer Institute

2. Optimizing Prostate MRI Before the MRI – Dedicated personnel who: Access medical records Obtain history PSA Prior biopsy results with location and Gleason score Understand the purpose of the examination Safety check for implants Evacuate bladder and bowel

3. Optimizing Prostate MRI During the MRI – Assure patient comfort to reduce motion – 3T or late model 1.5T with or without ERC Dedicated Technologist(s) Same machine – High quality T2 (no fat sat) – Diffusion weighted MRI Use b values between 100-1000 for ADC High b value image above 1500 – DCE MRI with temporal resolution <7 sec Carry out to 4 minutes

4. Optimizing Prostate MRI After the Exam – Rapid structured report PI-RADS v2 format PI-RADS Map – Images transferred to workstation for MR-US fusion biopsy Segment the prostate Localize the lesions Follow-up on path report

5. The PIRADS v2 mapping Schema

6. Limitations Total Hip Replacement Motion Obesity False borders of the tumor – Careful correlation with histology – Corona effect

7. Patient-Specific MR-based Mold Shah et al. Rev Sci Instrum. 2009 Oct;80(10):104301 (Research Highlight for Oct’09 issue) Tissue Blocks Obtained from Prostatectomy Specimen Virtual Mold T2W 3D PrintingMold Printed at CIT, NIH Marcelino Bernardo

8. Follow-up of Ablations Requires careful uniform imaging in followup Surrogates of residual disease: – Enhancement – DWI – PET agents?

9. Pre-treatment T2W MRI Pre-treatment ADC map Pre-treatment DCE MRI Post-treatment T2W MRI Post-treatment ADC map Post-treatment DCE MRI

10. PET Imaging of Residual Disease 58, M, PSA=8.2 Gleason 3+4 tumor

11. Summary Center of Excellence requires attention to detail before, during and after the MRI There are a number of important limitations of MRI in performing/monitoring ablation that must be acknowledged MRI for followup of ablation can be non- specific. – Newer PET agents may be helpful in detecting recurrence