Clare Tempany, M.D., Core PI
Prostate cancer represents one of the most significant challenges in medicine and public health facing the US healthcare system today. Its increased diagnosis has led to a virtual epidemic of the disease. The Prostate Core is working on applying an interactive comprehensive MR image-guided program for the diagnosis and treatment of localized prostate cancer. To that end, it has developed an MR-guided brachytherapy program. Since these procedures began significant advances have been made in MR guidance for localization, navigation and the delivery of therapy, like those seen today in neurosurgery. The Core is thus adapting and translating these tools and advances. MRI is uniquely suited to imaging the prostate as it allows excellent visualization of the gland, its boundary, its substructure and all surrounding tissues. Already, the Core has developed the software module MRProstateCare (in collaboration with the Computation Core) for use with the NCIGT's own computerized surgical navigational platform, Slicer, a computer navigational module for MR-guidance to help plan, control, and direct prostate biopsies.
The Core's main goal is to thus adapt recent advances in an open MR system to the diagnosis and treatment of men with prostate cancer. The challenge is to increase the information content of intraoperative image data by using multimodal features while at the same time preserving the interactivity and the near real-time features of intraoperative imaging. If this can be achieved, the precise delivery of treatment to maximize tumor control and to minimize side effects will be reached and will improve the patients quality of life after treatment. Post operative/treatment morbidity is critical to the growing number of prostate cancer patients who are choosing prostate brachytherapy as their primary treatment.
Cycle II 2010-2015
The Prostate Core has established a comprehensive MR-guided interventional program for the diagnosis and treatment of prostate cancer. We have developed imaging protocols, image registration, and image segmentation methods to guide and assist prostate image guided therapy (IGT). In this next phase, we will expand our research into new diagnostic, surgical, and radiation procedures. Our goals will focus on three major imaging research challenges involving the clinical application and quantitative assessment of multi-parametric prostate imaging, image processing and registration as well as the navigation and visualization tools for prostate interventions.
Our overall goal of this Core is to extend the MR-guided prostate intervention program. When we began, we focused on two areas, specifically: the first MR-guided prostate brachytherapy and biopsy programs. The biopsy program allows selected target sampling under real-time MR guidance. We demonstrated the procedure and the important contribution of 3D Slicer. We have shown that by sampling MR-defined targets, improvements in the diagnosis of prostate cancer can be achieved. We also demonstrated, with MR-guided brachytherapy, that sub-total treatments of the prostate can lead to very successful cancer control with excellent quality of life post-treatment. Worldwide, many groups and centers are following and adapting this approach. Others, as well as the NCIGT, are expanding diagnostic approaches and treatment options involving focal or sub-total gland treatments. Examples are cryotherapy, MRgFUS, HIFU, and photodynamic therapy. Multi-parametric MR imaging, image processing and real-time navigation and visualization tools have the potential to address many current deficiencies in these approaches.
Specific Aim 1: To develop and evaluate image-guided prostate surgery. This aim involves the development and validation of image-enhanced laparoscopic robotic prostatectomy (LRP) procedures. We will test our hypothesis that MR imaging, followed by segmentation and post-processing using the 3D Slicer, can create patient-specific MR anatomical maps that are valuable to the surgeon performing LRP. We will test our image-processing method to segment the prostate boundary, the dominant MR tumor, the neurovascular bundles (NVB), and the external urethral sphincter at the apex. We will generate 3D models of all these structures that will be provided to the surgeon in the operating room. We will determine the intraoperative value of this patient-specific, anatomical-topographical 3D map in the context of LRP. The ultimate advantage will be gained by integrating the 3D display with registered real-time intraoperative imaging.
Specific Aim 2: To improve and optimize MR-guided radiation therapy We will develop and test methods to improve and optimize radiation treatment of prostate cancer. MR guidance, using 3T MR imaging, tissue characterization, and image registration techniques should improve the planning and monitoring of the radiation dose to sub-zonal gland regions and peri-prostatic tissues. We will also develop methods to extract and study the tissue changes seen on MR, induced by radiation, over time. It will allow for the characterization of changes to normal and cancerous tissue using quantitative MR parameters obtained before, during, and after therapy. Correlation of these changes with total radiation dose delivered and the resultant clinical outcomes will provide insight into the effectiveness of radiation therapy.
Specific Aim 3: To optimize MR image guided prostate biopsy We will develop comprehensive methods to identify focal prostate lesions/targets using advanced 3T MR techniques; we will introduce enabling technologies, such as robotic-assisted needle guidance and placement. We will perform biopsy sampling with direct real-time MR in the magnet using the enabling technologies provided in part by our DBP project. We will expand our approach through the use of MR/US image registration to allow MR-enhanced transrectal ultrasound (TRUS)-guided biopsy procedures. The advanced 3T MR and multi-parametric imaging protocol will allow target identification and provide “added value” to improve accuracy in sampling the prostate. In the longer term, our goal is to use this approach to enhance focal therapy to provide an image-based lesion/target validation technique for MR-guided prostate focused ultrasound surgery (MRgFUS), a major internal collaborative research project (R01) this Core supports with the Focused Ultrasound Core.
- Afnan J., Tempany C.M. Update on Prostate Imaging. Urol Clin North Am. 2010 Feb;37(1):23-5. PMID: 20152516. PMCID: PMC2884280.
- Tokuda J., Fischer G.S., DiMaio S.P., Gobbi D.G., Csoma C., Mewes P.W., Fichtinger G., Tempany C.M., Hata N. Integrated Navigation and Control Software System for MRI-guided Robotic Prostate Interventions. Comput Med Imaging Graph. 2010 Jan;34(1):3-8. PMID: 19699057. PMCID: PMC2815337.
- Tokuda J., Fischer G.S., Papademetris X., Yaniv Z., Ibanez L., Cheng P., Liu H., Blevins J., Arata J., Golby A.J., Kapur T., Pieper S., Burdette E.C., Fichtinger G., Tempany C.M., Hata N. OpenIGTLink: an Open Network Protocol for Image-guided Therapy Environment. Int J Med Robot. 2009 Dec;5(4):423-34. PMID: 19621334. PMCID: PMC2811069.
Cycle I 2005-2010
Overall to accomplish its goals, the Image Guided Prostate Therapy Core has had in its first cycle the following aims: to adapt our approach to allow MR guided prostate biopsies to be performed so that the diagnosis and localization of prostate cancer may be improved by utilizing MR guidance for prostate biopsy; to implement and evaluate a fully integrated delivery system that will allow preoperative and intraoperative MR images of the prostate to be available on-line in the operating room (an image segmentation and registration method will be available in the operating room that will allow use of all accessible image based information for MR-guided brachytherapy); and to develop an MR and CT quality assurance program as there is a need for a reliable and accurate method to perform post-implant dosimetry.
NCIGT Projects in the which the Prostate Core provide leadership and central input are: