Genitourinar y Imaging • Original Research

Wassberg et al.
MRI Detection of Cancer Recurrence After Radical
Prostatectomy

Genitourinary Imaging
Original Research The Incremental Value of
Contrast-Enhanced MRI in the
Detection of Biopsy-Proven Local
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Recurrence of Prostate Cancer

After Radical Prostatectomy:
Effect of Reader Experience
Cecilia Wassberg1 OBJECTIVE. The purpose of this study is to retrospectively assess the incremental value
Oguz Akin1 of contrast-enhanced MRI (CE-MRI) to T2-weighted MRI in the detection of postsurgical
local recurrence of prostate cancer by readers of different experience levels, using biopsy as
Hebert Alberto Vargas1
the reference standard.
Amita Shukla-Dave1,2
MATERIALS AND METHODS. Fifty-two men with biochemical recurrence after
Jingbo Zhang1 prostatectomy underwent 1.5-T endorectal MRI with multiphase contrast-enhanced imaging
Hedvig Hricak1 and had biopsy within 3 months of MRI. Two radiologists (reader 1 had 1 year and reader 2
had 6 years of experience) independently reviewed each MRI study and classified the like-
Wassberg C, Akin O, Vargas HA, Shukla-Dave A,
Zhang J, Hricak H lihood of recurrent cancer on a 5-point scale. Areas under receiver operating characteristic
curves (A z) were calculated to assess readers’ diagnostic performance with T2-weighted MRI
alone and combined with CE-MRI. Interobserver agreement was assessed using Cohen kap-
pa statistics.
RESULTS. Thirty-three patients (63%) had biopsy-proven local recurrence of prostate
cancer. With the addition of CE-MRI to T2-weighted imaging, the A z for cancer detection in-
creased significantly for reader 1 (0.77 vs 0.85; p = 0.0435) but not for reader 2 (0.86 vs 0.88;
p = 0.7294). The use of CE-MRI improved interobserver agreement from fair (κ = 0.39) to
moderate (κ = 0.58).
CONCLUSION. CE-MRI increased interobserver agreement and offered incremental
value to T2-weighted MRI in the detection of locally recurrent prostate cancer for the rela-
tively inexperienced reader.

Keywords: contrast-enhanced MRI, locally recurrent
prostate cancer, MRI, prostate cancer, prostatectomy
DOI:10.2214/AJR.11.6923
Received March 27, 2011; accepted after revision
November 7, 2011.
The study was funded by National Institutes of Health
grant RO1-CA076423. H. A. Vargas was supported by the
Peter Michael Foundation.
1
Department of Radiology, Memorial Sloan-Kettering
Cancer Center, 1275 York Ave, New York, NY 10065.
Address correspondence to O. Akin (akino@mskcc.org).
2
Department of Medical Physics, Memorial Sloan-Ketter-
ing Cancer Center, New York, NY.
AJR 2012; 199:360–366
0361–803X/12/1992–360
© American Roentgen Ray Society
R
adical prostatectomy (RP) is a
common form of treatment of lo-
calized prostate cancer [1–3].
Studies with long-term follow-up
have shown that up to 40% of men who un-
dergo RP will experience recurrent disease
manifesting initially as an increasing serum
prostate-specific antigen (PSA) level [4, 5].
Detecting the site of prostate cancer recur-
rence after RP is critical for developing an
appropriate treatment strategy. Local recur-
rence can potentially be cured by radiothera-
py, whereas distant metastasis requires sys-
temic therapy [6].
Although PSA is not specific for the diag-
nosis of prostate cancer, after RP surgery, PSA
should decrease to an undetectable level (< 0.1
ng/mL) [7]. A detectable PSA level after RP
can be due to residual benign glands, extra-
prostatic PSA production in epithelial cells,
or recurrent cancer [8–10]. The most com-
monly used definition for biochemical recur-
rence after RP is a PSA value of 0.2 ng/mL or
greater followed by a further increase in PSA
[11–13]. In clinical practice, if a patient’s
PSA level increases after RP, prostate cancer
recurrence is suspected and a clinical work-
up is initiated. Imaging plays a critical role in
distinguishing between local recurrence and
distant spread of disease [14, 15]. Although
CT and bone scintigraphy are used to identi-
fy distant metastases in the lymph nodes and
bones, respectively, transrectal ultrasound or
endorectal MRI is used to identify local re-
currence [16]. Biopsy of the prostatic fossa is
not routinely recommended, especially dur-
ing early phase relapse with low PSA values
(< 0.5 ng/mL), because of a low detection
rate [17–19].
The use of endorectal MRI has gained clini-
cal acceptance and plays an important role in
the detection of local recurrence in the prosta-
tectomy bed [20–24]. Studies have shown that
detection of local recurrence of prostate can-
cer on MRI can be improved by the addition
of contrast-enhanced MRI (CE-MRI) [20, 21,

360 AJR:199, August 2012

 MRI Detection of Cancer Recurrence After Radical Prostatectomy
23, 24]. However, the studies were performed
using single or consensus readings with var-
ious reference standards. As a result, little is
known about the impact of reader experience
on the value of combining T2-weighted imag-
ing with CE-MRI or about the effect of such a
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combined protocol on interobserver variabil-
ity. In addition, the optimal way of integrating
findings from CE-MRI and T2-weighted im-
aging and the diagnostic performance of pro-
tocols that combine the two techniques need
further evaluation. Thus, the purpose of our
study was to assess the incremental value of
CE-MRI to T2-weighted MRI in the detec-
tion of postsurgical local recurrence of pros-
tate cancer by readers of different experience
levels, using biopsy as the reference standard.
Materials and Methods
Patient Population
This retrospective study was approved by our in-
stitutional review board with a waiver of informed
consent. We reviewed the medical records and ra-
diologic databases for the period from March 2005
to December 2008 to identify all patients who met
the following inclusion criteria: 1.5-T endorectal
CE-MRI of the prostatectomy bed performed after
postsurgical biochemical recurrence of prostate can-
cer (PSA level of ≥ 0.10 ng/mL after RP and a con-
firmatory increase of PSA level ≥ 0.2 ng/mL). One
hundred forty-seven patients met the inclusion crite-
ria. We excluded patients who did not undergo biop-
sy (n = 75), who were not biopsied within 3 months
before or after the MRI (n = 18), or who had other
primary tumors on biopsy (n = 2). Thus, 52 patients
were included in the study. Table 1 summarizes the
patients’ clinical and surgicopathologic character-
istics at inclusion.
MRI Technique
Images were obtained with a 1.5-T whole-body
MRI system (Signa HD, GE Healthcare). The pa-
tients were examined in the supine position. A
body coil was used for excitation, and a pelvic four-
channel phased-array coil combined with a bal-
loon-covered expandable endorectal coil (Prostate
eCoil, Medrad) was used for signal reception. First,
transverse, coronal, and sagittal T2-weighted fast
spin-echo images were obtained (TR/TE, 4000–
6000/120; echo-train length, 16; section thickness,
3 mm with no intersection gap; FOV, 12–14 cm;
and matrix, 256 × 192). Subsequently, a transverse
T1-weighted 3D fast spoiled gradient-recalled se-
quence (TR/TE, 4.5–6.5/1.5–2.2; flip angle, 12°;
bandwidth, 62.5 kHz; section thickness, 3 mm with
no intersection gap; FOV, 12–14 cm; and matrix,
256 × 192) with fat suppression was performed be-
fore and at a minimum of three time points (25–30
AJR:199, August 2012 361
TABLE 1: Patients’ Clinical and Surgicopathologic Characteristics
Characteristic
No. of patients
Age at MRI (y), median (range)
PSA level at MRI (ng/mL), mean (95% CI)
Time between RP and MRI (mo), mean (95% CI)
Time between MRI and biopsy (d), mean (95% CI)
Gleason score at prostatectomy (no. of patients)
G6 (3 + 3)
G7 (3 + 4, n = 13; 4 + 3, n = 11)
G8 (4 + 4, n = 5; 5 + 3, n = 2)
G9 (4 + 5, n = 8; 5 + 4, n = 2)
Unknown
Positive surgical margins (no. of patients)
Extracapsular extension (no. of patients)
Seminal vesicle invasion (no. of patients)
Note—PSA = prostate-specific antigen, RP = radical prostatectomy.
aHistopathologic reports listing pathologic stage were not available for three patients included in the study
because they underwent RP at a different institution.
seconds, 1 minute, and 3 minutes) after IV injec-
tion of 0.1 mmol/kg body weight dose of paramag-
netic contrast medium (gadopentetate dimeglu-
mine; Magnevist, Bayer HealthCare) by means of
a power injector with an injection rate of 2 mL/s,
followed by a 20-mL saline flush.
MRI Interpretation
All MRI studies were retrospectively and inde-
pendently reviewed by two readers who were aware
that the patients had post-RP biochemical recur-
rence of prostate cancer but were blinded to the pa-
tients’ other clinical and histopathologic findings.
Each reader independently scored each case ac-
cording to his or her estimate of the likelihood that
local recurrence was present on a 1–5 index scale
(1, definitely absent; 2, probably absent; 3, indeter-
minate; 4, probably present; and 5, definitely pres-
ent). Both readers first interpreted and assigned a
score on the basis of T2-weighted imaging alone (in
the axial, sagittal, and coronal planes). In the same
sitting, the readers then recorded a second score
on the basis of both T2-weighted imaging and CE-
MRI (the CE-MRI was performed in the axial plane
only). Reader 1 was a board-certified radiologist
and had 1 year of experience interpreting endorec-
tal MRI; reader 2 was a board-certified radiologist
and genitourinary specialist with 6 years of experi-
ence interpreting endorectal MRI.
Local recurrence was suspected if an area of
slight hyperintensity to surrounding muscles was
seen on T2-weighted imaging, particularly if the
area had a nodular appearance and if it showed
greater enhancement than the surrounding muscles
Value
52
66 (43–80)
2.2 (1.3–3.2)
85 (75.6–107.2)
15 (6.2–24.9)
8
24
7
10
3a
17
24
11
on CE-MRI. Each reader recorded the number, lo-
cation, and largest transverse diameter of recur-
rent tumors; tumor margins (well-defined or ill-de-
fined); presence of invasion of adjacent structures;
and the type of MRI sequence on which the lesion
was best seen (T2-weighted MRI or CE-MRI). Ac-
cording to published literature [20–24], locations
of suspected recurrence were classified as peri-
anastomotic (around the urinary bladder or mem-
branous urethra), retrovesical or bladder wall (be-
tween the urinary bladder and rectum and within
the urinary or bladder wall), within retained sem-
inal vesicles, or at the anterior or lateral surgical
margins of the prostatectomy bed.
Standard of Reference
For all patients, the reference standard was
histopathologic findings of tissue specimens ob-
tained by biopsy (transrectal ultrasound–guided
biopsy in 46 patients and transurethral bladder bi-
opsy in six patients). A patient was considered to
have local recurrence if the biopsy result showed
malignant cells consistent with prostate cancer. To
avoid potential bias based on a false-negative bi-
opsy result, a patient was considered free of local
recurrence only when the biopsy showed benign
tissue and 1-year follow-up showed stable PSA,
stable PSA and no change on follow-up endorectal
MRI, or negative repeat biopsy.
Statistical Analysis
The Fisher exact test was used to examine the
association between the initial surgical pathology
Gleason score and the recurrent pathology Gleason
 Wassberg et al.

TABLE 2: Gleason Scores From Surgical Pathology and Postoperative MRI Results
Biopsy Results From the 33 Patients for Whom Biopsy Results Receiver operating characteristic analysis
Were Positive for Local Recurrence of Prostate Cancer (Fig. 1) showed that adding CE-MRI to T2-
Radical Prostatectomy Histopathology Gleason Score, weighted imaging significantly (p = 0.0435)
Recurrent Carcinoma Gleason Score No. of Patients improved diagnostic accuracy for reader 1
(the less-experienced reader), increasing the
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G6
G7
G8
G7
G7
G8
G9
G8, G9
G9, G9
G6–9, poorly differentiated prostate cancer
G6–9, prostate adenocarcinoma, not further specified
score. The area under the receiver operating char-
acteristic curve (Az) was calculated to measure di-
agnostic accuracy for T2-weighted MRI alone as
well as T2-weighted MRI plus CE-MRI and was
graphically plotted for each reader. Sensitivity,
specificity, positive predictive value, and negative
predictive value were calculated (scores 1–3, no
suspicion of tumor; scores 4–5, suspicion of tumor)
for T2-weighted MRI alone and T2-weighted plus
CE-MRI for each reader. A p value of 0.05 or less
was considered to indicate statistical significance.
To assess interobserver agreement regarding the
presence or absence of local recurrence on a per-
lesion level, Cohen kappa statistics were calculat-
ed for T2-weighted MRI as well as T2-weighted
MRI plus CE-MRI findings. Kappa values were in-
terpreted as follows: less than 0.20 indicates poor
agreement, 0.20–0.39 indicates fair agreement,
0.40–0.59 indicates moderate agreement, 0.60–
0.79 indicates substantial agreement, and 0.80 or
higher indicates excellent agreement. A kappa val-
3
Az from 0.77 (95% CI, 0.65–0.90) to 0.85
1
(95% CI, 0.74–0.96); for reader 2, the Az in-
2 creased from 0.86 (95% CI, 0.76–0.96) to 0.88
16 (95% CI, 0.77–0.98), but the difference was
8 not statistically significant (p = 0.7294). When
MRI scores of 1–3 were considered negative
4
and scores of 4–5 were considered positive,
4 sensitivity in the detection of local recurrence
3 increased with the addition of CE-MRI from
1 73% (95% CI, 55–87%) to 88% (95% CI, 72–
97%) for reader 1 and from 91% (95% CI, 76–
4
98%) to 100% (95% CI, 89–100%) for read-
6 er 2, whereas specificity increased from 68%
(95% CI, 43–87%) to 74% (95% CI, 49–91%)
year of follow-up of each of these 19 pa- for reader 1 and remained at 58% (95% CI,
tients showed stable PSA (n = 12), stable 34–80%) for reader 2. Tables 3 and 4 show the
PSA and no change on follow-up endorectal readers’ sensitivity, specificity, positive pre-
MRI studies (n = 5), or negative repeat biop- dictive value, and negative predictive value for
sy (n = 2). In the latter two cases, repeat bi- using T2-weighted MRI alone and T2-weight-
opsies were performed 13 and 69 days after ed MRI plus CE-MRI together at different cut-
the initial biopsy. off points of the MRI suspicion scale.
Table 2 shows the Gleason scores from In determining the presence or absence of
initial surgical pathology and postsurgical local recurrence with T2-weighted MRI alone,
biopsy for patients with local recurrence. readers agreed in 71% of cases (κ = 0.39, in-
Gleason scores were provided in the biopsy dicating fair agreement). With the addition
reports of 23 patients, of whom 15 (65%) had of CE-MRI to T2-weighted MRI, the readers
a higher Gleason score on biopsy than at RP agreed in 83% of cases (κ = 0.58, indicating
(p = 0.04). moderate agreement).
1.0 1.0
0.9 0.9
0.8 0.8
0.7 0.7
Sensitivity (%)

Sensitivity (%)

ue of 1 would indicate perfect agreement, and kap- 0.6 0.6

pa of 0 or less would indicate no agreement other
0.5 0.5
than what would be expected by chance.
To further assess the impact of CE-MRI on 0.4 0.4
a per-lesion basis, increases or decreases in the 0.3 0.3
readers’ 5-point scale for the likelihood of recur-
0.2 0.2
rent cancer were recorded, and the numbers of le-
No discrimination No discrimination
sions correctly and incorrectly reclassified after 0.1 T2WI Reader 1, Az = 0.77 0.1 T2WI + CE-MRI Reader 1, Az = 0.85
T2WI Reader 2, Az = 0.86 T2WI + CE-MRI Reader 2, Az = 0.88
inspection of CE-MRI were determined. 0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
1 − Specificity 1 − Specificity
Results
Clinical Results A B
Of the 52 patients in the study, 33 (63%) Fig. 1—Receiver operating characteristic (ROC) curves.
had biopsy-proven local recurrence of pros- A and B, Graphs show accuracy of reader 1 and reader 2 for T2-weighted imaging (T2WI) alone (A) and T2WI
tate cancer. In 19 patients (37%), biopsy plus contrast-enhanced MRI (CE-MRI) (B). With addition of CE-MRI, area under ROC curve (A z ) increased
significantly for reader 1 (p = 0.0435) but not for reader 2 (p = 0.7294). Curves reflect that adding CE-MRI
was negative for local recurrence (benign improves interobserver variability. Sensitivity is defined as true-positive rate, and 1 − specificity is defined as
tissue or postoperative fibrosis); at least 1 false-positive rate.

362 AJR:199, August 2012

 MRI Detection of Cancer Recurrence After Radical Prostatectomy

TABLE 3: Diagnostic Performance of Endorectal T2-Weighted Imaging (T2WI) Alone and T2WI Plus Contrast-
Enhanced MRI (CE-MRI) for Detection of Local Recurrence of Prostate Cancer With 5-Point Scoring
System Dichotomized as Scores 1–3 (No Suspicion of Tumor) and Scores 4–5 (Suspicion of Tumor)
Sensitivity, % (No./Total) Specificity, % (No./Total) Positive Predictive Value, Negative Predictive Value,
Reader, Imaging Techniques [95% CI] [95% CI] % (No./Total) [95% CI] % (No./Total) [95% CI]
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Reader 1
T2WI 73 (24/33) [55–87] 68 (13/19) [43–87] 80 (24/30) [61–92] 59 (13/22) [36–79]
T2WI plus CE-MRI 88 (29/33) [72–97] 74 (14/19) [49–91] 85 (29/34) [69–95] 78 (14/18) [52–94]
Reader 2
T2WI 91 (30/33) [76–98] 58 (11/19) [34–80] 79 (30/38) [63–90] 79 (11/14) [49–95]
T2WI plus CE-MRI 100 (33/33) [89–100] 58 (11/19) [34–80] 80 (33/41) [65–91] 100 (11/11) [72–100]

TABLE 4: Diagnostic Performance of Endorectal T2-Weighted Imaging (T2WI) Alone and T2WI Plus Contrast-
Enhanced MRI (CE-MRI) for Detection of Local Recurrence of Prostate Cancer With 5-Point Scoring
System Dichotomized as Scores 1–2 (No Suspicion of Tumor) and Scores 3–5 (Suspicion of Tumor)
Sensitivity, % (No./Total) Specificity, % (No. Total) Positive Predictive Value, Negative Predictive Value,
Reader, Imaging Techniques [95% CI] [95% CI] % (No. Total) [95% CI] % (No. Total) [95% CI]
Reader 1
T2WI 94 (31/33) [80–99] 37 (7/19) [16–62] 72 (31/43) [56–85] 78 (7/9) [40–97]
T2WI plus CE-MRI 97 (32/33) [84–100] 42 (8/19) [20–67] 74 (32/43) [59–86] 89 (8/9) [52–100]
Reader 2
T2WI 100 (33/33) [89–100] 21 (4/19) [6–46] 69 (33/48) [54–81] 100 (4/4) [40–100]
T2WI plus CE-MRI 100 (33/33) [89–100] 37 (7/19) [16–62] 73 (33/45) [58–85] 100 (7/7) [59–100]

Descriptive Tumor Statistics
The readings of the more-experienced radi-
ologist were used to calculate descriptive sta-
tistics in cases where the radiologists disagreed.
There was substantial agreement regarding the
location of recurrent tumors (κ = 0.87). There
was a discrepancy between the readers in the
location of recurrence in six of 312 (1.9%) pos-
sible locations (six locations in each of the 52
patients). The locations for the biopsied recur-
rent tumors in the prostatic fossa were perianas-
tomotic in 16 patients (48%) (Fig. 2), retrovesi-
cal or bladder wall in 10 patients (30%) (Fig.
3), within retained seminal vesicles in five pa-
tients (15%), anterior or lateral surgical margins
in one patient (3%), and other (pelvic sidewall
or perirectal) in one patient (3%). The median
recurrent lesion size (i.e., maximal transverse
dimension) was 20 mm (range, 9–69 mm).
Thirty-one of the 33 biopsy-proven recurrenc-
es (94%) were well defined in relation to sur-
rounding tissue, whereas the other two (6%)
were ill defined. Invasion of adjacent structures
was noted in the rectum in 11 (33%) recurrent
lesions, in the bladder wall in 10 (30%) recur-
rent lesions, in the levator muscle in five (15%)
recurrent lesions, and in the pelvic sidewall in
three (9%) lesions.
The readers agreed that 82% (27/33) of
the lesions were better defined in relation to
surrounding organs with the addition of CE-
MRI to T2-weighted imaging. Adding CE-
MRI to T2-weighted imaging allowed cor-
rect reclassification and increased certainty
(i.e., correct upgrading or downgrading of
the likelihood of recurrence) in 13 patients
(25%) for reader 1 and six patients (12%) for
reader 2 (Figs. 4 and 5).
Discussion
Up to 40% of patients who undergo RP for
localized prostate cancer will have biochem-
ical recurrence. Localization of recurrent
prostate cancer is crucial for appropriate pa-
tient management, and MRI is gaining accep-

Fig. 2—71-year-old man 15 years after radical

prostatectomy for Gleason 7 (4 + 3) tumor. Follow-
up showed biochemical recurrence with elevated
prostate-specific antigen level of 0.52 ng/mL.
A, Transverse T2-weighted image shows 12-mm
nodule (arrow) suggestive of local recurrence in
posterior part of vesicourethral anastomosis.
B, With addition of contrast-enhanced MRI, less-
experienced reader correctly upgraded lesion (arrow)
from 4 to 5 on 5-point likelihood of recurrence scale.
A B

AJR:199, August 2012 363

 Wassberg et al.
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A
Fig. 3—77-year-old man 12 years after radical prostatectomy for Gleason 7 (4 + 3) tumor. Follow-up showed
biochemical recurrence with elevated prostate-specific antigen of 0.2 ng/mL. Transverse contrast-enhanced 850
MRI (CE-MRI) was performed.
A, CE-MRI at four time points (30 s, 1 min, 2 min, and 3 min) in this patient shows enhancement in 20-mm local 750
recurrence (arrows) in left bladder wall, with highest signal intensity at 1 min after injection.
B, Corresponding signal enhancement–time curve shows difference in contrast enhancement between
650
recurrent carcinoma and pelvic muscle.

Signal Intensity (AU)

550
Recurrent lesion
450 Pelvic muscle

350

250

150

50
0.0 60 120 240
Time (s)

tance as the most accurate imaging method
for identifying sites of local recurrence after
RP [20–26]. Our findings indicate that adding
CE-MRI to T2-weighted endorectal MRI can
facilitate postoperative detection of local re-
currence by relatively inexperienced readers.
Specifically, we found that, for a radiologist
with 1 year of experience reading endorectal
MRI, the addition of CE-MRI significantly
improved recurrent tumor detection, result-
ing in a level of diagnostic accuracy similar to
that of a radiologist with 6 years of experience
reading endorectal MRI. Furthermore, add-
ing CE-MRI to T2-weighted imaging mark-
edly improved interreader agreement.
Our results are in accordance with those
of two previous studies on the detection of
postoperative local recurrence, in which the
addition of CE-MRI to T2-weighted im-
aging significantly increased sensitivities
(from 48–61% to 84–88%) and specificities
(from 52–82% to 89–100%) [20, 21]. An-
other study [24] compared the accuracy of
CE-MRI alone and in combination with MR
spectroscopic imaging in patients at high risk
of local recurrence after RP; in the detection
of local recurrence, the use of CE-MRI alone
yielded an A z of 0.93, whereas the use of CE-
MRI combined with MR spectroscopic im-
aging yielded an A z of 0.96.
Substantial variability in accuracy due to
differing levels of reader experience has been
reported as an important concern in studies
of MRI of the prostate [27, 28]. However,
to our knowledge, the impact of reader ex-
perience on the value of CE-MRI for detect-
ing postoperative local recurrence of prostate
cancer has not previously been analyzed. Our
results are in agreement with those of a prior
study, which found that adding CE-MRI to
T2-weighted MRI significantly improved the
performance of two relatively inexperienced
readers in staging primary prostate cancer
but did not significantly benefit a more expe-
rienced reader [29]. Research has also shown
that a dedicated interactive training curricu-
lum in endorectal MRI can significantly im-
prove inexperienced readers’ accuracy in the
detection and staging of primary prostate
cancer [30].
In our study, the most common location for
local recurrence was perianastomotic (48%);
this finding was in concordance with earli-
er studies, in which 45–52% of recurrent le-
sions were perianastomotic [20, 24]. The
second most common location of local recur-
rence in our study was retrovesical or bladder
wall (30%). Conversely, Sella et al. [22] found
that retrovesical or bladder wall was the most
common location for local recurrence, with
40% of lesions, whereas perianastomotic was
the second most common, with 29% of le-
sions. The rate of recurrence in retained sem-
inal vesicles was 15% in our study, as com-
pared with 22% and 6% in studies by Sella et
al. [22] and Sciarra et al. [24], respectively.
Prior studies have used a variety of refer-
ence standards for local recurrence after RP,
most often biopsy, a significant PSA decrease
after external-beam radiation therapy, or fol-
low-up imaging with an increase of at least
20% in recurrent tumor size [20–22, 24].

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 MRI Detection of Cancer Recurrence After Radical Prostatectomy
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A B C
Fig. 4—73-year-old man 10 years after radical prostatectomy for Gleason 7 (4 + 3) tumor of pathologic stage pT3A, with left extracapsular extension but no seminal
vesicle invasion. Follow-up showed biochemical recurrence with elevated prostate-specific antigen level of 2.17 ng/mL.
A, Transverse T2-weighted image shows 20-mm soft-tissue mass (arrow) suggestive of local recurrence located retrovesically in residual tissue of left seminal vesicle.
B and C, On contrast-enhanced MRI 1 minute (B) and 3 minutes (C) after injection, clear enhancement (arrows) could be seen. Transrectal ultrasound–guided biopsy
verified Gleason score 7 local recurrence.

Fig. 5—66-year-old man 4 years after radical

prostatectomy for Gleason 7 (3 + 4) tumor. Follow-
up showed biochemical recurrence with elevated
prostate-specific antigen of 0.19 ng/mL and palpable
nodule at digital rectal examination.
A, Transverse T2-weighted image shows 22-mm
nodule (arrow) suggestive of local recurrence in right
posterior part of vesicourethral anastomosis.
B, With addition of contrast-enhanced MRI (CE-MRI),
level of suspicion did not increase for either of the
two readers, both of whom had assigned a score of
5 according to T2-weighted imaging; however, CE-
MRI allowed both readers to better demarcate local
recurrence (arrow) in relation to surrounding organs.
Transrectal ultrasound–guided biopsy verified
Gleason score 7 local recurrence.
A B

Interestingly, we found a trend toward high-
er Gleason scores at the time of local recurrence
than at surgery, reflecting histopathologic pro-
gression. More than half the patients with re-
current cancer who received a Gleason score
at RP had a higher Gleason score on postsurgi-
cal biopsy. To our knowledge, only one previ-
ous study has specifically investigated upgrad-
ing of prostate cancer at local recurrence after
surgery, and it found a similar, though not sta-
tistically significant, trend [31].
Our study had a number of limitations, in-
cluding its retrospective design. Because it
was performed at a tertiary care cancer cen-
ter, the results may not be generalizable to
other settings, because patient demographics,
image acquisition, and interpretation exper-
tise may vary across institutions. There is
also a sample selection bias because we in-
cluded only patients who underwent biopsy;
this selection bias may be reflected in the rela-
tively large mean diameter of the recurrent le-
sions and relatively high sensitivities found at
MRI. Furthermore, some patients were excluded
because they had a biopsy performed more
than 3 months before or after the MRI. We
chose 3 months as a cutoff to avoid the clinical
scenario in which disease progression or re-
currence would develop in the interval be-
tween the MRI and the biopsy, interfering
with our measurements of diagnostic accura-
cy. In addition, the number of patients studied
was relatively small, and the standard of refer-
ence used was not perfect, because a negative
biopsy result could not rule out recurrence
(though follow-up was at least 1 year for all
patients with benign biopsy results to mini-
mize this bias).
In conclusion, our results show that adding
CE-MRI to T2-weighted MRI increases ac-
curacy in the detection of postoperative local
recurrence of prostate cancer by relatively in-
experienced readers and improves agreement
between readers of differing levels of experi-
ence. Furthermore, the enhancement observed
in recurrent tumors on CE-MRI is useful for
defining the relationship of the tumor to sur-
rounding organs—information that may be
crucial for planning further local treatment.
Acknowledgment
We thank Ada Mueller for editing the
manuscript.
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