Haroon Rashid

Prostate Cancer Imaging
Haroon Rashid
Learning Objectives
 Review general concepts related to prostate cancer, including its clinical features,
anatomic landmarks, and imaging patterns.
 Summarize the strengths and limitations of prostate cancer imaging modalities.
 Describe the role of the different imaging modalities in several clinical contexts:
 Detection
 Staging
 Active surveillance
 Biochemical recurrence
Prostate Cancer
General information
Prostate cancer is the most common solid cancer in men worldwide. It usually grows slowly and may not
show symptoms in the initial phase. Urinary symptoms are the most common clinical manifestation.
Adenocarcinoma is the most common histologic type.
Screening
Screening has been done with a PSA test and digital rectal examination. If the tests suggest an increased
likelihood of prostate cancer (PSA ≥4.0 ng/mL or abnormal DRE), prostate biopsy is usually indicated.
New studies with screening through imaging methods are discussed.

Prostate Cancer
Prostate Biopsy (Histologic Diagnosis)
Systematic biopsy
10-12 cores are randomly obtained from the prostate, guided by TRUS.
MRI-targeted biopsy
After identifying areas of interest at MRI, the images are merged with the real-time TRUS images, allowing
targeted biopsies to specific lesions.
In-bore MRI-guided biopsy

Enables a visual MRI-controlled sample acquisition with needle-in documentation for patients with
previous negative systematic biopsy results and positive MRI findings. It allows even small lesions to be
sampled and helps detect more clinically significant cancer and less clinically insignificant cancer than
systematic biopsy, although it is more costly, more time-consuming, and less available.
Prostate Cancer
Gleason Score and International Society of Urological Pathology (ISUP) Grade Group Classification System
The Gleason score determines the histologic degree of aggressiveness of a tumor, and the sum of the two
generates the final score. The ISUP grade group refines Gleason score prognostic capacity.
ISUP grade group Gleason score Gleason pattern

1 ≤6 ≤3+3
2 7 3+4
3 7 4+3
4 8 4+4, 3+5, or 5+3
5 9 or 10 4+5, 5+4, or 5+5
Prostate Cancer
Clinically Significant Prostate Cancer Definition (PI-RADS v2.1)
- ISUP grade ≥2 (Gleason score ≥7), and/or

- Volume ≥0.5 mL, and/or
- Extraprostatic extension
TNM Staging: American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC)
The TNM staging system for prostate cancer is based on five criteria:
- Extension of the primary tumor (T): clinical (cT) and pathologic (pT) T stage
- Spread to nearby lymph nodes (N)
- Spread to other parts of the body (M)
- PSA level at diagnosis
- Histologic grade group (based on results of prostate biopsy or surgery)
- cT: based on information from the prostate biopsy, digital rectal examination, and imaging studies
- pT: based on surgery and tissue analysis
Prostate Cancer
Treatment
Treatments include external radiation therapy (in some cases, combined with brachytherapy to increase the
radiation dose to the primary tumor) with androgen deprivation therapy and radical prostatectomy
combined with extensive pelvic lymph node dissection.
Follow-up
After treatment, monitoring of PSA levels is important to determine if any disease was not resected and if
additional therapy is indicated:
- Undetectable PSA: continue to monitor serum PSA level
- PSA does not go undetectable or increases its serum levels: residual disease or biochemical recurrence is
presumed. Evaluate for metastatic disease and determine therapy and subsequent therapy
Prostate Cancer
Active Surveillance
Patients with low-risk, low-grade (Gleason 6), slow-growing tumors confined to the prostate gland may
consider monitoring of prostate cancer in its localized stage until further treatment is needed to halt the
disease at a curable stage. These patients may be followed with periodic evaluations with PSA, DRE,
prostate biopsy, and imaging examinations.
Biochemical Recurrence
Biochemical recurrence is an increase in PSA levels in patients who have had treatment with a curative
purpose for localized disease, in the absence of clinical or radiologic signs of recurrence.
Most accepted cutoffs: PSA level >0.2 ng/mL across two measures (and rising) after radical prostatectomy
or PSA level ≥than 2.0 ng/mL above the nadir after radiation therapy
Prostate Anatomy and Imaging Features
The main anatomic views and prostatic segmentation are shown in this scheme as a basis for FS FS
the detailed explanations of each segment in the next slides. Cranial
CZ - Central Zone PZ - Peripheral Zone SV - Seminal Vesicles PU - Prostatic Urethra TZ TZ

TZ - Transition Zone FS - Fibromuscular Stroma ED - Ejaculatory Duct PZ PZ
CZ
SV SV SV Base
FS
TZ TZ
CZ
CZ ED ED CZ PZ
FS
PU Base
ED
TZ
Base Mid Gland
TZ TZ Mid Gland FS
PZ TZ TZ
Mid Gland
PU PZ
PZ PZ Apex Caudal
Apex Apex
Sagittal Coronal Axial
Base
Axial T2WI
Mid Gland
Seminal vesicles – The seminal vesicles are located posterosuperiorly to the prostate. An
ejaculatory duct leaves each vesicle and enters the posterior surface of the prostate below the
bladder, draining into the prostatic urethra.
Apex
Bladder – It is in intimate contact with the prostatic base.
Base
Axial T2WI
Mid Gland
Neurovascular bundles - Pass posterolaterally to the prostate (at 5 and 7 o’clock) and emit
branches at the prostatic base and apex.
Apex
Base
Axial T2WI
Mid Gland
Retroprostatic angle - Fatty space between the posterior region of the prostate and the rectum.
Prostatic capsule - It is formed by a fibromuscular tissue with low T2WI signal intensity that
involves the prostate in different regions: anterior (where it is more deficient), lateral (where it
Apex
merges with the levator fascia), and posterior.
Base
Axial T2WI
Mid Gland
Peripheral zone - Located posterolaterally, it extends from the base to the apex of the prostate,
surrounding the prostatic urethra at the apex and surrounding the central gland posterolaterally,
from the base to the middle one-third of the gland. Origin of 75% of neoplasms. High
Apex symmetrical and homogeneous signal intensity at T2WI.
Base
Axial T2WI
Mid Gland
Central zone - Located around the ejaculatory ducts, composed of stroma, with low signal
intensity at T2WI. Origin of 5% of neoplasms.
Prostatic capsule - It is a linear fibrous tissue with low signal intensity at T2WI, formed by
Apex supporting connective tissue that separates the transition zone and the peripheral zone.
Base
Axial T2WI
Mid Gland
Transition zone - Involves the prostatic urethra, predominantly at the base. Heterogeneously
low signal intensity at T2WI. Origin of 15%-20% of neoplasms.
The central gland is formed by the union of the central zone and the transition zone. In a
Apex prostate with BPH, as in the example above, it can be difficult to differentiate the central zone.
Base
Axial T2WI
Mid Gland
Fibromuscular stroma - Aglandular region located in the anterior part of the prostate. Low
signal intensity at T2WI.
Prostatic urethra - It passes anteriorly to the central zone at the base and posteriorly to the
Apex transition zone. At the apex it is surrounded by the peripheral zone. The distal urethra is
characterized as a small ring of low signal intensity at T2WI.
Base
Coronal T2WI Sagittal T2WI
The images on the left show the prostate of

a 20-year-old patient, with emphasis on the
Mid Gland
peripheral zone, central zone, transition
zone, and fibromuscular stroma. The
peripheral zone is heterogeneous with areas
of lower T2 signal intensity, which is
common in younger patients.
Apex
Above we see examples of a prostate in
Axial T2WI coronal and sagittal views.
3D graphic depiction of the prostate shows axial drawings of the zonal anatomy at 3 different levels. The transitional zone (TZ) (in blue) is anterolateral to
the verumontanum. The central zone (CZ) (in orange) surrounds the ejaculatory ducts, and encloses the periurethral glands and the TZ. It is conical in
shape and extends downward to about the level of the verumontanum. The peripheral zone (PZ) (in green) surrounds the posterior aspect of the CZ in
the upper 1/2 of the gland and the urethra in the lower 1/2, below the verumontanum. The prostatic pseudocapsule is a visible boundary between the CZ
and PZ. The anterior fibromuscular stroma (AFMS) (in yellow) covers the anterior part of the gland and is thicker superiorly and thins inferiorly in the
prostatic apex.
Anterior-superior view of a resected prostate shows the urethra at the base. Paired bilateral seminal vesicles are attached to the
posterior aspect of the base, lateral to the tubular vas deferens. (From DP: Genitourinary.)
Current Imaging Modalities
TRUS CT MRI 68
Ga-PSMA PET/CT
Indications Indications Indications Indications

 Guides prostate biopsies  Monitor bone metastases* in high-risk  Tumor detection  Refining prostate cancer staging
 Guides brachytherapy seeds into the patients  Local-regional staging  Biochemical recurrence
prostate  PSA >20 ng/mL  Confined to prostate  Restaging and response assessment
 Gleason score >7
 Guides other ablative therapies  Tumor stage ≥T3  Extraprostatic extension
*Inferior to bone scanning and MRI  Follow-up, active surveillance, and
therapeutic response assessment
Advantages Advantages Advantages Advantages

 Wide availability  More accurate distinction of malignant  High resolution, excellent soft-tissue  Sensitive for detection of metastatic
 Low cost from benign causes because of increased contrast and restriction to water diffusion disease
radioisotope uptake at bone scanning  MRI-targeted biopsy using TRUS with MR  Accurate evaluation of lymph nodes and
fusion guidance local staging
Disadvantages Disadvantages Disadvantages Disadvantages

 Limited ability to define the in situ  Low rate for detection of nodal and  Inaccurate in the detection of nodal  Lymph nodes primarily less than 5 mm in
prostate cancer distant metastases metastases size can be missed
Transrectal US in Prostate Cancer
 A considerable portion of the gland can be undersampled
 Focal hypoechoic (60%) or isoechoic (40%) lesion in
 Risk of not diagnosing up to 30% of tumors (false
relation to the normal peripheral zone
negatives)
 Initial screening alone is not recommended
 Performs poorly as a diagnostic test for clinically significant
 Used to guide biopsies
prostate cancer
CG
PZ
The images show TRUS of the prostate in the axial plane, with its outline delimited by the dashed line and the surgical capsule
delimited by the dotted line. Nodule in the peripheral zone (PZ) right next to the middle one-third (red arrow). Heterogeneous central
gland (CG), with nodular pattern. Biopsy needle (blue arrow) to remove fragments.
CT in Prostate Cancer
CT is not as useful as MRI to evaluate the prostate gland. Yet, it can be used to assess metastases. CT assesses nodal invasion by
using lymph node diameter and morphology, and organ invasion by differences in morphology and changes in contrast
enhancement. Bone metastases represent the most frequent metastatic site in prostate cancer and occur at high frequency in
patients with advanced disease. The lesions are usually sclerotic. A mean attenuation of 885 HU and a maximum attenuation of
1060 HU provide reliable thresholds below which a metastatic lesion is the favored diagnosis. 1
Metastases in other organs or pelvic

Bone metastases Lymph nodes metastases
structures
Images show multiple metastatic bone implants in the spine, notably in L4 (blue arrow). Metastatic retroperitoneal lymph node enlargement, particularly in the
interaortocaval chain, with 4.0 cm in the largest axial axis (yellow arrow). Metastatic solid nodule in the left gluteal region (red arrow).
MRI in Prostate Cancer
 Stratify intermediate-risk patients into
high- and low-risk groups on the basis
 Avoid biopsy after negative MRI
of the presence of extracapsular
 Increase detection of clinically
extension
significant cancers Staging and
Cancer  Select patients for
 Decrease detection of clinically treatment
detection brachytherapy
insignificant cancers planning  Guide minimally invasive
ablative therapies
 Patient selection Active Posttreatment  Restaging in patients with

 Follow-up surveillance assessment suspected recurrent or
 Prostate Cancer Radiologic persistent tumor after
Estimation of Change in Sequential treatment (surgery, radiation
Evaluation (PRECISE) recommendations therapy, and hormone therapy)
PROMIS (Patient-Reported Outcomes Measurement Information System),
PRECISION (PRostate Evaluation for Clinically Important Disease: Sampling
Using Image-guidance Or Not?) trials and IMRIE (Is mpMRI Enough) study: Important role of mpMRI in T staging5,6
mpMRI as triage before biopsy and MRI-targeted biopsy is superior to
standard TRUS-guided biopsy.2–4
Improves detection of clinically significant cancers Risk-stratify patients who may benefit from more invasive treatment or
(12% higher detection of csPCa – PRECISION) exclude patients who may be harmed by overtreatment
Confirm the presence and localization of extraprostatic extension in high-

Reduces overdiagnosis of clinically insignificant cancers
risk men and confirm organ-confined disease in low-risk men
MRI staging criteria to identify extraprostatic extension, on the basis of a

mpMRI reduces the need for biopsies by approximately 30%, especially chronological concept of cancer growth from truly intraprostatic to truly
when the PSA density is < 0.15 extraprostatic, standardize morphologic staging, and decrease the existing
multireader variability
Multiparametric MRI evaluation:
Morphology Cellularity Permeability
(T1W and T2WI) (Diffusion/ADC Map) (Dynamic Contrast Enhancement)
T1WI b = 2000 DCE – early phase
T2WI ADC DCE – late phase

Nodular lesion located in the posterior and lateral region of the left basal peripheral zone, representing the typical imaging features that are highly suggestive of
a significant cancer in the peripheral zone, with hypointensity at T2 imaging (blue arrow), restriction to water diffusion (yellow arrows), and marked early
contrast enhancement (red arrow) with washout in the late phase (white arrow) at DCE imaging with subtraction.
Performance of mpMRI for detection of PCa 7

Sensitivity 89% / Specificity 73%
Diagnostic criteria for extraprostatic extension (tumor growth timeline) 6
Clearly confined tumor
Tumor contact with capsule
Capsular disruption
Unsharp prostatic margin
Bulging
Irregular prostatic contour
Periprostatic fat infiltration
Recto-prostatic angle obliteration
Periprostatic mass T2WI


Positive Predictive Value
(according to length of capsular contact):
56.5% if ≥10 mm
Capsular disruption 87.5% if ≥20 mm
100% if ≥25 mm
Bulging

Capsular disruption
Bulging

Capsular disruption
Bulging

Capsular disruption
Bulging

Capsular disruption
Bulging

Clearly confined tumor T2WI
Capsular disruption
Bulging
Rectoprostatic angle obliteration

Capsular disruption
Bulging

Rectoprostatic angle obliteration

Capsular disruption
Bulging

M staging: Distant metastases to the liver (yellow arrow) and lymph node in the hepatic Active surveillance in a patient with transurethral resection of the prostate with a
hilum (red arrow) in a patient with radical prostatectomy. Gleason score of 6 on two fragments and current PSA level of 1.4 ng/mL (PIRADS-2).
Biochemical recurrence: local recurrence after radical prostatectomy (PSA level of 0.45 ng/mL). Nodular lesion on the left posterolateral margin of the vesicourethral anastomosis
with low signal intensity at T2WI (yellow arrow), diffusion restriction at DWI (red arrow), and early enhancement at DCE MRI (blue arrow).
Prostate Imaging Reporting and Data System
(PI-RADS) Classification - Version 2.1
More standardized acquisition, interpretation, and reporting of prostate MRI, based on the findings of mpMRI
(T2WI, DWI, and DCE imaging), according to zonal anatomy.3,8
- Peripheral zone: DWI/ADC is the primary determining sequence

- Transition zone: T2WI is the primary determining sequence
- Determines the likelihood of clinically significant prostate cancer (Gleason ≥7)
- Postbiopsy changes, including hemorrhage and inflammation, may adversely affect the interpretation of
prostate MRI for staging in some instances
PI-RADS v2.1 Assessment Category
Detection rates for csPCa in men
1 Very low Clinically significant cancer highly unlikely
with no prior biopsy (PRECISION
trial):
2 Low Clinically significant cancer unlikely
3 Intermediate Clinically significant cancer equivocal

PI-RADS 3 12%
4 High Clinically significant cancer likely

PI-RADS 4 60%
5 Very high Clinically significant cancer highly likely PI-RADS 5

83%
DWI T2WI
Peripheral or Transition Zone Transition Zone
Normal PI-RADS 1 Normal or typical (encapsulated) nodule
1 1
Linear or wedge-shaped hypointense on ADC map or linear or <4 Partially encapsulated or nonencapsulated nodule or a
wedge-shaped hyperintense at DWI PI-RADS 2 DWI homogeneous mildly hypointense area between nodules
2
≥4 2
Focal hypointense on ADC map or focal hyperintense at high

DWI; may be markedly hypointense on ADC or markedly <5 Heterogeneous signal intensity with obscured margins or
DCE PI-RADS 3 DWI
hyperintense at DWI, but not both. lesions unqualified in other categories
3 + 5 3
Focal markedly hypointense on ADC map and markedly PI-RADS 4 Lenticular or noncircumscribed, homogeneous, moderately
hyperintense at DWI hypointense
4 4
Same as 4 but ≥1.5 cm or extraprostatic extension or invasive PI-RADS 5 Same as 4, but ≥1.5 cm or extraprostatic extension or invasive
behavior behavior
5 5
Source.—Reference 8.
This sequence of diffusion-weighed images (DWI) shows a tumor near the apex of the gland. With low b values (strength of diffusion sensitizing gradient) the signal
is similar to a T2WI with high signal observed in the PZ, bladder, and seminal vesicles. As the b value increases, there is a diffusion of water molecules except in
highly cellular areas, such as cancer, which has restricted diffusion. By a b value of 1,500, the tumor is well seen with loss of signal in the surrounding structures. The
This sequence of DWIs shows a tumor in the central portion of the prostate gland. These tumors can be particularly difficult to diagnose as they can be masked by
surrounding BPH. One of the features described on T2WI is a "smudgy," charcoal-like appearance in comparison to the more well-defined nodules seen in BPH. With
increasing b values, the tumor becomes evident. It is important to note that at low b values, the tumor may be isointense to the rest of the prostate (b 400 in this
Axial T2WI MR of the prostate shows BPH (white solid arrow) and a well-defined, encapsulated nodule (black solid arrow) in the peripheral zone of the left
midgland. The heterogeneous signal intensity of the nodule and the presence of a capsule strongly suggest an exophytic BPH nodule over carcinoma.
Axial T2WI MR of the prostate shows a hypertrophic transition zone with multiple well-defined nodules (white solid arrow) of various signal intensity. The signal
intensity of benign prostatic hyperplasia (BPH) nodules depends on the histologic composition.
Axial T2WI (left) and T1WI C+ (right) MR show the prostate. In the peripheral zone of the right apex, there is a lesion (white solid arrow) hypointense on T2WI with
early hyperenhancement postcontrast administration compatible with prostatic carcinoma.
Axial DWI MR (left) and apparent diffusion coefficient (ADC) map (right) in the same patient show restricted diffusion (i.e., ↑ signal intensity on DWI and ↓ signal
intensity on ADC) corresponding to the lesion (white solid arrow) in the right peripheral zone.
Axial T2WI MR of the prostate in a patient with elevated PSA and history of recurrent prostatitis shows a wedge-shaped, hypointense lesion (white solid arrow) in
the peripheral zone of the right midgland. Target biopsy revealed chronic inflammation and lack of cancer.
Axial DWI MR (b = 2,000) in the same patient shows marked restricted diffusion in the left PZ lesion (white solid arrow). DWI score is 5. Overall PI-RADS score is 5.
Axial DCE MR in the same patient in early phase shows focal enhancement (white solid arrow) earlier than the other tissue in the PZ (DCE score is positive). Notice
that the BPH nodule (white curved arrow) also enhances early, which should not be mistaken for cancer.
Future of Cancer Detection
MRI-first Risk-stratified Screening
MRI-first screening was associated with an improvement in the benefit-harm profile and cost-effectiveness compared with
biopsy-first screening. These improvements were greater when using risk-stratified screening on the basis of age and polygenic
risk profile than MRI-first age-based screening and were associated with less overdiagnosis and a comparable number of
prevented deaths from prostate cancer.14
Biparametric MRI Screening
The recent IP1-PROSTAGRAM (Imperial Prostate 1 Prostate Cancer Screening Trial Using Imaging) study suggests that when
screening the general population for prostate cancer, MRI using PI-RADS 4 or 5 to define a positive test result compared with
PSA alone at ≥3 ng/mL was associated with more men diagnosed with clinically significant cancer, without an increase in the
number of men advised to undergo biopsy or overdiagnosed with clinically insignificant prostate cancer (csPCa). 15
PSA Screening MRI Screening US Screening
≥3ng/ml PI-RADS ≥4 US Score ≥4
Biopsy rate: 9.9% x Biopsy rate: 10.6% x Biopsy rate: 12.8%

csPCa found: 7 csPCa found: 11 csPCa found: 4
csPCa missed: 10 csPCa missed: 6 csPCa missed: 13
Biparametric MRI at PI-RADS ≥4 has favorable performance characteristics for further testing in a large screening study
Latest Imaging Approaches in Advanced Prostate Cancer
Conventional imaging: High or very high-risk disease + life
Life expectancy >5 years and
Symptomatic unfavorable intermediate, high, or
 CT expectancy <5 years
very high-risk disease
 Bone scan (BS)
 mpMRI
Conventional imaging equivocal or negative findings
Advanced imaging:
 PET
 PET/CT Advanced imaging
 PET/MRI
 Whole-body MRI
Previous radical prostatectomy or radiotherapy
Results will influence subsequent treatment decisions
Biochemical recurrence Conventional imaging equivocal or negative findings
Sources.—References 27-29.
Conclusion
 The evolution of diagnostic methods has contributed to a more accurate detection of prostate cancer.
 TRUS has an important role in guiding systematic biopsies, but some tumors may be missed.
 CT is not as useful as MRI for evaluating the prostate. However, CT can be used to assess bone metastases
and some nodal and distant metastases.
 mpMRI has been used for tumor detection, local-regional staging, follow-up, active surveillance, and
therapeutic response assessment. TRUS with MRI fusion guidance improves the accuracy of transrectal
biopsies.

Haroon Rashid

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Haroon Rashid

Uploaded by

Copyright:

Available Formats

Prostate Cancer Imaging

 Summarize the strengths and limitations of prostate cancer imaging modalities.

New studies with screening through imaging methods are discussed.

In-bore MRI-guided biopsy

ISUP grade group Gleason score Gleason pattern

- ISUP grade ≥2 (Gleason score ≥7), and/or

CZ - Central Zone PZ - Peripheral Zone SV - Seminal Vesicles PU - Prostatic Urethra TZ TZ

Coronal T2WI Sagittal T2WI

The images on the left show the prostate of

Indications Indications Indications Indications

Advantages Advantages Advantages Advantages

Disadvantages Disadvantages Disadvantages Disadvantages

Metastases in other organs or pelvic

 Patient selection Active Posttreatment  Restaging in patients with

Confirm the presence and localization of extraprostatic extension in high-

MRI staging criteria to identify extraprostatic extension, on the basis of a

T1WI b = 2000 DCE – early phase

T2WI ADC DCE – late phase

Performance of mpMRI for detection of PCa 7

Clearly confined tumor

Tumor contact with capsule

Unsharp prostatic margin

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor

Tumor contact with capsule

Unsharp prostatic margin

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor

Tumor contact with capsule

Unsharp prostatic margin

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor

Tumor contact with capsule

Unsharp prostatic margin

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor

Tumor contact with capsule

Unsharp prostatic margin

Irregular prostatic contour

Periprostatic fat infiltration

Recto-prostatic angle obliteration

Periprostatic mass T2WI

Clearly confined tumor T2WI

Tumor contact with capsule

Unsharp prostatic margin