1. MR IMAGING IN PROSTATE CANCER
A REVIEW OF DEPARTMENTAL CASES
Sarbesh Tiwari

2. INTRODUCTION
2nd most common malignant tumor in male.
95% are adenocarcinoma
Higher incidence in African Americans, incidence
raising in India
Age : 6th to 7th decade.
Symptoms: Dysuria, hematuria, urgency+/‐
frequency of micturition, bone pain
Diagnosis: Combination of DRE & PSA.
Confirmation of diagnosis-
Transrectal biopsy under Ultrasound guidance

3. ZONAL ANATOMY OF PROSTATE
MC NEAL 1968

5. ZONAL DISTRIBUTION OF PROSTATE CANCER
70 % prostate CA ------ In Peripheral Zone of Prostate
20 % prostate CA ------ In Transitional Zone of Prostate
10 % prostate CA ------ In Transitional Zone of Prostate

6. NORMAL MRI APPEARANCE
OF PROSTATE
Normal prostate has homogenous low signal
on T1WI
Zonal anatomy is best demonstrated on T2WI
Comprise of low signal central zone and
higher signal peripheral zone
TZ and CZ appears similar in SI and loosely
termed the central gland

7. NORMAL T2 APPEARANCE OF PROSTATE

8. MR IMAGING IN PROSTATE CA
INDICATION –
To stage the extent of prostate cancer once the
diagnosis is established
To identify the presence of recurrent disease
following treatment
Persistent raised PSA with repeated negative
TRUS biopsies.
MRI is not used in the primary diagnosis of prostate
cancer. This is usually established following biopsy at
TRUS

9. MR IMAGING PROTOCOL
MRI is usually performed on 1.5T or 3T MRI using
endorectal and pelvic phase array coil.
Standard Sequences :
1. Axial T1WI of pelvis
2. Axial + Sagittal + Coronal T2WI
3. MR Spectroscopy of selected volume of prostate
Others,
4. Diffusion Weighted Imaging
5. Dynamic contrast enhanced MRI.

10. CONVENTIONAL MRI FINDINGS
TIWI : Tumor is isointense relative to gland
T2WI : Tumor appears as a region of low signal
intensity within normal high signal peripheral
zone
Detection of extra capsular extension:
1. Asymmetry into neurovascular bundle
2. Obliteration of recto-prostatic angle
3. Irregular bulging or breech of prostate capsule
4. Invasion of bladder / rectum / seminal vesicle.

11. MRI FINDINGS CONTD…
Diffusion Weighted Imaging :
Restricted diffusion with reduced ADC value.
: Increased cellularity of malignant
lesions, with reduction of the extracellular space and
restriction of the motion of a larger portion of water
molecules to the intracellular space
Dynamic contrast enhanced MRI :
Early, rapid, and intense enhancement with quick
washout of contrast material
: Increased tumor neovascularsation
and thus increased micro vascular density as
compared to normal prostate.

12. MR SPECTROSCOPY OF
PROSTATE
NORMAL METABOLITE OF PROSTATE
Citrate : Produced by normal epithelial cells
of prostate
Normal Peak at 2.6 ppm
Choline : Precursor of phospholipids cell
membrane
Normal Peak at 3.2 ppm
Creatine : Involved in cellular energy
Normal peak at 3 ppm

13. NORMAL MR SPECTROSCOPY
At 1.5 T At 3 T

14. MR SPECTROSCOPY OF
PROSTATE
Classic spectral signature of prostate cancer
consists of increased choline and decreased citrate
Ratio of (Choline + creatine)/ Citrate is usually
measured.
Normal range : 0.22 +/- 0.013, range upto 0.5.
Lower values for the Cho+cr /Cit ratio in the
peripheral areas than in the central glands.
Choline / creatine to citrate ratios:
> 0.5 : suspicious
> 1 : very suspicious
> 2 : abnormal

16. DEPARTMENTAL CASES

17. Case 1:
Clinical Detail : A 69 yrs old patient with post TURP status and biopsy
proven adenocarcinoma, presented for MR evaluation and staging of
the disease.
T1WI Axial T1WI Sagittal

18. T2WI Axial
T2WI Axial T2WI Sagittal

19. DWI MR Spectroscopy
Spectroscopy : Results Table

20. DIAGNOSIS
PROSTATIC CA WITH EXTRACAPSULAR
EXTENSION INTO LEFT SEMINAL VESICAL
WITHOUT ANY LYMPHADENOPATHY.
BLADDER WALL HYPERTROPHY DUE TO
PREVIOUS BOO.

21. CASE 2
•56 yrs old male presenting with
difficulty in micturition, poor
urinary stream and back pain
• Raised serum PSA- 20ng/ml
T2WI - Axial
T2WI - Axial T2WI - Axial

22. T1WI
T1WI-post contrast

23. MR Spectroscopy
Spectroscopy : Results Table

25. DIAGNOSIS
Prostate ca arising from the peripheral zone
with extra capsular extension into left
posterolateral periprostatic fat with infiltration
of anterior rectal wall.
Associated secondary deposits noted in
sacrum and lumbar vertebra

26. CASE 3
62 yrs old male presenting with urgency and increased frequency of
micturition with pain in left hip joint
T2WI : Axial

29. DIAGNOSIS
 BENIGN PROSTATIC HYPERPLASIA WITH
NORMAL SPECTROSCOPIC FINDINGS.
 UNILATERAL PAGETS DISEASE OF LEFT
ILLIAC BONE.

30. CONCLUSION
MRI serves as a powerful modality for
localization and staging of prostate cancer
Non ionizing and non invasive.
Excellent soft tissue resolution, allows better
delineation of primary tumor and nearby
extension.
Combination MR + MRS: Sensitivity 91%
Specificity 95%

31. REFERANCE
1. David Bonekamp, Michael A. Jacobs et.al Advancements in
MR Imaging of the Prostate: From Diagnosis to Interventions.
RadioGraphics 2011;31:677–703
2. Textbook of radiology and imaging . Volume 2 David Sutton 7th
edition.