Magnetic Resonance Imaging

Transcription

1 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 11 Bern Hmm n Ptrik Ash Lerning Ojetives To unerstn the urrent role of prostte MRI for imging-se trgete prostte iopsy, stging, n tive surveillne To lern how to optimize the multiprmetri prostte MR imging protool To illustrte how to use the PI-RADS lssifition for prostti lesion ssessment To unerstn the nee of struture reporting in ommuniting with the urologists To isuss the most ommon pitflls in multiprmetri MRI of the prostte 11.1 Introution Over the pst yers, ontinuing tehnil innovtion in omintion with ro reserh tivity hs resulte in high ignosti ury of mgneti resonne imging (MRI) of the prostte. At the sme time, the Prostte Imging Reporting n Dt System (PI-RADS) hs stnrize imge quisition n reporting n filitte the ommunition of imging finings to the urologist n n therefore e onsiere n oligtory key element in prostte MRI. This hs h tremenous impt on the ignosti workup of ptients with suspete prostte ner, with MRI eing inorporte in multiple prostte ner guielines (e.g., NICE, AUA, Germn S3-Guieline) y now. As iret result, imging-se trgete prostte iopsy hs inrese lmost t the sme spee, n urologists not only hevily rely on urte interprettion of MRI of the prostte B. Hmm (*) P. Ash Deprtment of Riology, Chrité Universitätsmeizin Berlin, Berlin, Germny e-mil: ern.hmm@hrite.e ut tively lim high-qulity MRI sns for their ily prtie euse prostte MRI hs iret impt on their ner etetion rte. Furthermore, prigm shift is tking ple in the urologil ommunity regring the re of lowgre prostte ner ptients, where therpy is more n more reple y tive surveillne (AS). Prostte MRI plys n importnt role in AS not only uring the initil ssessment whether the ptient is nite for AS ut lso uring the surveillne of the isese. Therefore, ny ominl n genitourinry riologist if not lrey performing prostte MRI will susequently e involve, n we forest prostte MRI to e n inispensle ignosti step for ny ptient with linil suspiion for prostte ner or uring surveillne of low-gre prostte ner in the ner future PI-RADS The Europen Soiety of Uroriology (ESUR) hs introue PI-RADS (Prostte Imging Reporting n Dt System) in An upte version (PI-RADS v2) ws pulishe in 2015 in ollortion with the Amerin College of Riology (ACR) n the AMeTeh Fountion. PI-RADS is not se on eviene from linil reserh trils rther thn on expert knowlege; however, severl stuies hve onfirme tht the PI-RADS system improves the ignosti ury of mpmri. The overll rtionle for implementtion of PI-RADS ws to improve etetion, loliztion, hrteriztion, n risk strtifition in ptients with suspete ner in tretment nïve prostte glns. PI-RADS is urrently not pplile to ssess tretment response in prostte ner ptients. The following speifi efinitions n ims regring MR imging n reporting re trgete y PI-RADS: The Author(s) 2018 J. Holer et l. (es.), Diseses of the Aomen n Pelvis , IDKD Springer Series, 99

2 Clinil Consiertions Timing of mpmri fter prostte iopsy oes not neessrily nee to e postpone sine linilly signifint ner is likely in lotion not ltere y post iopsy hemorrhge when the iopsy ws negtive. For lol stging of prostte ner, ely of minimum of 6 weeks might e vntgeous. No speifi ptient preprtion is neessry; however, the ministrtion of spsmolyti rug my e enefiil. Bowel lening is not reommene; however, the ptient shoul evute the retum if possile Tehnil Consiertions The fiel strengths of 1.5 n 3 T n oth e equte (even without n enoretl oil t 1.5 T) when the sn prmeters re tilore to smll fiel-of-view imging of the prostte n ontemporry snner tehnology is use (speifilly multihnnel phse-rry surfe oils n high-performne grients); however, 3 T is the preferre fiel strength (higher signl-to-noise rtio, shorter sn time). Multiprmetri MRI of the prostte shoul inlue the following sequenes: T2-weighte imging: 2D turo spin-eho sequene, slie thikness 3 mm (no interslie gp), n in-plne sptil resolution 0.7 mm (phse-enoing iretion) x 0.4 mm (frequeny-enoing iretion). Diffusion-weighte imging (DWI): spin-eho EPI (eho plnr imging) sequene with ft sturtion, slie thikness 4 mm (no interslie gp), in-plne sptil resolution 2.5 mm (phse- n frequeny-enoing iretion), n t lest two -vlues (low -vlue of s/mm 2 n high -vlue of s/mm 2 ) with onseutive lultion of n ADC mp. If SNR llows, very high -vlue of s/mm 2 shoul e mesure. An lterntive is to lulte high -vlue, whih is less SNR ritil. Dynmi ontrst-enhne (DCE) imging: 2D or 3D grient-eho sequene with temporl resolution elow 10 s (preferly elow 7 s) per quisition, slie thikness 3 mm (no interslie gp), n in-plne sptil resolution 2 mm (phse- n frequeny-enoing iretion). Slie orienttion n slie thikness shoul mth for ll mpmri sequenes to llow sie-y-sie omprison. Also, lrge fiel-of-view sequene overing the pelvi lymph noes n the skeleton shoul e quire Assessment of Prostti Lesions One mjor key element of PI-RADS is soring the likelihoo of prostti lesion to e linilly signifint prostte ner on 5-point Likert-type sle (Tle 11.1). Sine severl ifferent efinitions of linilly signifint prostte ner exist, PI-RADS efines it s Gleson sore 7 (inluing 3+4 with prominent ut not preominnt Gleson 4 omponent), n/or volume 0.5, n/or extr prostti extension (EPE). The soring system is se on typil imging finings on the respetive multiprmetri MR sequene (ext efinitions oring to PI-RADS, see Tles 11.2, 11.3 n 11.4; for exmples, see Figs. 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, n 11.13). For this purpose, typil exmples for eh sore n sequene re inlue in the Tle 11.1 PI-RADS lssifition (5-point Likert-type sle) PI-RADS 1 PI-RADS 2 PI-RADS 3 PI-RADS 4 PI-RADS 5 Very low (linilly signifint ner is highly unlikely to e present) Low (linilly signifint ner is unlikely to e present) Intermeite (the presene of linilly signifint ner is equivol) High (linilly signifint ner is likely to e present) Very high (linilly signifint ner is highly likely to e present) Tle 11.2 T2-weighte imging Sore Peripherl zone (PZ) 1 Uniform hyperintense signl intensity (norml) 2 Liner or wege-shpe hypointensity or iffuse mil hypointensity, usully inistint mrgin 3 Heterogeneous signl intensity or non-irumsrie, roune, moerte hypointensity, inlues others tht o not qulify s 2, 4, or 5 4 Cirumsrie, homogenous moerte hypointense fous/ mss onfine to prostte n <1.5 m in gretest imension 5 Sme s 4 ut 1.5 m in gretest imension or efinite extrprostti extension/ invsive ehvior Tle 11.3 Diffusion-weighte imging (DWI) B. Hmm n P. Ash Trnsition zone (TZ) Homogeneous intermeite signl intensity (norml) Cirumsrie hypointense or heterogeneous enpsulte noule(s) (BPH) Heterogeneous signl intensity with osure mrgins, inlues others tht o not qulify s 2, 4, or 5 Lentiulr or nonirumsrie, homogeneous, moertely hypointense, n <1.5 m in gretest imension Sme s 4, ut 1.5 m in gretest imension or efinite extrprostti extension/invsive ehvior Sore Peripherl zone (PZ) or trnsition zone (TZ) 1 No normlity (i.e., norml) on ADC n high -vlue DWI 2 Inistint hypointense on ADC 3 Fol milly/moertely hypointense on ADC n isointense/ milly hyperintense on high -vlue DWI 4 Fol mrkely hypointense on ADC n mrkely hyperintense on high -vlue DWI; <1.5 m in gretest imension 5 Sme s 4 ut 1.5 m in gretest imension or efinite extrprostti extension/invsive ehvior

3 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er Tle 11.4 Dynmi ontrst-enhne (DCE) imging Sore Peripherl zone (PZ) or trnsition zone (TZ) Negtive No erly enhnement or iffuse enhnement not orresponing to fol fining on T2-weighte n/or DWI or fol enhnement orresponing to lesion emonstrting fetures of BPH on T2-weighte imging Positive Fol n erlier thn or ontemporneously with enhnement of jent norml prostti tissues n orrespons to suspiious fining on T2-weighte n/or DWI 101 PI-RADS pulition. The gol is to inrese the ignosti ury for etetion of prostte ner n to reue the vriility in imge interprettion. Most preliminry stuies report goo reer greement whih is higher for peripherl zone (PZ) lesions s ompre to trnsition zone (TZ) lesions. Also, greement is higher for PI-RADS sore 4 n 5 ompre to lower sores. In the PI-RADS version 2, the ignosti weighting of the multiprmetri sequenes hs een hnge ompre to the first version. Now, onept of ominnt sequene hs Fig ( ) Norml peripherl zone. () Axil n () oronl T2-weighte sequene showing uniform hyperintense signl intensity of the peripherl zone (PI-RADS sore 1). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge n () ADC mp (ominnt sequene for the peripherl zone) with no normlity onsistent with n overll PI-RADS sore of 1

4 102 B. Hmm n P. Ash Fig (, ) Norml trnsition zone. () Axil n () oronl T2-weighte sequene (ominnt sequene for the trnsition zone) showing homogeneous intermeite signl intensity of the non-enlrge trnsition zone (PI-RADS sore 1) Fig ( e) PI-RADS 2 hnges of the peripherl zone. () Axil n () oronl T2-weighte sequene showing liner hypointensities in the ilterl peripherl zone (PI-RADS sore 2). () Diffusionweighte high -vlue (lulte = 1400 s/mm 2 ) imge shows no res of inrese signl intensity. () ADC mp shows no fol hypointense res (ominnt sequene for the peripherl zone) in the peripherl zone (PI-RADS sore 2). (e) DCE sequene shows no fol or erly enhnement (DCE negtive) onsistent with n overll PI-RADS sore of 2. Liner T2 hypointensities in the peripherl zone re frequent fining n my represent hnges relte to hroni prosttitis or post iopsy srring

5 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 103 e Fig (ontinue)

6 104 B. Hmm n P. Ash Fig ( ) PI-RADS 2 finings of the trnsition zone in ptient with enign prostti hyperplsi (BPH). () Axil n () oronl T2-weighte sequene (ominnt sequene for the trnsition zone) showing multiple irumsrie heterogeneous enpsulte noules (rk T2-rim) within the enlrge trnsition zone (overll PI-RADS sore 2). () Diffusion-weighte high -vlue (lulte = 1400 s/ mm 2 ) imge shows no fol res of moertely inrese signl intensity. () ADC mp shows no fol hypointense res (PI-RADS sore 2)

7 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 105 e Fig ( e) Protrue BPH noe in the right nterior gln. () Axil n () oronl T2-weighte sequene (ominnt sequene for the trnsition zone) showing irumsrie heterogeneous enpsulte noule (overll PI-RADS sore 2). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows inrese signl intensity. () ADC mp shows fol hypointensity whih is relte to stroml BPH omponents whih orrespons to the BPH noule (therefore PI-RADS sore of 2). (e) DCE sequene showing fol enhnement whih orrespons to the lesion tht emonstrtes ler fetures of BPH noe (therefore DCE negtive) onsistent with n overll PI-RADS sore of 2

8 106 B. Hmm n P. Ash e Fig ( e) PI-RADS 3 hnges of the peripherl zone. () Axil n () oronl T2-weighte sequene showing heterogeneous nonirumsrie hnges of the ilterl peripherl zone (PI-RADS sore 3). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows milly hyperintense signl intensity. () ADC mp (ominnt sequene for the peripherl zone) shows moertely hypointense hnges in the ilterl peripherl zone (PI-RADS sore 3). (e) DCE sequene shows no fol erly enhnement (DCE negtive) onsistent with n overll PI-RADS sore of 3. Rnomize TRUS-guie prostte iopsy revele mil hroni prosttitis with no eviene for prostte ner

9 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 107 e Fig ( e) PI-RADS 3 hnges of the trnsition zone in ptient with enign prostti hyperplsi (BPH). () Axil n () oronl T2-weighte sequene (ominnt sequene for the trnsition zone) showing heterogeneous signl intensity with osure mrgins within the enlrge trnsition zone (overll PI-RADS sore 3). () Diffusionweighte high -vlue (lulte = 1400 s/mm 2 ) imge shows milly hyperintense signl intensity. () ADC mp shows moertely hypointense res (PI-RADS sore 3). (e) DCE sequene shows iffuse enhnement not orresponing to fol fining on ny other sequene (DCE negtive). Rnomize TRUS-guie iopsy revele no mlignny; therefore, the finings n e ttriute to BPH with preominntly stroml (T2 hypointense) omponents

10 108 B. Hmm n P. Ash e Fig ( e) PI-RADS 4 lesion in the peripherl zone. () Axil n () oronl T2-weighte sequene showing moerte iffuse (nonirumsrie) hypointensity of the ilterl peripherl zone (PI-RADS sore 3). () Diffusion-weighte high -vlue (lulte = 1400 s/ mm 2 ) imge shows milly hyperintense signl intensity in the right nterior n lterl peripherl zone (PI-RADS sore 3). () ADC mp orresponingly shows moerte hypointense signl intensity (ominnt sequene for the peripherl zone) in the right nterior n lterl peripherl zone (PI-RADS sore 3). (e) DCE sequene shows fol n ontemporry enhnement (DCE positive) onsistent with n upgring to n overll PI-RADS sore of 4. MRI/US fusion-guie iopsy revele Gleson = 7 enorinom (PSA level ws 6.9 ng/ml)

11 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 109 e Fig ( e) PI-RADS 4 lesion in the peripherl zone. () Axil n () oronl T2-weighte sequene showing irumsrie 11 mm hypointense mss in the left lterl peripherl zone (PI-RADS sore 4). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows fol mrkely hyperintense signl intensity of the mss. () ADC mp (ominnt sequene for the peripherl zone) orresponingly shows fol mrkely hypointense signl intensity of the mss (PI-RADS sore 4). (e) DCE sequene shows fol n erly enhnement (DCE positive) orresponing to the fol mss seen on T2-weighte n DWI onsistent with n overll PI-RADS sore of 4. MRI/US fusion-guie iopsy revele Gleson = 7 enorinom (PSA level ws 8.1 ng/ml)

12 110 B. Hmm n P. Ash Fig ( ) PI-RADS 4 lesion in the trnsition zone. () Axil T2-weighte sequene (ominnt sequene for the trnsition zone) showing irumsrie lentiulr 14 mm hypointense mss in the left nterior trnsition zone with ulging of the prostti psule (PI-RADS sore 4). () Diffusion-weighte high -vlue (lulte = 1400 s/ mm 2 ) imge shows fol mrkely hyperintense signl intensity of the mss. () ADC mp orresponingly shows fol mrkely hypointense signl intensity of the mss (PI-RADS sore 4). MRI/US fusion- guie iopsy revele Gleson = 8 enorinom (PSA level ws 9.8 ng/ml). The ptient h unergone rnomize TRUS- guie iopsy 3 months erlier with no eviene for mlignny. The nterior lotion is typil for enorinom misse y rnomize iopsy; therefore, MRI is prtiulrly useful in ptients with negtive rnomize iopsy n persisting linil suspiion for prostte ner

13 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 111 e Fig ( e) PI-RADS 5 lesion in the peripherl zone. () Axil n () oronl T2-weighte sequene showing irumsrie 18 mm hypointense mss in the right lterl peripherl zone (PI-RADS sore 5). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows fol mrkely hyperintense signl intensity of the mss. () ADC mp (ominnt sequene for the peripherl zone) orresponingly shows fol mrkely hypointense signl intensity of the mss (PI-RADS sore 5). (e) DCE sequene shows fol n erly enhnement (DCE positive) orresponing to the fol mss seen on T2-weighte n DWI onsistent with n overll PI-RADS sore of 5. MRI/US fusion-guie iopsy revele Gleson = 7 enorinom (PSA level ws 11.2 ng/ml). Also note the wege-shpe T2 hypointensities in the left lterl peripherl zone whih emonstrte moertely hypointense signl on the ADC mp n no fol enhnement (PI-RADS 3). On iopsy multifol prostte ner ws ignose with Gleson = 6 pttern in the left prostti loe

14 112 B. Hmm n P. Ash Fig ( ) PI-RADS 5 lesion in the trnsition zone. () Axil n () oronl T2-weighte sequene (ominnt sequene for the trnsition zone) showing irumsrie lentiulr 20 mm hypointense mss in the nterior trnsition zone with miniml ulging of the prostti psule (PI-RADS sore 5). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows fol mrkely hyperintense signl intensity of the mss. () ADC mp orresponingly shows fol mrkely hypointense signl intensity of the mss (PI-RADS sore 4). MRI/US fusion-guie iopsy revele Gleson = 7 enorinom (PSA level ws 14.7 ng/ml)

15 11 Mgneti Resonne Imging of the Prostte in the PI-RADS Er 113 Fig ( ) Lolly vne prostte ner with seminl vesile infiltrtion. () Axil T2-weighte sequene showing iffuse hypointensity of the entire prostte (zonl ntomy not visile) with extension into the ilterl seminl vesiles (PI-RADS sore 5). () Diffusion-weighte high -vlue (lulte = 1400 s/mm 2 ) imge shows mrkely hyperintense signl intensity of the entire prostte. () ADC mp orresponingly shows mrkely hypointense signl intensity of the prostte (PI-RADS sore 5). Rnomize TRUS-guie iopsy revele Gleson = 9 enorinom (PSA level ws 26.5 ng/ml)

16 114 Tle 11.5 Peripherl zone (PZ) DWI T2 DCE PI-RADS sore 1 Any Any 1 2 Any Any 2 3 Any Negtive 3 Positive 4 4 Any Any 4 5 Any Any 5 Tle 11.6 Trnsition zone (TZ) T2 DWI DCE PI-RADS sore 1 Any Any 1 2 Any Any Any Any Any 4 5 Any Any 5 een introue. The ominnt sequene epens on the prostti zone the lesion is lote; therefore ientifition of the zonl ntomy is ruil. The re t the se of the prostte where the entrl zone orers the peripherl zone n the nterior gln where the nterior horn of the peripherl zone orers the trnsition zone n the nterior firomusulr strom might e hllenging in this respet. The DWI sequene is the ominnt sequene for the peripherl zone where most prostte ners re lote. The T2-weighte sequene is the ominnt sequene for the trnsition zone. The ominnt sequene efines the finl PI-RADS sore with the exeption of PI-RADS 3 lesions, where for the peripherl zone the DCE sequene n for the trnsition zone the DWI sequene efines the finl PI-RADS sore (see Tles 11.5 n 11.6). If prtiulr sequene nnot e quire or is nonignosti ue to rtifts (e.g., DWI when ertin hip implnts re present), it shoul e mrke with x. In this sitution, the following rules pply: Assessment without DWI (pplies to PZ n TZ): the T2-weighte sequenes efine the finl PI-RADS sore with the exeption of PI-RADS 3 if the lesion is DCE negtive, the finl sore remins 3; if the lesion is DCE positive, the finl sore is 4. Assessment without DCE (only pplies to the peripherl zone sine DCE is not neee for trnsition zone soring): the DWI sore represents the finl PI-RADS sore Struture Reporting A very importnt tsk of PI-RADS is to simplify n stnrize the terminology n ontent of riology reports n to enhne interisiplinry ommunitions with referring liniins. A omprehensive mpmri report shoul therefore inlue the following ontents: The volume of prostte shoul e reporte oring to the ellipsoi formul: mximum AP imeter x mximum trnsverse imeter x mximum longituinl imeter The forementione PI-RADS sore is ssigne to up to four intrprostti lesions with sore 3. In se of multiple lesions, n inex lesion shoul e efine. The inex lesion is the one with the highest PI-RADS sore. In se multiple lesions qulify for the highest PI-RADS sore, extrprostti extension (EPE) outlsses lesion size. For eh lesion PI-RADS sore is ssigne to the series n the imge numer where the lesion is est visulize shoul e reporte to ssist the urologist in seleting optiml imges for MRI/US fusion-guie prostte iopsy. The lesion size lso nees to e reporte. Mesurement of eh lesion is preferre on the xil imges; the DWI sequene shoul e use for peripherl zone lesions n the T2-weighte imges for trnsition zone lesions. If lesion is not well elinete on the xil sequenes, then nother plin shoul e use. Another ruil element of full PI-RADS report is setor mp in whih the lesions shoul e inite, sine this prtiulrly enhnes the ommunition with the urologist. For this mtter, the prostte is suivie into three xil heights, the se, the migln, n the prostti pex, respetively. The seminl vesiles shoul lso e inlue for ses of extrprostti extension. The zonl ntomy (peripherl zone, trnsition zone, entrl zone, n nterior firomusulr strom) n the urethr shoul lso e inorporte into the setor mp Conluing Remrks B. Hmm n P. Ash Comprehensive multiprmetri MRI of the prostte shoul inlue lesion soring n reporting oring to the PI-RADS system. This will ssist to hieve high level of ignosti ury n ssure thriving ommunition with the urologist. Key Points Continuing tehnil innovtion n ro reserh tivity hve resulte in high ignosti ury of MRI of prostte. Prostte MRI plys n importnt role for imgingse trgete prostte iopsy. In ptients unergoing tive surveillne of prostte rinom, MRI hs eome inispensle for initil ssessment s well s uring the surveillne of the isese. PI-RADS stnrizes imge quisition n filittes ommunition with the urologists. It is onsiere n oligtory key element in prostte MRI. Comprehensive multiprmetri MRI of the prostte shoul inlue lesion soring n reporting oring to the PI-RADS system.

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