Interac(ve Experience with Prostate Imaging Repor(ng and Data System Version 2 (PI-RADS v2)
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1 Interac(ve Experience with Prostate Imaging Repor(ng and Data System Version 2 (PI-RADS v2) E Hassanzadeh 1,2, MD; E Velez 3, BS; F M Fennessy 1,4, MD, PhD; R M Dunne 1,2, MBBCh; M G Harisinghani 1,5, MD; C M Tempany-Afdhal 1,2, MD; D I Glazer 1,2, MD 1. Harvard Medical School 2. Brigham and Women s Hospital 3. University of California, San Francisco 4. Dana-Farber Cancer InsGtute 5. MassachuseJs General Hospital
2 ObjecGves 1. IntroducGon to Prostate Imaging ReporGng and Data System Version 2 (PI-RADS v2) scoring system for interpretagon of prostate mulgparametric MRI 2. ApplicaGon of PI-RADS v2 scoring system using illustragve examples 3. Highlight common challenges to interpretagon of prostate mpmri and applicagon of PI-RADS v2
3 Overview of PI-RADS v2 Components Scoring Case examples of using PI-RADS v2 scoring Peripheral Zone Transi(on Zone Pearls & PiIalls Measurement Table of Contents DWI, T2W, DCE scoring Benign lesions (BPH, granulomatous prosta((s, prosta(c ducts) Confounding factors (hemorrhage, ar(fact)
4 PI-RADS v2 PI-RADS v2 is designed to improve detecgon, localizagon, characterizagon, and risk stragficagon in pagents with suspected cancer in treatment naïve prostate glands Consists of : A. Technical recommendagon for MRI acquisigon B. Scoring system for image interpretagon
5 Technical recommendagons MagneGc field strength: 1.5 Tesla and 3 Tesla InsGtuGonal decision for the use of endorectal coil (ERC) Recommended sequences: 1. T2 weighted images (T2W) 2. Diffusion weighted images (DWI) /corresponding ADC maps, b-values Dynamic Contrast-Enhanced images (DCE)
6 Scoring system Overall PI-RADS score Clinical Significance 1 Very low (clinically significant PCa is highly unlikely to be present) 2 Low (clinically significant PCa is unlikely to be present) 3 Intermediate (the presence of clinically PCa disease is equivocal) 4 High (clinically significant PCa is likely to be present) 5 Very high (clinically significant PCa is highly likely to be present) A lesion with a Gleason score 7, volume >0.5 cc, or extraprostagc extension is considered clinically significant
7 PI-RADS steps: a 3.b 1. Localize the lesion 2. Measure the lesion! ADC for peripheral zone lesions! T2W for transigon zone lesions
8 PI-RADS steps: a 3.b 3.a. Scoring/Peripheral zone(pz) Depends only on DWI and DCE DWI Descrip(on 1 No abnormality (i.e. normal) on ADC and high b-value DWI 2 IndisGnct hypointense on ADC 3 Focal mildly/moderately hypointense on ADC and isointense/mildly hyperintense on high b-value DWI 4 Focal markedly hypontense on ADC and markedly hyperintense on high b-value DWI; <1.5cm in greatest dimension 5 Same as 4 but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior DCE - + Descrip(on no early enhancement, or diffuse enhancement not corresponding to a focal finding on T2 and/or DWI or focal enhancement corresponding to a lesion demonstragng features of BPH on T2WI focal, and; earlier than or contemporaneously with enhancement of adjacent normal prostagc Gssues, and; corresponds to suspicious finding on T2W and/or DWI
9 PI-RADS steps: a 3.b 3.b. Scoring/Transi(on zone(tz) Depends only on T2W and DWI T2W Descrip(on 1 Homogeneous intermediate signal intensity (normal) 2 Circumscribed hypointense or heterogeneous encapsulated nodule(s) (BPH) 3 Heterogeneous signal intensity with obscured margins Includes others that do not qualify as 2, 4, or 5 4 LenGcular or non-circumscribed, homogeneous, moderately hypointense, and <1.5 cm in greatest dimension 5 Same as 4, but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior
10 Overview of PI-RADS v2 Components Scoring Case examples of using PI-RADS v2 scoring Peripheral Zone Transi(on Zone Pearls & PiIalls Measurement DWI, T2W, DCE scoring Table of Contents Benign lesions (BPH, granulomatous prosta((s, prosta(c ducts) Confounding factors (hemorrhage, ar(fact)
11 Case Localize 2. Measure 3. Score (Peripheral zone) + T2W 5 DWI 5 DCE + T2W 5 DWI 1400 Circumscribed, homogenous moderate hypointense focus/mass confined to prostate; and but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior Focal markedly hypontense 1.59 on cm ADC and markedly hyperintense on high b-value DWI; and but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior focal, and; earlier than or contemporaneously with enhancement of adjacent normal prostagc Gssues, and; corresponds to suspicious finding on T2W and/or DWI ADC Click here for score descrip(on DCE
12 Case 2 1. Localize 2. Measure 3. Score(Transi(on zone) 2.02 cm 5 T2W 5 T2W 5 DWI 1400 LenGcular or non-circumscribed, homogeneous, moderately hypointense; and but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior + DCE DWI 5 Focal markedly hypontense on ADC and markedly hyperintense on high b-value DWI; and but 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior DCE + focal, and; earlier than or contemporaneously with enhancement of adjacent normal prostagc Gssues, and; corresponds to suspicious finding on T2W and/or DWI ADC Click here for score descrip(on
13 Overview of PI-RADS v2 Components Scoring Case examples of using PI-RADS v2 scoring Peripheral Zone Transi(on Zone Pearls & PiIalls Table of Contents Measurement DWI, T2W, DCE scoring Benign lesions (BPH, granulomatous prosta((s, prosta(c ducts) Confounding factors (hemorrhage, ar(fact)
14 Pearl: Measurement A diameter of 1.5 cm is an indicagon for upscoring a lesion from a 4 to a 5 " This case receives a score of 5 based on T2W coronal on both DWI and T2W T2W. Axial DWI 1400 DCE 1.52 cm T2W. Coronal 1.26 cm ADC If lesion measurement is difficult or compromised on ADC (for PZ) or T2W (for TZ), measurement should be made on the sequence that shows the lesion best. The largest dimension is meant to be measured for accurate scoring
15 Pearl: DWI scoring Compare the two cases: 1.51 cm PI-RADS v2 emphasizes on evalua(ng DWI along with ADC DWI: 3 Focal mildly/moderately hypointense on ADC and isointense/mildly hyperintense on high b-value DWI cm ADC ADC DWI 1400 DWI 1400 DWI: 5 Focal markedly hypointense on ADC and markedly hyperintense on high b-value DWI; and 1.5cm in greatest dimension or definite extraprostagc extension / invasive behavior.
16 Pearl: T2W scoring in TZ lesions T2W : 2 Circumscribed hypointense or heterogeneous encapsulated nodule(s) (BPH) T2W T2W: 5 LenGcular or non-circumscribed, homogeneous, moderately hypointense 1.5cm in greatest dimension or definite extraprostagc extension/invasive behavior T2W
17 Pilall: Benign lesions Benign prostagc hyperplasia (BPH) Grandular with cysgc degeneragon Hyperintense on T2W, hyperintense on ADC (Blue Arrow) Stromal Hypointense on T2W, hypointense on ADC (Yellow arrow) T2W ADC DWI BPH on T2W receives a PIRADS score of 2, regardless of the appearance on DWI/ADC
18 Pilall : Benign lesions Granulomatous prosta((s can appear as high score prostate cancer 5 + T2W PI-RADS v2 score 5 DCE DWI Pathology: Granulomatous prosta((s 5? ADC
19 Pilall : Benign lesions 3 Ductal structures can appear as high score prostate cancer + T2W 4 DWI 1400 DCE PI-RADS v2 score? cm Pathology: Seminal vesicle/ ejaculatory duct (ssue ADC
20 Pilall : Hemorrhage PI-RADS v2 recommends to wait 6-8 w before mpmri acquisigon aper biopsy T1W images should always be correlated with T2W hypointensiges for presence of hemorrhage Halo sign on T1W might point out the lesion In case of hemorrhage subtracgon images are essengal to evaluate DCE
21 T1W / T2W correlagon in case of hemorrhage Hemorrhage appears as hypointensity on T2W and hyperintensity on T1W T2W T1W
22 Halo sign on T1W Post biopsy hemorrhage can outline prostate cancer on T1W T1W
23 Pilall : ArGfact ERC induced argfacts due to: Induced magnegc field inhomogeneity Possible misplacement Can quickly be checked for on localizer images T2W ADC DWI 1400 The lesion has been obscured on T2W due to the proximity to the ERC
24 Take home message PI-RADS v2 offers standardized recommendagons for MRI acquisigon and can be used in stepwise fashion for interpretagon for prostate cancer diagnosis and risk stragficagon Readers should be aware of common pearls and pilalls while interpregng mpmri
25 Useful references hjp:// Barentsz JO, Weinreb JC, Verma S, Thoeny HC, Tempany CM, Shtern F, et al. Synopsis of the PI-RADS v2 Guidelines for MulGparametric Prostate MagneGc Resonance Imaging and RecommendaGons for Use: Eur Urol Sep 8. pii: S (15) doi: /j.eururo
26 Thank you! Elmira Hassanzadeh
1 Uniform hyperintense signal intensity (normal). 2 Linear (arrow), wedge-shaped, or diffuse mild hypointensity, usually indistinct margin.
Figure 3 PI-RADS assessment for peripheral zone on T2-weighted imaging. 1 Uniform hyperintense signal intensity (normal). 2 Linear (arrow), wedge-shaped, or diffuse mild hypointensity, usually indistinct
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