Imging Assessment of Primry Prostte Cncer, Focused on Advnced MR Imging nd PET/CT Jin Hee Jng 1, Je Young Byun 1, Minsung Kim 1, Young Joon Lee 1, Sun Nm Oh 1, Sung Eun Rh 1, Ie-Ryung Yoo 2 Imging ssessment of prostte cncer is one of the most difficult sections of oncology imging. Detecting, loclizing nd stging of the primry prostte cncer y preopertive imging re still chllenging for the rdiologist. Mgnetic resonnce (MR) imging provides excellent soft tissue contrst nd is widely used for solid orgn imging, ut results of preopertive imging of the prostte glnd with conventionl MR imging is unstisfctory. Positron emission tomogrphy nd computed tomogrphy (PET/CT) is the cornerstone in oncology imging, ut some limittions prohiit the ssessment of primry prostte cncer with PET or PET/CT. Recent studies to overcome these insufficient ccurcies of imging evlution of primry prostte cncers with dvnced MR techniques nd PET nd PET/CT re reported. In this rticle, we review the imging findings of prostte cncer on vrile modlities, focused on MR imging nd PET/CT. Index words : Prostte cncer Oncologic imging MRI technique PET/CT Introduction Imging ssessment of prostte cncer hs very importnt role for the mngement of ptients with dignosed or suspected prostte cncer. At the sme time, imging of prostte cncer is one of the most difficult sections of oncology imging nd still chllenging for the rdiologist. Trnsrectl ultrsound (TRUS), mgnetic resonnce (MR) imging, nd computed tomogrphy (CT) re the most commonly nd widely used modlities for preopertive stging, guidnce for iopsy or tretment, nd postopertive follow-up (1, 2). But reported sensitivity nd specificity of these conventionl modlities re unstisfctory (1-5). To overcome insufficient ccurcies of these conventionl modlities, the dvnced MR imging nd comined positron emission tomogrphy nd computed tomogrphy (PET/CT) re recruited. In this review, we will discuss imging findings of prostte JKSMRM 12:89-99(2008) 1 Deprtment of Rdiology, Kngnm St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore. 2 Deprtment of Nucler Medicine, Kngnm St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore. Received; Septemer 20, 2008, ccepted; Octoer 31, 2008 Corresponding uthor : Je Young Byun, M.D., Deprtment of Rdiology, Kngnm St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore, 505 Bnpo-dong, Seocho-gu, Seoul 137-701, South Kore Tel. 82-2-590-2785, 2468 Fx. 82-2-599-6771 E-mil: jyyun@ctholic.c.kr - 89-
Jin Hee Jng et l cncer on vrile imging modlities, focused on MR imging nd PET/CT. Trnsrectl ultrsound Generlly, prostte cncer shows nonspecific findings on TRUS. Prostte cncer in the peripherl zone is usully seen s hypoechoic mss (Fig. 1) on TRUS (6). Mss with ulging or irregulr contour on TRUS suggests extrcpsulr extension, nd length of the contct of lesion with prostte glnd is ssocited with the proility of extrcpsulr invsion (7). In the MR imging er, the clinicl role of TRUS is limited to ssess volume of prostte glnd for prostte specific ntigen (PSA) density, nd guidnce for systemic iopsy, trgeted-extrprosttic iopsy or rchytherpy. Computed tomogrphy Evluting the intrprosttic ntomy of the prostte glnd nd extrprosttic involvement with CT is limited nd not recommended. Smll prostte cncer is poorly defined on CT scn. Only some lrge tumors cn e delineted on CT. The role of CT in clinicl prctice is in ssessing nodl stging, distnt metstsis, nd seline study for loclly dvnced disese (i.e. gross extrcpsulr disese, gross seminl vesicle invsion, or invsion of surrounding structures including ldder, rectum, levtor ni muscles or pelvic floor) nd these re eyond the coverge of this review. Conventionl MR imging Reported ccurcies of the prostte cncer detection of MR imging re widely vrile nd guideline for the indictions of MR imging in the ptients with dignosed or suspected prostte cncers still hs controversies (1-5). Generlly, MR imging of the prostte glnd is helpful in ptients with negtive TRUS-guided iopsy in spite of high PSA vlue, or in ptients with iopsy-proven prostte cncer for preopertive stging. Hemorrhge fter iopsy limits the ccurcy of prostte MR imging, so dely of 6-8 weeks etween iopsy nd MR imging is needed (8-10). Optiml imge resolution is cquired y high tesl (more thn 1.5T) mgnet mchine comined with pelvic phsed-rry coil nd endorectl coil. MR imging with endorectl coil provides etter imges with incresed sptil resolution nd contrst in demonstrting contour of tumor nd ssessment of extrprosttic invsion. But prolems induced y endorectl coil, such s ptient s discomfort, ner field rtifct, rtifct y peristlsis, distortion of imges of peripherl zone y llooning of proe, should e considered. Conventionl MR imging for the prostte glnd includes () the xil sgittl spin echo or fst spin echo Fig. 1. Prostte cncer with extrcpsulr involvement on TRUS TRUS () of 67-yer-old mle ptient with high PSA level (37.9 ng/ml) shows 1.2 1.0 cm sized, reltively welldefined hypoechoic mss (rrow) with ulging contour in right peripherl zone. Axil T2-weighted imge of similr section () shows smll hypointense nodule (rrow) with ulging contour in right peripherl zone. Cpsulr surfce overlying low SI nodule is poorly differentited with periprosttic ft. Rdicl prosttectomy ws performed, nd prostte cncer with extrcpsulr invsion (T3, Gleson s score 7) ws confirmed in right peripherl zone. - 90-
Imging Assessment of Primry Prostte Cncer, Focused on Advnced MR Imging nd PET/CT T1-weighted imges (TR 400-500, TE 10-15), () xil, sgittl nd coronl spin echo or fst spin echo T2- weighted imges (TR 3500-4000, TE 130-140), nd (c) contrst enhnced xil nd coronl T1-weighted imges with or without ft sturtion. Especilly thin (3-mm) slice nd smll field of view re helpful in evlution of locl stging including the extrprosttic involvement (3). On T1-weighed imges, oth prostte prenchym nd prostte cncer pper s homogeneous Fig. 2. Post-iopsy hemorrhge on T1-weighted imge Axil T1-weighted imge fter outside prostte iopsy shows ptchy hyperintensity (rrow) in left peripherl zone, suggesting post-iopsy hemorrhge. intermedite signl intensity (SI). Hence, T1-weighted imges re used for ssessment of pelvic lymph nodes nd pelvic ones, rther thn primry prostte cncer. Hemorrhge fter previous iopsy is seen s high SI on T1-weighted imges (Fig. 2), which is helpful to differentite the post-iopsy hemorrhge nd prostte crcinoms, oth re seen s low SI on T2-weighted imges. On T2-weighted imges, the prostte cncer in peripherl zone is seen s low SI (Fig. 1, 3), in contrst with high SI of norml peripherl zonl prenchym (11). Most prostte cncer rises from the peripherl zone, so T2-weighted imges hve mjor role in the detection of prostte cncer. But, some enign conditions such s prosttitis nd hemorrhge cn e seen s focl low SI within peripherl zone; hence correltion with other sequence is needed. For this purpose, scnning xil T1- nd T2-weighted imging of prostte glnd with the sme slice thickness nd field of view for lignment of the two sequences is helpful. Involvement of prosttic cpsule, extrprosttic ft, neurovsculr undles, seminl vesicle nd ldder se re ssessed with T2-weighted imges (Fig. 4, 5, nd 6). In cses with extrprosttic invsion, locl stging of prostte cncer is T3 or T4, which mens the less chnce for curtive surgicl tretment (12, 13). Norml prenchym of the trnsition zone shows low SI on T2-weighted imge (Fig. 7), which mkes difficult Fig. 3. Prostte cncer on conventionl T2-weighted imge Axil T2-weighted imge () shows smll hypointense nodule (rrow) in the sucpsulr portion of left peripherl zone. Coronl T2-weighted imge () shows well-demrcted hypointense lesion (rrow) in left peripherl zone. Note the intct hypointense cpsule on T2-weighted imge. A smll denocrcinom (Stge T2, Gleson s score 7) in left peripherl zone ws surgiclly confirmed. - 91-
Jin Hee Jng et l Fig. 4. Extrcpsulr invsion An ovoid hypointense nodule (rrow) is seen in right peripherl zone on xil T2-weighted imge. Mrgin of the mss is poorly defined (doule rrows) nd drk signl cpsule is not seen in right lterl spect of the mss, s compred with intct cpsule (rrowheds) on contrlterl side of prostte. Findings re comptile with prostte cncer in right peripherl zone with extrcpsulr invsion. Prostte cncer with extrcpsulr invsion (T3, Gleson s score 6) ws confirmed y rdicl prosttectomy. Fig. 6. Seminl vesiculr invsion Coronl T2-weighted imge revels the irregulr shped hypointense mss (rrow) involving the left peripherl zone of prostte glnd with extension into seminl vesicle superiorly. Norml high signl intensity of seminl vesicle (rrowhed) is replced y low signl intensity mss (open rrow). Rdicl prosttectomy found the prostte cncer in left peripherl zone with seminl vesiculr invsion, which mens locl stging s T3. Fig. 5. Neurovsculr undle invsion Two seril xil T2-weighted imges of prostte glnd show nodulr hypointense mss (rrows) in the mid-portion of left peripherl zone on xil T2-weighted imges ( nd ). Focl ulging contour (rrowhed) with olitertion of low SI cpsule nd indistinct mrgin etween mss nd djcent ft suggests extrcpsulr invsion. Axil T2-weighted imge of lower level () discloses nodulr ulging, contcting with the neurovsculr undle (open rrow). Note the intct right side of prosttic cpsule nd right neurovsculr undle. Surgicl specimen disclosed neurovsculr undle invsion y prostte cncer. - 92-
Imging Assessment of Primry Prostte Cncer, Focused on Advnced MR Imging nd PET/CT to detect cncers in the trnsition zone. Findings helpful in detecting cncers in the trnsition zone re followings; [] homogenous low SI on T2-weighted imge, [] ill-defined or spiculted mrgin, [c] deficit of low SI rim which is chrcteristic of enign denom, [d] olitertion of surgicl pseudocpsule (trnsition zone-to-peripherl zone oundry of low SI), [e] urethrl or nterior firomusculr stroml invsion, [f] lenticulr-shped lesion (14). Dynmic contrst-enhnced MR Imging Prostte cncer hs incresed vsculrity like other mlignnt tumors, nd it is proly due to neovsculriztion nd incresed interstitil spce (15). These pthologicl chrcteristics re ssocited to more rpid enhncement of prostte cncer fter intrvenous contrst gent thn norml prenchym (Fig. 8). Becuse the norml prostte prenchym is vsculr, more rpid injection nd rpid scnning of prostte glnd re required to detect the incresed vsculrity of prostte cncer. After intrvenous infusion of full dose of gdolinium chelte (0.1 mmol/kg) injected t 3 ml/sec, seril 3D cquisitions of prostte glnd re required for ssessment of enhncement pttern of prostte lesion. Generlly 3D T1-weighted spoiled grdient echo sequence is used c d Fig. 7. Prostte cncer in trnsitionl zone On sgittl nd coronl T2-weighted imges ( nd ) of prostte glnd, homogenous hypointense mss (rrows) is noted in trnsitionl zone. On xil T2-weighted imge (c), mrgin of the mss (rrow) is poorly defined without discernile low signl intensity rim. At 30 seconds fter intrvenous contrst infusion (d), erly nodulr enhncement of the mss (rrow) is seen. Adenocrcinom involving trnsitionl zone with extrcpsulr invsion (T3, Gleson score 7) ws surgiclly confirmed. - 93-
Jin Hee Jng et l nd imges re cquired serilly with 5 to 10 seconds intervl. Reports out the dynmic contrst-enhnced MR imging of prostte cncers with high tesl mchine showed considerle outcomes for detecting nd loclizing the prostte cncers (16, 17). Direct inspection of imges, color mpping of vrile perfusion prmeters, nd signl intensity curves of region-of-interest re used for nlysis of enhncement ptterns. But nlyses of dynmic contrst-enhnced MR imging nd its results remin controversil, so further studies re needed. Diffusion-weighted imge Diffusion-weighted imge (DWI) reflects the diffusion coefficient of the tissue, using the dditionl diffusion grdients. DWI is widely used for detection of cytotoxic edem of hypercute or cute infrction of rin (18). Clinicl ppliction of DWI is extended, s promising method for detection nd locliztion of mlignnt tumors (19, 20). As well s other cncer cells, prostte cncer shows restricted diffusion nd decresed pprent diffusion coefficient (ADC) vlue (Fig. 9), due to high cellulrity, enlrgement of nuclei, hyperchromtisms nd ngultions of the nucler contour (21, 22). Contrst of the cncer from norml prostte prenchym is ssocited primrily with the difference of ADC vlues etween the cncer nd norml prenchym, nd the individul vriility of c Fig. 8. Dynmic contrst-enhnced MR Imging Dynmic contrst-enhnced MR imging of prostte glnd of sme ptient in Figure 4 ws performed. Precontrst imge () shows no focl lesion. At 30 seconds fter intrvenous contrst infusion, focl re in right peripherl zone (rrow) shows stronger enhncement thn other prostte prenchym (). Axil T2-weighted imge (c) shows sme loction nd size of tumor with dynmic contrst enhncement study. c Fig. 9. Diffusion-weighted imge Axil T2-weighted imge () shows ovl hypointense mss (rrow) in right peripherl zone. DWI (=1000, ) shows incresed SI of mss with decresed ADC vlue (c), suggesting diffusion restriction. Rdicl prosttectomy ws done, nd denocrcinom (T2, Gleson s score 9) in right peripherl zone ws confirmed. (Reprinted with permission, from reference 2) - 94-
Imging Assessment of Primry Prostte Cncer, Focused on Advnced MR Imging nd PET/CT ADC vlues is nother fctor for the ADC vlues (22-25). Recent reports suggest the dignostic vlue of DWI, conjunction with other imging modlities (22, 25, 26). Also high tesl MR units cn mke the difference of ADC vlue wider thn conventionl MR units (27). There is no consensus out the vlue of the DWI of prostte glnd, ut recent studies used the vlue from 800 to 1000 (28, 29). DWI of prostte is cquired y grdient-echo echo-plnr imges, which is one of the most fst imging sequences of MR. Short cquisition time is nother dvntge of DWI. MR spectroscopy MR spectroscopy provides metolic informtion out prosttic tissue y displying the reltive concentrtions of chemicl compounds within contiguous smll volumes of interest (voxels). Threedimensionl proton MR spectroscopic metolic mpping of the entire glnd is possile with resolution of 0.24 ml. Norml prostte glndulr prenchym hs reltively high concentrtion of citrte due to citrteproducing metolism. MR spectroscopy of prostte cncer revels decresed level of citrte nd incresed Fig. 10. MR spectroscopy T2-weighted imge () shows sutle hypointense lesion (rrows) in left peripherl zone nd trnsitionl zone. ADC mp () shows decresed ADC vlue in the corresponding re (rrows). Multi-voxel 3D MR spectroscopy t midglnd level (c) revels the incresed choline pek nd decresed citrte pek t corresponding re (green ox) of prostte cncer. Totl cquisition time ws within 9 minutes (TR/TE 800/140 msec). (Courtesy of Dr. BK Prk, Smsung Medicl Center, Seoul, Kore) c - 95-
Jin Hee Jng et l level of choline, which represent the ccelerted cell memrne turnover (Fig. 10). So we cn loclize the prostte cncer with MR spectroscopy, with incresed ccurcy in detecting nd loclizing prostte cncer (3, 30-32). Another distinguishing feture of MR spectroscopy is the ssessment of metolic chrcteristic of neoplsm. Some reports suggest MR spectroscopy cn predict the ggressiveness nd tretment response of tumor (32). These re helpful to estimte the prognosis of ptients with prostte cncer with MR spectroscopy. PET nd PET/CT PET nd PET/CT re whole ody imging modlities sed on the detection of nnihiltion photons relesed when specific rdionuclides emit positrons tht undergo nnihiltion with electrons (33). Rdiophrmceuticls of PET nd PET/CT re composed of isotopes emitting positron nd metolic surrogtes tht prticiptes into the metolic pthwy. PET/CT fuses the metolic informtion of PET scn on the ntomicl frme of CT, so results in more ccurte locliztion of uptke nd improved dignostic ccurcy thn PET lone. c d Fig. 11. Prostte cncer detected on PET/CT A 74-yer-old mle ptient with mlignnt srcom in right nsl cvity hd een performed PET/CT for restting fter surgicl removl of tumor. Note nodulr moderte FDG uptke (mx nd men SUV 3.3/2.8, rrow) in just inferior spect of FDG collection within the urinry ldder on fusion imges of PET/CT ( nd ). In this circumstnce, differentil dignosis for this nodulr FDG uptke includes primry mlignnt nodule, metsttic nodule, or even enign hyperplstic nodule. Serum PSA level is modertely incresed (5.7 ng/ml). Axil T2-weighted imge (c) revels nodulr hypointense mss (rrow) in right peripherl zone. TRUS (d) shows nodulr hypoechoic mss (rrow) on right peripherl zone. Trnsrectl iopsy ws performed under TRUS guidnce, d denocrcinom of prostte glnd, with Gleson score 6 ws found. - 96-
Imging Assessment of Primry Prostte Cncer, Focused on Advnced MR Imging nd PET/CT Vrile positron emitters re used for PET nd PET/CT. Among those rdionuclides, 18 F-deoxyglucose ( 18 F -FDG) is most widely used nd ville in common clinicl settings. FDG is n nlogue of glucose nd 18 F -FDG PET detects the tissues with fcilitted glucose metolism nd ssesses the glucose metolic ctivity of tissue semi-quntittively (33). Most mlignnt tumor showed incresed uptke nd utiliztion of glucose, due to incresed metolic demnds (34). Hence, we cn find the tumors with incresed glucose metolism with 18 F-FDG PET nd PET/CT. Vice vers, detection nd locliztion of tumors with decresed or slightly incresed glucose metolism with 18 F -FDG PET nd PET/CT is difficult. Well-differentited prostte cncer utilizes less glucose thn other mlignnt tumors, so less 18 F -FDG uptke thn others (Fig. 11). 18 F -FDG is excreted vi kidneys nd ccumulted in the ldder, just ove the prostte glnd (35). This ccumultion cn msk the sutle uptke of prostte cncer. Also, enign hyperplstic nodules of prostte glnd nd inflmmtion such s prostitis csue uneven hot uptke of prostte ckground prenchym, which lso cn msk or mimic the uptke of prostte cncer. These difficulties mke the sensitivity of 18 F -FDG PET for prostte cncer low, so 18 F -FDG PET for prostte cncer hs limited role for ssessing the primry prostte cncer (36-39). Other metolic trcers contining 11 C re lterntive to increse the ccurcy of PET for prostte cncer. However, 11 C hs very short hlf-life, which limits the clinicl ppliction of these mterils. 11 C -choline is used for synthesis of phospholipid, hence cn e used s nother mrker for cellulr prolifertion (40). A recent report compring the 11 C -choline PET nd MR imging/spectroscopy shows tht PET is more ccurte regrding the locliztion of min primry prostte cncer lesion thn MR imging/spectroscopy (41). In this report, they suggest tht 11 C -choline PET reflects tumor volume rther thn tumor grde. But enign prostte hyperplsi nd prosttitis my cuse high uptke of 11 C -choline. Another study on smll series of ptients reported tht the sttisticlly insignificnt difference of uptke on 11 C -choline PET etween the prostte cncer nd enign hyperplstic nodules, ut tendency towrds higher vlues in crcinom ws noted (40). 11 C -cette cn e used s n indictor of tumor growth, ecuse of cette is ssocited with ctive sl lipid metolism which is prt of cell memrne synthesis (42). Acette is not excreted vi urinry system nd shows lower physiologic uptke round the pelvic cvity thn FDG. Sndlom et l suggest vlue of PET with 11 C -cette in detecting nd loclizing fter rdicl prosttectomy (43). PET with 11 C -methionine my represents incresed mino cid trnsport nd metolism, nd recent report suggests the dignostic vlue of PET with 11 C-methionine in ndrogen-resistnt prostte cncer (44). Conclusion Prostte cncers show vrile imging findings ccording to the imging modlities. Hence, imging ssessment of prostte cncer is very difficult nd pproch with multiple imging modlities is essentil. MR imging hs criticl role in preopertive imging ssessment in ptients with prostte cncer. Appliction of dynmic contrst enhncement, DWI nd MR spectroscopy re the promising methods for detecting nd chrcterizing the prostte cncers. Also, PET/CT could e nother cornerstone for stging nd loclizing the prostte cncer. References 1.Hrick H, Choyke PL, Eerhrdt SC, Lieel SA, Scrdino PT. Imging prostte cncer: multidisciplinry perspective. Rdiology 2007;243:28-53. 2. 변재영. 전립선암의다양한영상과전망. Rdiology Digest 2007;2:8-18. 3.Hrick H, White S, Vigneron D, Kurhnewicz J, Kosco A, Levin D, et l. Crcinom of the prostte glnd: MR imging with pelvic phsed-rry coils versus integrted endorectlpelvic phsed-rry coils. Rdiology 1994;193: 703-709. 4.Scheidler J, Hrick H, Vigneron DB, Yu KK, Sokolov DL, Hung LR, et l. Prostte cncer: locliztion with threedimensionl proton MR spectroscopic imgingclinicopthologic study. Rdiology 1999;213:473-480. 5.Kim JK, Hong SS, Choi YJ, Prk SH, Ahn H, Kim CS, et l. Wsh-in rte on the sis of dynmic contrst-enhnced MRI: usefulness for prostte cncer detection nd locliztion. J Mgn Reson Imging 2005;22:639-646. 6.Shinohr K, Wheeler TM, Scrdino PT. The ppernce of prostte cncer on trnsrectl ultrsonogrphy: correltion of imging nd pthologicl exmintions. J Urol 1989;142:76-82. 7.Ukimur O, Troncoso P, Rmirez EI, Bin RJ. Prostte - 97-
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