Prostate cancer ranks as the most common primary malignant tumor in men and the second most common cause of cancer-related deaths in men. Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of this article.
It is primarily a disease of the elderly male. In the United States, approximately 200,000 new cases are diagnosed each year.
Prostate cancer is usually detected by:
- an elevated (greater than 4 ng/dL) prostate-specific antigen (PSA); normal is 1-4 ng/dL
- abnormal digital rectal examination
Clinically patients can present with:
- urinary symptoms, e.g. nocturia, hesitancy, urgency, terminal dribble
- often collectively known as LUTS (lower urinary tract symptoms)
- hematuria (in advanced disease) 27
- back pain (from metastatic spread to the spine)
Clinical scores that may be useful in assessing symptoms severity include:
- IPSS: international prostate symptoms score, 35 points score mainly assessing urinary symptoms
- IIEF: international index of erectile function
95% of prostate cancers are adenocarcinomas which develop from the acini of the prostatic ducts 15. They arise in the posterior/peripheral (70%) prostate gland more commonly than the anterior and central prostate gland (30%) 21.
Prostate cancer can spread by local invasion (typically into the bladder and seminal vesicles; urethral and rectal involvement are rare), lymphatic spread (pelvic nodes first followed by para-aortic and inguinal nodes), or by haematogenous metastases 23. Common sites of haematogenous metastases are 22,23:
- bone (90%)
- lung (~45%)
- liver (~25%)
- pleura (~20%)
- adrenal glands (~15%)
Pathologic specimens are graded using the Gleason score, which is the sum of the most prevalent and second most prevalent types of dysplasia, each on a scale of 1 to 5, with 5 being the most dysplastic.
Transrectal ultrasonography (TRUS) is often initially performed to detect abnormalities and to guide biopsy, usually following an abnormal PSA level or DRE.
Ultrasound is used to direct biopsy of suspicious, hypoechoic regions, usually in the peripheral zone. Because of the high incidence of multifocality, systematic sextant biopsies are recommended.
On ultrasound, prostate cancer is usually seen as a hypoechoic lesion (60-70%) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40% of lesions).
Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland.
The primary indication for MRI of the prostate is in the evaluation of prostate cancer after an ultrasound-guided prostate biopsy has confirmed cancer in order to determine if there is extracapsular extension 1,2,4. Increasingly MRI is also being used to detect and localize cancer when the PSA is persistently elevated, but routine TRUS biopsy is negative. Both the American College of Radiology (ACR) and European Society of Uroradiology (ESUR) advocate the use of multiparametric MRI (mpMRI) in prostate imaging 20.
MRI-guided prostate biopsy is also being used, particularly in those cases where TRUS biopsy is negative but clinical and PSA suspicion remains high 12. Following radical prostatectomy, patients with elevated PSA should also be examined using MRI.
Often a PI-RADS score is given to assess the probability of the lesion being malignant.
- T1: useful for detection of prostate contour, neurovascular bundle encasement, and post-biopsy hemorrhage 15
- using an endorectal coil, on T2-weighted images prostate cancer usually appears as a region of low signal within a normally high signal peripheral zone 1,13
- most significant cancers occur along the posterior portion of the gland abutting the rectum
- DWI/ADC: often shows restricted diffusion
dynamic contrast enhancement (DCE): (dynamic contrast enhancement in prostate cancer)
- shows enhancement but it can be difficult to distinguish from prostatitis or benign prostatic hyperplasia (especially in the central zone lesions 19)
- more specific than T2 signal 17
- involves post-processing time
MR spectroscopy: (MR-spectroscopy in prostate cancer)
- increased choline: citrate or choline+creatine: citrate ratios are seen in prostate cancer (see below for more details) 15
Routine use of body 3.0 T magnets now means that endorectal coils have become unnecessary for prostate imaging due to the improved signal to noise and spatial resolution associated with higher field strength.
MRI parameters routinely assessed include the presence of a mass with a low T2 signal, restricted diffusion with reduced ADC, and increased tissue capillary permeability using dynamic contrast-enhanced (DCE) imaging and calculation of the so-called Ktrans (a calculated time constant for permeability). These so-called multiparametric techniques are increasingly being used in the assessment of prostate malignancy with MRI 11.
Extracapsular extension carries a poor prognosis. Assess for:
- asymmetry/extension into the neurovascular bundles
- obliteration of the rectoprostatic angle
- involvement of the urethra
- extension into the seminal vesicles (normal seminal vesicles have high signal on T2)
Lymphadenopathy is best appreciated on T1-weighted images.
The addition of MR spectroscopy (MRS) with fast T2-weighted imaging is an area of research that holds promise for the detection of disease. The normal prostate produces a large amount of citrate from the peripheral zone, which tumors do not 3. In normal prostate tissue citrate and polyamine levels are high and choline levels low. The reverse is the case in a tumor.
Not accurate at detecting in situ prostate cancer. Scans of the abdomen and pelvis are commonly obtained before the onset of radiation therapy to identify bony landmarks for planning.
Tc-99m MDP bone scan
- technetium-99m bone scan is usually used to detect osseous metastases
- gallium-68-PSMA PET can be used for diagnosis, staging, restaging, evaluation of therapy response and prognostication in prostate cancer 26
- fluorine-18-fluciclovine PET is used to detect and localize suspected prostate cancer recurrence based on elevated prostate-specific antigen in men who have undergone prior treatment
Treatment and prognosis
Generally, patients with a Gleason score of <7 and a PSA of <10 ng/L are considered to have potentially curable disease. These patients undergo prostatectomy, brachytherapy, or external beam radiation 5.
Patients that do not meet these criteria will usually undergo a combination of hormone therapy and external beam radiation.
General imaging differential considerations include:
- benign prostatic hypertrophy (BPH)
- prostatic sarcoma
- other prostatic tumors: rare (e.g. melanoma of prostate 9)
- direct invasion of the prostate by bladder or rectal adenocarcinoma
Differential considerations (mimics) on MRI include 24:
- anterior fibromuscular stroma: anterior, symmetric, usually hypoenhancing
- central zone of the prostate: symmetric, central, tends not to wash out on DCE
- periprostatic veins and periprostatic lymph nodes
- bacterial prostatitis
- granulomatous prostatitis
- amyloidosis (rare)
- calcification, necrosis, hemorrhage
- 1. Hricak H, Choyke PL, Eberhardt SC et-al. Imaging prostate cancer: a multidisciplinary perspective. Radiology. 2007;243 (1): 28-53. doi:10.1148/radiol.2431030580 - Pubmed citation
- 2. Thornbury JR, Ornstein DK, Choyke PL et-al. Prostate cancer: what is the future role for imaging? AJR Am J Roentgenol. 2001;176 (1): 17-22. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Hahn P, Smith IC, Leboldus L et-al. The classification of benign and malignant human prostate tissue by multivariate analysis of 1H magnetic resonance spectra. Cancer Res. 1997;57 (16): 3398-401. Cancer Res. (link) - Pubmed citation
- 4. Sala E, Eberhardt SC, Akin O et-al. Endorectal MR imaging before salvage prostatectomy: tumor localization and staging. Radiology. 2006;238 (1): 176-83. doi:10.1148/radiol.2381052345 - Pubmed citation
- 5. Lee JK, Stanley RJ, Heiken JP. Computed body tomography with MRI correlation. Lippincott Williams & Wilkins. (1998) ISBN:0781702917. Read it at Google Books - Find it at Amazon
- 6. Beyersdorff D, Taymoorian K, Knösel T et-al. MRI of prostate cancer at 1.5 and 3.0 T: comparison of image quality in tumor detection and staging. AJR Am J Roentgenol. 2005;185 (5): 1214-20. doi:10.2214/AJR.04.1584 - Pubmed citation
- 7. Bartolozzi C, Selli C, Olmastroni M et-al. Rhabdomyosarcoma of the prostate: MR findings. AJR Am J Roentgenol. 1988;150 (6): 1333-4. AJR Am J Roentgenol (citation) - Pubmed citation
- 8. Prando A, Wallace S. Helical CT of prostate cancer: early clinical experience. AJR Am J Roentgenol. 2000;175 (2): 343-6. AJR Am J Roentgenol (full text) - Pubmed citation
- 9. Wong JA, Bell DG. Primary malignant melanoma of the prostate: case report and review of the literature. Can J Urol. 2006;13 (2): 3053-6. - Pubmed citation
- 10. Kundra V, Silverman PM, Matin SF et-al. Imaging in oncology from the University of Texas M. D. Anderson Cancer Center: diagnosis, staging, and surveillance of prostate cancer. AJR Am J Roentgenol. 2007;189 (4): 830-44. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.07.2011 - Pubmed citation
- 11. Cornud F, Delongchamps NB, Mozer P et-al. Value of multiparametric MRI in the work-up of prostate cancer. Curr Urol Rep. 2012;13 (1): 82-92. Curr Urol Rep (full text) - doi:10.1007/s11934-011-0231-z - Pubmed citation
- 12. Roethke M, Anastasiadis AG, Lichy M et-al. MRI-guided prostate biopsy detects clinically significant cancer: analysis of a cohort of 100 patients after previous negative TRUS biopsy. World J Urol. 2012;30 (2): 213-8. World J Urol (full text) - doi:10.1007/s00345-011-0675-2 - Pubmed citation
- 13. Verma S, Rajesh A. A clinically relevant approach to imaging prostate cancer: review. AJR Am J Roentgenol. 2011;196 (3_supplement): S1-10 Quiz S11-4. doi:10.2214/AJR.09.7196 - Pubmed citation
- 14. Claus FG, Hricak H, Hattery RR. Pretreatment evaluation of prostate cancer: role of MR imaging and 1H MR spectroscopy. Radiographics. 2004;24 Suppl 1 (suppl 1): S167-80. doi:10.1148/24si045516 - Pubmed citation
- 15. Bonekamp D, Jacobs MA, El-Khouli R et-al. Advancements in MR imaging of the prostate: from diagnosis to interventions. Radiographics. 2011;31 (3): 677-703. doi:10.1148/rg.313105139 - Free text at pubmed - Pubmed citation
- 16. Ito H, Kamoi K, Yokoyama K et-al. Visualization of prostate cancer using dynamic contrast-enhanced MRI: comparison with transrectal power Doppler ultrasound. Br J Radiol. 2003;76 (909): 617-24. doi:10.1259/bjr/52526261 - Pubmed citation
- 17. Ocak I, Bernardo M, Metzger G et-al. Dynamic contrast-enhanced MRI of prostate cancer at 3 T: a study of pharmacokinetic parameters. AJR Am J Roentgenol. 2007;189 (4): 849. doi:10.2214/AJR.06.1329 - Pubmed citation
- 18. Verma S, Turkbey B, Muradyan N et-al. Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management. AJR Am J Roentgenol. 2012;198 (6): 1277-88. doi:10.2214/AJR.12.8510 - Pubmed citation
- 19. Alonzi R, Padhani AR, Allen C. Dynamic contrast enhanced MRI in prostate cancer. Eur J Radiol. 2007;63 (3): 335-50. doi:10.1016/j.ejrad.2007.06.028 - Pubmed citation
- 20. Quon J, Kielar AZ, Jain R et-al. Assessing the utilization of functional imaging in multiparametric prostate MRI in routine clinical practice. Clin Radiol. 2015;70 (4): 373-8. doi:10.1016/j.crad.2014.12.001 - Pubmed citation
- 21. Salamipour H, Weissleder R, Wittenberg J et-al. Primer of diagnostic imaging. Mosby. ISBN:032302422X. Read it at Google Books - Find it at Amazon
- 22. Bubendorf L, Schöpfer A, Wagner U et-al. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum. Pathol. 2000;31 (5): 578-83. Pubmed citation
- 23. Held-Warmkessel J. Contemporary issues in prostate cancer. Jones & Bartlett Learning. ISBN:0763730750. Read it at Google Books - Find it at Amazon
- 24. Kitzing YX, Prando A, Varol C et-al. Benign Conditions That Mimic Prostate Carcinoma: MR Imaging Features with Histopathologic Correlation. Radiographics. 2016;36 (1): 162-75. doi:10.1148/rg.2016150030 - Pubmed citation
- 25. Choi YJ, Kim JK, Kim N et-al. Functional MR imaging of prostate cancer. Radiographics. 2007;27 (1): 63-75. doi:10.1148/rg.271065078 - Pubmed citation
- 26. Kallur KG, Ramachandra PG, Rajkumar K, Swamy SS, Desai I, Rao RM, Patil SG, Sridhar PS, Madhusudhan N, Krishnappa RS, Bhadrasetty V, Kumara HM, Santhosh SD, Ajaikumar BS. Clinical Utility of Gallium-68 PSMA PET/CT Scan for Prostate Cancer. Indian journal of nuclear medicine : IJNM : the official journal of the Society of Nuclear Medicine, India. 32 (2): 110-117. doi:10.4103/0972-3919.202255 - Pubmed
- 27. Gofrit ON, Katz R, Shapiro A, Yutkin V, Pizov G, Zorn KC, Duvdevani M, Landau EH, Pode D. Gross hematuria in patients with prostate cancer: etiology and management. (2013) ISRN surgery. 2013: 685327. doi:10.1155/2013/685327 - Pubmed
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