Multiparametric magnetic resonance imaging of the prostate: current
                  concepts

Multiparametric MR (mpMR) imaging is rapidly evolving into the mainstay in prostate cancer (PCa) imaging. Generally, the examination consists of T2-weighted sequences, diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) evaluation, and less often proton MR spectroscopy imaging (MRSI). Those functional techniques are related to biological properties of the tumor, so that DWI correlates to cellularity and Gleason scores, DCE correlates to angiogenesis, and MRSI correlates to cell membrane turnover. The combined use of those techniques enhances the diagnostic confidence and allows for better characterization of PCa. The present article reviews and illustrates the technical aspects and clinical applications of each component of mpMR imaging, in a practical approach from the urological standpoint.

Prostate cancer; Magnetic resonance imaging; Diffusion-weighted imaging; Dynamic contrast enhancement

Authorship

Leonardo Kayat Bittencourt Mailing Address: Dr. Leonardo Kayat Bittencourt. Avenida das Américas, 4666, sala 325, Centro Médico Barrashopping, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102. E-mail: lkayat@gmail.com

PhD, Associate Professor of Radiology, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil, Titular Member, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Radiologist at CDPI and Multi-Imagem Clinics, Rio de Janeiro, RJ, Brazil.Universidade Federal FluminenseBrazilNiterói, RJ, BrazilPhD, Associate Professor of Radiology, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil, Titular Member, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Radiologist at CDPI and Multi-Imagem Clinics, Rio de Janeiro, RJ, Brazil.

Daniel Hausmann

MD, Resident, Institute of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.Heidelberg UniversityGermanyMannheim, GermanyMD, Resident, Institute of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Natalia Sabaneeff

Titular Member, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Radiologist at CDPI Clinic, Rio de Janeiro, RJ, Brazil.Colégio Brasileiro de Radiologia e Diagnóstico por ImagemBrazilRio de Janeiro, RJ, BrazilTitular Member, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Radiologist at CDPI Clinic, Rio de Janeiro, RJ, Brazil.

Emerson Leandro Gasparetto

PhD, Associate Professor, Department of Radiology, Universidade Federal do Rio de Janeiro (UFRJ), Radiologist at CDPI and Multi-Imagem Clinics, Rio de Janeiro, RJ, Brazil.Universidade Federal do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilPhD, Associate Professor, Department of Radiology, Universidade Federal do Rio de Janeiro (UFRJ), Radiologist at CDPI and Multi-Imagem Clinics, Rio de Janeiro, RJ, Brazil.

Jelle O. Barentsz

PhD, Chair of Research and Professor, Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands.Radboud University Medical CenterNetherlandsNijmegen, NetherlandsPhD, Chair of Research and Professor, Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands.

Mailing Address: Dr. Leonardo Kayat Bittencourt. Avenida das Américas, 4666, sala 325, Centro Médico Barrashopping, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102. E-mail: lkayat@gmail.com

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (10)

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Figure 1
MR imaging of the normal prostate. T2-weighted sequence in the axial plane showing the prostate capsule (white arrowhead), the peripheral zone (ZP), the surgical capsule (black arrowhead) and internal gland (asterisk).

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Figure 2
Typical aspect of PCa in the peripheral zone on T2-weighted MR images, showing as a hypointense nodular lesion at right, marked by arrow heads in the axial (A) and sagittal (B) planes.

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Figure 3
Appearance of PCa in the internal gland on T2-weighted MR images in the axial plane. It is noteworthy a hypointense area in the left internal gland (arrow), with indistinct contours, and signs of rupture of the surgical capsule (arrowhead) extending into the adjacent peripheral zone.

Thumbnail

Figure 4
T2-weighted MR images of the prostate, showing typical findings of extracapsular tumor extension marked by arrowheads in the following examples: asymmetry of the neurovascular bundle (A), tumor involvement of the neurovascular bundle (B), spiculated contour of the prostatic capsule (C), and focal bulging on the contour of the prostatic capsule (D).

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Figure 5
Signs of tumor extension to the seminal vesicles on T2- weighted images, identified by arrowheads. The key is to find hypointense areas replacing the usual hyperintense seminal vesicle, promoting wall thickening and obliterating their lumina, with either a diffuse (A) or focal (B) appearance.

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Figure 6
Examples of MRSI prostate spectra. A: Typical spectral analysis of normal prostate tissue, showing a high citrate (Ci) peak, with a low choline (Cho) peak, and the peak of creatine (Cr) used as comparison parameter for the other metabolites. On B, we observe the spectral signature of typical aggressive PCa, with a high choline (Cho) peak and low citrate (Ci) levels.

Thumbnail

Figure 7
Signal intensity versus time curve in a typical tumor lesion. The image A represents the early arterial phase of DCE evaluation, showing a focal area of early contrast enhancement in the peripheral zone at right (outlined by the red line). Normal appearing areas were also outlined in the contralateral peripheral zone (yellow) and internal gland (green). The resulting curves (B) show that the suspicious lesion (red curve) is characterized by a high and steep rise (washin), flowed by a marked decrease (washout), with a significantly different behavior from the other curves.

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Figure 8
Semi-quantitative post-processing of DCE. Image A represents the parametric map generated from DCE evaluation of the same patient of Figure 7, corresponding to the area under the curve during the first minute (positive enhancement index – PEI). Note that on this map, the suspected area cited in Figure 7 is coded in red (arrowheads), standing out from the other portions of the prostatic parenchyma. On B, one observes a fusion between the DCE parametric map and the T2-weighted sequence in the axial plane, enabling better correlation of anatomic and functional findings.

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Figure 9
ADC map of the same patient from Figure 1, showing excellent distinction of the zonal anatomy. The normal peripheral zone (ZP) shows high ADC values relative to the normal internal gland (GI). This fact probably explains the great utility of DWI in detecting tumors in the peripheral zone, which present themselves as foci of restricted diffusion (i.e., “dark lesions”) over a region with facilitated (i.e., “bright”) diffusion.

Thumbnail

Figure 10
Detection of PCa with DWI. ADC map of the same patient in Figure 7 (A) showing a suspicious hypointense focal lesion in the right peripheral zone (arrowheads), determining restricted water diffusion, with ADC values around 750 × 10–6 mm/s2, while the contralateral peripheral zone exhibits ADC values in the range of 1,600 × 10–6 mm/s2. The fusion of information from DWI with T2-weighted images (B) shows that the lesion detected on ADC map, coded in red (arrowheads) has topographic correspondence with suspicious areas on T2-weighted image. The patient underwent radical prostatectomy, and the surgical specimen was sent for ex vivo MR examination (C), which showed a suspicious lesion (arrowhead) in the same region as of preoperative MR examination. The whole mount specimen at the same level and orientation of the MR images (D) also shows the tumor area (arrowhead) on the same location indicated by MR images. Asterisks on C and D represent areas with BPH.

Figure 1 MR imaging of the normal prostate. T2-weighted sequence in the axial plane showing the prostate capsule (white arrowhead), the peripheral zone (ZP), the surgical capsule (black arrowhead) and internal gland (asterisk).

Figure 2 Typical aspect of PCa in the peripheral zone on T2-weighted MR images, showing as a hypointense nodular lesion at right, marked by arrow heads in the axial (A) and sagittal (B) planes.

Figure 3 Appearance of PCa in the internal gland on T2-weighted MR images in the axial plane. It is noteworthy a hypointense area in the left internal gland (arrow), with indistinct contours, and signs of rupture of the surgical capsule (arrowhead) extending into the adjacent peripheral zone.

Figure 4 T2-weighted MR images of the prostate, showing typical findings of extracapsular tumor extension marked by arrowheads in the following examples: asymmetry of the neurovascular bundle (A), tumor involvement of the neurovascular bundle (B), spiculated contour of the prostatic capsule (C), and focal bulging on the contour of the prostatic capsule (D).

Figure 5 Signs of tumor extension to the seminal vesicles on T2- weighted images, identified by arrowheads. The key is to find hypointense areas replacing the usual hyperintense seminal vesicle, promoting wall thickening and obliterating their lumina, with either a diffuse (A) or focal (B) appearance.

Figure 6 Examples of MRSI prostate spectra. A: Typical spectral analysis of normal prostate tissue, showing a high citrate (Ci) peak, with a low choline (Cho) peak, and the peak of creatine (Cr) used as comparison parameter for the other metabolites. On B, we observe the spectral signature of typical aggressive PCa, with a high choline (Cho) peak and low citrate (Ci) levels.

Figure 7 Signal intensity versus time curve in a typical tumor lesion. The image A represents the early arterial phase of DCE evaluation, showing a focal area of early contrast enhancement in the peripheral zone at right (outlined by the red line). Normal appearing areas were also outlined in the contralateral peripheral zone (yellow) and internal gland (green). The resulting curves (B) show that the suspicious lesion (red curve) is characterized by a high and steep rise (washin), flowed by a marked decrease (washout), with a significantly different behavior from the other curves.

Figure 8 Semi-quantitative post-processing of DCE. Image A represents the parametric map generated from DCE evaluation of the same patient of Figure 7, corresponding to the area under the curve during the first minute (positive enhancement index – PEI). Note that on this map, the suspected area cited in Figure 7 is coded in red (arrowheads), standing out from the other portions of the prostatic parenchyma. On B, one observes a fusion between the DCE parametric map and the T2-weighted sequence in the axial plane, enabling better correlation of anatomic and functional findings.

Figure 9 ADC map of the same patient from Figure 1, showing excellent distinction of the zonal anatomy. The normal peripheral zone (ZP) shows high ADC values relative to the normal internal gland (GI). This fact probably explains the great utility of DWI in detecting tumors in the peripheral zone, which present themselves as foci of restricted diffusion (i.e., “dark lesions”) over a region with facilitated (i.e., “bright”) diffusion.

Figure 10 Detection of PCa with DWI. ADC map of the same patient in Figure 7 (A) showing a suspicious hypointense focal lesion in the right peripheral zone (arrowheads), determining restricted water diffusion, with ADC values around 750 × 10–6 mm/s2, while the contralateral peripheral zone exhibits ADC values in the range of 1,600 × 10–6 mm/s2. The fusion of information from DWI with T2-weighted images (B) shows that the lesion detected on ADC map, coded in red (arrowheads) has topographic correspondence with suspicious areas on T2-weighted image. The patient underwent radical prostatectomy, and the surgical specimen was sent for ex vivo MR examination (C), which showed a suspicious lesion (arrowhead) in the same region as of preoperative MR examination. The whole mount specimen at the same level and orientation of the MR images (D) also shows the tumor area (arrowhead) on the same location indicated by MR images. Asterisks on C and D represent areas with BPH.

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