Prostatic carcinoma is an important medical issue and a major social concern in recent times.

Globally the burden is expected to increase upto 1.7 million fresh cases and 499000
fresh deaths by the year 2030 mainly due to increasing ag expectancy due to better
health care facilities available16

MR imaging has been used to detect prostatic carcinoma since decades with varying level of
success. New advances in sequences and new techniques are introduced in view to
provide better accuracy, localisation , spread of tumour to surrounding tissue, which
aids in diagnosing prostatic carcinoma. Contrast enhanced MRI and MR spectroscopy
and diffusion weighted sequences show improved results. DCE MRI provides great
tissue characterisation and aids in staging prostatic carcinoma.

1Gibbs et al1 in year 2001 conducted a study in which twelve pateints with a mean age of 69
years and eight healthy volunteers with a mean age of 29 years where enrolled and T 2
weighted FSE imaging to locate the prostate was done and mean ADC for normal and
malignant peripheral zone were obtained. They concluded that prostate cancer can cause
restricted diffusion of water relative to normal tissue, resulting in decreased signal in
malignant lesions on ADC map.

2 In the year 2002 a study was conducted to measure the apparent diffusion coefficient
(ADC) value at which prostatic cancer and normal prostatic tissue can be differentiated. They
found that the ADC value for normal PZ was higher than for CG and cancer in PZ. They
concluded that the ADC value is lower for prostatic cancer than for normal tissue.ADC value
for normal peripheral zone was 1.9x10-3and for cancer prostate in peripheral zone was
1.32x10-3.

3 Piotr Kozlowski in 2006 conducted a study in which he studied whether on combining the
dynamic contrast enhanced MRI and diffusion weighted sequence if there was improvement
in diagnostic sensitivity or not .for which he concluded that alone the diffusion weighted
study was only 54% sensitive and alone contrast enhance sequence was 59 % sensitive
,which when used in combination incraeds the sensitivity to 87%

4 Study was done by Haider3 in 2007 where 49 patients with prostate cancer to compare T2W
MRI alone and T2 combined with DWI. Patients underwent staging MRI before radical
prostatectomy and at least weeks after biopsy. Each lesion was given score from 0-5 ranging
from definitely no cancer to definitely cancer images looking at only T2WI first
thenT2WI+ADC. T2WI and T2+DWI were scored for likely of tumor and were compared
with whole mount histological result. They concluded that sensitivity for T2W+DWI was
81% as compared to 54% for T2W scan.

5 In 2009 by V. Panebianco was done with purpose to evaluate the role of dynamic contrast
enhanced MRI sequences and MR spectroscopic sequences in patients with increased PSA
levels and negative trans-rectal ultrasonography biopsy results in detecting foci of tumour
which gave the result of better guidance of biopsy site with MR spectroscopy and contrast
enhanced MRI .

6Another study was done in 2009 to find the visibility of prostatic tumor on DWI in relation
to Gleason score. The imaging results were compared to histopathology data. They concluded
that ADC value significantly decreases as the Gleason score increases, thereby DWI may
help differentiate between low risk and high risk prostate cancer.

7Mazaheri et al in year 2009 did a retrospective study to determine the accuracy of diffusion
weighted magnetic resonance imaging for identifying cancer in the prostate peripheral zone
and to assess the accuracy of tumor volume measurements made with T2-weighted imaging
and combined T2-weighted and DW MR imaging by using surgical pathologic examination
as the reference standard. Forty-two patients underwent endorectal MR at 1.5 T before
undergoing radical prostatectomy. Associations between volume measurements from imaging
and from pathologic examination were assessed by using concordance correlation coefficients
(CCCs). In identifying malignant voxels, respective ADC cutoff values of 0.0014 and 0.0016
mm2/sec yielded sensitivity of 82% and 95% and specificity of 85% and 65%, respectively.
The CCCs of combined T2-weighted and DWMR imaging (ADC cutoff, 0.0016 mm2/sec)
was significantly higher than that of T2-weighted imaging alone. They concluded Adding
DW MR to T2-weighted imaging can significantly improve the accuracy of prostate PZ
tumor volume measurement.

8 Aytekin Oto et al6 in 2010 performed a study to analyze the diffusion Weighted scan in
central gland (CG) prostate cancer, stromal hyperplasia (SH), and glandular hyperplasia (GH)
and to determine the role of these parameters in the differentiation of CG cancer from benign
CG. The average ADCs were 1.0x10-3, 1.27x10-3, and 1.7x 10-3, respectively, in CG
carcinoma, Stromal Hyperplasia and Glandular Hyperplasia and differed significantly.

9 Baris Turkbey et al7 in the year 2010 performed a study To investigate whether apparent
diffusion coefficients (ADCs) derived from diffusion-weighted (DW) magnetic resonance
(MR) imaging at 3 T correlate with the clinical risk of prostate cancer in patients with
tumours that are visible on MR images, with MR imaging/trans rectal ultrasonography (US)
fusion–guided biopsy as a reference. Forty-eight consecutive patients who underwent DW
imaging during 3-T MR imaging with an endorectal coil were included in this retrospective
study. Mean ADCs of cancerous target tumors were correlated with Gleason and D’Amico
clinical risk scores. ADC was found to distinguish tumors in the peripheral zone with
intermediate to high clinical risk from those with low clinical risk with a correct classification
rate of 0.73.

10 In 2010 verma et al8 did a study to evaluate the relationship between apparent diffusion
coefficient (ADC) values, tumour volume, and total Gleason grade in patients with prostate
cancer before radical prostatectomy. Patients with prostate cancer who had undergone
endorectal prostate MRI at 1.5 T before radical prostatectomy were included. A total of 197
tumours were studied; 128 (65%) tumours were found in the peripheral zone and 69 (35%)
were found in the central gland. The ADC value was found to be negatively correlated with
the Gleason grade. Higher ADC values were found to be associated with lower Gleason
grades in the peripheral zone prostate cancers. No association was found in the central zone
prostate cancers. Both ADC values and tumor volumes were found to significantly predict
tumor aggressiveness, specifically in the peripheral zone. They concluded that ADC values
were found to be negatively correlated with the postsurgical Gleason grade in patients with
prostate cancer.

11 M Abd-Alazeez conducted in 2014 which concluded that multiparametric MRI helps in

detecting and also to rule out prostatic carcinoma which are clinically significant before the
first biopsy in this study 258 candidates were enrolled out of which 141 showed any cancer
and 77 had target histopathological condition . hence it was concluded

16. Ferlay J., Shin H.R., Bray F. International Agency for Research on Cancer; Lyon, France: 2010.
GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10.
AIMS AND OBJECTIVE

To evaluate the role of Diffusion weighted imaging for detection and local staging of
prostatic cancer and to compare it with T2WI.

To evaluate the sensitivity and specificity of various MRI techniques: T2WI, DWI , MR
specectroscopy for diagnosing of prostatic carcinoma using histopathology as gold standard.

To obtain histopathological diagnosis in each patient (either by TRUCUT biopsy or from

surgical specimen as relevant in each case) and correlate with imaging findings.
X OF REFERENCES

1. Gibbs P, Tozer TJ, Liney GP and Turnbull LW Comparison of quantitative T2

mapping and diffusion-weighted imaging in the normal and pathologic prostate.
Magnetic resonance in medicine 2001;46:1054-1058
2. Issa B. In vivo measurement of the ADC in normal and malignant prostatic tissues
using echo-planar imaging.J of Magn Reson Imaging 2002;16:196-200
3. Kozlowski, P., Chang, S., Jones, E., Berean, K., Chen, H. and Goldenberg, S.
(2006). Combined diffusion-weighted and dynamic contrast-enhanced MRI for
prostate cancer diagnosis—Correlation with biopsy and histopathology. Journal of
Magnetic Resonance Imaging, 24(1), pp.108-113.

4. Haider MA, Kwast TH, Tanguay J, Evans AJ, Hashmi AT, Lockwood G,
Trachtenberg J et al. Combined T2-weighted and diffusion-weighted MRI for
localisation of prostate cancer. AJR 2007;189:323-328
5. Woodfield CA, Tung GA, Grand DJ, Machan JT, Pezullo JA and Renzulli JF.
Diffusion-weighted MRI of peripheral zone prostate cancer: Comparison of tumor
ADC with Gleason score and percentage of tumor on core biopsy. AJR
2010;194:316-322
6. Mazaheri Y, Hricak H, Fine SW, Akin O, Ishill MN, Reuter VE et al. Prostate tumor
volume measurement with combined T2 weighted imaging and diffusion – weighted
MR correlation with pathologic tumor volume. genitourinary imaging
2009;252:449-452
7. Oto A, Kayhan A, Jiang Y, Trehakova M, Antic T, Dahi F et al. prostate cancer:
differentiation of central gland cancer from benign prostatic hyperplasia by using
Diffusion-weighted and dynamic contrast enhanced MR imaging. genitourinary
imaging 2010;257:715-723
8. Turkbey B, Shah VP, Pang Y, Bernardo M, Xu S, Kreucker J et al. Is apparent
diffusion coefficient associated with clinical risk scores for prostate cancer that are
visible on 3-T MR images. genitourinary imaging 2011;258:488-495
9. Verma S, Rajesh A, Morales A, Lemen L, Delworth M, Bills G et al. Assesment of
aggressiveness of prostate cancer: correlation of apparent diffusion coefficient with
 histologic grade after radical prostatectomy. genitourinary imaging AJR
2011;196:374-381
10. Hambrock T, Somford DM, Huisman H, Witjes TA, Scheenen T, Barentsz JO et al.
Relationship between apparent diffusion coefficients at 3.0 T MR imaging and
gleason grade in peripheral zone prostate cancer. genitourinary imaging 2011;
259:453-461
11. Lim HK, Kim JK, Kim KA and Cho KS. prostate cancer apparent diffusion
coefficient map with T2 weighted images of detection – A multireader study
genitourinary imaging 2009;250:145-151
12. Shimofusa R, Fujimoto H, Akamata H, Motoori K, Yamamoto S, Ito H et al.
Diffusion-weighted imaging of prostate cancer.J Comput Assist Tomogr
2005;29:149-153

13. Kozlowski P, Chang SD, Jones EC, Berean KW, Chen H, Goldenberg SL et al.
Combined diffusion-weighted and dynamic contrast enhanced MRI for prostate
cancer diagnosis: Correlatoin with biopsy and histopathology. J Magn Reson
Imaging 2006;24:108-113

14. Desouza NM, Reinsberg SA, Scurr ED, Brewster JM and Payne GS Magnetic
resonance imaging in prostate cancer: the value of apparent diffusion coefficients for
identifying malignant nodules. The british journal of radiology 2007; 80:90-95

15. Choi YJ, Kim JK, Kim N, Kim KW, Choi EK., and Cho KS: Functional MR Imaging
of Prostate Cancer. RadioGraphics 2007;27:63-75

16. Presti JC, Hricak H,Narayan PA,Shinohara K,White S, Carroll PR et al. Local
Staging of Prostatic Carcinoma : Comparison of Transrectal Sonography and
Endorectal MR Imaging. AJR 1996;166:103-108
17. Cornud F, Hamida K , Flam T, Helenon O, Chretein Y, Thiounn N et al. Endorectal
color Doppler sonography and endorectal MR imaging features of nonpalpable
prostate cancer correlation with radical prostatectomy findings. AJR 2000; 175:
1161-1168
 18. Li H, sugimura K, Kaji Y, Kitamura Y, Hara I, Fujii M et al. conventional MRI
capabilities in the diagnosis of prostate cancer in the transition zone. AJR
2006;186:729-742

in normal and malignant prostatic tissues using echo-planar imaging.J of Magn Reson
Imaging 2002;16:196-200Woodfield CA, Tung GA, Grand DJ, Machan JT, Pezullo JA and
Renzulli JF. Diffusion-weighted MRI of peripheral zone prostate cancer: Comparison of
tumor ADC with Gleason score and percentage of tumor on core biopsy. AJR 2010;194:316-
322

Mazaheri Y, Hricak H, Fine SW, Akin O, Ishill MN, Reuter VE et al. Prostate tumor volume
measurement with combined T2 weighted imaging and diffusion – weighted MR correlation
with pathologic tumor volume. genitourinary imaging 2009;252:449-452

Panebianco, V., Sciarra, A., Ciccariello, M., Lisi, D., Bernardo, S., Cattarino, S., Gentile, V.
and Passariello, R. (2010). Role of magnetic resonance spectroscopic imaging ([1H]MRSI)
and dynamic contrast-enhanced MRI (DCE-MRI) in identifying prostate cancer foci in
patients with negative biopsy and high levels of prostate-specific antigen (PSA). La
radiologia medica, 115(8), pp.1314-1329.

Oto A, Kayhan A, Jiang Y, Trehakova M, Antic T, Dahi F et al. prostate cancer:

differentiation of central gland cancer from benign prostatic hyperplasia by using Diffusion-
weighted and dynamic contrast enhanced MR imaging. genitourinary imaging 2010;257:715-
723

Turkbey B, Shah VP, Pang Y, Bernardo M, Xu S, Kreucker J et al. Is apparent diffusion

coefficient associated with clinical risk scores for prostate cancer that are visible on 3-T MR
images. genitourinary imaging 2011;258:488-495

Verma S, Rajesh A, Morales A, Lemen L, Delworth M, Bills G et al. Assesment of

aggressiveness of prostate cancer: correlation of apparent diffusion coefficient with histologic
grade after radical prostatectomy. genitourinary imaging AJR 2011;196:374-381

Abd-Alazeez, M., Kirkham, A., Ahmed, H., Arya, M., Anastasiadis, E., Charman, S.,
Freeman, A. and Emberton, M. (2013). Performance of multiparametric MRI in men at risk
of prostate cancer before the first biopsy: a paired validating cohort study using template
prostate mapping biopsies as the reference standard. Prostate Cancer and Prostatic Diseases,
17(1), pp.40-46.

MATERIALS AND METHODS

SOURCE OF DATA:
The proposed study will be conducted in the Department of Radiodiagnosis at Govt Medical
college and Hospital Sector 32 , Chandigarh. Patients of clinically suspected prostate cancer
at primary presentation will be enrolled for the study. The clinical criteria for the suspicion of
cancer prostate will be a combination of patient’s symptoms of hematuria ,frequency
hemospermia, urgency, hesistancy and nocturia along with serum PSA levels of more than 4
ng/ml or with digital rectal examination findings of a hard prostate .

Study: prospective study

Sample & Duration: The study will be done over a period of one and half years from 2018
and data will be collected during this period from all the patients who undergoes MRI and
transrectal ultrasound investigation for suspected prostate cancer.

Place: MRI Scan will be done at Govt Medical college and Hospital Sector 32 , Chandigarh

Equipment used:

MRI study will be performed using Machine with a 1.5 Tesla scanner with a body phase
array coil. T1W, T2W scan will be taken in axial, coronal and saggital planes. Fast spin echo
T2 image will be acquired in axial, coronal planes to provide anatomical details .Diffusion
Weighted data will be acquired using single shot EPI sequences, at B value 0 and 1000.

DATA ANALYSIS:

Collected findings will be analyzed by correlating it with laboratory, surgical as well as

clinical data.
TRUCUT biopsy or surgical specimen of prostate will be obtained in every case for

histopathological diagnosis. Imaging diagnosis on MRI and TRUS will be compared with
final histopathological diagnosis.

The sensitivity and specificity of MRI and TRUS vs histopathology will be calculated for:

T2WI B) DWI C) MR spectroscopy D) combination E) TRUS

Inclusion criteria:

Patients of clinically suspected prostate cancer at primary presentation will be enrolled for the
study

Exclusion criteria

1. Any patient with documented prior treatment for any prostatic carcinoma.

2. Patients with any metallic implants whereby MRI examination is contraindicated.

Plan for data analysis:

Data will be entered in Microsoft Excel sheet and will be analyzed using SPSS version 12.0
statistical software. Data will be depicted in the form of tables and charts. Appropriate
statistical tests like Chi Square test and other non parametric tests will be used.

Does the study require any investigations or interventions to be

conducted on patients or other humans or animals? If so, please describe
briefly.

Yes, Patients will have to undergo Magnetic Resonance Imaging of the prostate and

TRUCUT biopsy of the prostate for histopathological diagnosis.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes

INDEX OF REFERENCES

We performed a cross-sectional study to evaluate the efficacy of TRUS, MRI, MRI+MRS in

various prostatic pathologies, with the main focus on detecting prostate cancer.

A total of 30 patients were informed about the nature, and objective of the study and written
informed consent was taken following an approval of an institutional ethics.

All patients with a strong clinical suspicion of prostate pathologies (lower urinary tract
symptoms like increased frequency of micturition, hesitancy, urgency and hard/enlarged
prostate on digital rectal examination), enlarged prostate on ultrasound of the abdomen or
raised PSA levels (>4 ng/ml) were included in the study.

Patients unwilling or unable (claustrophobic) to undergo MRI/MRS, with metallic hip

implants or any other metallic implants or devices that might distort local magnetic fields and
compromise the quality of MRI/MRS together with patients who underwent a recent prostatic
biopsy were excluded from the study.

All patients underwent TRUS and later MRI with T1WI, T2WI, DWI and 3D PRESSMRS
sequences; ADC values and Cho Cr/Cit ratios were calculated.

Machines Used – Ultrasonography (USG) machine – Mylab 50 and my lab 40, Corevision.
MRI – 1.5 Tesla (GE health care)