SRINIVASAN.

PV
The face of
carcinoma prostate is
changing
TRUS & Bx
COLOR & POWER DOPPLER
CE-TRUS
ELASTOSONOGRAPHY
CT [SPECT ]
MRI [ MRSI,DCE-MRI,DWI-MRI ]
BONE SCAN
PET
Gray-scale
Multi planar [end / side firing]
High frequency [6-10 MHz]
Focal range [1-4 cm/2-8 cm]
Coupling medium
Machine setting
Probe manipulation
Three prostate Dimentions
Formulas [ pi/6 x TD x AP x LD, pi/6 x TD 3,
Pi/6 x TD 2 X AP ]
PLANIMETRY-more accurate
Applications of prostate volume[psaD]
Sensitivity-75%,Specificity-44%[Djavan et
al,2000]

Hypoechoic lesions [17-
57% Frauscher et
al,2002]
Contour abnormality
Lobar asymmetry in
echotexture
Extra capsular
extension[loss of bright
white periprostatic fat]
Abnormal DRE
PSA > 4
Clinically suspected secondaries
Raised PSA velocity
Antibiotics
Enema
Analgesia
Patient positioning
Bx sample
Spatial orientation
FNAB
TPPBx
TUPBx
Infections [2%Lindert et al,2000]
Bleeding [Rectal bleeding2.1-21.7%,
Haematospermia 9.8-50.4% Djavan et
al,2001]
Vasovagal [1.4-5.3% Djavan et al,2001]
AUR [0.2-0.4% raaijmaker et al,2002]
CT has no role in prostate cancer detection or
primary tumor staging.

Poor separation between the prostate and
the levator muscle is and intraprostatic
anatomy.

Useful in the nodal staging of prostate cancer.
Useful as a baseline examination in high-risk patients.

Used to monitor bone metastases.[ bone scanning and
MR are superior ]

Lytic and blastic bone metastases only be visible in CT.

Allows more accurate distinction of malignant from
benign causes of increased radioisotope uptake at bone
scanning .

Can be used to monitor responses to systemic therapy.
MR can detect cancer but is not recommended as an
initial screening tool (PSA, DRE, TRUS Bx)

However ? +ve PSA but ve biopsy

Does this patient have cancer ???
MR helps target repeat biopsy to suspicious areas

Local Staging (to determine best treatment)
No ionizing radiation
High soft-tissue contrast
High resolution imaging
True 3D volumetric
imaging
Multi-parametric
imaging
T1/T2 weighting,
Functional, Diffusion,
Can provide real-time
imaging capabilities
Most patients with prostate CA have indolent cancer
High (+/- intermediate) risk groups
( ie significant chance of tumor progression)

Staging MR would be cost effective if performed
ONLY in the subgroup of patients with

Palpable tumor
PSA > 10
At least 50 % positive cores for malignancy
High Gleason grade and score
Currently imaging at 1.5 Tesla scanner is recommended

Endorectal /Surface Coil MRI combination is best for
anatomic detail
High SNR
High spatial resolution of 0.5 mm

Newer MR techniques available today are

T2 Weighted Imaging
Dynamic contrast enhanced MRI (DCE-MRI)
MR Spectroscopic Imaging (MRSI)
Diffusion weighted Imaging (DWI)
Lymphotropic Nanoparticle-enhanced MRI (Ferumoxtran-10)
Accurate tumor staging is essential to determine appropriate
treatment (ie is curative surgery an option ?)

Extracapsular Extension (ECE)
Seminal Vesicle Invasion (SVI)
Bladder/Rectal Invasion
Lymph Node Metastases

Only carcinomas confined within the prostate gland, are
potentially curable by radical prostatectomy

Staging usually classified using TNM classification
To confirm organ-confined disease
radical surgical prostatectomy could be offered
without adjuvant radiation therapy.

If disease is largely organ-confined with small volume
periprostatic or seminal vesicle spread, radical radiotherapy
can still be offered
with / without pelvic nodal irradiation or
with / without adjuvant hormonal therapy

To confirm clinically suspected apical tumor or extent of LN
metastases which will affect radiotherapy margins.

MRI should be delayed at least 4-8 weeks after biopsy

Post biopsy hemorrhage may hamper tumor detection in
the gland

May result in under or overestimation of tumor presence
and local extent

MR exclusion sign: cancers are resistant to the
development of post biopsy haemorrhage


Contour deformity/
angulated margin

Irregular bulge /capsule
retraction

Capsular breach & direct
tumor extension

Obliteration of rectoprostatic
angle

Asymmetry of neurovascular
bundles



Contiguous low SI from
base of gland in SV

Extension of soft tissue
along ejaculatory ducts

Asymmetric decrease
in SI of SV

Decreased conspicuity
of SV wall on T2WI



Varies widely for cancer detection

Without endorectal coil
Sensitivity : 45 %
Specificity : 73 %

With Endorectal coil
Sensitivity : 77 - 91 %
Specificity : 27 - 61 %
Endorectal Coil MRI T2 imaging
(high sensitivity) and add:

Dynamic contrast-enhanced MRI (DCE-MRI)

MR Spectroscopic Imaging (MRSI)

Diffusion-weighted MRI (DWI)
Cancers results in tumor angiogenesis

Increased no. of vessels

Increased permeability of vessels

Increased interstitial tissue space

Faster seq. can scan entire gland in few seconds

Various perfusion parameters are electronically
extracted according to time seq.

Perfusion parameter for cancer detection [Early
wash in & wash out]

Improves specificity compared to T2W scans

Reported to improve staging
Peripheral zone cancers
Sensitivity : 96 %
Specificity: 97 %

Compared to 75 % and 53 % respectively on T2WI

Not tested in multi institutional trials

Suffers from lack of uniformly accepted analytic method

Still of unproven benefit as per ACR guidelines
3D proton MR spectroscopic metabolic mapping of
the entire gland is possible with a resolution of 0.24
ml per voxel.

Proton MR spectroscopy displays concentrations of
citrate, creatine, and choline metabolites found in
the prostate gland and cancer.

Normal prostate tissue contains high levels of
citrate -higher in the PZ than in the central gland.
Healthy peripheral-
zone voxels typically
have (Cho + Cr)/Cit
ratios less than 0.5

Because of the
proximity, the choline
and creatine peaks
cannot be separated

There is an association between primary tumor
volume and local extent of disease, progression, and
survival

A review of a large number of prostate cancers in
surgical and autopsy specimens showed
Capsular penetration
Seminal vesicle invasion and
Lymph node metastases
usually found only with tumors larger than 1.4 cc



Another study - ECE in 18 % with vol. < 3 cc
79% with volume > 3 cc

Tumor volume significant predictor of ECE

Bx, TRUS and T2-MRI are disappointing in volume
estimation

MRS provides more accurate volume estimation

Relative tumor volume is
determined on MRS
[counting the voxels
containing abnormal spectra]

Improves Dx of ECE for even
less experienced reader

Decrease inter observer
variability further studies
required


Technically demanding and time consuming

Improvement in diagnostic accuracy and staging
have been reported but not proved in multi
institutional trials

ACR clinical trial is currently underway

Currently cannot be considered as routine
diagnostic tool


Diffusion is the process of thermally induced
random molecular displacement Brownian motion

Diffusion properties of tissues are related
Amount of tissue water
Tissue permeability

Cancer tends to have restricted diffusion due to
High cell densities
Abundant intracellular membranes







ADVANTAGES
Short acquisition time
High contrast resolution between tumor and normal tissue
No need for endorectal Coil

DISADVANTAGES
Poor spatial resolution
Potential risk of image distortion by post biopsy Hg
Early metastases can occur in small nodes

Size and shape of nodes inaccurate for staging

ABNORMAL NODES

Rounded configuration

Short axis > 10 mm if oval, > 8 mm if round

T1 OR T2 SI not helpful

Enhancement suggestive of metastatic lymph node
Normal sized nodes - contain cancer as micro
metastases

Enlarged nodes may be reactive
Neither CT nor MRI is accurate as laparoscopic nodal
dissection

Initial step prior to radical prostatectomy remains nodal
dissection

MR is at least as accurate as CT in nodal staging.

ULTRA SMALL SUPER PARAMAGNETIC MR
contrast agents taken up by macrophages

Injected intravenously and imaged 24 hrs later

Cannot enter tumor (no macrophages)

Can differentiate normal/reactive lymph nodes from
malignant ones

Iron based contrast agents not approved by FDA
(Ferumoxtran-10)
Radionuclide bone scanning has no role in
prostate cancer detection or local staging.

However, continues to be the mainstay of
diagnosis of initial spread of cancer to bone.
Use of the bone scan has been modified in
recent years by the measurement of PSA
level.
PSA is < 10 ng/mL , chances of a positive bone
scan are less than 1%.
PSA is 1050 ng/mL, increases to about 10%,
PSA level > 50 ng/mL, it increases to about
50%.
Generally bone scan is reserved for patients
with PSA level greater than 10 ng/mL.
The most common appearance
is of a focal area of increased
tracer uptake, usually in the axial
skeleton, related to host
osteoblastic bone response to
tumor invasion .
Less commonly, an area of
reduced uptake may be present,
which reflects extensive damage
to bone with little osteoblastic
response.
Bone scans are more reliable
than symptoms alone in the
evaluation of bone metastatic
disease.
Single photon emission computed tomographic
(SPECT) studies of the skeleton have been
shown to be more sensitive in the detection of
metastatic disease than planar images alone
and are usually performed when symptoms or
clinical suspicion for disease are present,
particularly bone pain.

This technique has particular utility in the
evaluation of the spine in patients with low back
pain who present for evaluation of possible
metastatic disease.

Sites of abnormal uptake may be localized to
the vertebral body or posterior elements,
leading to other radiologic techniques for
confirmation.

Uptake in facet joints, in the absence of signs of
metastatic disease on radiographs, may indicate
active arthritis as the cause of a patients back
pain .

Combined SPECT/CT, a recent development,
adds anatomic information to SPECT, and its
incremental value to SPECT is yet to be
evaluated .

PET uses compounds labeled with positron-
emitting radioisotopes to detect pathologic
processes .
Most clinical PET studies to date have been
performed with the glucose analogue
fluorine 18 (18F) fluorodeoxyglucose (FDG).
Cancers have increased metabolism and
utilize the less-efficient glycolytic pathway,
both of which lead to increased glucose
analogue uptake .
Increased glucose uptake and metabolism
in tumors are facilitated by an elevated
expression of glucose transporters, which
has been shown in several cancers .
The magnitude of the elevated FDG uptake
and accumulation in tumors is commonly
expressed by the standardized uptake
value, defined as the ratio of activity per
unit mass in the lesion to the administered
activity per unit mass in the patient.

Use of PET/CT units results in
improved attenuation correction
of the PET emission data.
Capacity of PET/CT to
demonstrate tumor location in
the prostate bed and to better
assess pelvic lymph node
disease.
Furthermore, combined PET/CT
allows differentiation between
tumor and tortuous ureter or
bowel in the midabdomen or
pelvis .
In the evaluation of bone
metastasis, precise localization
of metastatic disease is possible.
Substantial progress has been made in the imaging of
prostate cancer, particularly in MR imaging, MR
spectroscopic imaging, PET/CT, and SPECT/CT.

These advances are beginning to translate into better
treatment selection and more accurate image-guided
therapies, including surgery and radiation therapy.

These advances in imaging, and future advances in
molecular imaging, will contribute to long-term
improvements in morbidity from prostate cancer and
patients quality of life and to a decrease in mortality from
prostate cancer that we are now just beginning to see.