Further Reading

1. DeVita VT, Hellman S, Rosenberg SA (Eds) (2001) Carroll PR, Lee RL, Foks ZY, etal. In: Cancer Principles and Practice of Oncology, 6th Edition. Lippincott Williams and Wilkins, Philadelphia, USA, pp. 1418-1469. The leading oncology reference text provides a comprehensive review of the management ofprostate cancer.

2. Husband J, Resnick H (Eds) (1998) Jages G and Basentz J. Prostate Cancer In: Imaging in Oncology. Isis Medical Media Ltd, Oxford, UK, pp. 239-257. Aimed at the clinical radiologist, this textbook has a detailed chapter reviewing prostate cancer imaging.

3. Kirby RS etal. (1998) Fast Facts; Prostate cancer. Health Press. Concise easily readable overview of the diagnosis and management of prostate cancer.

4. Royal College of Radiologists Clinical Oncology Information Network & British Association of Urological Surgeons (1999) Guidelines on the management of prostate cancer. Clinical Oncology 11:55-81. Also known as the UK COIN guidelines.

5. Partin AW, Kattan MW, Subong EN etal. (1997) Combination of prostate-specific antigen, clinical stage and Gleason score to predict pathological stage of localised prostate cancer. A multi- institutional update. JAMA 277:1445-1451. Partin 's tables may be used to predict the probability of extra-capsular disease extension.

6. Chodak GW, Thisted RA, Gerber GS et al. (1994) Results of conservative management of clinically localized prostate cancer. N. Engl.J. Med. 330:242-248. Data showing the 10-year disease specific survival for clinically localized disease (managed conservatively) is 87% for well and moderately differentiated tumours, dropping to 34% for poorly differentiated tumours.

7. Outwater EK, Petersen RO, Siegelman ES, et al. (1994) Prostate carcinoma: assessment of diagnostic criteria for capsular penetration on endorectal coil MR images. Radiology 193:333-339. Results from 30 patients who underwent MR imaging and prostatectomy. Diagnostic criteria of extra-capsular extension are presented although it is concluded that the sensitivity and specificity are generally low.

8. D'Amico AV, Whittington R, Schnall M etal. (1995) The impact of the inclusion of endorectal coil magnetic resonance imaging in a multivariate analysis to predict clinically unsuspected extraprostatic cancer. Cancer 75:2368-2372. Study showing a positive MRI stratified patients with an intermediate clinical risk of locally advanced prostate cancer into groups with a 78% versus 21 % 3-year rate of actuarial freedom from PSA failure.

9. Getty DJ, Seltzer SE, Tempany CMC, et al. (1997) Prostate cancer: relative effects of demographic, clinical, histologic, and MR imaging variables on the accuracy of staging. Radiology 204: 471-479. Optimal merging of diagnostic test results yielded an improvement in the overall accuracy of prostate cancer staging.

10. Sonnad SS, Langlotz CP and Schwartz JS. (2001) Accuracy of MR imaging for staging prostate cancer: a meta-analysis to examine the effect of technologic change. Acod. Radiol. 8(2): 149-157. Meto-onolysis of 27 studies comparing MRI with a pathological standard in clinically localised prostate cancer. A summary receiver operating characteristic curve for all studies had a maximum joint sensitivity and specificity of 74%. At a specificity of 80% on this curve, sensitivity was 69%.

11. Jager GJ, Severens JL, Thornbury JR et al. (2000) Prostate Cancer Staging: Should MR Imaging Be Used? -A Decision Analytic Approach. Radiology 215:445-451. Concluded that it is not yet conclusively determined whether preoperative MRI staging is appropriate, but results of decision analysis suggest that MRI staging is cost-effective for men with moderate or high prior probability of extra -capsular disease.

Figure 12.1. Normal prostate anatomy.

(a) Transaxial T2W1. The normal zonal anatomy of the prostate is well demonstrated on T2W1. The central gland (C) is comprised of central and transitional zones, and encloses the urethra. These zones are low signal on T2W1 and may thus mask any low signal tumour within. Fortunately, 75% of tumours arise in the peripheral zone (P) of the gland, and are usually well demarcated from the high signal glandular stroma. The pseudocapsule is seen as a thin surrounding low signal band (arrowheads). Lateral to the pseudocapsule, the high signal periprostatic venous plexus (V) can sometimes cause confusion as to the true margin of the gland. The neurovascular bundles supplying the corpora cavernosa are positioned at the 5 and 7 o'clock positions, just outside the pseudocapsule (arrows). The rectum (R) is closely applied to the prostate separated by the thin low signal Denonvilliers' fascia. The bladder (B) may be seen anteriorly on transaxial sections. (b) Coronal T2W1. The seminal vesicles (S) are high signal with regular thin-walled tubules. The prostate sits within the levator sling (L). Laterally, the obturator internus muscles (O) form the pelvic sidewalls.

Figure 12.2. Benign prostatic hypertrophy (BPH).

Transaxial T2W1. BPH results in enlargement of the transitional zone of the gland. The peripheral zone is thinned (short arrows), and the normal high signal intensity may diminish, although not usually to the extent seen with tumour infiltration. The hypertrophied transitional zone (TZ) has heterogeneous signal on T2W1.

Figure 12.3. Stage T2a prostate cancer.

Transaxial T2W1. Low signal tumour is seen within the peripheral zone of the right lobe of the prostate (arrow). Changes of BPH are noted. The tumour occupies less than one half of one lobe indicating stage T2a disease. There is no evidence of extension beyond the pseudocapsule.

Figure 12.4. Stage T2b prostate cancer.

Transaxial T2W1. Tumour involving more than one half of one lobe is classified as T2b (arrow). The low signal is contiguous with the pseudocapsule for>12.0 mm, which increases the probability of microscopic extra-capsular disease. This may influence patient selection for brachytherapy or other radical treatments.

Figure 12.5. Stage T2c prostate cancer.

Transaxial T2W1. Tumour (arrows) involves both lobes, crossing the midline. Tumour is also seen within the central gland (T). There is no extra-capsular extension.

Figure 12.6. Stage T3a prostate cancer.

Transaxial T2W1. Extra-capsular extension is most commonly seen from the posterior and lateral aspects of the prostate, often in the region of the neurovascular bundle. Here, small volume low signal tumour breaches the prostatic pseudocapsule on the left (arrow), indicating stage 3a disease.

Figure 12.7. Stage 3a prostate cancer.

Transaxial T2W1. Tumour in the central gland can breach the anterior pseudocapsule extending into the fat deep to the symphysis pubis (arrows). Anterior extra-capsular extension is usually not detectable clinically.

Figure 12.8. Stage T3b prostate cancer.

(a) Sagittal T2W1 and (b) transaxial T2W1. The prostate is enlarged due to BPH. Low signal is seen in the right peripheral zone in keeping with tumour. There are indirect signs of extra-capsular disease as the pseudocapsule is retracted and thickened (arrowheads), and there is contiguity with the tumour over a prolonged distance (>12.0 mm). Both seminal vesicles and ejaculatory ducts (arrows) are replaced with material of similar signal intensity indicating T3b disease.

Figure 12.9. Stage T3a/T4 prostate cancer.

Transaxial T2W1. There is extra-capsular tumour extension (arrows) into the right neurovascular bundle

(arrowhead), and posteriorly to the right levator muscle (L). MR staging is equivocal and clinical correlation may be required to distinguish between stage T3a and stage T4 disease. In stage T4 disease the tumour is 'fixed' to the pelvic sidewall.

Figure 12.10. Stage T4 prostate cancer.

Coronal T2W1. There is extra-capsular extension of tumour on the left (arrow) with tumour bulging into the left levator muscle (L). This would be stage T3a were it not for the muscular invasion.

Figure 12.11. Stage T4 prostate cancer.

(a) Transaxial T2W1, (b) coronol T2W1 and (c) coronol T1W1. Tumour extends to the right pelvic sidewall

(arrows). Bilateral hydroureter (arrowheads) is present due to invasion of the bladder trigone (BT). A trace of ascites (A) is seen in the rectovesical pouch. Several small perirectal nodes (N) are noted. Bilateral hydronephrosis (asterisks) is confirmed on the TI-weighted images.

Figure 12.12. Stage T4 prostate cancer.

(a) Transaxial T2W1 and (b) sagittal T2W1. There is an extensive tumour (T) infiltrating the bladder

(arrowheads) and rectum (arrow). A balloon catheter (B) is in situ. Inferiorly, disease extends through the pelvic floor into the perineum (asterisk). Marrow hyperplasia due to anaemia accounts for the signal change in the sacrum (S).

Figure 12.13. Stage N1 prostate cancer.

Coronal T2W1. The obturator and iliac nodes are most commonly involved in prostate cancer. Here, there is a large left external iliac nodal metastasis (long arrow). A small right external iliac node has similar signal intensity and is likely to be involved (short arrow). Local extra-capsular tumour extension is seen from the right side of the prostate (arrowhead) abutting the levator ani muscle (L).

Figure 12.14. Stage N1 prostate cancer.

Sagittal T2W1. Multiple pre-sacral nodes (arrows) in a patient with a T4 prostatic tumour (T) involving the bladder base (arrowheads).

Figure 12.15. Stage N1 M1b prostate cancer.

Transaxial T2W1. Metastasis in a right inguinal node (long arrow). There is extracapsular tumour extension anteriorly at the prostatic apex (arrowheads). Note also a smaller node in between the prostatic apex and the pubic symphysis (short arrow). There is a bone metastasis in the right pubic bone (crossed arrows).

Figure 12.16. Stage M1a prostate cancer.

Coronal T1W1. Multiple interaortocaval and paraaortic retroperitoneal lymph nodes are present (arrows), indicating stage M1a disease. A transaxial upper T1W block of images may assist in equivocal cases.

Figure 12.17. Stage M1b Prostate cancer

Sagittal T2W1. A bone metastasis is present in the third sacral segment (arrow) indicating stage M1b disease.

The local staging is T4 disease as there is direct invasion of the bladder base (arrowheads) from a large prostate tumour (T), which is also engulfing the seminal vesicles (asterisk).

Figure 12.18. Stage M1c prostate cancer.

Transaxial T1W1. There are multiple hepatic metastases (arrows). Extra-skeletal non-lymph node metastases are classified as stage M1c disease.

Figure 12.19. Stage M1c prostate cancer.

Transaxial T2W1. An unusual metastasis is seen within the left spermatic cord (arrow). The metastasis is differentiated from an inguinal lymph node by its medial position, similar to the uninvolved right spermatic cord, and the compressed left spermatic cord structures (arrowheads) seen posteriorly. Note a metastasis (asterisk) in the right pubic bone and other smaller bone metastases throughout the pelvis. lliopsoas bursa (I).

Figure 12.20. Post prostatectomy tumour recurrence.

Transaxial T2W1. Following radical prostatectomy, there is normally a ring of low signal representing postoperative fibrosis in the prostatic bed. Recurrent tumour usually shows as an area of intermediate signal intensity within the fibrotic tissue or adjacent periprostatic fat. In this example the recurrent tumour (arrow) is present between the 7 o'clock and 9 o'clock positions within the fibrous ring.

Figure 12.21. Post radiotherapy tumour recurrence.

Transaxial T2W1. Following radiotherapy, the prostate gland reduces in size and signal intensity decreases on

T2W1, most obviously in the peripheral zone. Local tumour recurrence is usually heralded by a rise in PSA. This patient with a rising PSA had developed a bone metastasis (arrow) in the right ischium.

Figure 12.22. Fibromuscular bands.

Transaxial T2W1. The fibromuscular bands traversing the peripheral zone may appear prominent, as a normal variant (arrows). These linear radial bands should be easily distinguished from the more amorphous mass-like low signal change representing tumour infiltration.

Figure 12.23. Prostatitis.

Transaxial T2W1. This patient had prostatitis producing diffuse low signal change throughout the peripheral zone. Tumour and inflammation may be indistinguishable on MR imaging and prostatic biopsy is required to diagnose tumour in the absence of widespread metastatic disease.

Figure 12.24. Post biopsy haemorrhage.

(a) Transaxial T1W1 and (b) transaxial T2W1 .There is post biopsy haemorrhage producing an asymmetrical left-sided bulge to the prostate peripheral zone. Methaemoglobin accounts for the high signal on the T1 and

T2W1 (arrows). Low signal (arrowheads) in the right peripheral zone of the prostate is consistent with tumour.The signal changes associated with haemorrhage evolve over several weeks and, depending on the stage of evolution, haemorrhage may either mask or simulate tumours in the peripheral zone on T2W1. Repeat imaging can help in equivocal cases, but, in our experience, changes can persist up to three months.

Figure 12.25. False positive seminal vesicle invasion.

(a) Transaxial T2W1 and (b) coronal T2W1. A localised increase in fibrous tissue is normally found around the insertion of the vas deferens and origin of the ejaculatory ducts, which may encompass the medial tips of the seminal vesicles (arrows). This should not be interpreted as tumour invasion (Stage T3b) unless there is contiguous tumour extending from the adjacent prostate.

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