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Prostate Carcinoma


KEY FACTS

Imaging

  • 70% of prostate carcinomas occur in peripheral zone

  • Transrectal ultrasonography (TRUS)

    • Hypoechoic lesion in peripheral zone

  • Multiparametric MR imaging

    • Classification of lesions according to Prostate Imaging Reporting and Data System (PI-RADS)

      • –

        5 categories of risk for clinically significant cancer from PI-RADS 1 = very low, to PI-RADS 5 = very high

    • T1WI

      • –

        Persistent blood from biopsy shows high signal intensity

    • T2WI

      • –

        Peripheral zone: Hypointense mass ± extracapsular extension

      • –

        Transition zone: Hypointense lenticular, noncircumscribed mass

      • –

        Extracapsular extension: Breech of capsule, obliteration of rectoprostatic angle, invasion into neurovascular bundle and seminal vesicles

    • DWI

      • –

        Focal, markedly hypointense on ADC and markedly hyperintense on high (> 1,400) b-value DWI

    • DCE

      • –

        Focal enhancement earlier or contemporaneous with adjacent gland

    • MRS

      • –

        ↓ citrate level; ↑ choline level

      • –

        ↑ choline + creatine:citrate ratio

Top Differential Diagnoses

  • Benign prostatic hyperplasia (BPH)

  • Bladder carcinoma

  • Prostatitis

Pathology

  • > 95% of tumors are adenocarcinoma

Clinical Issues

  • Most common noncutaneous cancer in American men

  • 2nd most common cause of cancer deaths in men after lung cancer

  • Most important factor affecting choice of treatment is establishing likelihood of clinically localized disease

Graphic shows the Prostate Imaging Reporting and Data System (PI-RADS, version 2) algorithm to assign each lesion to 1 of 5 categories of risk for clinically significant cancer. DWI is the dominant sequence in the peripheral zone. T2WI is the dominant sequence in the transition zone.

Axial T2WI MR through the prostate apex shows a 2.0-cm hypointense lesion
in the left peripheral zone (T2 score = 5).

Axial DWI (b = 1,500 s/mm²) MR demonstrates the mass in the left peripheral zone as markedly hyperintense
.

Axial ADC map shows the mass in the left peripheral zone as markedly hypointense
(DWI score = 5). The lesion is assigned a category of PI-RADS 5, corresponding to a very high risk of clinically significant cancer. At biopsy, the mass was proven to be adenocarcinoma (Gleason score 3+4 = 7).

TERMINOLOGY

Abbreviations

  • Prostate cancer (PC)

  • Peripheral zone (PZ)

  • Transition zone (TZ)

  • Central zone (CZ)

  • Diffusion-weighted imaging (DWI)

  • Apparent diffusion coefficient (ADC)

  • Dynamic contrast enhanced study (DCE)

Synonyms

  • Prostate cancer

Definitions

  • Malignancy of prostate gland

    • > 95% of tumors are adenocarcinoma

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