1) Prostate cancer is one of the most common cancers in elderly men and early detection can lead to complete cure. Accurate localization and staging is important for treatment planning. 2) While prostate biopsy is the standard diagnostic technique, ultrasound has low sensitivity and the biopsy is essentially blind. Multi-parametric MRI can improve biopsy results by localizing suspicious areas for targeted biopsy and assessing extra-prostatic extension and clinical staging. 3) The study evaluated 50 patients undergoing multi-parametric MRI and biopsy to diagnose prostate cancer. MRI showed high specificity and sensitivity over clinical assessment alone in diagnosing and staging prostate cancer.

1. Role of conventional and
functional MRI in assessment of
prostate cancer
Mohamed A Amin
El Menia University
1

2. Under-supervision

3. Prostate cancer is one of the most common
malignancies in elderly men, prostate cancers grow
slowly so early detection can lead to complete cure.
Accurate localization and staging has a great impact
upon therapy planing
The gold standard diagnosis of prostate cancer
based on histopathological assessment.
3
introduction

4. TRUS guided biopsy is the standard technique in
diagnosis of prostatic carcinoma, however
ultrasound has low sensitivity in prostate cancer
detection and localization, so TRUS-biopsy
considered blind systematic technique (non-
targeting technique).
Multi-parametric MRI used to improve the TRUS
guided biopsy results and overcome TRUS-biopsy
disadvantages.
4

5. 5
Disadvantages biopsy
Limited range 17mm of gun needle length
Complications of interventional: pain, hemorrhage & infection
Difficult to assess previous biopsy site
False negative results
Unnecessary sampling of normal tissue

6. 6
Limitations of needle length
17mm

7. 7
What can mp-MRI add?
Pre-biopsy:(suspicious Pca patient)
Exclude normal prostate
Localized suspicious areas for targeted biopsy
Assess extra-glandular extension
Post-biopsy: (diagnosed Pca patient)
Clinical staging with limited (TNM) to pelvis

8. The optimal guide for mp-MRI reading
Normal MRI anatomy
PI-RADS score
Correlation between MRI-
ultrasound

9. 9
Normal
anatomy
of
the
prostate
Zonal anatomy
Segmental anatomy
MRI anatomy

10. AFT = anterior fibromuscular tissue, CZ = central zone, ED = ejaculatory duct,
NVB = neurovascular bundle, PUT = periurethral tissue, PZ = peripheral zone,
U = urethra, TZ = transitional zone.
10
Zonal anatomy

11. Segmental anatomy developed
mainly with the raise of mp-MRI
aiming for accurate localization
of the suspected areas prepared
to targeted biopsy
Best correlated with HR T2WI
11
Segmental anatomy

12. 12
MRI anatomy (T2 based)
APEX
PZ
Urethra
R
PZ

13. 13
MRI anatomy (T2 based)
Mid-gland
PZ
PZ
CG
NVB

14. 14
MRI anatomy (T2 based)
Base
ED
AFML
BPH
nodule

15. 15
MRI anatomy (T2 based)
Prosto-seminal
v angle level
UB
SV SV

16. 16
MRI anatomy (T2 based)
Recto-porstatic
angle
Recto-prostatic angle

17. 17
MRI anatomy (T2 based)
Prosto-seminal v
angle
PS angle
Central zone

18. Aiming to standardize the prostate cancer
assessment, PI-RADS systems created.
There are two versions, V2 is more simplified, bases
mainly on T2WI for assessment of central gland,
DWI/ADC for assessment of peripheral zone.
PI-RADS based upon multi-parametric MRI
18
PI-RADS score

19. 19
mp-MRI
Advanced MRI Imaging:
Dynamic contrast enhanced MRI.
MR spectroscopy.
DWI.
Conventional MR Imaging:
T2WI in axial, sagittal and coronal planes

20. How to calculate PI-RADS score

21. mp-MRI/TRUS biopsy correlation

22. Prostatic carcinoma

23. Conventional T2WI
Biopsy-proved adenocarcinoma in a 64-year-old man. Axial (a) and coronal (b)
T2-weighted MR images show an area of low signal intensity in the base of the
left peripheral zone (arrow), a finding indicative of a tumor.
23

24. Diffusion-weighted Imaging
Biopsy-proved adenocarcinoma in a 72-year-old man. (a) Axial T2-weighted MR
image shows a low-signal-intensity lesion in the right lobe of the prostate
(arrow). (b) ADC map shows a low ADC value in the lesion (arrow), a finding
indicative of decreased diffusion. A targeted biopsy was performed.
24

25. MR Spectroscopy

26. Cancer Normal
26

27. DEC-MRI
Biopsy-proved adenocarcinoma in a 61-year-old man. (a) Wash-in MR image obtained
with a fast field echo sequence (17/2.9; flip angle, 20°) shows a higher wash-in rate in
the leftt peripheral zone (arrow) than in other areas. (b) Washout MR image obtained
with the same sequence as a shows a higher washout rate in the right peripheral
zone (arrow) than in other areas.
27

29. Methodology
29

30.  This prospective study included 50 male patients referred to
the department of Radiology, El-Minya University with
clinical diagnosis of suspected prostatic carcinoma during
period extended from March 2013 to March 2016
 MR studies were performed on a 1.5-T units (Siemens
medical systems: MAGNETOM Avanto 1.5T,18 channels &
Philips Medical Systems: Achieva 1.5T, 8channels) using
pelvic phased array coils
30

31. Clinical
• Axial
Biopsy
• Axial, coronal and sagittal
• TR/TE: 2000/90), 512× 512 matrix, 3mm, no gap & FOV14-cm
Medications
• DWI/ADC map in axial, coronal and sagittal
• EPI, Multiple b values 0-50-400-800/1000s/mm2 , ADC map
MRS
• Multi-voxel MRS, 14x12x12pixel size with PRESS
- Patient preparation

32. T1WI
• Axial
• TR/TE: 650/7, 512x512matrix, 3mm, no gap & FOV 14cm
T2
• Axial, coronal and sagittal
• TR/TE: 2000/90), 512× 512 matrix, 3mm, no gap & FOV14-cm
Diffusion
• DWI/ADC map in axial, coronal and sagittal
• EPI, Multiple b values 0-50-400-800/1000s/mm2 , ADC map
MRS
• Multi-voxel MRS, 14x12x12pixel size with PRESS
- Protocol of mp-MRI

33. Results
33

34. This study included 50 males presented to radiology
department Minia University with clinical diagnosis of prostatic
carcinoma. The patients were divided into two groups
according to the final histo-pathological diagnosis, Group I
included 14 patients with benign prostatic lesions and Group II
included 36 patients with prostatic carcinoma.
34

35. Age
35

36. Clinical assessment
36

37. 37

38. Distribution regrading location
38

39. 39

40. 40

41. 41

42. 42

43. 43

44. 44

45. 45

46. 46

47. 47

48. 48

49. 49

50. Case presentation
50

51. 78 yrs patient
Urine retention
PSA 9 ng/ml
51
T2 ADC T2
T2 T2
ADC

52. 68 yrs patient
PSA 8 ng/ml
52
T2 DWI ADC

53. 65 yrs patient
PSA 20 ng/ml
53
T2
T2
DWI ADC
ADC
DWI

54. 66 yrs patient
PSA 26 ng/ml
54
T2 T2
T2 T2
ADC
ADC

55. 62 yrs patient
PSA 70 ng/ml
55
T2
T2 T2
ADC DWI
ADC

56. 65 yrs patient
PSA 1100 ng/ml
56
T2 T2
T2 T2
ADC
ADC

57. 66 yrs patient
PSA 1700 ng/ml
57
T2 T2
T2 DWI ADC
ADC

58. 66 yrs patient
PSA 2100 ng/ml
58
T2
T2
DWI ADC
DWI ADC

59. 63 yrs
patient
PSA 81
ng/ml
59
T2 DWI ADC
MRS

60. Conclusion
• Prostate cancer is one most common cancer in elderly males, affecting
mainly lifestyle with risk of morbidity rather than affect the lifetime (low
mortality rate).
• MRI has a high specificity and sensitivity in evaluation of pretreatment
assessment ether in primary diagnosis or staging over clinical assessment
alone (PSA level and DRE), and other modalities like ultrasound.
• In spite of prostatic biopsy is still the gold standard technique in diagnosis of
prostate cancer. The combination of multi-parametric MR and prostatic
biopsy is very beneficial, as mp-MRI will add multiple advantages
60

61. Thank you
61