Prostate cancer - Vincent Batista Lemaire

PI-RADS PROSTATE IMAGING-REPORTING
AND DATA SYSTEM: 2015,VERSION 2
Dr. Vincent Batista Lemaire
Locum Consultant Radiologist
St. Richards Hospital ,West Sussex Hospitals Trust, NHS .
Chichester , England , UK .

PI-RADS PROSTATE
IMAGING-REPORTING
AND DATA SYSTEM:
2015,VERSION 2
F R O M C O L L A B O R A T I O N O F A M E R I C A N
C O L L E G E O F R A D I O L O G Y
( A C R ) , E U R O P E A N S O C I E T Y O F
U R O R A D I O L O G Y ( E S U R ) A N D A D M E T E C H
F O U N D A T I O N

WHY THE PI-RADS
Global
standardization
Diminish
variation in :
* acquisition
*interpretation
* reporting

- Worldwide , there are and estimated 1,600,000 new cases of
prostate cancer and 366,000 prostate cancer death annually,
making it the most commonly diagnosed cancer in men and the
seventh leading cause of male cancer death .
- Prostate cancer is the second most commonly cancer diagnosed
in the United States after skin cancer, with 161,000 new prostate
cancer diagnoses and approximately 26,700 prostate cancer
deaths.
- 1 in 6 men would develop prostate cancer in their lifetime; however
, only 1 in 34 men would die from prostate cancer.
- Good prognosis but some are aggressive .
- 70% of death due to prostate cancer occur after age 75.

- Older age is the strongest risk factor for the development of prostate
cancer.
- Black men are twice as likely to die of prostate cancer than other
men.
- Family history have an increase risk of 2.5 fold
- The risk of prostate cancer among men with elevated PSA levels is
lower in men with urinary symptoms than in men without symptoms.

How to make the diagnosis and deliver the best preventive and
treatment options?

Sensitivity is the number of true positive results divided by the sum of
the true positive results and false negative results .
Specificity is the number of true negative results divided by the sum
of the true negative results and false positive results .
Our primary goal is to find a screening strategy that will improve
sensitivity without sacrificing specificity.

One study of 6,630 men volunteering for DRE and prostate-specific antigen
screening tests, 45% of the cancers that were detected were missed by the
DRE. Other authors have reported finding cancer in 15% to 18% of men with
a normal DRE.
If a lump is found, the chances are about 1 in 4 that it is cancerous.
Abnormal prostate findings include nodules, asymmetry, or induration. DRE
can detect tumours in the posterior and lateral aspects of the prostate gland;
an inherent limitation to the digital examination is that only 85 percent of
cancers arise peripherally where they can be detected with a finger
examination [86]. Stage T1 cancers are non palpable by definition.
Digital rectal exam

DIGITAL RECTAL EXAM
A new study found that, while not 100% accurate, digital rectal examination
(DRE) should remain a standard for screening for prostate cancer and may
even be able to identify cases of the disease that are not picked up by
the prostate specific antigen (PSA) test. The results of the study were
reported in The Canadian Journal of Urology.
Our study confirms that the digital rectal exam remains an important part of
screening such patients because 31 percent of cancers in our study would
have been missed by using age-specific PSA cut offs alone,” Raman said

The DRE is also inexpensive, costing approximately $28 (Crawford
et. al. 1999). Though it is readily available by appointment in a
doctor's office, there is discomfort for the patient and a risk of slight
bleeding (American Cancer Society 2006).
With the DRE test, the experience of the doctor is of utmost
importance, yet, new, inexperienced urologists often perform the test.
The sensitivity is 27.1% and the specificity is 49.0% (Marcus
2004).
Digital rectal exam

PROSTATE-SPECIFIC ANTIGEN (PSA) — PSA is a glycoprotein
produced by prostate epithelial cells. In men with prostate cancer
PSA production is increased and the tissue barriers between the
prostate gland lumen and the capillary are disrupted. PSA elevations
can precede clinical disease by 5 to 10 years.
Screening: beginning at age 50, though not with men who have a
comorbidity that limits their life expectancy to less than 10 years .
We suggest that providers first discuss screening with men at high
risk for prostate cancer, including black men, men with a family
history of prostate cancer, particularly in relatives younger than age
65, and men who are known or likely to have the BRCA1 or BRCA2
mutations, beginning at age 40 to 45.
PSA

PSA
*The PSA test is simply a blood test, widely available to the general
population.
* It is costs the patient roughly $30 to $60.
* The sensitivity is 64% and the specificity is 91% .

PSA
Serum PSA levels were considered normal if they fell into specific thresholds
based
on age :
<50 years, PSA <2.5 ng/mL;
51-60 years, PSA <3.5 ng/mL;
61-70 years, PSA <4.5 ng/mL;
and >70 years, PSA <6.5 ng/mL).

PSA
The traditional cut off for an abnormal PSA level in the major screening studies
has been 4.0 ng/mL. .
In a pooled analysis, the estimated sensitivity of a PSA cut off of 4.0 ng/mL was
21 percent for detecting any prostate cancer and 51 percent for detecting
high-grade cancers (Gleason ≥8). Using a cut off of 3.0 ng/mL increased
these sensitivities to 32 and 68 percent, respectively. The estimated
specificity was 91 percent for a PSA cut off of 4.0 ng/mL and 85 percent for a
3.0 ng/mL cut off. PSA has poorer discriminating ability in men with
symptomatic benign prostatic hyperplasia [48].

PSA: NATIONAL COMPREHENSIVE CANCER
NETWORK :GUIDELINES 2014
1. Baseline testing at age 45-49 years with retesting at 50 years in patent with a
level below 0.7ng/ml.
2. Annual or biannual retesting in those with a level of 1.0ng/ml or higher.
3. For patient aged 50-70 years with a normal RE and PSA below 3 ng/ml, the
NCCN recommends retesting every 1-2 years.

ELEVATED PSA
- DRE : transient elevation from 0.26 to 0.4ng/ml
- Ejaculation : can increase PSA levels by up to 0.8 ng/mL, though levels return to
normal within 48 hours.
-Bacterial prostatitis; Asymptomatic prostatic inflammation can also elevate PSA
levels, but this diagnosis is made on biopsy and so cannot generally be used
to defer screening
-Prostate biopsy , transurethral resection of the prostate (TURP): A screening
PSA test should not be performed for at least six weeks following either of
these procedures.
-Acute urinary retention.

PSA
PSA: relatively low sensibility , increased PSA is not equivalent with
tumour..
Screening is controversial: over diagnosis and overtreatment

TRUS biopsies based on a systematic approach tend to target the peripheral
aspects of the gland and are likely to miss 30-40% of prostate cancer located in the
anterior, midline transition zone, or apex. Today, however, many tumours are being
identified at a very early stage, often as extremely small lesions that are hard to spot
on
ultrasound and hard to sample using a TRUS biopsy alone.
"If we adopted this approach, we could reduce the number of men needing biopsies
by
50% (223 vs 109), we could reduce the biopsy cores we took by 80% (2672 vs 322)
and,
most importantly, we could reduce the diagnosis of low-risk prostate cancer by up
to
90% (47 vs 5), and still we'd find 12% more intermediate- to high-risk cancers (79 vs
89).
“For patients with intermediate- to high-risk cancer, the estimated sensitivity of MRI
plus
biopsy was 92.34% — "far outperforming that of the TRUS plus biopsy (70.44%),"
said
TRUS BIOPSY

*Clinically significant cancer was defined as Gleason score 4+3
or
a maximum cancer core length of 6 mm or longer .
*MRI picks up 93% of aggressive cancers , compared with 48%
for
biopsy.
*More than a quarter (27%) of all men with suspected cancer
could
avoid a biopsy .
*If subsequent TRUS-biopsy were directed by MP-MRI findings,
up to
18% more cases of significant cancer might be detected .

GLEASON SCORE AND ZONAL
ANATOMY

The scoring system is named after Donald Gleason (1920-2008), a
pathologist at the Minneapolis Veterans Affairs Hospital, who developed it
with colleagues at that facility in the 1960s. In 2005, the Gleason system
was altered by the International Society of Urological Pathology. The criteria
were refined and the attribution of certain patterns changed. It has been
shown that this 'modified Gleason score' has higher performance than the
original one, and is currently assumed standard in urological pathology.
Gleason grading system

GLEASON GRADING SYSTEM
A total score is calculated based on how cells look under a microscope, with
half the score based on the appearance of the most common cell
morphology (scored 1—5), and the other half based off the appearance
of the second most common cell morphology (scored 1—5). These two
numbers are then combined to produce a total score for the cancer.
The Gleason Grade/Score has two main points: 1: Based on architectural
patterns, rather than cytological ones. The second feature of Gleason
grading is that the grade is not based on the highest (least
differentiated) pattern within the tumor, instead it is a combination
of the most often and second most often patterns seen. Gleason
realized that prostatic carcinomas have multiple patterns and that the
prognosis of prostatic carcinoma was split between the most prevalent
and the second most prevalent neoplasm pattern.

What does it mean?
A Gleason score
A 2 and 6 is a low grade prostate cancer, likely to grow very slowly. A
Gleason score of 7 is an intermediate grade that will grow at a moderate
rate. A Gleason score of 8 to 10 is a high grade cancer that is likely to grow
more quickly.
If your Gleason score is low and you are older or have early stage disease
your urologist is likely to suggest active monitoring rather than surgery or
radiotherapy. This is because your cancer may not spread or have any impact
upon your health. If you have a high Gleason score, are younger or have
higher stage disease, your urologist is more likely to suggest you have active
treatment.

GLEASON 3+4 AND GLEASON 4+3
Despite the confusing numbering system, 3+3 is the lowest possible
Gleason score reported today. 3+3 doesn't metastasize, and some
pathologists, therefore, don't even think it should be called "cancer." It is
generally, depending on other case characteristics, low-risk.
Gleason scores that add up to 7 are generally intermediate risk. 3+4 is
generally a favourable intermediate risk, and 4+3 is generally an
unfavourable intermediate risk. The difference is the amount of Gleason
pattern 4 cells present. The more pattern 4, the more aggressive the tumor.
3+4 means less than 50% pattern 4, and 4+3 means greater than 50%
pattern 4.

1. Multifocal and heterogeneous cancer is
common , occurring in 60%
2. Cancer with high Gleason score are more likely
to exhibit pronounced imaging characteristic
on mpMRI with accordingly high PI-RADS
scores.
3. Early stage Gleason score 3+ 3, mpMRI does
poorly .

ZONAL ANATOMY OF THE PROSTATE
GLAND
John E Mc Neal ,1930-
2005, worked at Standford

ZONAL ANATOMY OF THE PROSTATE GLAND

ZONAL ANATOMY OF THE PROSTATE
GLAND

FASCIA AROUND THE PROSTATE
1.prostatic fascia: anteriorly and antero-laterally , it is in direct continuity
with the fibromuscular stroma .
2.Laterally : it fuses with the endopelvic fascia.
3.posteriorly , it fuses with , and is indistinguishable from , Denonvilliers
fascia with lies between the prostate and the rectum and covers the
seminal vesicle posteriorly .

PELVIC FASCIAE IN UROLOGY
B RAYCHAUDHURI AND D CAHILL
THE ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 2008 90:8, 633-637
The findings of the study were as follows:
The ‘capsule’ of the prostate does not exist. Rather, the fibromuscular band
surrounding the prostate forms an integral part of the gland.
The prostate is surrounded by fascial structures – anteriorly/anterolaterally
by the prostatic fascia and posteriorly by the Denonvilliers' fascia.
Laterally, the prostatic fascia merges with the endopelvic fascia.
The posterior longitudinal fascia of the detrusor comprises a ‘posterior
layer’ of the detrusor apron, extending from the bladder neck to the
prostate base.
The neurovascular structures tend to be located posterolaterally, at 5 and 7
o’clock ,but may not always form a bundle. A significant proportion of
fibres may lie away from the main nerve structures, along the
lateral/posterior aspects of the prostate.

PELVIC LYMPH NODE DISSECTION
Pelvic lymph node dissection (PLND) in prostate cancer is the most
effective method for detecting lymph node metastases
The accuracy of standard imaging modalities such as computed
tomography scan or magnetic resonance imaging (MRI) in detecting
nodal metastases remains poor.

MULTIPARAMETRIC MRI
 Axial T1 LFOV Pelvis
 Axial, coronal, (sagittal) T2 SFOV Prostate
 Axial DWI (b=0,150,500,1000) with ADC map
 High b value (b1400, b2000)
 Volume T1 fat sat (VIBE)
pre- and dynamic post-contrast

MULTIPARAMETRIC MRI
1. It is not intended to make a diagnosis .
2. The main goal is to suggest the target site in patient with suspicious
findings .

ANATOMY OF THE PROSTATE
A normal prostate gland is approximately 20 gr in volume, 3 cms in length,
4 cms wide and 2 cms depth . The base of the gland is in continuity to
the bladder, and anterior to the rectum. The prostate ends at the apex
before becoming the striated external urethral sphincter. The sphincter
is a vertically oriented tubular sheath that surrounds the membranous
urethra and prostate.(Maruve,Nicolas)
Volume uses the ellipsoid formula : height x width x length transverse
diameter x 0.52 (Phi/6 =0.52)
68 y/o ; 255 g

ANATOMY OF THE
PROSTATE
77 465 grams
66 y/o 275 grams

ESUR/ACR GUIDELINES V2
PI-RADS DEFINITION OF TOTAL SCORE
PI RADS CLASSIFICATION DEFINITION
1 MOST PPROBABLLY BENIGN
2 PROBABLY BENIGN
3 INDETERMINATE , EQUIVOCAL
4 PROBABLY MALIGNANT
5 HIGHLY SUSPICIOUS OF
MALIGNANCY,

MRI SPECTROSCOPY
1. ESUR v1
2. Citrate is synthesized and stored in large quantities in normal glandular
tissue of the prostate and is therefore used as an organ marker for
healthy prostate tissue.
3. Choline refers to the sum of choline-containing compounds. The
intensity of choline reflects the extent of membrane turnover and is
significantly elevated in cancerous tissue.

STAGING THE PROSTATE CANCER
T1: too small to be seen , T3: T3a,has broken through the capsule
biopsy + T3b, has spread into de seminal vesicle
T2: T2a: in only half of one lobe . T4: spread into other body organs nearby, such
T2b: more than half of one lobe. as rectum , bladder, muscles or side of
T2c: more than one lobe pelvis

EXTRACAPSULAR EXTENSION MAKE A T3
Criteria for extracapsular extension :
Irregular bulge in the capsule.
Obliteration of the recto prostatic angle
Asymmetry in the neurovascular bundle
Angulation /step off appearance
Focal capsular retraction or thickening
Breach of the capsule with evidence of tumour extension
LENGTH OF CASPSULAR CONTACT WITH A CUT OFF =15 MM

STAGING AND RISK GROUP
I Have Heard That Other Factors May Be Included When Evaluating
Treatment.
Yes, other factors such as the number of biopsies and the presence of Gleason
Score 7 (4+3) versus a Gleason Score (3+4) may influence the treatment
decision. The number of + biopsies is also strongly predictive of outcomes but
not typically part of the risk grouping systems. An example would be a person
with a multiple + biopsies (>34%-50%) Gleason 7. His cancer would be
considered a High Intermediate Risk and require a combination of External
Beam and radiation while another patient with only a few + biopsies (< 34%-
50%) could be a Low Intermediate Risk patient and be a good candidate for
an implant alone. These factors should be discussed with you
doctor.(Prostate cancer center of Seattle)
Summarised: multiple biopsies >34% and more than 5 mm are high risk
factors.
Gleason 4+3=7 or higher, PSA >20 ng and more important ,T3 or higher.

STAGING AND RISK GROUP
What is My Risk Group?
Low, Intermediate and High Risk groups have been identified by NCCN (National
Comprehensive Cancer Network) and D’Amico classifications.
Low Risk: (NCCN and D’Amico) – PSA < 10.0 And Gleason Score < 7 cT1c-T2a
Intermediate Risk: NCCN – PSA > 10.0 < 20.0 And/Or Gleason = 7 And/Or cT2b-
c D’Amico – PSA > 10.0 < 20.0 And/Or Gleason = 7 And/Or cT2b
High Risk: NCCN – PSA > 20.0 And/Or Gleason 8-10 And/Or cT3 Or 2 or More
Intermediate Risk Features D’Amico – PSA > 20.0 And/Or Gleason 8-10
And/Or cT2c-T3

STAGING PROSTATE CANCER
Very low risk clinically localized prostate cancer is defined as disease detected
by
biopsy only (no abnormalities detected on rectal examination or imaging),
Gleason
score of 6 or less on biopsy and a serum PSA <10ng/ml. Within the prostate, the
extent of disease must be limited (fewer than three positive biopsy cores with less
than 50% involvement in any core and a PSA density of less than 0.15
ng/mL/gram.2
Low risk, clinically localized prostate cancer is disease limited to one lobe of the
prostate or with no apparent tumor (diagnosis based only on biopsy, serum PSA
< 10
ng/ml and a Gleason score ≤ 6.

STAGING PROSTATE CANCER
low-risk PCa (clinical stage T1–T2a, biopsy Gleason score 6 or less, and PSA
less than 10 ng/mL); 556 (35.7%) had intermediate-risk disease (clinical
stage T2b – T2c, biopsy Gleason score 7, or PSA 10–20 ng/mL); and 343
(22%) had high-risk PCa (clinical stage T3a, biopsy Gleason score 8–10, or
PSA greater than 20 ng/mL).
The researchers designated intermediate-risk PCa as unfavorable if it met at
least 1 of the following 2 criteria: biopsy Gleason score 4 + 3 and/or presence
of 2 or more intermediate-risk criteria. All other men with intermediate-risk
PCa were designated as having favorable intermediate-risk disease

T2 MRI NORMAL TRANSITIONAL ZONE 58 Y/O

T2 MRI NORMAL TRANSITIONAL ZONE 58Y/O

T2 AX NORMAL PERIPHERAL ZONE: 65 Y/O

T2 COR NORMAL PERIPHERAL ZONE: 65 Y/O

T2 SAG NORMAL PERIPHERAL ZONE: 65 Y/O

ADC AX : NORMAL PERIPHERAL ZONE: 65 Y/O

B1400X : NORMAL PERIPHERAL ZONE: 65 Y/O

DCE AX : NORMAL PERIPHERAL ZONE: 65 Y/O

PROSTATE CANCER :AFS
1. The anterior fibromuscular stroma is devoid of glands .
2. Could form up to 30% of the gland .
3. No prostate tumour arise from it apart of the very rare sarcomas.
4. Could be affected by tumour arising from the anterior PZ or the anterior
TZ .
5. Low signal on T2W.

PROSTATE CANCER TZ
1. The central zone surrounds the ejaculatory ducts and consist of 25%
of the glandular tissue and origins 1-8% of prostate cancer and the TZ
the 20%.
2. The TZ surrounds the urethra and the epithelium consist of transitional
cells similar to bladder epithelium.
3. The most common patter is benign prostatic hyperplasia where there
are well defined nodules , hyperintense when made of hyperplasic
glands or hypointense when they are made of hyperplastic stroma .
4. Most of the cases will show enhancement .
5. The most common report for TZ will be PI-RADS 2 , probably benign .

PROSTATE CANCER TZ
The dominant sequence would be the T2 followed by DWI .

TZ: 60 Y/O ; PSA =?,> , DRE BPH 28GR
AFM heart shaped , PI-RADS 1

TZ: 63 Y/O ; PSA =4.53 , DRE BPH 61GR
Thick AFS, PI-RADS 2

TZ: 68 Y/O ; PSA =17 , DRE : NAD ,48GR
PI-RADS 5 , charcoal sign , had prostatectomy, artefacts on DWI due to THR

TZ: 66 Y/O ; PSA =11 , DRE : LEFT FIRM
,82GR
PI-RADS 5 , charcoal sign , capsular invasion , bladder invasion

TZ: 69 Y/O ; PSA =8 , DRE BPH 65GR
28/10/15
30/12/16
PI-RADS 3 , equivocal
PI-RADS 1, most probably

TZ: 76 Y/O ; PSA =6.58 , DRE : FIRM LEFT
61GR
Lenticular shaped PI-RADS 4

TZ: 72 Y/O ; PSA =7 , DRE : BPH, 73GR
Right anterior apex –mid gland PI-RADS 5

TZ: 72 Y/O ; PSA =7 , DRE : BPH, 73GR
Right anterior apex –mid gland PI-RADS
5

TZ: 74 Y/O ; PSA 2014 =6 , 2015= 9 ; DRE
BPH 25GR
PI-RADS 1 PATHOLOGY : Gleason 5+4=9

TZ: 75 Y/O ;PSA 2015 =9 ,2016= 11 ; DRE
BPH ,25G

TZ: 75 Y/O ;PSA 2015 =9 ,2016= 11 ; DRE
BPH ,25G
No
Enhancement

TZ: 72 Y/O ;PSA 7 ; DRE BPH ,43G

TZ: 72 Y/O ;PSA 7 ; DRE BPH ,43G
PI-RADS 5 PATHOLOGY : Gleason
3+3=6

TZ: 76 Y/O ;PSA 42 ; DRE : BPH ; FIRM,34G

TZ: 56 Y/O ;PSA 14 ; DRE : FIRM,32 G

TZ: 56 Y/O ;PSA 14 ; DRE : FIRM;32 G

TZ: 70 Y/O ;PSA FROM 4 TO 8 14 ; DRE :
BPH, 47G
Charcoal sign

TZ: 70 Y/O ;PSA FROM 4 TO 8 14 ; DRE :
BPH, 47G

TZ: 79 Y/O ;PSA 12.5 ; DRE : FIRM ,BPE,
54G
charcoal sign

TZ: 79 Y/O ;PSA 12.5 ; DRE : FIRM ,BPE,
54G
PI-RADS 5, charcoal sign

TZ: 74 Y/O ;PSA 22 ; DRE : FIRM , 74G
charcoal sign

PI-RADS 5 ; Gleason 4+3=7

EXTERNAL BEEN RADIATION : F/U MRI 8
MONTHS LATER: PSA FROM 22 TO 0.7 AND
PROSTATE FROM 74 G TO 46 G.

PI-RADS 5 , capsular and seminal vesicle invasion , bony mets, Gleason
4+5=9

PI-RADS 5 , capsular and seminal vesicle invasion , bony mets, Gleason 4+5=9

15 months later ,PI-RADS 5 , capsular and seminal vesicle invasion , bony
mets, Gleason 4+5=9

PROSTATE CANCER CENTRAL ZONE
69 Y/O , PSA 5.3; DRE FIRM RIGHT LOBE ;
DILATED DUCT AND LOW SIGNAL. PI-RADS 4

PROSTATE CANCER:PZ
From 70-80% of adenocarcinoma arise in the PZ
The dominant sequence would be the DWI followed by the T2
The most common report would be PI-RADS 1 .

PZ ( R MID GLAND): 67 Y/O ;PSA 5.16 ; DRE
: BPH , 36G
PI-RADS 3+1=4 ; Gleason 3+3 =6

PZ ( R POSTERIOR APEX): 67 Y/O ;PSA 19 ;
DRE : BPH , 39G
PI-RADS 3 ; Gleason 4+4 =8, in both posterior apex

PZ ( R POSTERIOR APEX): 61 Y/O ;PSA
HIGH ;
DRE : BPH , 28G
PI-RADS 3 +1 ; Gleason 3+3=6

PZ ( R PL MID GLAND ): 72 Y/O ;PSA 3.9 ;
DRE : NODULE LEFT LOBE , 96G
PI-RADS 5 ; Gleason 3+3=6

PZ ( LEFT ANT APEX ): 72 Y/O ;PSA 5.5 ;
DRE : SMALL AND FIRM R>L , 76G
PI-RADS 4 ; Gleason 3+3 .

PZ +TZ COMPLETE : 75 Y/O ;PSA 16 ;
DRE : BPH , 54G

PZ +TZ COMPLETE : 75 Y/O ;PSA 16 ;
DRE : BPH , 54G
PI-RADS 5 ; Gleason 3+4=7 but length capsular contact >15
and
Seminal vesicle invasion.

PZ : (LEFT PM BASE AND MID GLAND) : 72
Y/O ;PSA 10 ; MODERATE DRE : BPH , 29G
PI-RADS % ; Gleason 3+4=7

PZ (R POST APEX/MID GLAND)60 Y/O; PSA
11;
DRE: R FIRM , 40G

PZ (R POST APEX/MID GLAND)60 Y/O; PSA
11;
DRE: R FIRM , 40G
PI-RADS 5 ; Gleason 3+4, capsular contact 20 mm on sag

PZ (L POST LAT APEX)73 Y/O; PSA 11;
DRE: BPH , 32G
PI-RADS 5 ; Gleason 3+4=7 ; bladder polyp

PZ (R POST LAT APEX/MID GLAND )58 Y/O;
PSA 3.7; DRE: BPH , 19G
PI-RADS 4; Gleason
3+4=7

PZ (R POST LAT APEX )62 Y/O; PSA 4.8;
DRE: BPH , 65G
PI-RADS 3+1=4; Gleason 3+4

PZ (R POST LAT MID GLAND )69 Y/O; PSA
5.9 ; DRE: NODULE RIGHT APEX , 43G
PI-RADS 5; Gleason 3+4

PSA 15 ; DRE: FIRM , 114G
PI-RADS 5; Gleason 4+4=8, length of capsular contact>15mm

PSA 15 ; DRE: FIRM , 114G
PI-RADS 5; Gleason 4+4=8, length of capsular
contact>15mm

PZ (BASE B/L )78 Y/O; PSA 6 ; DRE: FIRM ,
22G,TURP 2008
PI-RADS 1 ; Gleason 4+4= B/L, apex and base

PZ (R PL/ANTERIOR APEX ) 68 Y/O; PSA 5.4
; DRE: NODULAR R SIDE , 24G,FH: FATHER
PI-RADS 5; Gleason 5+4=9 ; length capsular contact 17 mm

PZ (R PL MID-GLAND AND LEFT PL
MID/APEX ) 72 Y/O; PSA 5.6 ; DRE:
IRREG.RIGHT LOBE 58G
PI-RADS 5, Right Gleason 5, left Gleason 4=9, length capsular contact 26mm

PZ (R PL MID-GLAND AND LEFT PL
MID/APEX ) 72 Y/O; PSA 5.6 ; DRE: IRREG.
RIGHT LOBE,58G
PI-RADS 5, Right: Gleason 5, left Gleason 4=9 , length capsular contact 26mm

PZ (L PL APEX ) 66 Y/O; PSA 7 ;
DRE: FIRM LEFT LOBE,38G
PI-RADS 5; Gleason 4+3=7; length capsular contact 18 mm , fat effacement.

PZ (L PL APEX ,R PL BASE ) 66 Y/O; PSA 19
;
DRE: NODULE RIGHT BASE,45G
Left apex :PI-RADS 4 ; Gleason 4+3, length capsular contact 15 mm

PZ (L PL APEX ,R PL BASE ) 66 Y/O; PSA 19
;
DRE: NODULE RIGHT BASE,45G
Right PL base : PI-RADS 3+1=4;Gleason 4+3=7

PZ (L PL APEX ) 59 Y/O; PSA 5.2; DRE:
BPH,32G
PI-RADS 5; Gleason 4+3=7

PZ TZ(L LOBE ) 68 Y/O; PSA 70 ;
DRE: APEX FIRM,36G
PI-RADS 5,large mass 39 x 26 mm , left seminal vesicle invasion ,Gleason 4+4

PZ TZ(L LOBE ) 68 Y/O; PSA 70 ;
DRE: APEX FIRM,36G
PI-RADS 5,large mass 39 x 26 mm , left seminal vesicle invasion ,Gleason 4+4.

MULTIFOCAL ,79 Y/O; PSA 39 ;
DRE: NODULAR MALIGNANT ,78G
PI-RADS 5 elsewhere , Gleason 5+5=10, length capsular contact 30
mm .
Probably invading rectal wall , left para-rectal fat lymph node

PI-RADS 5 elsewhere , Gleason 5+5=10, length capsular contact 30 mm
.

PI-RADS 5 elsewhere , Gleason 5+5=10, length capsular contact 30 mm .

OTHER TUMOURS
Lymphoma
Rhabdomyosarcoma
Rhabdomyosarcoma: 37
years old; PSA 2.5 , DRE
nodular

OTHER TUMOURS
Prostatic cystadenoma ; 74 y/o; awaiting PSA

CHECK FOR :
1. Length of capsular contact.
2. Seminal vesicle invasion : T2 hypointense and enhancement.
3. Recto-prostatic interphase
4. Neurovascular bundle at position 5 and 7 o’clock
5. Lymphadenopathy
6. Bony lesions
7. Benign prostate findings
8. Incidental findings

CHECK FOR LENGTH OF CAPSULAR
CONTACT

CHECK FOR SEMINAL VESICLE INVASION

CHECK FOR RECTO-PROSTATIC
INTERPHASE

CHECK FOR NEUROVASCULAR BUNDLE

CHECK FOR BENIGN PROSTATE FINDINGS
1. Prostatitis: biopsy results, mimics ca
2. Granulomatous prostatitis
3. Corpora amilacea calcification
4. Utricle cyst : tear drop shape in sagittal
5. Mullerian duct cyst : lateral to the midline
6. Ejaculatory cyst: more lateral
7. Retention cyst at the periphery
8. abscess

GRANUMOLATOUS PROSTATITIS : 74 Y/O , PSA not yet ; MRI EXTENSIVE
PI-RADS 5; PATHOLOGY : EXTENSIVE GRANULOMATOUS
PROSTATITIS

Corpora amilacea calcification and prostatitis

Cysts

Prostate abscess : 58 y/o

Prostate abscess post treatment 2 months later

Prostate gland replaced by a giant haemorrhagic cyst after pelvic trauma 20
years before; 57 y/o ; PSA 5.24

CHECK FOR INCIDENTAL FINDING
Incidental finding: in :
1. Bladder
2. Lower ureters
3. Rectus/sigmoid
4. Inguinal area/spermatic cord
5. Muscle
6. Bones
7. Vessels
8. Kidney (locator sequences)

CHECK FOR INCIDENTAL FINDINGS:
BLADDER
cathete
r
Uro-lift

BLADDER
Bladder hernia and diverticula

BLADDER
TCC bladder

URETER
Ectopic ureter , Wiegert-Meyer Law , ending in verumontanum

URETER
TCC left ureter

KIDNEY
Left RCC spotted in a localiser sequence

CHECK FOR INCIDENTAL FINDINGS: RECTO-
SIGMOID
Diverticulosis
Rectal tumour

ANEURYSM

ACTIVE SURVEILLANCE (AS)
- Strategy that delays curative therapy for low risk disease
- In low grade 3+ 3=6 Gleason , to avoid over treatment.
- In intermediate grade (Gleason 3+4) low volume disease to delays-postpone
treatment until require
ICIS: Masterclass in Imaging
of prostatic cancer 22nd
January 2016

On low-risk patient for AS, monitoring involves:
- PSA testing every 3 months for 2 years, then every 6 months: using PSA
velocity over 0.75ng/ml/year would allow the identification of men with
progressive disease who would benefit from a follow-up imaging exam.
- Regular DRE
- MpMRI every 2 years, very accurate detecting tumor >0.5 cc volume
ICIS: Masterclass in
Imaging of prostatic cancer
22nd January 2016

- The absence of a detectable lesion (that is PI-RDAS 1,2, and probably 3)
make a patient suited for AS .
- Patient with PI-RADS 4 and 5 should not undergo AS
- Unfavourable features:
- Low mean ADC values of intra-prostatic dominant lesions are correlates with
higher Gleason scores. Cut value: 1000 micro m2/s
- A tumor contact length with the prostatic capsule of more than 15 mm
increases risk of having pathological ECE.
- PSA level> 10ng/ml
ICIS: Masterclass in Imaging
of prostatic cancer 22nd
January 2016

WATCHFUL SURVEILLANCE:
Foregoes curative therapy of prostate cancer due to attendant co-
morbidities and initiates interventions only when symptoms occur.
22nd January 2016

PRECLUDES RADICAL SURGERY
Extensive ECE/SVI.
CT or whole body DWI for TNM staging lymphadenopathy . The
prevalence of metastasis in operated apparently N0 disease is 20-
30% in intermediate risk and 30-40% in high risk disease.
Nerve sparing surgery is usually not performed in the side of a palpable
tumor when serum PSA level >20ng or Gleason score > 8
22nd January 2016

TREATMENT OPTIONS
A. pT2 : assuming no capsular involvement:
1. Prostatectomy : da Vinci Robotic assisted best surgical procedure.
2. Proton beam therapy + hormones : best non surgical approach. Very
expensive.
3. Image assisted Intensity modulated radiotherapy + hormones . Less
expensive and widely available.
4. Brachytherapy + hormones .
5. Gamma knife ; HIFU ; others .
B. pT3: suspicious of capsular involvement : proton beam therapy + hormones ;
IMRT+ hormones; Brachytherapy +IMRT+ hormones .
C.pT3b or higher: chemotherapy is added
Note: hormone increase the efficiency of proton beam, IMRT and brachytherapy .

SATISFACTION OF SEARCH
COULD MISS IMPORTANT
FINDINGS

BIBLIOGRAPHY
Bibliography:
Final Recommendations Statement: prostate cancer: Screening. U.S. Preventive Services Task Force. October 2014.
Thomas R Gest , Prostate Anatomy Medscape /1923122
Raychaudhuri and Cahili, Pelvic fasciae in Urology ,RCS annals, Vol :90Issue:8, Nov 2008, pp633-637.
Kennth Iczkowski, Prostate carcinoma : core biopsies Pathology Outlines 2003-2016.
R H Oyen et al , Benign hyperplastic nodules that originates in the peripheral zone of the prostate gland ,: RSNA
Radiology , December 1993, Vol 189, issue 3 .
Jelle O. Barentz et al. ESUR prostate MR guidelines 2012: Eur(2012)22: 746-757
Jeffrey C. Weinreb et al . PI-RADS Prostate Imaging-Reporting and Data System: 2015, Version 2 . Eur Urology 69
(2016) 16-40.
Jelle O.Barentz wet al. Synopsis of the PI-RADS v2 Guidelines for Multiparametric Prostate Magnetic Resonance
Imaging and Recommendations for Use. European Urology 69 (2016) 41-49.
John Kurhanewicz at al. Multiparametric magnetic resonance imaging in prostate cancer: present and future. Curr.
Opin Urol.2008 January ; 18(1): 71-77.
Janet NL wt al. Sarcoma of the prostate: a single institutional review. Am J Clin Oncol, 2009 Feb; 32 (1): 27-9
Arda Kayhan et al. Multi-parametric MR imaging of transition zone prostate cancer: Imaging features, detection and
staging. World/Radiol 2010 May 28; 2 (5): 180-187
M. Rothkle et al. PI-RADS Classification : Structured Reporting for MRI of the Prostate: Magneton Flash; Issue 4/2013,
30-38
Heminder Sokhi; Anwar R Padhani. Whole Body Diffusion-Weighted MRI for Bone Marrow Tumor detection. Magneton
Flash ; Issue 4/2013,pp6-12
Pelvic Lymph Node Dissection During Robot-assisted Radical Prostatectomy: Efficacy, Limitations, and
Complications—A Systematic Review of the Literature Guillaume Ploussard a,b,c,*, Alberto Briganti d, Alexandre
de la Taille c,e, Alexander Haese f, Axel Heidenreich g, Mani Menon h, Tullio Sulser i, Ashutosh K. Tewari j,
James A. Eastham k
Hashim U Ahmed , et al . Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS):
a paired validating confirmatory study. Lancet Vol:389, February 25, 2017.

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