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Prostate Imaging - PI-RADS v2.1
- 1. PROSTATE IMAGING PI-RADS V2.1 DR. PANKAJ SAINI RADIOLOGY & MEDICAL IMAGING
- 2. PROSTATE IMAGING • USG – Routine Ultrasound for LUTS • TRUS – Trans rectal USG evaluation • MRI – 1980 – Prostate Imaging – Reporting and Data System • T1 Morphological assessment / loco regional • Staging in biopsy proven case • MRSI – Spectroscopy • PSA
- 3. CLINICAL APPLICATIONS • Include not only locoregional staging, • Tumor detection • Localization (registration against an anatomical reference) • Characterization • Risk stratification • Active disease surveillance • Assessment of suspected recurrence • Image guidance for biopsy, surgery, focal therapy and radiation therapy.
- 4. MULTI PARAMETERIC MRI - MPMRI • mpMRI anatomic T2W imaging with functional and physiologic assessment • Diffusion – weighted imaging (DWI) • Apparent Diffusion Coefficient (ADC) maps • Dynamic Contrast-Enhanced (DCE) MRI • MR proton spectroscopy • Clinically significant cancer - csPCa • Reducing mortality • Increasing confidence in benign diseases and dormant malignancies • Reduce morbidity reduce unnecessary biopsies and treatment
- 5. PI-RADS • PI-RADS V1 • ESUR • Focus • Technique • Significant Lesion Detection • Clinical application • EPE & Staging PI-RADS v2 • PI-RADS V2 • ACR, ESUR, AdmeTech • Focus • Lesion detection & Characterization • Including benign findings • Interpretation & Reporting • Explicit instructions for mapping and measuring individual lesion • Images, Scoring criteria • Lexicon
- 6. PI-RADS • PI-RADS V1 • Same imaging for PZ & TZ • T2WI, DWI & DCE • Unclear integration of parameters PI-RADS v2 • PI-RADS V2 • PZ and TZ different weighting • DWI dominates for PZ • T2W dominates for TZ • DCE Minor role • Stage 3/4 characterization • Two additional zones in base PZ • Simple algorithms • Assessment category “living” document that will evolve as clinical experience and scientific data a
- 7. TECHNICAL SPECIFICATIONS • Imaging plane angle, Location, and Slice thickness for all sequences are identical. • M-DIXON – chemical shift FAT SAT combined with FSE • T2W • Slice thickness: 3mm, no gap. • FOV: generally : 16-22 cm • In plane dimension: ≤0.7mm (phase) x ≤0.4mm (frequency) • T1W • Pre and Post contrast orthogonal planes and T1 FSE Axial T1W without fat suppression • DWI / ADC • High B value > 1400 sec / mm2 TE: ≤90 msec; TR: ≥3000 msec PI-RADS v2
- 8. •T1-Weighted (T1W) • Hemorrhage within the prostate and seminal vesicles • Delineate the outline of the gland • Detection of nodal and skeletal metastases • Intravenous gadolinium- PI-RADS v2 MULTI PARAMETERIC MRI - MPMRI
- 9. ANATOMY ANATOMY Prostate Density PSAD = PSA Value Prostate Volume •Prostate Volume • L x W x H x 0.52
- 10. SECTOR MAP •The segmentation model used in PI-RADS v2 •European Consensus Meeting and the ESUR Prostate MRI Guidelines 2012. •forty-one sectors/regions • thirty-eight for the prostate ANATOMY
- 11. ANATOMY • Base (just below the urinary bladder) • The mid gland • The apex. • Four histologic zones: • AFMS – No glandular tissue • TZ – 5% of the glandular tissue • CZ – 20% of the glandular tissue • PZ – 70%–80% of the glandular tissue ANATOMY • Benign Prostatic Hyperplasia (BPH) • the TZ will account for an increasing percentage of the gland ANATOMY
- 12. • Approximately 70-75% prostate cancers originate in the PZ • 20-30% in the TZ. • Cancers originating in the CZ are uncommon • cancers that occur in the CZ are usually secondary to invasion by PZ tumors. • “Central gland” to refer to the combination of TZ and CZ is discouraged • “Prostate capsule” landmark for assessment of extra prostatic “EPE”. • It is incomplete anteriorly and apically • “Surgical capsule” interface of the TZ with the PZ. ANATOMY ANATOMY
- 13. BENIGN FINDINGS • Benign prostatic hyperplasia (BPH) • Hemorrhage • Cysts • Prostatitis • Abscess • Calcifications • Atrophy • Fibrosis
- 14. BENIGN PROSTATIC HYPERPLASIA (BPH) • Response to testosterone, after conversion to dihydrotesosterone. • BPH arises in the TZ • BPH found in the PZ or CZ • mixture of stromal and glandular hyperplasia • band-like areas and/or • encapsulated round nodules • circumscribed or encapsulated margins. • Cystic atrophy seen as T2 hyperintensity • Mixture of signal intensities. • BPH nodules may be highly vascular on DCE • Range of signal intensities on DWI. • increase gland volume – LUTS • MRI PSA Density (PSA/prostate volume) BENIGN FINDINGS
- 15. BENIGN PROSTATIC HYPERPLASIA (BPH) BENIGN FINDINGS
- 16. HEMORRHAGE • Hemorrhage in the PZ and/or • Seminal vesicles • After biopsy • Focal or diffuse • Hyperintense on T1W • Iso-hypointense signal on T2W • Chronic blood products appear hypointense on all BENIGN FINDINGS
- 17. CYSTS • A variety of cysts can occur in the prostate and adjacent structures. • “simple” fluid • Markedly hyperintense on T2W and dark on T1W. • Blood products or proteinaceous fluid • Variety of signal characteristics, including hyperintense signal on T1W BENIGN FINDINGS
- 18. PROSTATITIS • Commonly seen, often sub- clinical • Decreased signal in the PZ on both T2W and the ADC map. • Increase perfusion, resulting in a “false positive” DCE result. • Band-like, wedge-shaped • Diffuse rather than focal, round, oval, or irregular • ADC map reduced signal • not as pronounced nor as focal as in cancer BENIGN FINDINGS
- 20. CALCIFICATION S • markedly hypointense foci (e.g. signal voids) on all pulse sequences BENIGN FINDINGS ATROPHY • Aging or from • Chronic inflammation • Wedge-shaped low signal on T2W • Mildly decreased signal on ADC • loss of glandular tissue. • ADC • not as low as in cancer • Contour retraction of the involved prostate. FIBROSIS • Prostatic fibrosis can occur after inflammation • wedge- or band- shaped areas of low signal on T2W.
- 21. PI-RADS V2.1 • Prostate Imaging-Reporting and Data System version 1 (PI-RADS v1) was published in 2012, • American College of Radiology (ACR), ESUR and the AdMeTech Foundation established a Steering Committee to build upon, update and improve upon the foundation of PI-RADS v1. • This effort resulted in the development of PI-RADS v2. • “living” document that will evolve as clinical experience and scientificPI-RADS v2
- 22. EVALUATION OF THE TZ • A Focal lesion/region • More restricted diffusion on high b-value images & ADC maps • A focal lesion that is different • Obscured margins • Lenticular shape • Invasive behavior on T2W images • Even if without differing restricted diffusion PI-RADS v2
- 24. EVALUATION OF THE TZ • T2W score dominant factor in the TZ • Restricted diffusion a feature of malignancy • Atypical nodules in the TZ may contain cancer • PCa associated with high DWI scores in atypical TZ nodules • Atypical TZ nodules (T2W score of 2) upgraded to PI-RADS 3 with DWI 4 • Stromal hyperplasia should not be upgraded on the basis of mildly/moderately restricted PI-RADS v2
- 25. EVALUATION OF THE CENTRAL ZONE • T2W and ADC images as bilaterally symmetric low signal intensity tissue encircling the ejaculatory ducts from the prostatic base to the verumontanum. • It is symmetrically, mildly hyperintense on high b-value DWI • does not demonstrate early enhancement nor • Asymmetric increased signal PI-RADS v2
- 26. EVALUATION OF THE CENTRAL ZONE • Asymmetry in size alone may be a normal variant • Benign prostatic hyperplasia (BPH) in the TZ, which may deform, displace or cause asymmetry of the CZ. • Discrete nodule in the midline above the level of the verumontanum • Symmetric signal on ADC/DWI images PI-RADS v2
- 27. EVALUATION OF THE AFMS ANTERIOR FIBROMUSCULAR STROMA • Bilaterally symmetric shape (“crescentic”) • Symmetric low signal intensity • Similar to obturator or pelvic floor muscles on all T2W, ADC, and high b-value DWI • No early enhancement. • Pca • Increased T2W signal • Restricted DWII • Low signal on ADC • Asymmetric enlargement or focal mass • Early enhancement • Since PCa does not originate in the AFMS Zone of origin is not always certain PI-RADS v2
- 29. T2-WEIGHTED (T2W) • csPCA in the PZ / T2W features of TZ tumors • Round or ill-defined hypointense focal lesions. • Non-circumscribed homogeneous • Moderately hypointense lesions • “erased charcoal” or “smudgy fingerprint” • Spiculated margins • Lenticular shape • Absence of a complete hypointense capsule • invasion of the urethral sphincter & AFMS The more features present, the higher the likelihood of a clinically significant TZ cancer. PI-RADS v2
- 30. PI‐RADS ASSESSMENT FOR T2W PI-RADS v2 PI-RADSTM v2.1 Score Peripheral Zone (PZ) Transitional Zone (TZ) PIRADS 1 – Very low (clinically significant cancer is highly unlikely to be present) Uniform hyperintense signal intensity (normal) Normal appearing TZ (rare) or a round, completely encapsulated nodule. (“typical nodule”) PIRADS 2 – Low (clinically significant cancer is unlikely to be present) Linear or wedge-shaped hypo intensity or diffuse mild hypo intensity, usually indistinct margin A mostly encapsulated nodule OR a homogeneous circumscribed nodule without encapsulation. (“atypical nodule”) OR a homogeneous mildly hypointense area between nodules PIRADS 3 – Intermediate (the presence of clinically significant cancer is equivocal) Heterogeneous signal intensity or non- circumscribed, rounded, moderate hypo intensity Includes others that do not qualify as 2, 4, or 5 Heterogeneous signal intensity with obscured margins Includes others that do not qualify as 2, 4, or 5 PIRADS 4 – High (clinically significant cancer is likely to be present) Circumscribed, homogenous moderate hypointense focus/mass confined to prostate and <1.5cm In greatest Lenticular or non-circumscribed, homogeneous, moderately hypointense, and <1.5 cm in greatest dimension
- 31. DIFFUSION-WEIGHTED IMAGING (DWI) • “High b-value” images utilize a b-value of at least 1400 sec/mm2. • Most clinically significant cancers have restricted/impeded diffusion compared to normal tissues • ADC values correlate inversely with histologic grades However there is considerable overlap between BPH, low grade cancers, and high grade cancers. • ADC values, using a threshold of 750-900 μm2/sec, may assist differentiation between benign and malignant • ADC values below the threshold correlating with clinically PI-RADS v2
- 32. PI‐RADS ASSESSMENT OF DWI PI-RADS v2 B3000 ADC MAP IMAGE
- 33. DIFFUSION-WEIGHTED IMAGING (DWI) PI-RADS v2 • Compared to ADC maps alone, conspicuity of clinically significant cancers is sometimes improved on high b-value images • especially in those adjacent to or invading the anterior fibromuscular stroma, subcapsular location At the apex and base of the gland.
- 34. PI‐RADS ASSESSMENT OF DWI • Signal intensity in a lesion should be visually compared to the average signal of “normal” prostate tissue in the histologic zone in which it is located. PI-RADS v2
- 35. DYNAMIC CONTRAST-ENHANCED (DCE) MRI • Positive (+) • Focal & Early enhancement • T2 WI &/or DWI lesion • Negative (–) • No early enhancement • Diffuse enhancement PI-RADS v2
- 36. EXTRA PROSTATIC EXTENSION – EPE • Seminal vesicle invasion • T2 W Images • DCE • DWI • Morphology • Obliteration of angle with base • Neuro vascular bundle – asymmetry • Bulging capsule • Tumor capsule interface of >1 cm • Bladder wall invasion • Retropubic space / peri rectal fat plane obliteration PI-RADS v2
- 37. EXTRA PROSTATIC EXTENSION – EPE • Seminal vesicle invasion • DCE PI-RADS v2 • T2 W Images Obliteration of angle with base
- 38. EPE – LYMPH NODE PI-RADS v2 • DWI & T1W Post GBCA • Pelvic and Retroperitoneal node • Size, morphology • Shape (round / Oval) • Enhancement pattern • 8mm short axis LEVEL 1 TNM GREEN Regional DISTANT M1a RED Metastatic
- 39. PI-RADS v2 •T2 W Hyperintensity •DWI •DCE EPE – BONE METASTASIS
- 40. EPE – EXTRA PROSTATIC EXTENSION PI-RADS v2
- 43. PI-RADS v2 POST OPERATIVE RECURRENCE
- 44. REPORTING FORMAT •Clinical details •PSA •Volume – PSAD •Localization / Index lesion / Size / EPE •Sectoral localization •Benign findings •Lymph node / adjacent structure / secondary changes PI-RADS v2
- 45. LOOKING AHEAD • DCE-MRI – Ancillary role for PZ • MRSI – Availability • MRDB – MR Directed Biopsy • MRGB – MR Guided Biopsy • Recurrence / Post Rx • Multi Centric trials • Learning curve / Subjectivity • Reporting / Interobserver variations • Accreditation standards PI-RADS v2
- 46. SUMMARY • PI-RADS V2.1 • Higher accuracy over TRUS guided biopsy in CSPCa detection • Fails to detect all cancers; however does detect CSPCa • Good performance; robustly trained Radiologist and Urologist • Multidisciplinary team; MPMRI of biopsy naïve and guided biopsy • ProtecT Study (2016) – Surgery delayed time-to-metastasis development • PIVOT Study (2017) – Curb overdiagnosis and Treatment related morbidity PI-RADS v2
- 47. Facebook – Medical Imaging Portal THANK YOU FOR YOUR KIND ATTENTION
- 48. REFERENCES AND ACKNOWLEDGEMENT • Prostate Imaging and Data Reporting System - https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/PI- RADS • Anwar RP, Jeffrey W, Andrew BR, Geert V, Baris T, Jelle B. PI-RADS V2 Status update and future directions. EUROPEAN UROLOGY 75 (2019) 385–396. https://doi.org/10.1016/j.eururo.2018.05.035 • Andrei SP, Andrew BR, Jelle OB, Jefery CW, Katarzyna FM. PI-RADS Version 2: A Pictorial update. RadioGraphics 2016; 36:1354–1372 Published online 10.1148/rg.2016150234 • Bittner N, Merrick GS, Butler WM, Bennett A, Galbreath RW. Inci- dence and pathological features of prostate cancer detected on transperineal template guided mapping biopsy after negative trans- rectal ultrasound guided biopsy. J Urol 2013;190:509–14. http://dx. doi.org/10.1016/j.juro.2013.02.021. • Tosoian JJ, JohnBull E, Trock BJ, et al. Pathological outcomes in men with low risk and very low risk prostate cancer: implications on the practice of active PI-RADS v2
Editor's Notes
- Today we will be speaking about prostate imaging with emphasis on PIRADs2… 2.1 in 2019 as here we have tried to keep abreast with the latest updates…
- four histologic zones: the anterior fibromuscular stroma, contains no glandular tissue the transition zone (TZ), surrounding the urethra proximal to the verumontanum, contains 5% of the glandular tissue the central zone (CZ), surrounding the ejaculatory ducts, contains about 20% of the glandular tissue the outer peripheral zone (PZ), contains 70%–80% of the glandular tissue
- Approximately 70-75% of prostate cancers originate in the PZ and 20-30% in the TZ. Cancers originating in the CZ are uncommon cancers that occur in the CZ are usually secondary to invasion by PZ tumors. “central gland” to refer to the combination of TZ and CZ is discouraged as it is not reflective of the zonal anatomy as visualized or reported on pathologic specimens. “prostate capsule”. A thin, dark rim partially surrounding the prostate on T2W It serves as an important landmark for assessment of extraprostatic extension of cancer. It is incomplete anteriorly and apically “surgical capsule” The prostatic pseudocapsule on T2W MRI is a thin, dark rim at the interface of the TZ with the PZ. the neurovascular bundles Nerves that supply the corpora cavernosa with arterial branches from the inferior vesicle artery and accompanying veins that course posterolateral at 5 and 7 o'clock to the prostate bilaterally; potential route for extraprostatic extension (EPE) of cancer. Approximately 70-75% of prostate cancers originate in the PZ and 20-30% in the TZ. Cancers originating in the CZ are uncommon cancers that occur in the CZ are usually secondary to invasion by PZ tumors. “central gland” to refer to the combination of TZ and CZ is discouraged as it is not reflective of the zonal anatomy as visualized or reported on pathologic specimens. “prostate capsule”. A thin, dark rim partially surrounding the prostate on T2W It serves as an important landmark for assessment of extraprostatic extension of cancer. It is incomplete anteriorly and apically “surgical capsule” The prostatic pseudocapsule on T2W MRI is a thin, dark rim at the interface of the TZ with the PZ. the neurovascular bundles Nerves that supply the corpora cavernosa with arterial branches from the inferior vesicle artery and accompanying veins that course posterolateral at 5 and 7 o'clock to the prostate bilaterally; potential route for extraprostatic extension (EPE) of cancer.
- Approximately 70-75% of prostate cancers originate in the PZ and 20-30% in the TZ. Cancers originating in the CZ are uncommon cancers that occur in the CZ are usually secondary to invasion by PZ tumors. “central gland” to refer to the combination of TZ and CZ is discouraged as it is not reflective of the zonal anatomy as visualized or reported on pathologic specimens. “prostate capsule”. A thin, dark rim partially surrounding the prostate on T2W It serves as an important landmark for assessment of extraprostatic extension of cancer. It is incomplete anteriorly and apically “surgical capsule” The prostatic pseudocapsule on T2W MRI is a thin, dark rim at the interface of the TZ with the PZ. the neurovascular bundles Nerves that supply the corpora cavernosa with arterial branches from the inferior vesicle artery and accompanying veins that course posterolateral at 5 and 7 o'clock to the prostate bilaterally; potential route for extraprostatic extension (EPE) of cancer.
- Approximately 70-75% of prostate cancers originate in the PZ and 20-30% in the TZ. Cancers originating in the CZ are uncommon cancers that occur in the CZ are usually secondary to invasion by PZ tumors. “central gland” to refer to the combination of TZ and CZ is discouraged as it is not reflective of the zonal anatomy as visualized or reported on pathologic specimens. “prostate capsule”. A thin, dark rim partially surrounding the prostate on T2W It serves as an important landmark for assessment of extraprostatic extension of cancer. It is incomplete anteriorly and apically “surgical capsule” The prostatic pseudocapsule on T2W MRI is a thin, dark rim at the interface of the TZ with the PZ. the neurovascular bundles Nerves that supply the corpora cavernosa with arterial branches from the inferior vesicle artery and accompanying veins that course posterolateral at 5 and 7 o'clock to the prostate bilaterally; potential route for extraprostatic extension (EPE) of cancer.
- Pathologically, it presents as an immune infiltrate, the character of which depends on the agent causing the inflammation.
- Pathologically, it presents as an immune infiltrate, the character of which depends on the agent causing the inflammation.
- if there is restricted diffusion in multiple, similar appearing nodules scattered throughout the TZ, thus making restricted diffusion a feature of the background, these should not be scored.
- Schematic diagram of features of nodules in the TZ and their corresponding scores. Assessment of nodule shape and margins should be done in at least two planes. Oval or spherical shape and cystic change are acceptable features within nodules.
- Although the T2W score is the dominant factor that determines the PI-RADS assessment category in the TZ, restricted diffusion is also a feature of malignancy. Occasionally, atypical nodules in the TZ may contain cancer, and DWI may be helpful to identify them. Given the increased likelihood of PCa associated with high DWI scores in atypical TZ nodules, atypical TZ nodules (T2W score of 2) are upgraded to PI-RADS assessment category 3 if they have a DWI score of >4 (i.e., with markedly Mildly/moderately restricted diffusion is commonly encountered in mostly encapsulated and unencapsulated lesions in the TZ. Such lesions may represent areas of stromal hyperplasia and should not be upgraded on the basis of mildly/moderately restricted diffusion. Therefore, findings with a T2W score of 1 or 2 should not be upgraded to a PI-RADS assessment category of 2 or 3, respectively, based on a DWI score of a 3 (i.e., mildly/moderately restricted diffusion).
- Asymmetry in size alone may be a normal variant, especially in the setting of benign prostatic hyperplasia (BPH) in the TZ, which may deform, displace or cause asymmetry of the CZ. Occasionally, the normal CZ may appear as a discrete nodule in the midline above the level of the verumontanum; symmetric signal on ADC/DWI images and/or lack of early contrast enhancement may help differentiate benign from malignant tissue.
- Bilaterally symmetric shape (“crescentic”) symmetric low signal intensity similar to that of obturator or pelvic floor muscles T2W, ADC, and high b-value DWI without early enhancement. Abnormalities with increased T2W signal intensity relative to the pelvic muscles, with high signal intensity on high b-value DWI, low signal on ADC compared to adjacent pelvis muscle signal intensity (and hence relatively lower signal on ADC than normal AFMS), asymmetric enlargement or focal mass, and early enhancement may all be helpful to detect PCa Since PCa does not originate in the AFMS, when reporting a suspicious lesion in the AFMS, criteria for either the PZ or TZ should be applied, It is understood that the zone of origin is not always certain, an inevitable limitation of PI-RADS assessment methodology.
- Schematic diagram of PI-RADS v2.1 scoring for TZ that incorporates DWI for determination of assessment category for partially encapsulated or circumscribed, non- encapsulated nodules with clearly restricted (impeded) diffusion (DWI score 4 or 5) is scored a 3 (dotted lines indicate the region of a near isointense lesion where the borders are indistinct or difficult to define because of the near isointensity).
- TZ cancers may be difficult to identify on T2W images since the TZ is often composed of variable amounts of glandular (T2-hyperintense) and stromal (T2-hypointense) tissue intermixed with each other, thus demonstrating heterogeneous signal intensity.
- Pi-Rads V1 there was a 5 point scale for scoring DCE curves with modifiers
- If both DWI and DCE are inadequate or absent, assessment should be limited to stagingfor determinationofEPE.
- Not covered in PI-RADS