A review of prostate gland mpMRIs performed in our institution (CT Scanner) from January 2015 to may 2017 was conducted,
selecting a few representative patients to present a case-based PI-RADS review.
International articles and the PI-RADS v2 guidelines were consulted.
PI-RADS v2 1
- 5-point scale based classification.
- A 39 sections anatomical map should be used for lesion localization.
- The mpMRI assessment category indicates the probability of correlation to clinically significant prostate gland cancer in a specific sector.
Table 2: PI-RADS category assessment.
Clinically significant cancer is defined (pathology) as:
- Gleason >7 (including 3+4 with prominent but not predominant Gleason 4)
- Tumoral volumen >0.5 ml and/or extraprostatic extension (EPE).
PZ lesions1 evaluation
Table 4: PZ lesions reading algorithm.
TZ lesions1 evaluation
Table 3: TZ lesions reading algorithm.
Lesions anatomical map (39 sectors) 1
Fig. 12: Lesions anatomical map (39 sectors) proposed by the ACR.
Building a report
Fig. 13: mpMRI reading algorithm.
Patient 1
- Clinical information: Serum prostate specific antigen (PSA) level elevation up to 9ng/ml.
History of negative biopsy in 2015
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with an endorectal coil.
15 ml of gadolinium were administered.
- Calculating the volume: Prostate gland dimensions 6.7 x 4.3 x 6.6 cm x 0.523 = 98.8 g.
Fig. 14: T2WI A. Sagittal midline. B. axial towards the base.
References: Grupo CT Scanner
PZ evaluation
1.5 cm lesion with poorly defined margins in the PZplL,
mid portion,
moderately hypointense on ADC.
Low hypointensity on T2WI.
Positive DCE.
Fig. 15: Patient 1 PZ evaluation, lesion #1 Mid portion A. Axial T2WI B. ADC C. Coronal T2WI D. DCE.
References: Grupo CT Scanner
Do not forget that signal intensity and ADC cuantitative values must be correlated to molecular diffusion restriction images (DWI) with high b values (1400-2000).
TZ evaluation
Prominent TZ with multiple heterogeneous images,
predominantly hypointense,
with well defined margins imprinting the vesical floor.
1.2 cm ovoid heterogeneous lesion with poorly defined margins on T2WI,
towards the base,
TZpL sector.
Low hypointensity on ADC,
positive DCE.
Fig. 16: Patient 1 TZ evaluation, lesion #2, Gland base A. axial T2WI B. ADC C. DCE D. Coronal T2WI.
References: Grupo CT Scanner
PI-RADS category assessment
- PZplL sector mid portion lesion PI-RADS 4 category (high,
clinically significant cancer is likely to be present).
- TZpL sector base lesion PI-RADS 3 category (intermediate,
the presence of clinically significant cancer is equivocal).
Fig. 17: Patient 1 Sector map and lesion index.
Additional findings:
- Prostatic growth due to estromal predominance hyperplasia.
- Chronic prostatitis.
- Normal seminal vesicles.
- Non suspicious adenopaties.
- Bone structures with usual intensity signal.
Fig. 18: Patient 1 additional findings A. axial T2WI with broad FoV for pelvic structures evaluation. B. axial T2WI. Normal intensity seminal glands.
References: Grupo CT Scanner
Patient 2
- Clinical information: History of BPH.
PSA level 6.5ng/ml
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with a 30 channel,
surface coil.
15 ml of gadolinium were administered.
76g prostate gland,
heterogeneous with multiple nodular lesions in the TZ,
hyperintense mixed with hypointense linear images.
Left renal cyst,
non inflammatory colonic diverticulae.
Fig. 19: Patient 2 Prostatic base. A. T2WI B. ADC C. DCE D. Axial T2WI upper abdomen.
References: Grupo CT Scanner
Mixed prostatic hyperplasia.
Patient 3
- Clinical information: PSA level elevation to 9.4 ng/ml
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with a 30 channel surface coil.
15 ml of gadolinium were administered.
30.6 g prostate gland.
2.1 cm lesion,
TZa and TZp involving right and left sectors extending from the base to the mid portion,
involving the AS.
Ill defined margins,
hypointense on T2WI and ADC.
Positive DCE.
Positive I nternal and external iliac lymph nodes.
Peripheral zones of chronic prostatitis.
Pancreatic and hepatic cysts.
Fig. 20: Patient 3 A. T2WI B. ADC C.DCE D. Fused T2W/DCE E. sagittal T2WI F. Sector map.
References: Grupo CT Scanner
PI-RADS category assessment:
- Right and left TZa and TZp lesion,
extending from apex to mid portion PI-RADS 5 category (very high,
clinically significant cancer is highly likely to be present).
Patient 4
- Clinical information: PSA level elevation up to 10.1 ng/ml.
History of negative biopsy in 2016.
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with a 30 channel,
surface coil.
15 ml of gadolinium were administered.
72g prostate gland.
5.9 mm lesion,
apical PZaL lesion.
Low hypointensity on ADC and T2WI.
Negative DCE.
Fig. 21
Poorly margined lesion,
mid portion PZaL,
mildly hypointense on ADC.
Irregular and hypointense on T2WI.
Negative DCE. Fig. 22
Chronic prostatitis.
Pancreatic,
hepatic and renal cysts. Fig. 23
PI-RADS category assessment:
- Apical PZaL sector lesion PI-RADS 3 category (intermediate,
the presence of clinically significant cancer is equivocal).
- Mid portion PZaL sector PI-RADS 3 category (intermediate,
the presence of clinically significant cancer is equivocal).
Fig. 24: Sector map.
Patient 5
- Clinical information: PSA level elevation up to 8 ng/ml.
History of of three negative biopsies.
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with an endorectal coil.
15 ml of gadolinium were administered.
39.2 g prostate gland.
12 mm lesion,
basal TZpL and central zone,
poorly defined margins,
hypointense on ADC and T2WI.
Negative DCE.
Meniscus shaped hypointense lesion,
basal TZpR contiguous to the PZ and CZ.
Negative DCE.
3 mm rounded lesion,
apical PZplR,
mild hypointensity on ADC.
Hypointense on T2WI.
Negative DCE.
Chronic prostatitis.
Fig. 25: Patient 5. Upper-lnae: Prostatic base lesion #1. A. T2WI B. ADC C. DCE. Mid-lane: base lesion #2 A. T2WI B. ADC C. DCE. Lower-lane: prostatic apex. A. T2WI B. ADC C. DCE.
References: Grupo CT Scanner
PI-RADS category assessment:
- Base TZpL sector lesion PI-RADS 3 category (intermediate,
the presence of clinically significant cancer is equivocal).
- Base TZpR sector lesion PI-RADS 3 category (intermediate,
the presence of clinically significant cancer is equivocal).
Fig. 26: Patient 5 Sector map
References: Grupo CT Scanner
Apical PZplR sector lesion PI-RADS 2 category (low,
clinically significant cancer is unlikely to be present).
REMEMBER: only lesions category 3,4 or 5 should be mapped and included in the lesion's index.
Patient 6
- Clinical information: Recently biopsy-diagnosed acinar adenocarcinoma at the base,
non treated.
Recent PSA 5.7 ng/ml,
one month ago 4.35 ng/ml.
- Technique description: Following our center's protocol a prostate mpMRI was acquired using a 1.5T Scanner with a 30 channel,
surface coil.
15 ml of gadolinium were administered.
38 g prostate gland.
2 cm lesion,
apical and mid portion PZplR and PZpmR.
Hypointense on ADC.
Irregular and hypointense on T2WI.
Positive DCE.
Seminal vesicles with increased AP diameter,
suspicious for obstruction.
External iliac chain adenomegaly.
Fig. 27: Patient 6. A. T2WI B. ADC C.DCE D. And E. Coronal T2WI, F. Sector map.
References: Grupo CT Scanner
PI-RADS category assessment:
- Apical and mid portion PZplR and PZpmR lesion PI-RADS 5 category (very high,
clinically significant cancer is highly likely to be present).