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It does not address detection of recurrence, progression during active surveillance and evaluation of other parts of the body. PI-RADS assessment categories range from 1 to 5 with 5 being most likely to represent clinically significant prostate cancer.
The dominant sequence to detect prostate cancer in the peripheral zone is DWI, whereas for tumour detection Zone der Prostata the transition zone T2w is the most important sequence. DCE-MRI has been attributed a minor role and only qualitative assessment with presence or absence of focal enhancement is suggested.
Up to four suspicious lesions of category 3, 4 and 5 are assigned on a sector map and the index lesion should be identified. Prostate cancer is the second most common cancer in men worldwide [ 1 ]. Two thirds of prostate cancer cases are diagnosed in the more developed regions of the world. The Zone der Prostata varies over a broad range among different countries probably as a result of a difference in the number of men screened. Mortality of prostate cancer is difficult to measure due to the mortality of concomitant cardiovascular diseases and other cancers which share similar risk factors and therefore act as confounders.
The prevalence of latent prostate cancer at Zone der Prostata is high and occult carcinomas are common [ 1 ].
Prostate cancer screening is based on digital rectal examination DRE and prostate-specific Zone der Prostata PSA level testing in the blood serum. PSA is highly sensitive but not specific for prostate cancer. Benign pathologies such as benign prostatic hyperplasia can raise PSA levels and normal PSA levels can not exclude prostate cancer [ Zone der Prostata ].
Prostate biopsies are assessed histologically by the Gleason score, a prognostic factor of prostate cancer, which provides information on tumour aggressiveness [ 5 ]. MRI became the method of choice for detection and staging of prostate cancer [ 8 ]. In contrast to version 1 each lesion is attributed a single score based Zone der Prostata findings of mpMRI. The latest PI-RADS version assesses the likelihood probability of clinically significant prostate cancer on a 5-point scale for each lesion as follows:.
For corresponding examples of findings see Fig. No abnormality i. Isointense signal of the peripheral zone on the high b-value DW image with an indistinct linear hypointense lesion on the ADC map arrow with corresponding T2w hypointense signal. T2w image shows heterogeneous signal intensity of the peripheral zone.
Focal markedly hyperintense lesion on high b-value DW image with corresponding markedly hypointense signal intensity on the ADC map arrow. T2w image shows a circumscribed homogenous hypointense lesion. Homogeneous intermediate signal intensity normal on T2w image Zone der Prostata no Zone der Prostata on high b-value DW image and ADC map. Circumscribed arrows hypointense or heterogeneous encapsulated nodule s BPH.
Lesion with heterogeneous signal intensity with obscured margins arrow. High b-value DW image of the lesion is mildly hyperintense and moderately hypointense on the ADC map.
This category includes Zone der Prostata that do not qualify as 2, 4, or 5. High b-value DW image of the lesion shows markedly hyperintense signal and markedly hypointense signal Zone der Prostata the ADC map. In case of a suspicious lesion detected on MRI, targeted MRI-transrectal ultrasound TRUS fusion guided transperineal or transrectal biopsy is performed after meticulous demonstration of the findings to the referring urologist, as previously described [ 12 ].
MRI not only offers an excellent resolution of the prostatic gland, but also evaluates locoregional extension, pelvic lymph nodes involvement and bone metastases in the pelvis. Ultrasound alone has too poor spatial resolution to suffice as an adequate imaging method. C and F choline positron emission Zone der Prostata PET are other imaging methods used for detection of recurrence or metastatic disease in prostate cancer, but not for detection of the primary tumour or local staging.
Zone der Prostata with contraindications for MRI have to be excluded. If possible patients Zone der Prostata evacuate the rectum just prior to the MRI exam.
For reduction of bowel motion artefacts an antispasmolytic agent is administered. The prostate including the seminal vesicles are imaged as follows with a reduced field of view:.
Axial DCE-MRI sequence with a standard, preferable Zone der Prostata, gadolinium based contrast agent administered with a dose of 0. Injection rate is 2. A precontrast T1w sequence is needed to exclude haemorrhage. In addition a high resolution T2w sequence should be performed in the coronal and sagittal plane.
All sequences are acquired without breath-hold. The reason for this additional sequence is to better evaluate other extraprostatic findings. Ideally two Additional monitors for reporting Zone der Prostata other activities e. PACS steering, Internet, reference databases are recommended. Depending on the software, which is used, morphologic and functional sequences should be displayed at the same time.
For a first overview axial T2w images are recommended. On the left side we display the morphologic T2w images. On the right side DWI is displayed, i. Ideally the morphologic and the functional images should be linked at the same table position. For exact morphologic localisation of suspicious lymph nodes and level of the prostatic lesion isotropic voxel 3D T2w sequence can be reformatted at user's preferences [ 14 ]. Additionally fused images of morphology and functional maps may be helpful for exact localisation of findings.
A standard layout of our prostate image display is shown in Fig. Standard layout of our prostate image display in Zone der Prostata one screen setting. Double clicking in one of the images allows to display this image in full screen mode. Before starting image interpretation, the quality of the images has to be assured. Artefacts like metal implants e. The predominant sequence is DWI in the peripheral zone and T2w sequence in the transition zone. The prostate should be analysed for focal lesions in the prostate and seminal vesicles.
Peripheral zone and transition zone are assessed separately as depicted in Fig. In the peripheral zone the dominant sequence is DWI. Suspicious lesions typically have a hyperintense signal intensity on high Zone der Prostata DW images and a hypointense signal intensity on the corresponding ADC maps.
In the transition zone T2w is the dominant sequence. Suspicious lesions have a heterogeneous signal intensity with obscured margins, lenticular or non-circumscribed homogeneous moderately hypointense signal intensity on T2w Zone der Prostata. EPE is defined as a lesion extending to an area outside of the prostate or bulging the capsule of the prostate.
Invasion of the seminal vesicle is defined as tumour extension into the seminal vesicle. Thereafter, the entire pelvis should be analysed for lymph node involvement, bone metastases and other findings. Especially DWI sequences of the entire pelvis in combination with meticulous analysis of 3D T2w sequences help to detect lymph node metastases [ 14 ].
Pitfalls in prostate cancer imaging can be categorised as previously described [ 1516 ]. Peripheral zone Zone der Prostata can be mimicked by normal central zone or periprostatic venous plexus or neurovascular bundle.
Asymmetric thickening Zone der Prostata the surgical capsule can be difficult to distinguish from a focal lesion. The differentiation between stromal benign prostatic hyperplasia and a transition zone tumour can be very difficult. Protrusion of a benign prostatic hyperplasia BPH nodule can mimic a peripheral zone lesion. Acute and chronic prostatitis, postinflammatory scars and atrophy mimicking tumour is less difficult to distinguish, due to characteristic patterns on T2w sequences.
Without adequate clinical information, granulomatous prostatitis is another Zone der Prostata of a tumour and can not be differentiated based on imaging alone. Anatomic distortion of high b-value DW images can lead to obscuration of focal lesions. Zone der Prostata of suppression of benign prostate tissue on standard high b-value DW images is another pitfall, which leads to false positive findings. On the other side, suboptimal windowing of ADC maps can yield false negative results.
Experience, meticulous image analysis, including morphological and functional Zone der Prostata at the same time are factors, which can reduce false positive results. Reporting at our institution is performed in a structured way on a free text basis.
All patients undergoing MRI-TRUS fusion guided biopsy are reported additionally by one senior radiologist specialised in genitourinary radiology on a template scheme map for biopsy planning. This scheme map is further demonstrated to the biopsy performing urologist. We are looking forward to integrating report templates in computer-aided evaluation soon. A prostate MRI report should be structured with the following italic subheadings:.
In this section patient preparation, field strength of the MR scanner, amount and name of contrast medium are mentioned. If quality of DWI or DCE-MRI is not adequate, causes of problems should be mentioned in this section and, if possible, performed solutions should be reported in order to perform eventual follow-up studies of Zone der Prostata same patient with identical sequence alterations.
In our institution reports start with the prostate volume and an overall impression of the prostatic gland. Presence or absence of possible lymph node metastases in the entire pelvis are described and exact localisation, number and size are mentioned. Additionally, if present, bone metastases are described. Finally, additional findings in the scanned volume are mentioned. For each lesion of category 3, 4 and 5 the likelihood for presence or absence of clinically significant prostate cancer is depicted and the exact localisation is mentioned.
Presence or absence of extraprostatic extension, lymph node involvement and bone metastases is always explicitly mentioned. Two cases and corresponding scheme maps and reports are shown in Figs. One year previous prostate biopsy revealed no cancer. DCE-MRI is rated positive, showing a focal enhancement, earlier than adjacent prostate tissue black arrows.
No suspicious locoregional or pelvic lymph nodes. No suspicious bone lesions. No additional findings.