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Pretreatment Evaluation of Prostate Cancer: Role of MR Imaging and ¹H MR Spectroscopy¹

¹ From the Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, C278, New York, NY 10021 (F.G.C., H.H.); and Department of Diagnostic Radiology, University of Arizona, Tucson (R.R.H.). Received March 30, 2004; revision requested April 19; revision received May 5 and accepted May 11. All authors have no financial relationships to disclose. Supported by National Institutes of Health grant R01 CA76423. Address correspondence to F.G.C. (e-mail: clausf@mskcc.org).

View larger version (150K): [in a new window]   Figure 1a.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (136K): [in a new window]   Figure 1b.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (132K): [in a new window]   Figure 1c.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (132K): [in a new window]   Figure 1d.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (121K): [in a new window]   Figure 1e.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (125K): [in a new window]   Figure 1f.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (148K): [in a new window]   Figure 1g.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (170K): [in a new window]   Figure 1h.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (165K): [in a new window]   Figure 1i.  Normal prostate zonal anatomy in a 60-year-old man depicted with T2-weighted axial MR images obtained at the level of the seminal vesicles (a), the base of the prostate (b), the mid-gland (c, d), the apex (e), and the membranous urethra (f), as well as coronal (g), midsagittal (h), and parasagittal (i) MR images. The letters in g correspond to the anatomic levels used for images a-f. The vertical line in g indicates the membranous urethral length. B = urinary bladder, C = central zone, FS = anterior fibromuscular stroma, P = peripheral zone, SV = seminal vesicles, T = transition zone, U = urethra.

View larger version (111K): [in a new window]   Figure 2a.  Postbiopsy hemorrhage. T1- (a) and T2- (b) weighted axial MR images and T2-weighted coronal MR image (c) demonstrate extensive bilateral postbiopsy hemorrhage in the peripheral zones. The transition zone in the left lobe demonstrates high signal intensity on the T1-weighted image (arrow in a) and low signal intensity on the T2-weighted images (arrow in b and c).

View larger version (178K): [in a new window]   Figure 2b.  Postbiopsy hemorrhage. T1- (a) and T2- (b) weighted axial MR images and T2-weighted coronal MR image (c) demonstrate extensive bilateral postbiopsy hemorrhage in the peripheral zones. The transition zone in the left lobe demonstrates high signal intensity on the T1-weighted image (arrow in a) and low signal intensity on the T2-weighted images (arrow in b and c).

View larger version (179K): [in a new window]   Figure 2c.  Postbiopsy hemorrhage. T1- (a) and T2- (b) weighted axial MR images and T2-weighted coronal MR image (c) demonstrate extensive bilateral postbiopsy hemorrhage in the peripheral zones. The transition zone in the left lobe demonstrates high signal intensity on the T1-weighted image (arrow in a) and low signal intensity on the T2-weighted images (arrow in b and c).

View larger version (101K): [in a new window]   Figure 3a.  Normal prostate gland depicted with T2-weighted axial MR image (a) and spectra obtained with 1H MR spectroscopy (b, c). The spectra grid for the cellular metabolites citrate (Cit), choline (Ch), and creatine (Cr) shown in b corresponds to the grid overlaid on the T2-weighted axial image.

View larger version (71K): [in a new window]   Figure 3b.  Normal prostate gland depicted with T2-weighted axial MR image (a) and spectra obtained with 1H MR spectroscopy (b, c). The spectra grid for the cellular metabolites citrate (Cit), choline (Ch), and creatine (Cr) shown in b corresponds to the grid overlaid on the T2-weighted axial image.

View larger version (17K): [in a new window]   Figure 3c.  Normal prostate gland depicted with T2-weighted axial MR image (a) and spectra obtained with 1H MR spectroscopy (b, c). The spectra grid for the cellular metabolites citrate (Cit), choline (Ch), and creatine (Cr) shown in b corresponds to the grid overlaid on the T2-weighted axial image.

View larger version (143K): [in a new window]   Figure 4a.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 71-year-old man with a PSA level of 5.65 ng/mL. (a, b) T2-weighted axial MR image (a) and T2-weighted coronal MR image (b) show that the dominant tumor (T) within the left peripheral zone extends from the apex to the base. Obliteration of the left rectoprostatic angle (arrow in a) is indicative of extracapsular extension. (c) On the spectra from 1H MR spectroscopy, voxels marked with * show an increase in choline (Ch/Cr) and a marked decrease in or absence of citrate (Cit); these voxels correspond to the low-signal-intensity region on the axial MR image (a). The metabolic profile is indicative of a high-grade tumor. Findings at surgery and histopathologic examination helped confirm a large Gleason grade 8 tumor with extracapsular extension (stage T3a).

View larger version (146K): [in a new window]   Figure 4b.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 71-year-old man with a PSA level of 5.65 ng/mL. (a, b) T2-weighted axial MR image (a) and T2-weighted coronal MR image (b) show that the dominant tumor (T) within the left peripheral zone extends from the apex to the base. Obliteration of the left rectoprostatic angle (arrow in a) is indicative of extracapsular extension. (c) On the spectra from 1H MR spectroscopy, voxels marked with * show an increase in choline (Ch/Cr) and a marked decrease in or absence of citrate (Cit); these voxels correspond to the low-signal-intensity region on the axial MR image (a). The metabolic profile is indicative of a high-grade tumor. Findings at surgery and histopathologic examination helped confirm a large Gleason grade 8 tumor with extracapsular extension (stage T3a).

View larger version (94K): [in a new window]   Figure 4c.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 71-year-old man with a PSA level of 5.65 ng/mL. (a, b) T2-weighted axial MR image (a) and T2-weighted coronal MR image (b) show that the dominant tumor (T) within the left peripheral zone extends from the apex to the base. Obliteration of the left rectoprostatic angle (arrow in a) is indicative of extracapsular extension. (c) On the spectra from 1H MR spectroscopy, voxels marked with * show an increase in choline (Ch/Cr) and a marked decrease in or absence of citrate (Cit); these voxels correspond to the low-signal-intensity region on the axial MR image (a). The metabolic profile is indicative of a high-grade tumor. Findings at surgery and histopathologic examination helped confirm a large Gleason grade 8 tumor with extracapsular extension (stage T3a).

View larger version (141K): [in a new window]   Figure 5a.  Four different prostate cancer cases with extracapsular extension of the tumor (T). T2-weighted axial MR images show an asymmetric bulge and spiculated margin (arrow in a), obliteration of the rectoprostatic angle (arrow in b), breach of the capsule with direct tumor extension and envelopment of the neurovascular bundle (arrow in c), and asymmetry of the neurovascular bundles (arrows in d).

View larger version (151K): [in a new window]   Figure 5b.  Four different prostate cancer cases with extracapsular extension of the tumor (T). T2-weighted axial MR images show an asymmetric bulge and spiculated margin (arrow in a), obliteration of the rectoprostatic angle (arrow in b), breach of the capsule with direct tumor extension and envelopment of the neurovascular bundle (arrow in c), and asymmetry of the neurovascular bundles (arrows in d).

View larger version (149K): [in a new window]   Figure 5c.  Four different prostate cancer cases with extracapsular extension of the tumor (T). T2-weighted axial MR images show an asymmetric bulge and spiculated margin (arrow in a), obliteration of the rectoprostatic angle (arrow in b), breach of the capsule with direct tumor extension and envelopment of the neurovascular bundle (arrow in c), and asymmetry of the neurovascular bundles (arrows in d).

View larger version (146K): [in a new window]   Figure 5d.  Four different prostate cancer cases with extracapsular extension of the tumor (T). T2-weighted axial MR images show an asymmetric bulge and spiculated margin (arrow in a), obliteration of the rectoprostatic angle (arrow in b), breach of the capsule with direct tumor extension and envelopment of the neurovascular bundle (arrow in c), and asymmetry of the neurovascular bundles (arrows in d).

View larger version (127K): [in a new window]   Figure 6a.  Biopsy-proved adenocarcinoma in a 61-year-old man. (a, b) T2-weighted axial MR images obtained at the level of the base of the prostate (a) and at the seminal vesicles (b) show a low-signal-intensity tumor (T) in the base of the right lobe with extracapsular extension (arrow in a) and invasion into the seminal vesicles bilaterally (arrows in b). (c) T2-weighted coronal image shows asymmetry of the right and left lateral aspects of the base, with an angulated contour of the right base (arrow), a finding that is highly suggestive of extracapsular extension of the tumor (T). (d) On the T2-weighted sagittal MR image, the fat plane between the seminal vesicle and the posterior urinary bladder is obliterated (arrow). The angle made by the posterior bladder wall and the anterior border of the seminal vesicles is more convex than that seen in healthy men (cf Fig 1i).

View larger version (144K): [in a new window]   Figure 6b.  Biopsy-proved adenocarcinoma in a 61-year-old man. (a, b) T2-weighted axial MR images obtained at the level of the base of the prostate (a) and at the seminal vesicles (b) show a low-signal-intensity tumor (T) in the base of the right lobe with extracapsular extension (arrow in a) and invasion into the seminal vesicles bilaterally (arrows in b). (c) T2-weighted coronal image shows asymmetry of the right and left lateral aspects of the base, with an angulated contour of the right base (arrow), a finding that is highly suggestive of extracapsular extension of the tumor (T). (d) On the T2-weighted sagittal MR image, the fat plane between the seminal vesicle and the posterior urinary bladder is obliterated (arrow). The angle made by the posterior bladder wall and the anterior border of the seminal vesicles is more convex than that seen in healthy men (cf Fig 1i).

View larger version (143K): [in a new window]   Figure 6c.  Biopsy-proved adenocarcinoma in a 61-year-old man. (a, b) T2-weighted axial MR images obtained at the level of the base of the prostate (a) and at the seminal vesicles (b) show a low-signal-intensity tumor (T) in the base of the right lobe with extracapsular extension (arrow in a) and invasion into the seminal vesicles bilaterally (arrows in b). (c) T2-weighted coronal image shows asymmetry of the right and left lateral aspects of the base, with an angulated contour of the right base (arrow), a finding that is highly suggestive of extracapsular extension of the tumor (T). (d) On the T2-weighted sagittal MR image, the fat plane between the seminal vesicle and the posterior urinary bladder is obliterated (arrow). The angle made by the posterior bladder wall and the anterior border of the seminal vesicles is more convex than that seen in healthy men (cf Fig 1i).

View larger version (162K): [in a new window]   Figure 6d.  Biopsy-proved adenocarcinoma in a 61-year-old man. (a, b) T2-weighted axial MR images obtained at the level of the base of the prostate (a) and at the seminal vesicles (b) show a low-signal-intensity tumor (T) in the base of the right lobe with extracapsular extension (arrow in a) and invasion into the seminal vesicles bilaterally (arrows in b). (c) T2-weighted coronal image shows asymmetry of the right and left lateral aspects of the base, with an angulated contour of the right base (arrow), a finding that is highly suggestive of extracapsular extension of the tumor (T). (d) On the T2-weighted sagittal MR image, the fat plane between the seminal vesicle and the posterior urinary bladder is obliterated (arrow). The angle made by the posterior bladder wall and the anterior border of the seminal vesicles is more convex than that seen in healthy men (cf Fig 1i).

View larger version (181K): [in a new window]   Figure 7a.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 58-year-old man with a PSA level of 50.0 ng/mL. T2-weighted axial (a) and sagittal (b) MR images reveal a large tumor (T) that invades the entire prostate gland and demonstrate gross extracapsular extension and direct invasion of the urinary bladder (arrow in a) and seminal vesicles (arrow in b).

View larger version (193K): [in a new window]   Figure 7b.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 58-year-old man with a PSA level of 50.0 ng/mL. T2-weighted axial (a) and sagittal (b) MR images reveal a large tumor (T) that invades the entire prostate gland and demonstrate gross extracapsular extension and direct invasion of the urinary bladder (arrow in a) and seminal vesicles (arrow in b).

View larger version (171K): [in a new window]   Figure 8a.  Biopsy-proved Gleason grade 7 adenocarcinoma in a 62-year-old man with a PSA level of 15.1 ng/mL. T2-weighted axial (a) and sagittal (b) MR images demonstrate diffuse tumor invasion of the prostate gland with direct tumor (T) extension to the wall of the urinary bladder and the anterior rectal wall (white arrow). The multiple low-signal-intensity lesions (black arrows in a) in the pubic bones are consistent with bone metastases.

View larger version (188K): [in a new window]   Figure 8b.  Biopsy-proved Gleason grade 7 adenocarcinoma in a 62-year-old man with a PSA level of 15.1 ng/mL. T2-weighted axial (a) and sagittal (b) MR images demonstrate diffuse tumor invasion of the prostate gland with direct tumor (T) extension to the wall of the urinary bladder and the anterior rectal wall (white arrow). The multiple low-signal-intensity lesions (black arrows in a) in the pubic bones are consistent with bone metastases.

View larger version (177K): [in a new window]   Figure 9.  Biopsy-proved Gleason grade 8 adenocarcinoma in a 74-year-old man with a PSA level of 20.2 ng/mL. T2-weighted axial MR image shows a midline low-signal-intensity lesion in the peripheral zone with focal smooth bulging of the capsule. The patient was treated with intensity-modulated radiation therapy. The MR imaging findings, in particular the close spatial relationship between the tumor (T) and rectal wall, were helpful for designing the radiation treatment plan.