Prostate Imaging - PI-RADS v2.1

Imaging of the prostate with emphasis on evlauation for carcinoma, gains precedence as the curability and disease free survival rates are high. MRI with PIRADS protocol brings uniformity and enables the surgeons and radiologists to converse with great clarity and better stratification of the disease status.

1. Prostate Imaging pi- rads V 2.1 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 - MP mri 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 Biopsy naïve

5. Pi- Rads PI-RADS V 1 ESUR Focus Technique Significant Lesion Detection Clinical application EPE & Staging PI-RADS v2 PI-RADS V 2 ACR, ESUR, AdmeTech Focus Lesion detection & Characterization Including benign findings Interpretation & Reporting Explicit instructions for mapping and measuring individual lesion Images, Scoring criteria Lexicon Atlas

6. Pi- Rads PI-RADS V 1 Same imaging for PZ & TZ T2WI, DWI & DCE Unclear integration of parameters PI-RADS v2 PI-RADS V 2 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 accrue.

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 / mm 2  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-based contrast agent (GBCA) PI-RADS v2 Multi parameteric mri - MP mri

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 two for the seminal vesicles one for the external urethral sphincter 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 perce ntage of the gland volume. 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. “NVBS” posterolateral at 5 and 7 o'clock potential route for extra prostatic extension (EPE) of cancer. 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 MR sequences 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

19. Abscess BENIGN FINDINGS

20. Calcifications 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 v 2.1 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 scientific data accrue. PI-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

23. 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 diffusion. T2W score of 1 or 2 should not be upgraded PI-RADS v2

24. 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 intensity on high b-value DWI. PI-RADS v2

25. 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 and/or lack of early contrast enhan cement Differentiate benign from malignant tissue PI-RADS v2

26. 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

27. Nearly Iso intense

28. 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

29. 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 dimension. Lenticular or non-circumscribed, homogeneous, moderately hypointense, and <1.5 cm in greatest dimension PIRADS 5 – Very high (clinically significant cancer is highly likely to be present) Same as 4, but ≥1.5cm in greatest dimension or definite extra prostatic extension / invasive behavior Same as 4, but ≥1.5cm in greatest dimension or definite extra prostatic extension / invasive behavior

30. 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 significant cancers. PI-RADS v2

31. PI‐RADS Assessment of DWI PI-RADS v2 B3000 adc map image

32. 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.

33. 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

34. Dynamic Contrast-Enhanced (DCE) MRI Positive (+) Focal & Early enhancement T2 WI &/or DWI lesion Negative (–) No early enhancement Diffuse enhancement PI-RADS v2

35. 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

36. Extra prostatic extension – EPE Seminal vesicle invasion DCE PI-RADS v2 T2 W Images Obliteration of angle with base

37. 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

38. PI-RADS v2 T2 W Hyperintensity DWI DCE EPE – Bone metastasis

39. EPE – Extra prostatic extension PI-RADS v2

40. caveat PI-RADS v2 Limited DWI Limited DCE

41. Flow chart PI-RADS v2

42. PI-RADS v2 Post operative recurrence

43. 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

44. 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

45. summary PI-RADS V2.1 Higher accuracy over TRUS guided biopsy in CS PCa detection Fails to detect all cancers; however does detect CS PCa Good performance; robustly trained Radiologist and Urologist Multidisciplinary team; MP MRI of biopsy naïve and guided biopsy ProtecT Study (2016) – Surgery delayed time-to-metastasis development PIVOT Study (2017) – Curb overdiagnosis and Treatment related morbidity Unchanged cancer Specific 10 Yr Survival under Active Surveillance (AS) Urinary PCa gene methylation test PI-RADS v2

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47. 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 surveillance. J Urol 2013;190:1218–22. http://dx. doi.org /10.1016/j.juro.2013.04.071. PI-RADS v2

48. ANATOMY Sector map Vertical line Midline Upper gland Lower gland