PROSTATE PRIYANKA prostate anatomy and physiology

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1. Imaging of prostate Moderator: dr h n pradeep Presenter: dr priyanka s v

2. ANATOMY OF PROSTATE VARIOUS IMAGING MODALITIES PROSTATE PATHOLOGIES ULTRASOUND -GUIDED BIOPSY PI-RADS

3. Anatomy of prostate

4. VARIOUS IMAGING MODALITIES CONVENTIONAL IMAGING USG CT MRI BONE SCAN PETCT

5. CONVENTIONAL IMAGING IVP & MCU, Long standing bladder outlet obstruction RGU – stricture, perineal abscess (Prostatitis ) Skeletal metastasis

6. SONOGRAPHIC APPEARANCE

7. EQUIPMENT

8. seminal vesicles Vas deferens

9. Computed tomography

10. Plays no role in primary tumor detection or local staging, but it helps with detection of lymphadenopathy and distant metastases . CT is of great value in radiotherapy planning and confirming seed placement with brachytherapy.

11. MAGNETIC RESONANCE IMAGING

12. On T1 :

13. On T2

14. SEQUENCES Tl-weighted image T2-weighted images DWI Dynamic contrast-enhanced imaging MR spectroscopy .

15. RADIONUCLIDE BONE SCAN : Play no role in primary tumor detection or local staging. Mainstay for detecting bone metastases in men with skeletal symptoms or PSA greater than 10 ng / mL.

16. Prostate pathologies

17. CYSTIC PROSTATIC LESIONS INFECTIOUS PROCESSES OF THE PROSTATE BENIGN PROSTATIC HYPERTROPHY PROSTATE CANCER

18. CYSTIC PROSTATIC LESIONS

19. Mullerian duct cysts Prostatic utricle cysts Arise from the region of the verumontanum, extend slightly lateral to the midline Always arise from the level of the verumontanum and are always in the midline Cysts typically extend well above the prostate gland and may occur as large pelvic masses. Variable in size (8-10 mm in length) but are usually smaller than mullenian duct cysts and usually do not extend above the prostate gland. 3rd and 4th decades, described in children and older men Earlier in life, typically in the 1st and 2nd decades No associated genito urinary abnormalities . Variety of genitourinary abnormalities No urethral communication Communicate with urethra never contain spermatozoa. May contain spermatozoa fluid described as serous, mucoid, and clear brown or green. white or brown fluid

20. Ejaculatory Duct Cysts

21. Benign Prostatic Hyperplasia with Cystic Degeneration

22. Retention Cysts

23. CAVITARY PROSTATITIS

24. TURP DEFECT.

25. Other Cystic Lesions Prostatic Abscess Parasitic cysts (eg, echinococcus cyst, bilharzial cyst) Cystic carcinoma Differentials Seminal vesicle cyst Vas deferens cyst or diverticulum , and Bladder diverticulum

26. Infectious processes of the prostate

27. Acute and chronic prostatitis Caused by gonococcal , staphylococcal, streptococcal, or E. coli bacteria; mycotic organisms; and possibly viruses. Healthy subjects: E. coli and staphylococci Immunocompromised patients, unusual organisms are more commonly seen.

28. Cross-sectional imaging may be useful if there is a concern for prostate abscess or malignancy. Radiographic findings nonspecific and include periprostatic stranding and an oedematous appearance of the prostate. Prostate abscess may appear as focal regions of hypodensity with surrounding enhancement on CT, with occasional septations within. MRI findings include varying T1 signal within the abscess and enhancement of the peripheral rim with gadolinium.

29. Prostatic Abscess

30. Granulomatous prostatitis Granulomatous prostatitis is an inflammation of the prostate gland, which contains granulomatous tissue. Nonspecific type More common and is the result of the escape of prostatic contents (secretions, seminal plasma, corpora amylacea , spermatozoa) and bacterial products or urine into the prostatic tissue. Specific type Produced by known aetiological agents such as Mycobacterium tube rculosis , T. pallidum , B. abortus , schistosomiasis and various fungi.

31. Tuberculosis of the prostate is almost always secondary , and is commonly associated with tuberculosis infections of the genitourinary tract. Granulomas develop just beneath the mucosa and spread throughout the transition zone. Abscess formation follows, with caseation, cavitation and fibrosis . Rupture into the periprostatic space, the urethra, or even the rectum may also occur. Occasionally, fistulas form in the perineum.

32. Benign Prostatic Hypertrophy

33. Enlarged prostate Evidence of Bladder outlet obstruction Poor emptying of the bladder, Indentation of the bladder base . Thickening and trabeculation of the bladder wall Interureteric ridge elevation (J shape or "hooking'" of the distal ureters)

34. Long-standing severe bladder outlet obstruction, When detrusor hypertrophy can no longer compensate for bladder outlet obstruction, the bladder begins to dilate . Bladder diverticula , may be larger than the bladder itself, and may actually deviate the bladder. Upper urinary tracts can become dilated because of high-intravesical pressure. Contrast excretion is delayed. and renal function may be impaired. Bilateral symmetric uretero pyelocaliectasis.

35. IVU

36. TRUS IN BPH Plays only a small role in the assessment of BPH. Used primarily Clinical concern for prostate cancer (BPH is one cause for PSA elevation) Precise gland volume determination to help determine and follow appropriate surgical or medical treatments.

37. CT

38. MRI

39. MEDIAN LOBE HYPERTROPHY

40. Treatment of BPH MEDICAL: alpha blockers ( doxazosin )and 5 alpha reductase inhibitors ( finasteride ). SURGICAL intervention. : TURP

41. Prostate cancer

42. Pathology : More than 95% of prostatic neoplasms are adenocarcinomas , which typically originate in the epithelium of prostatic acini in the peripheral zone of the prostate. Other prostate tumours are rare , Squamous cell carcinomas Endometrioid carcinomas arising from the prostatic utricle Carcinosarcoma Melanomas and Mesenchymal neoplasms such as rhabdomyosarcoma, leiomyosarcoma, or fibrosarcoma.

43. Screening for Prostate Cancer Digital rectal examination (DRE) and Prostate-specific antigen (PSA). Normal 4ng/ mL No imaging modality is used for screening for prostate cancer.

44. Dissemination Local spread Lymphatic spread : most commonly involve the obturator , the external iliac, and the internal iliac nodes. Hematogenous spread

45. TRUS

46. CT Virtually no role in prostate cancer detection or primary tumor staging. Usually fails to reveal tumor within the prostate gland as neither size of the gland nor its density are helpful in indicating carcinoma. The major role of CT is in the nodal staging of prostate cancer.

47. CT should be performed only PSA > 20ng/Ml Gleason score > 7,and/or Clinical tumor stage T3 or higher. Criterion for detection of positive nodal disease at CT is based on node size ( 1 cm diameter), and nodal enlargement due to metastases occurs relatively late .

48. MRI Used for prostate cancer detection , although it is recommended only if cancer is suspected despite negative transrectal US and biopsy findings. MR imaging can also aid in local and distant staging .

49. DWI & ADC

50. MR Spectroscopy

51. Dynamic Contrast-enhanced MR Imaging In prostate cancer, increased tumor vascularity leads to early hyper enhancement , rapid washout of contrast material from the tumor, in comparison with normal prostate tissue

52. Tc-99m methylene diphosphonate scintigraphy (Bone scan )

53. metastasis Mri is superior to bone scan Bone scan Chest radiograph for thoracic mets

54. ULTRASOUND-GUIDED BIOPSY

55. ULTRASOUND-GUIDED THERAPY Used to guide instrumentation into the prostate for therapy both transrectally and transperineally. Radiotherapy Brachytherapy Cryotherapy Radiofrequency ablation therapy HIFU Gene therapy with viral injection Photodynamic therapy.

56. PERMANENT RADIOACTIVE SEED IMPLANTS Gold/I-125, etc Implanted on USG guidance Number and site of seeds are determined b y computer generated treatment plan tailored for each patient Become inert after about 10 months Limited damage to surrounding tissues Single OPD procedure

57. PI-RADS

58. PI-RADS Classification: To improve the quality of the procedure and reporting, a group of experts of the European Society of Urogenital Radiology (ESUR) have published a guideline for MRI of the prostate. This is based on a Likert scale with scores ranging from 1 to 5.

59. For routine clinical work, diagnosis of suspected prostate cancer should be made if the PI-RADS score is 4 (≥ 10 points if 3 techniques are used and ≥ 13 points if 4 techniques are used) or higher.

60. COMMUNICATION

61. SUMMARY The peripheral zone slightly more echogenic than the transition zone and is T2 hyperintense MRI: detect and stage cancer . Any cystic lesion of the prostate gland in a patient with the appropriate clinical findings must be viewed with suspicion as a possible abscess No imaging modality is used for screening for prostate cancer . The major role of CT is in the nodal staging of prostate cancer . METS: Mri is superior to bone scan MRS: Increased choline and Decreased citrate

62. Textbook of URORADIOLOGY.FIFTH EDITION : N.REED DUNNICK,MD. Carol M. Rumack. Diagnostic ultrasound. 4 th edition. Chapter 10.The Prostate. A Clinically Relevant Approach to Imaging Prostate Cancer: Review. AJR 2011; 196:S1–S10 0361–03X/11/1963–S1 © American Roentgen Ray Society. Hricak et al . Imaging Prostate Cancer: A Multidisciplinary Perspective. Radiology 2007; 243:28–53. M. Röthke ; D. Blondin; H.-P. Schlemmer; T. Franiel : PI-RADS Classification: Structured Reporting for MRI of the Prostate. Clinical Men’s Health. REFERENCES