Magn Reson Imaging Clin N Am

12 (2004) 557–579

MR imaging and MR spectroscopic imaging

of prostate cancer
Arumugam Rajesh, MB, BSa, Fergus V. Coakley, MDb,*
a
University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road,
Leicester LE 5 4PN, United Kingdom
b
Department of Radiology, University of California, San Francisco, Box 0628,
M-372, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA

Prostate cancer incidence and mortality rates
vary worldwide. In the United States, prostate
cancer is the most common noncutaneous malig-
nancy affecting men and is the second-leading
cause of cancer death. Approximately 8% of
American men will be diagnosed with prostate
cancer during their lifetime, and 20% of these men
will die of the disease [1].
Epidemiology
Risk factors for developing prostate cancer
include advancing age, African-American ethnic-
ity, and a positive family history. The role of diet
and other factors also has been investigated.
During the 1990s, the incidence of prostate cancer
increased and later decreased, probably as a result
of the emergence of widespread serum prostatic-
specific antigen (PSA)–level testing that changed
diagnostic sensitivity. The age-adjusted mortality
increased over the same period, however, suggest-
ing an increase in disease prevalence or aggres-
siveness. More recently, the age-adjusted
mortality has decreased, which could reflect ear-
lier diagnosis that allows more effective treatment
(Fig. 1). Alternatively, these changes in mortality
simply may be a result of ‘‘attribution bias,’’
particularly because the changes have paralleled
those of incidence. Given the indolent natural
history of prostate cancer, a true improvement in
treatment likely would take several years to affect
mortality. The absence of a lag between the
* Corresponding author.
E-mail address: Fergus.Coakley@radiology.ucsf.edu
(F.V. Coakley).
1064-9689/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.mric.2004.03.011
incidence and mortality changes may support this
latter explanation [2].
Despite the sizeable mortality from prostate
cancer, many cases are subclinical, and small foci
of incidental prostate cancer can be detected in
up to 40% of men at autopsy [3]. The autopsy
incidence of histologic prostate cancer seems
constant among countries and races, but the
clinical incidence of prostate cancer is higher in
Western countries and in African Americans. The
management of early-stage prostate cancer is
controversial because patients whose disease is
indolent and incidental cannot be distinguished
reliably from patients whose disease is progressive
and life-threatening. Current methods of prostate
cancer evaluation by digital rectal examination
(DRE), transrectal ultrasound (TRUS), Gleason
score, sextant biopsy, and serum PSA assay
generally can predict only behavior for indolent
or aggressive cancers. Most patients fall between
these extremes, when the techniques are of limited
accuracy [4–6]. Because of the prevalence and
mortality of prostate cancer and the limitations of
current evaluation methods, prostate cancer is
a major medical and socioeconomic problem.
Staging
The tumor, node, metastasis (TNM) and
Jewett-Whitmore staging systems are used
commonly, and are based on the local, nodal,
and distant extent of disease [7,8]. Table 1 summa-
rizes the staging systems. Staging of prostate
cancer is crucial to predicting prognosis and
planning treatment. A general understanding of
prognosis and treatment strategies by stage
558 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Fig. 1. Epidemiologic trends in prostate cancer incidence and mortality in the United States from 1992 to 2003.

facilitates clinically relevant radiologic interpreta-
tion of prostate MR imaging and MR spectro-
scopic imaging. Prognosis is related closely to
stage. Despite the prevalence of prostate cancer,
published studies on prognosis are relatively
sparse. Good prognostic studies are lacking be-
cause the mortality from unrelated causes is high in
elderly men with prostate cancer, and long-term
follow-up of 10 to 15 years is required for meaning-
ful evaluation in lower-stage disease. Table 2
summarizes the available data on prognosis of
prostate cancer by stage [9–13].
Treatment options are related to stage, and are
summarized in Table 3 [14]. There are many

Table 1
Staging systems for prostate cancer
Jewett-Whitmore TNM Description
A I (T1N0M0) Organ-confined tumor. Clinically and radiologically inapparent.
B II (T2N0M0) Organ-confined tumor. Clinically or radiologically apparent.
T2A: Localized to a quadrant
T2B: Localized to one side
T2C: Bilateral
C III (T3N0M0) Extracapsular extension, or seminal vesicle invasion.a
T3A: Unilateral or bilateral extracapsular extension
T3B: Seminal vesicle invasion
D1 IV (N1-2) Locoregional adenopathy.
N1: Microscopic nodal metastases
N2: Macroscopic nodal metastases
D2 IV (T4 or N3 or M1-2) Distant spread.
T4: Invasion of the bladder, external sphincter, or rectum
N3: Extraregional nodal metastases
M1: Elevated acid phosphatase
M2: Distant visceral or bony metastases
a
In the fourth edition of the American Joint Committee on Cancer staging system, unilateral and bilateral
extracapsular extension were classified separately as T3A and T3B. This distinction was dropped from the fifth and
subsequent editions.
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 559

Table 2
Prognosis in prostate cancer by stage
5-y disease- 10-y disease-
Jewett-Whitmore TNM 2-y mortality specific mortality specific mortality
A and B I/II — 10% 9–22%
C III — 18% 40%
D1 IV — 34% —
D2 IV 42% — —

controversies and unanswered questions in the
management of prostate cancer, primarily because
of the inability to predict accurately the natural
history of localized disease [15]. Some recent
studies have questioned the validity of watchful
waiting or surveillance as an option for those with
localized disease and a reasonable life expectancy.
A Danish Cancer Registry study showed that
patients with clinically localized prostate cancer
who are candidates for curative therapy at
diagnosis have significant excess mortality when
treated expectantly and followed for 10 or more
years [16]. A recent Scandinavian, randomized,
controlled trial demonstrated improved outcome
at 8 years or more of follow-up when radical
prostatectomy was compared with watchful wait-
ing [17]. These results may not apply directly to the
North American population of men with newly
diagnosed prostate cancer, however, in whom
disease is impalpable more frequently and detected
by PSA testing alone. Watchful waiting may be an
appropriate option for some of these patients with
early low-grade or small-volume tumors.
Anatomy of the prostate
Overview
The prostate is a pale, firm exocrine gland
shaped like an inverted pyramid that surrounds
the urethra between the bladder neck and geni-
tourinary membrane. The base lies superiorly
(just below the bladder) and the apex lies in-
feriorly (just above the urogenital diaphragm).
The ejaculatory ducts pass obliquely through the
gland to enter the prostatic urethra at the
verumontanum. The normal adult gland meas-
ures approximately 4 cm (transverse)  3 cm
(anteroposterior)  3 cm (craniocaudad), and
weighs 15 to 20 g. It functions as an accessory
sex gland, and contributes approximately 0.5 mL
to the normal ejaculate volume of 3.5 mL. The
secretions of the prostate are thought to help
liquefy semen. The contemporary approach to
prostate anatomy describes the internal structure
in terms of zones.
Zonal anatomy
The simplest conceptual approach to the
zonal anatomy of the prostate is the two-com-
partment model, where the prostate is likened to
a cone containing a scoop of ice cream [18]. The
cone is the peripheral zone, and makes up 70%
of the prostate gland by volume in young men.
The ducts of the peripheral zone glands drain to
the distal prostatic urethra. The scoop of ice
cream is the central zone, and makes up 25% of
the prostate gland volume in young men (Fig. 2).
The ejaculatory ducts traverse the central zone,

Table 3
Treatment in prostate cancer by stage
Jewett-Whitmore TNM TMN Conventional treatment options
A and B I/II T1 and T2 < 10-y life expectancy: radiotherapya; watchful waiting
> 10-y life expectancy: prostatectomy; radiotherapy
C III T3 Radiotherapy; adjuvant hormonal therapy in high-risk patients
D1 IV N1-2 Hormonal therapyb
D2 IV N3/M1-2 Hormonal therapy; palliative radiotherapy for bony metastases;
second-line agents for hormone refractory cancer
a
Includes standard external beam radiotherapy, three-dimensional conformal radiotherapy, intensity-modulated
radiotherapy, and brachytherapy.
b
Includes subcapsular orchidectomy, estrogens, antiandrogens, and luteinizing hormone-releasing hormone
agonists.
560 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Fig. 2. (A) Schematic coronal view of the prostate in a young man, illustrating the contemporary zonal description of
prostatic anatomy. In a younger man, most of the central gland is composed of central zone tissue. (B) Schematic
coronal view of the prostate in an older man, illustrating the progressive enlargement of the transition zone that occurs
with age as a result of benign prostatic hyperplasia. Most of the central gland is composed of transition zone tissue.

and the ducts of the central zone drain to the Prostate capsule
region of the verumontanum clustered around
The anatomic or true capsule of the prostate is
the entry of the ejaculatory ducts. The remaining
a 2- to 3-mm thick layer of fibromuscular tissue,
5% of the prostate consists of the transition
indistinct from the surrounding fascial tissue [19].
zone, which is composed of two small bulges of
The anatomic capsule should not be confused
tissue that surround the anterior and lateral parts
with the surgical or pseudocapsule that develops
of the proximal urethra in a horseshoe-like
around the central gland in the aging hyperplastic
fashion. This two-compartment model is deficient
prostate. The prostatic capsule comprises the
anteriorly, where the peripheral zone is interrup-
fibromuscular stroma that lies between the glan-
ted by the anterior fibromuscular stroma, a band
dular components of the prostate and the peri-
of smooth muscle mixed with fibrous tissue that
prostatic loose connective tissue. The histology of
forms a thick shield over the anterior aspect of
the capsule is particularly complex at the apex,
the gland. As a result, the peripheral zone lies
because the fibromuscular band is demarcated less
predominantly lateral and posterior to the cen-
well and the glandular elements are not confined
tral zone.
as clearly. Occasionally, glandular elements are
The zonal anatomy of the prostate changes
found loose in the apical fibromuscular stroma.
with age (Figs. 2 and 3). The transition zone
This is particularly relevant to the pathologist
becomes bigger as a result of benign prostatic
attempting to assess extracapsular extension at the
hyperplasia and compresses the surrounding cen-
prostatic apex because the apex does not have
tral zone. The latter becomes the surgical pseu-
clearly defined histologic landmarks. At the pros-
docapsule and is radiologically noteworthy
tatic base, the periphery of the prostate is com-
because on axial T2-weighted images through
posed predominantly of prostatic stroma, which
the base of the prostate, the compressed central
merges imperceptibly with the bladder muscula-
zone may mimic low T2-signal tumor in the
ture and the stroma of the seminal vesicles.
peripheral zone around the transition zone
Glandular elements are sparse in this region and
(Fig. 4). One approach to incorporate and sim-
usually form epithelial islands surrounded by
plify the age-related changes in the prostate zonal
thick bundles of fibromuscular stroma.
anatomy is to refer to the transition and central
zones collectively as the central gland. Using this
Neurovascular bundle
terminology, the prostate is composed of the
peripheral zone and central gland, such that the Sympathetic nerve fibers from the lumbar sym-
central gland is composed mainly of central zone pathetic chain pass inferiorly into the pelvis along-
tissue in young men and mainly of transition zone side the aorta and iliac arteries [20].
tissue in older men. Because prostate cancer is Parasympathetic fibers enter the pelvis as direct
largely a disease of older men, in the population branches of S2 to S4. Both sets of fibers intermix as
that comes to MR imaging, it is reasonable to a mesh of nerves posterior to the bladder, seminal
regard central gland and transition zone as nearly vesicles, and prostate. This mesh is known as the
synonymous. pelvic plexus. The cavernous nerve arises as many
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 561

Fig. 3. (A) Coronal T2-weighted image of the prostate in a young man. The prostate is small, and zonal differentiation is
not appreciable. (B) Coronal T2-weighted image of the prostate in a middle-aged man. The transition zone (asterisk) is
visible and moderately enlarged from benign prostatic hyperplasia. The compressed central zone (arrows) is seen at the
periphery of the transition zone. (C) Coronal T2-weighted image of the prostate in an older man. The transition zone
(asterisk) is enlarged markedly by benign prostatic hyperplasia. The central zone (thick arrows) is compressed and forms
the pseudocapsule. The peripheral zone (thin arrows) also is compressed.

fine fibers from the pelvic plexus, containing
sympathetic and parasympathetic nerves. The cav-
ernous nerve then runs inferiorly, as one or several
large bundles, along the posterolateral aspect of the
prostate. Arterial and venous prostatic vessels in
this location accompany the cavernous nerve, and
together these structures form the neurovascular
bundles.
Prostatic anatomy as seen on MR imaging
The zonal anatomy of the prostate cannot be
distinguished on T1-weighted images because of
uniformly intermediate signal intensity [20]. The
prostatic zones are well demonstrated on T2-
weighted images (Fig. 5). The anterior fibromus-
cular stroma is of low T1 and T2 signal intensity
[21]. The peripheral zone is of high T2 signal
intensity, similar to or greater than the signal of
adjacent periprostatic fat. The anatomic or true
capsule surrounding the peripheral zone appears
as a thin rim of low signal intensity on T2-
weighted images. The central and transition zones
are of lower T2 signal intensity than the peripheral
zone, possibly because of more compact smooth
muscle and sparser glandular elements [21]. There
is also an age-related increase in the T2 signal
intensity of the peripheral zone [22].
562 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Fig. 4. (A) Axial T2-weighted image of the prostate shows symmetric low T2 signal intensity (arrows) at the base of the
gland, which could be interpreted as tumor. (B) Coronal T2-weighted image of the prostate showing the axial level (line)
through which (A) was obtained, demonstrating that the low T2 signal at this level is caused by transverse sectioning
through the pseudocapsule and does not represent cancer.

The proximal urethra is rarely identifiable,
unless a Foley catheter is present or a transurethral
resection has been performed. The verumontanum
can be visualized as a high T2–signal intensity
structure. The distal prostatic urethra can be seen
as a low T2–signal intensity ring in the lower
prostate because it is enclosed by an additional
layer of muscle [20]. The ability of MR imaging to
provide multiplanar images of the prostate, with
separation of the gland from adjacent structures,
makes it the ideal modality to perform volumetric
measurements. The prostate volume is half the
product of the maximum craniocaudad, antero-
posterior, and transverse dimensions [23]. The vas
deferens and seminal vesicles are seen particularly
well on axial and coronal images, whereas the
neurovascular bundles can be seen best on axial
images. The penile root can be seen inferiorly,
separated from the prostatic apex by the urogen-
ital membrane.
For descriptive purposes, the prostate is de-
scribed conventionally in terms of sextants, based
on division of the gland into thirds in the cranio-
caudad direction (base, midgland, and apex), and
then into left and right sides. Accordingly, the six
sextants are the left base, left midgland, left apex,
right base, right midgland, and right apex.

Technique of prostate MR imaging

Fig. 5. Axial T2-weighed MR image of the prostate,
illustrating the zonal anatomy and neurovascular
bundles (arrows).
MR imaging and MR spectroscopic imaging
allow a ‘‘one-stop shop’’ for detailed anatomic
and metabolic evaluation of the prostate gland.
Neither TRUS nor CT can offer this simultaneous
coverage and tissue detail. MR spectroscopic
imaging is a method of demonstrating normal
and altered tissue metabolism, and is therefore
fundamentally different from other imaging mo-
dalities that only assess abnormalities of struc-
ture. MR imaging, and especially MR
spectroscopic imaging, are relatively new technol-
ogies in continued evolution. It is too early to
judge their true role, which may not be estab-
lished for years. For example, an early multi-
institutional trial showing no difference between
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 563

Fig. 6. (A) Photograph of the inflatable balloon-covered endorectal coil used for MR and MR spectroscopic imaging of
the prostate. Use of this coil improves the quality of the images and is crucial for spectral acquisition. (B) Coronal T2-
weighted image of the prostate obtained without an endorectal coil. (C) Coronal T2-weighted image of the prostate
obtained with an endorectal coil, showing the improvement in spatial resolution and noise reduction.

TRUS and MR imaging in staging accuracy is T1-weighted MR imaging

cited frequently as evidence that MR imaging has
T1-weighted images of the pelvis aid in the
no role in the assessment of prostate cancer [24].
detection of postbiopsy hemorrhage, lymphade-
This study was conducted without the incorpora-
nopathy, and bone metastases (Figs. 7 and 8).
tion of MR spectroscopic imaging, with sequences
Approaches to T1-weighted images vary, with
and equipment that are obsolete by current
some centers only obtaining relatively thick sec-
standards, and without the use of endorectal coils
tions from the iliac crests to the symphysis pubis,
(Fig. 6). MR imaging and MR spectroscopic
and other centers also obtaining thin section T1-
imaging can be performed as one combined
weighted images through the prostate that corre-
examination that takes approximately 60 minutes.
spond to the thin section T2-weighted images.
An endorectal coil is essential for performance of
Spin-echo imaging is a reasonable sequence choice
MR spectroscopic imaging, and significantly im-
because of the low susceptibility to artifact as
proves the staging accuracy of MR imaging [25].
compared with gradient-echo sequences. The
It is helpful, but not crucial, to postprocess to
authors’ protocol uses axial spin-echo T1-weight-
compensate for the reception profile of the
ed images obtained from the aortic bifurcation to
endorectal coil [26].
564 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

tumor as low T2 signal intensity foci in the

Fig. 7. Axial T1-weighted MR image of the prostate in
a patient who had undergone transrectal biopsy recently.
A large area of hemorrhage is visible as a region
of increased T1 signal intensity (arrow) in the left side of
the gland.
the symphysis pubis, using the following param-
eters: repetition time (TR)/echo time (TE) = 700/
8 milliseconds, slice thickness = 5 mm, interslice
gap =1 mm, field of view (FOV) = 24 cm, matrix
256  192, frequency direction transverse (to
prevent obscuration of pelvic nodes by endorectal
coil motion artifact), and one excitation.
T2-weighted MR imaging
T2-weighted images in the axial and coronal
planes are the cornerstone of MR imaging in
prostate-cancer evaluation. These images clearly
depict the distinction between the peripheral zone
and the central gland, allow the detection of
peripheral zone (Fig. 9), and facilitate staging by
demonstration of extracapsular extension and
seminal-vesicle invasion. These features usually
are assessed best on thin-section axial images,
although the coronal plane is helpful for the
sextant localization of tumor in the craniocaudad
direction as being in the base, midgland, or apex.
The coronal plane also is useful in the assessment
of seminal-vesicle invasion. The authors’ protocol
uses thin-section high–spatial resolution axial, and
coronal T2-weighted fast spin-echo images of
the prostate and seminal vesicles are obtained
using the following parameters: TR/effective
TE = 5000/96 milliseconds, echo train
length = 16, slice thickness = 3 mm, interslice
gap = 0 mm, FOV = 14 cm, matrix 256  192,
frequency direction anteroposterior (to prevent
obscuration of the prostate by endorectal coil
motion artifact), and three excitations. Fat satu-
ration does not seem to have either a positive or
negative effect on staging accuracy [27], and its use
is therefore a matter of preference.
Gadolinium-enhanced MR imaging
The central gland and peripheral zone enhance
homogeneously in the normal prostate, with the
central gland enhancing more than the peripheral
zone [28–30]. Benign prostatic hyperplasia results
in marked inhomogeneity of central gland en-
hancement [28,29]. Some reports suggest that
prostate cancer enhances more rapidly than adja-
cent peripheral zone tissue, and can be demon-

Fig. 8. (A) Axial T1-weighted image of the prostate in a 78-year-old man shows a low T1–signal intensity focus (arrow)
in the left superior pubic ramus, suspicious for metastasis. (B) Bone scintigraphy shows increased uptake (arrow) in the
left superior pubic ramus, confirming the presence of a metastasis. The bone scan was interpreted initially as showing
increased uptake as a result of urinary contamination, and the correct interpretation was rendered only after the MR
imaging was performed and both studies were correlated directly.
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579
Fig. 9. Axial T2-weighted image of the prostate, show-
ing a tumor in the left midgland as a focus of reduced
signal intensity (arrow).
strated on early dynamic contrast-enhanced im-
ages [31]. Other studies have shown no significant
difference between the enhancement pattern of
prostate cancer and noncancerous peripheral zone
tissue [32]. In clinical practice, gadolinium-en-
hanced images have not improved tumor locali-
zation or staging [28,29], with the possible
exception of better visualization of seminal-vesicle
invasion in equivocal cases [28,30]. In general,
gadolinium-enhancement is not considered help-
ful in routine prostate MR imaging. Macromo-
lecular contrast media are in development and
may prove more useful because tumor micro-
vessels are permeable to macromolecular contrast
molecules and normal microvessels are not (stan-
dard small molecular contrast media pass through
the endothelium of normal and neoplastic micro-
vessels) [33].
Technique of MR spectroscopic imaging
Technical aspects of MR spectroscopic imaging
MR imaging uses strong magnetic fields to
induce coherent spinning of hydrogen protons,
and then applies radiofrequency pulses to gener-
ate a map of proton signal intensity by spatial
location. The signal intensity of all hydrogen
protons is combined, although the signals from
hydrogen protons in different molecules have
slightly different frequencies (a property known
as chemical shift). MR spectroscopic imaging
exploits the chemical-shift property to produce
a map of signal intensity versus frequency (ie,
a spectrum) and spatial location. The x and y axes
of the spectral trace from an individual voxel
represent frequency and intensity, respectively. By
565
convention, the x axis is plotted as the downward
frequency shift relative to water expressed in ppm
(this denominator adjusts for magnetic field
strength, so the x-axis units are fixed irrespective
of the type of MR-imaging scanner used). Chem-
icals with greater degrees of shift are plotted
further to the left, and vice versa.
The metabolic peaks relevant to prostate MR
spectroscopic imaging are choline, creatine, and
citrate, occurring at shifts of approximately 3.2,
3.0, and 2.6 ppm, respectively. MR spectroscopic
imaging of prostate cancer is characterized by
raised choline (a normal cell-membrane constitu-
ent that is elevated in many tumors), reduced
citrate (a constituent of normal prostatic tissue),
or both (Fig. 10) [34]. The ratio of choline and
creatine to citrate in sextants with normal pros-
tatic tissue has been established as 0.22  0.13
(John Kurhanewicz, personal communication,
2003). The spectral peaks of creatine and choline
often overlap, and may be inseparable. Inclusion
of creatine in this ratio is not considered a poten-
tial source of error because creatine seems to
remain at a relatively constant level in healthy and
cancerous prostatic tissue. The y axis lacks
absolute units. Each spectrum is derived from
a small volume of tissue known as a voxel. Several
mechanisms have been developed for overlaying
the spectral information from the voxels on the
corresponding anatomic images, including over-
laid coded grids and color overlays. The ratio of
choline and creatine to citrate is related to the
Gleason score of the tumor (Fig. 11) [35]. No
other imaging modality can provide such a direct
evaluation of tumor aggressiveness.
The use of MR spectroscopic imaging to
detect tumor metabolism is conceptually appeal-
ing, and in neuroimaging virtual biopsy refers to
the ability of MR spectroscopic imaging to
provide noninvasive tissue characterization of
brain tumors [36]. Such optimistic terminology
would not be appropriate for prostatic MR
spectroscopic imaging, which is constrained by
substantial technical hurdles and a relatively
limited number of validation studies. Some of
the technical challenges in obtaining high-quality
MR spectra of the prostate can be appreciated by
considering the resolution required in the x and y
axes. Citrate protons spin with a frequency that
is 2.6 Hz per T less than water protons, which
spin with a frequency of 42.6 MHz (ie,
42,600,000 Hz) per T. The concentration of
metabolites detected at MR spectroscopic imag-
ing is 1 to 10 mmol/L, which is approximately
566 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Fig. 10. (A) MR spectrum from a voxel of normal peripheral zone tissue. The identifiable peaks are choline, creatine,
and citrate. The polyamine ‘‘peak’’ cannot be distinguished at 1.5 T, but accounts for the ‘‘blurring’’ or ‘‘filling in’’ of the
dip between choline and creatine. (B) MR spectrum from a voxel of prostate cancer in the peripheral zone. When
compared with the normal spectrum in (A), the choline peak is elevated, the citrate peak is absent, and the polyamine
‘‘peak’’ is reduced (seen as a deepening of the dip between choline and creatine).

10,000 to 100,000 times less than the molar Spectral acquisition and processing
concentration of water protons. For these and
After review of the axial T2-weighted images,
other reasons, the possible sampling volume that
a spectroscopic imaging volume is selected to
can be interrogated with current MR spectroscop-
maximize coverage of the prostate and minimize
ic imaging technology is small, and the voxels are
the inclusion of periprostatic fat and rectal air.
relatively large. For example, the authors’ stan-
Three-dimensional (3D) MR spectroscopic imag-
dard endorectal MR spectroscopic imaging pro-
ing data are acquired using a water- and lipid-
tocol has a voxel size of 0.34 cm3. A spherical
suppressed double-spin echo point-resolved
tumor must be at least 0.66 cm3 in size to fill
spectroscopy sequence optimized for the quantita-
complexly a 0.034 cm3 voxel, assuming the ideal
tive detection of choline and citrate. Water and
scenario of tumor and voxel having the same
lipid suppression is achieved using the band-selec-
geometric center. Otherwise, incomplete filling of
tive inversion with gradient dephasing technique
a voxel by tumor may result in partial volume
[40]. Susceptibility artifacts from periprostatic fat
artifact.
and rectal air are eliminated using outer voxel
Combined MR imaging and MR spectroscop-
saturation pulses [41]. Data sets are acquired as
ic imaging of the prostate can be performed in
16  8  8 phase-encoded spectral arrays (1024
less than 1 hour using a standard clinical 1.5T
voxels) with a nominal spectral resolution of 0.24
MR imaging scanner and commercially available
cm3 to 0.34 cm3, TR/TE = 1000/130 milliseconds,
endorectal coils [37–39]. An endorectal coil is
and 17-minute acquisition time. The 3D-MR
essential for performance of spectroscopy, and
spectroscopic imaging data are processed on an
improves the MR imaging component, resulting
UltraSparc workstation (Sun Microsystems, Mou-
in higher staging accuracy [25]. The total exam-
tainview, California) using research software
ination time includes coil placement, patient
previously developed specifically for 3D-MR
positioning, and MR imaging and MR spectro-
spectroscopic imaging studies. All spectral data
scopic imaging data acquisition. Several vendors
are apodized with a 1-Hz Gaussian function. Data
are offering or are close to releasing product
are Fourier-transformed in the time domain and
versions of this combined MR imaging and MR
three spatial domains. Corrections to phase,
spectroscopic imaging examination.
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 567

Fig. 11. (A) Coronal T2-weighted image of the prostate, showing the spectral grid from which the spectra in (B) were
acquired. Asymmetric low T2 signal intensity, suggestive of tumor, is visible throughout the right side of the prostate. (B)
Spectra from the grid shown in (A) show marked abnormality (elevated choline and reduced or absent citrate)
throughout the left side of the prostate (outlined area). Such marked metabolic abnormalities are associated with more
aggressive cancers, and biopsy confirmed the presence of Gleason score 9 adenocarcinoma.

baseline, and frequency are performed using re-
search software.
Spectral evaluation
Spectra are interpreted and scored based on
prior research and current understanding of pros-
tate cancer metabolism [39]. The level of citrate is
characteristically high in normal prostatic tissue
[42,43]. Citrate levels fall in prostate cancer, but
also can be reduced by prostatitis or postbiopsy
hemorrhage [44]. The level of choline, a cell-mem-
brane constituent, is increased in prostate cancer as
a result of increased membrane turnover [39,45].
The level of polyamines recently has been recog-
nized to decrease in prostate cancer [46,47]. The
polyamine peak occurs between the creatine and
choline peaks, and currently cannot be resolved
entirely from these peaks. Decreased polyamine
levels can be recognized subjectively as a sharper
separation of the creatine and choline peaks,
however [39]. Based on these considerations, the
levels of creatine, choline, and citrate are integrated
to determine their relative concentrations. Peak
area ratios of choline plus creatine to citrate, citrate
to normal citrate, and choline to creatine are
calculated. The estimation of choline-to-creatine
peak area ratio is only possible in regions of cancer
because in healthy voxels there is poor in vivo
resolution of these species as a result of the
presence of a large polyamine resonance. Spectro-
scopic voxels are scored on a standardized five-
point scale, using the following criteria:
1. A primary score of 1 to 5 is assigned based on
mean healthy value ratios of choline plus
creatine to citrate. A score of 1 is assigned to
voxels with a choline plus creatine–to-citrate
ratio within one standard deviation of the
mean healthy value. A score of 2 is assigned to
voxels with a choline plus creatine–to-citrate
ratio between one and two standard devia-
tions above the mean healthy value. A score
of 3 is assigned to voxels with a choline plus
568 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579
creatine–to-citrate ratio between two and
three standard deviations above the mean
healthy value. A score of 4 is assigned to
voxels with a choline plus creatine–to-citrate
ratio between three and four standard devia-
tions above the mean healthy value. A score
of 5 is assigned to voxels with a choline plus
creatine–to-citrate ratio more than four stan-
dard deviations above the mean healthy value.
2. An initial adjustment is made to the primary
score to incorporate elevation of choline
relative to creatine and reduction in poly-
amines. When the choline-to-creatine ratio is
greater than or equal to 2 with a primary
score of 2 or 3, the overall score is increased
to a 4. When the choline-to-creatine ratio is
less then 2 or there was no reduction in
polyamines with a primary score of 4 or 5, the
overall score is decreased by 1 (ie, 3 and 4).
3. A final adjustment is made to the score to
incorporate poor voxel signal-to-noise ratio.
Poor signal-to-noise ratio is defined as a ratio
of less than 8 for voxels with a score of 3 to 5,
and less than 5 for voxels with a score of 1 to
2. In the presence of poor signal-to-noise
ratio, a score of 1 becomes 3, scores of 2 or 4
become 3, and scores of 5 become 4. Scores of
3 are not changed by low signal-to-noise
criteria.
This standardized scoring system results in
a final score from 1 to 5, and is designed so that
the following interpretative scale can be applied: 1
is considered probably benign, 2 is possibly
benign, 3 is equivocal, 4 is possibly malignant,
and 5 is probably malignant. In addition to the 5-
point scoring system, readers are allowed to
designate spectra as unusable if they showed
significant lipid contamination or misalignment
of metabolite resonance peaks. This five-point
scale distinguishes benign and malignant tissue
with reasonable accuracy [48].
Applications of MR imaging and MR
spectroscopic imaging
Role of MR imaging and MR spectroscopic
imaging in prostate-cancer diagnosis
MR imaging findings in prostate cancer first
were described in the early 1980s [49]. These early
reports were uncertain about the exact MR im-
aging appearance of prostate cancer because of
the limitations in contrast and spatial resolution
of the MR imaging technology available at that
time. Further research established that prostate
cancer is characterized by low T2–signal intensity
in the normally high T2 signal intensity peripheral
zone [50]. The presence of reduced T2 signal
intensity in the peripheral zone is of limited
sensitivity, however, presumably because some
tumors are isointense (Fig. 12) [51,52]. MR
spectroscopic imaging also may show no convinc-
ing metabolic abnormality in some patients (see
Fig. 12). The finding is also of limited specificity
because there are other causes of low T2 signal
intensity in the peripheral zone, such as hemor-
rhage, prostatitis, scarring, radiotherapy, cryosur-
gery, and hormonal therapy (Figs. 13 and 14).
Only a few studies have investigated the
accuracy of MR imaging in the diagnosis of
prostate cancer because MR imaging generally is
reserved as a staging study in patients with
biopsy-proven prostate cancer. In a study of 33
patients with an elevated PSA and at least one
negative sextant biopsy before MR imaging [53],
two readers rated the likelihood of malignancy as
low, intermediate, or high. Repeat biopsy was
positive in 1 of 18 patients considered low likeli-
hood, one of eight patients considered intermedi-
ate likelihood, and five of seven patients
considered high likelihood. A more recent similar
study of 38 patients with prior negative biopsies,
12 of whom had a positive post–MR imaging
biopsy, demonstrated a sensitivity of 83% and
a positive predictive value of 50% for the MR-
imaging diagnosis of prostate cancer [54]. These
results suggest MR imaging can be used in this
setting to stratify patients with a high and low
probability of a subsequent positive biopsy. The
potential incremental benefit of MR spectroscopic
imaging in this setting has not been reported, but
based on the results for tumor localization, one
would expect a positive impact. The use of MR
imaging as screening tool in the general popula-
tion would result in an unacceptably large number
of false positive and negative results. This would
also be impractical for logistical and financial
reasons.
Role of MR imaging and MR spectroscopic
imaging in prostate cancer localization
Sextant biopsy traditionally has been regarded
as the standard of reference for nonsurgical tumor
localization [55]. The limitations of sextant biopsy
are being recognized increasingly, however
[56,57]. In a study with two readers using
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 569

Fig. 12. (A) Axial T2-weighted image of the prostate, showing the spectral grid from which the spectra in (B) were
acquired. No convincing mass-like foci of low T2 signal intensity are visible. (B) Spectra from the grid shown in (A)
demonstrate no convincing metabolic abnormality in the peripheral zone. (C) Corresponding whole mount step section
pathologic preparation with areas of cancer outlined. A large tumor is present in the right side of the prostate, despite the
lack of findings at MR and MR spectroscopic imaging.
570 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579
Fig. 13. Axial T2-weighted image of the prostate in
a patient who has received hormonal therapy. The
prostate is small, of uniformly low T2 signal intensity,
and relatively featureless (compare to Fig. 5).
step-section histopathology as the standard of
reference in 53 patients [58], MR imaging alone
had a sensitivity of 77% to 81% and a specificity
of 46% to 61% for the sextant localization of
prostate cancer. The addition of MR spectroscopic
imaging reduced the sensitivity slightly to 68% to
73%, but specificity increased substantially to
70% to 80%. In another study of 47 patients
using step-section histopathologic analysis of
radical prostatectomy specimens as the standard
of reference [59], the separate and combined
accuracy of preoperative sextant biopsy, MR
imaging, and MR spectroscopic imaging were
compared. When all three tests were positive for
cancer in a sextant, sensitivity was 33% and
specificity was 98%. Conversely, a single positive
test had a sensitivity of 94% and a specificity of
38%. This suggests that when correct tumor
localization is crucial, only sextants that are
positive at biopsy, MR imaging, and MR spec-
troscopic imaging should be considered as defi-
nitely cancer-containing.
The results described above refer to the sextant
localization of prostate cancer, which is not
synonymous with volumetric localization. In a re-
cent study [60], MR imaging and MR spectro-
scopic imaging were performed in 37 patients
before radical prostatectomy. Two independent
readers recorded peripheral-zone tumor-nodule
location and volume and results were analyzed
using step-section histopathologic tumor volume-
try as the standard of reference. The mean volume
of all peripheral-zone tumor nodules (n = 51) was
0.79 cm3 (range 0.02–3.70 cm3). Readers detected
20 (65%) and 23 (74%) of the 31 peripheral-zone
tumor nodules greater than 0.5 cm3. For these
nodules, tumor volume measurements by MR
imaging alone and combined MR imaging and
MR spectroscopic imaging all were correlated
positively with histopathologic volume (Pearson’s
correlation coefficients of 0.49 and 0.55, respec-
tively), but only measurements by combined MR
imaging and MR spectroscopic imaging reached
statistical significance (P < .05). When all nodules
were analyzed, tumor volume measurements were
correlated poorly and not statistically significantly
with histopathologic tumor volume (Table 4).
These results for prostate cancer tumor volume
measurement may seem disappointing, partic-
ularly in the context of other studies indicating
high accuracy for sextant localization. Two fac-
tors probably account for this discrepancy. First,
because per-sextant rather than per-nodule anal-
ysis does not require size concordance between
imaging and pathology, a small imaging abnor-
mality counts as a true positive even if the tumor
is pathologically much larger, and vice versa.
Second, there has been a general downward stage
migration of prostate cancer because of wide-
spread PSA testing. For example, the rate of
organ-confined disease in patients undergoing
prostatectomy and MR imaging at the University
of California, San Francisco between 1992 and
1995 was 56% (43 of 77) [61], compared with 89%
(33 of 37) in 1999 [60]. High accuracy is difficult to
achieve when imaging smaller tumors.
Role of MR imaging and MR spectroscopic
imaging in prostate cancer staging
From the inception of prostate MR imaging,
the hope has been that the modality would be
more accurate in local staging and detection of
extraprostatic disease. Disappointingly, an early
multi-institutional study examining the detection
of extracapsular extension showed no difference in
the area under the receiver operating characteris-
tic curve for MR imaging (0.67) compared with
TRUS (0.62) [4]. Single-institution studies since
then have shown higher overall staging accuracies
of 86% to 88% [62,63], which probably reflects
improved technology and better diagnostic crite-
ria. Multivariate feature analysis has shown the
MR imaging findings that are most predictive of
extracapsular extension are a focal irregular
capsular bulge, asymmetry or invasion of the
neurovascular bundles, and obliteration of the
rectoprostatic angle (Fig. 15) [61]. The addition of
MR spectroscopic imaging to MR imaging
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 571

Fig. 14. (A) Axial T2-weighted image of the prostate shows foci of reduced T2 signal intensity (arrows) in the peripheral
zone bilaterally. (B) Axial T2-weighted image of the prostate, showing the spectral grid from which the spectra in (C)
were acquired. (C) Spectra from the grid shown in (B) show several voxels with elevated choline in the left gland (outlined
area), but no abnormal metabolism elsewhere. Biopsy confirmed Gleason score 7 adenocarcinoma in the left midgland
and apex.

increases staging accuracy for less-experienced
readers and reduces interobserver variability [63].
The value of MR imaging staging has been
demonstrated in a 5-year follow-up study of
1025 men who were staged radiologically before
prostatectomy [64]. The MR-imaging detection of
extracapsular extension conferred a significantly
worse prognosis in the 39% of patients with
moderate or high-risk tumors. Similarly, a decision
analysis model suggested that preoperative MR
imaging was cost-effective for men with moderate
or high probability of extracapsular disease [65].
Reader variation in the interpretation of prostate
MR imaging remains a barrier to greater accep-
tance of this technique for preoperative staging
[66,67]. Radiologists interpreting prostate MR
imaging should be aware that high specificity,
even if accompanied by low sensitivity, is a more
572 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Table 4
Correlation between MR imaging and MR spectroscopic imaging measurement of peripheral zone tumor volume and
histopathologic tumor volume in a study of 37 men with 51 proven peripheral zone tumor nodules at radical
prostatectomy [60]
All nodules Nodules > 0.5 cm3
Method of tumor Correlation coefficient Correlation coefficient
volume measurement (95% confidence interval) P value (95% confidence interval) P value
MR imaging alone 0.21 (ÿ0.22, 0.54) 0.28 0.49 (ÿ0.06, 0.80) 0.07
MR imaging and MRS imaging 0.32 (ÿ0.22, 0.65) 0.21 0.55 (ÿ0.04, 0.82) 0.04
Only MR and MRS imaging volume measurement of tumors >0.5 cm3 showed a statistically significant correlation
with histopathologic volume.

cost-effective approach in patients being consid-
ered for surgery [68].
Extracapsular extension generally is reported
as a simple binary observation, either present or
absent. This is an oversimplification because
extracapsular extension is a continuum that varies
in degree. It is instructive to consider how this
affects prognosis and imaging accuracy. The
prognostic importance of the degree of extracap-
sular extension was evaluated in a 10-year follow-
up study of 617 men with T1 to T3A node-negative
prostate cancer after radical prostatectomy [69].
The 10-year risk for recurrence (clinical, radiologic,
or biochemical) was 32% in patients with micro-
scopic extracapsular extension (the presence of no
more than a few malignant cells immediately
outside the capsule on no more than two sections)
compared with 42% in patients with more estab-
lished extracapsular extension, suggesting micro-
scopic extracapsular extension is nearly as
important as macroscopic extracapsular extension
with respect to prognosis. This is an important
finding because microscopic extracapsular exten-
sion is unlikely to be visualized directly by any
currently available radiologic test. The degree of
extracapsular extension is an important variable
that almost certainly affects MR imaging staging
accuracy. This was shown directly in one study of
34 patients undergoing endorectal MR imaging
before radical prostatectomy [70]. The sensitivity
of MR imaging for extracapsular extension of less
than 1 mm was only 14% (one of seven sites
detected), compared with 71% (five of seven sites
detected) for extracapsular extension greater than
1 mm.
Role of MR imaging and MR spectroscopic
imaging in treatment planning
Anecdotally, MR imaging and MR spectro-
scopic imaging results may be of value to patients
with prostate cancer deciding whether to undergo

Fig. 15. (A) Axial T2-weighted image showing an irregular capsular bulge at the left base associated with an underlying
region of low T2 signal intensity (arrow). The findings are consistent with extracapsular extension of tumor (T3A
disease). (B) Axial T2-weighted image showing asymmetric low T2 signal intensity in the left seminal vesicle (arrow),
consistent with seminal vesicle invasion (T3B disease).
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579
Fig. 16. Coronal T2-weighted image in a 58-year-old
man with a PSA of 9.2 and biopsy-proven Gleason 7
cancer. The tumor was considered organ-confined on
a DRE. MR imaging shows asymmetric low T2 signal
intensity extending into the left seminal vesicle (arrow),
consistent with seminal vesicle invasion. In view of this
finding, the patient chose radiation treatment rather
than radical prostatectomy.
surgery or radiation therapy (Fig. 16), although
the influence of MR imaging and MR spectro-
scopic imaging on such decision-making is diffi-
cult to quantify in systematic studies. The display
of the tumor relationship to the neurovascular
bundles on MR imaging is helpful to the urologist
in planning the surgical approach, although this
has not been validated scientifically.
The relationship between periprostatic anato-
my and operative outcomes has been investigated.
In a study of 211 consecutive patients with newly
diagnosed prostate cancer undergoing radical
prostatectomy performed by a single surgeon
[71], membranous urethral length was measured
on preoperative endorectal MR imaging (Fig. 17)
and correlated with postoperative urinary conti-
nence. After controlling for age and surgical
technique, multivariate analysis showed that
membranous urethral length was related to the
time to stable postoperative continence (P = .02),
such that a longer membranous urethra was
associated with a shorter time to stable conti-
nence. In another study, MR imaging was per-
formed in 143 patients with newly diagnosed
prostate cancer before radical prostatectomy
[72]. Two independent readers rated the promi-
nence of the periprostatic veins (based on number
and size) at four anatomic sites on a 3-point scale.
Prominence of the anterior and posterior apical
periprostatic veins was associated positively with
573
Fig. 17. Coronal T2-weighted image of the prostate,
demonstrating measurements of the membranous ure-
thral length.
blood loss (correlation coefficients of 0.22 and
0.17, P < .01 and .05, respectively).
Several possible roles for MR imaging and MR
spectroscopic imaging have been suggested in
radiation treatment planning. Using fiducial
markers and image fusion software, it has been
shown that CT overestimates the clinical target
volume by 34% when compared with MR imag-
ing [73], and that dose-volume planning with MR
imaging would decrease radiation dose to the
bladder, rectum, and femoral heads. This result
is hardly unexpected because the radiation-plan-
ning CT scans are performed without intravenous
contrast, which limits soft-tissue contrast of CT in
the prostate and perineum (Fig. 18). Several
groups have reported using MR spectroscopic
imaging to increase the brachytherapy radiation
dose in prostatic locations considered suspicious
for cancer [74,75]. Such studies, which suggest
technically successful dose escalation in spectro-
scopically suspicious locations implies improved
clinical outcome, must be viewed with caution,
given the limited ability of MR imaging and MR
spectroscopic imaging to assess tumor volume.
More convincing evidence of benefit was shown
in a study of 390 patients with prostate cancer
treated by brachytherapy, either alone (46%) or
in combination with external beam radiotherapy
(54%). MR imaging was used to evaluate stage
and guide therapy in 327 patients [76]. MR
imaging findings changed the overall treatment
recommendation in 60 patients with most of these
574 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579

Fig. 18. (A) Axial CT image in a 72-year-old man with recurrent tumor after radical prostatectomy. No obvious
abnormality is appreciable because the soft-tissue contrast of CT is limited, particularly in the distinction of perineal
structures. (B) Axial T2-weighted MR image in the same patient shows a large mass (arrows) in the prostatectomy bed.

patients receiving combined therapy instead of therapy for prostate cancer in whom subsequent
monotherapy after MR imaging documented more biopsy confirmed locally recurrent prostate cancer
extensive disease. Seed distribution was modified in nine hemiprostates of six patients, Teh and
in 183 patients, mostly related to coverage of bulky colleagues [79] found that the presence of three or
or extracapsular disease seen on MR imaging. more MR spectroscopic imaging voxels with
Freedom from PSA progression at a mean follow- isolated (ie, absent citrate) elevation of choline
up of 38 months was used as the endpoint. Cox showed a sensitivity and specificity of 87% and
regression analysis showed that only the percent- 72%, respectively. Conversely, the presence of
age of positive cores (P = .001) and failure to have complete metabolic atrophy demonstrated a nega-
MR imaging staging (P = .0008) predicted for tive predictive value of 100% for the exclusion of
failure. This suggests that MR imaging improves local recurrence (Fig. 20); that is, a negative
treatment planning in terms of technical success spectroscopic study in a patient with a rising
and with respect to clinical outcome. PSA after radiotherapy may be a presumptive
marker of distant failure, and indicate that
Role of MR imaging and MR spectroscopic systemic rather than local therapy is required.
imaging in posttreatment follow-up
The role of MR imaging and MR spectroscopic
imaging in posttreatment follow-up of patients
with prostate cancer is not well established,
partially because it is frequently clinically unclear
whether patients with a rising PSA after treatment
have local or distant recurrence. In the authors’
experience, MR imaging and MR spectroscopic
imaging are of limited utility after prostatectomy,
and only the occasional patient demonstrates an
unequivocal locally recurrent tumor (Fig.19). The
ability of MR imaging to detect local recurrence is
limited after radiation or hormonal therapy
because the prostate becomes shrunken with
diffusely low T2 signal intensity and indistinct
zonal anatomy [77,78]. MR spectroscopic imaging Fig. 19. Sagittal T2-weighted image in an 83-year-old
may be of value in the detection or exclusion of man with a rising PSA 8 years after a radical prostatec-
locally recurrent prostate cancer after radiation tomy. The surgical specimen demonstrated T3B cancer.
therapy. In a preliminary study of 21 patients with A large mass of recurrent tumor is visible in the pro-
biochemical failure after external beam radiation statectomy bed.
 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579 575

Fig. 20. (A) Axial T2-weighted image of the prostate, showing the spectral grid from which the spectra in (B) were
acquired. The patient had a rising PSA after receiving external beam radiation for prostate cancer 2 years previously. (B)
Spectra from the grid in (A) show random noise, with no detectable metabolites in the prostate. The finding of complete
metabolic atrophy in an irradiated gland is consistent with satisfactory local tumor control, and therefore suggests that
the rising PSA is a result of distant failure.

Summary and are yet to be defined fully. Areas of active

research interest include volumetric localization of
The primary indication for prostate MR im-
prostate cancer, in vivo MR spectroscopic imag-
aging and MR spectroscopic imaging is the
ing findings at high field strength (3 T), in vitro
evaluation of men with newly diagnosed prostate
MR spectroscopic imaging findings at very high
cancer with a moderate or high risk for extrac-
field strength (7–11 T), novel spectroscopic
apsular extension who are uncertain whether to go
markers of malignancy such as polyamines and
undergo surgery or radiotherapy. Other applica-
spermine, and interventional MR guidance of
tions of MR imaging and MR spectroscopic
biopsy and therapy [39,80,81]. MR spectroscopic
imaging in prostate cancer are under investigation
576 A. Rajesh, F.V. Coakley / Magn Reson Imaging Clin N Am 12 (2004) 557–579
imaging remains a relatively novel technique, and
successful implementation is demanding in terms
of adequate fat and water suppression, postpro-
cessing, and coverage. Nonetheless, only MR
imaging and MR spectroscopic imaging allow
combined structural and metabolic evaluation of
prostate cancer location, aggressiveness, and
stage, and MR imaging provides clinically and
therapeutically relevant information on prostatic
and periprostatic anatomy. The technology re-
mains in evolution, and continued advances in
accuracy and utility are likely.
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