Saeed Ali

Prostate
• No imaging modality can reliably demonstrate the presence or
absence of cancer in the prostate. That diagnosis relies on biopsy,
which is best performed using transrectal US for guidance
• CT is inferior to MR in staging and has no role in the detection of
prostate cancer
• MR provides the best assessment of local and nodal spread .
• The role of PET-CT in prostate cancer is limited by the low
metabolic activity of the tumor and high normal radionuclide
activity in the bladder obscuring the prostate gland and
surrounding tissues
Normal MR Anatomy
• The prostate is divided into three glandular zones surrounding the urethra
• The peripheral zone contains approximately 70% of prostate tissue and is
draped around the remainder of the gland like a catcher’s glove holding a
baseball. Most prostate cancers (70%) arise in the peripheral zone.
Thetransitional zone consists of two small areas of periurethral glandular
tissue. Although it contains only 5% of prostatic tissue in the normal young
man, it is the site of benign prostatic hypertrophy and may enlarge greatly in
the older man. The central zone consists of the glandular tissue at the base of
the prostate through which course the ducts of the vas deferens and seminal
vesicles and the ejaculatory ducts. Although the central zone makes up 25%
of glandular tissue, only 10% of cancers arise there. 
The peripheral zone is draped around the remainder of the gland like a catcher’s glove holding a baseball. Most prostate
cancers (70%) arise in the peripheral zone.
The transitional zone consists of two small areas of periurethral glandular tissue,it is the site of benign prostatic
hypertrophy and may enlarge greatly in the older man.
The central zone consists of the glandular tissue at the base of the prostate through which course the ducts of the vas
deferens and seminal vesicles and the ejaculatory ducts. Although the central zone makes up 25% of glandular tissue,
only 10% of cancers arise there. 
The anterior portion of the prostate is occupied by nonglandular tissue called the anterior fibromuscular stroma. The base
of the prostate is that portion adjacent to the base of the bladder and the seminal vesicles (base to base). The apex of the
prostate rests on the urogenital diaphragm.
• Prominent veins are frequently visualized in the periprostatic
tissues
• Lymphatic drainage of the prostate goes to regional pelvic lymph
nodes with channels to paraaortic and inguinal nodes.
• Periprostatic venous connections to vertebral veins offer a route for
the hematogenous spread of tumor to the axial skeleton.
• On T1WI, the prostate gland is uniform intermediate to low signal
similar to skeletal muscle. The high-signal periprostatic fat defines
the margin of the prostate. Periprostatic veins and neurovascular
bundles are low signal.
• On T2WI, the internal structure (zonal anatomy) of the prostate is
demonstrated. The peripheral zone is high in signal due to higher
water content and looser acinar structure. The central zone is lower in
signal due to more compact muscle fibers and acinar structure. The
central and transitional zones become heterogeneous with age and
the development of benign prostatic hyperplasia. The anterior
fibromuscular stroma is low in signal and has poorly defined margins.
 Normal Prostate - MR. Axial plane T2-weighted MR of a normal prostate in a 40-year-old man demonstrates the high-
intensity peripheral zone (arrowheads), the urethra (long arrow), and the surrounding lower intensity transitional zone. B,
bladder; r, rectum; oi, obturator internus muscle.
echo
• On transrectal US, the central and peripheral zones are nearly
equal in echogenicity and are usually distinguished mainly by
position.
• It is useful to describe the gland on US as having a peripheral zone
and an inner gland comprised of the central and transitional zones
and their pathologic alterations.
• The anterior fibromuscular stroma is seen as a hypoechoic area at
the anterior superior aspect of the gland.
Enlarged Prostate. Midline sagittal US
image shows an enlarged prostate (P)
protruding into and elevating the base of the
urine-filled bladder (B). The urethral orifice
(arrow) forms a V-shaped depression in the
prostate. The bladder wall is markedly
thickened (between arrowheads).
Prostate carcinoma
• Approximately 10% of males over the age of 50 will develop clinical
prostate carcinoma in their lifetime
• The primary issue is differentiating lethal from nonlethal disease
• The Gleason histologic grading system is used to assess the degree of
differentiation of the tumor
• The new staging system incorporates prostate-specific antigen (PSA)
levels and Gleason scores into prognostic groupings.
• Most tumors are adenocarcinoma (95%)
• Prostate cancer spreads by local extension, lymphatic vessels to
regional nodes, and by hematogenous dissemination.t
• Penetration of tumor through the capsule or into the seminal
vesicles greatly worsens the prognosis.
• Involvement of the axial skeleton by hematogenous metastases is
common.
• Metastases to the lungs, liver, and kidneys occur in the terminal
phases of the disease.
• On MR T2WI, cancers appear as areas of low signal within the high-signal
peripheral zone
• Cancer is isointense with prostate tissue on T1WI, which are best used for
assessing the invasion of periprostatic fat and for detecting nodal involvement.
• DWI: often shows restricted diffusion
• dynamic contrast/DCE:shows enhancement - but it can be difficult to
distinguish from prostatitis or benign prostatic hyperplasia (especially in the
central zone lesions 
• Recent biopsy limits the specificity of MR because areas of hemorrhage may
mimic tumor.
• Cancers in the transitional zone are more difficult to detect
• MRI parameters routinely assessed include the presence of a mass
with low T2 signal, restricted diffusion with reduced ADC and
increased tissue capillary permeability using dynamic gadolinium
contrast enhanced imaging and calculation of the so-called Ktrans
(a calculated time constant for permeability). These so called multi-
parametric techniques are increasingly being used in assessment of
prostate malignancy with MRI
=
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Prostate Carcinoma. Proton density-weighted axial plane MR image demonstrates a low signal intensity
carcinoma (fat arrow) in the high signal intensity peripheral zone of the prostate. The tumor is confined to
prostate gland and measures approximately 2 cm. The urethra (skinny arrow) and dark transitional zone are
evident.
• MR findings include:
1. homogeneous low-signal area in the transitional zone
2. lesions with spiculated or poorly defined margins
3. lack of the low-signal rim frequently present with adenomatous
nodules
4. interruption of the low-signal surgical pseudocapsule separating
the transitional zone from the peripheral zone
5. invasion of the urethra or the anterior fibromuscular zone
6. lenticular shape of the nodule
• Criteria for extracapsular extension of tumor include:
1. asymmetry of neurovascular bundles
2. tumor envelopment of neurovascular bundle
3. angulated contour of the prostate gland
4. irregular, spiculated margins of the prostate gland
5. obliteration of the rectoprostate angle
• US findings associated with prostate cancer include:
• distinct hypoechoic nodule
• poorly marginated hypoechoic area in the peripheral zone
• mass effect on surrounding tissues
• asymmetric enlargement of the prostate
• deformation of prostatic contour
• heterogeneous area in the homogeneous gland
• focal increased vascularity in the peripheral zone with color flow US.
• All findings are nonspecific.
• CT is limited to the demonstration of adenopathy and distant
spread of tumor, because it cannot differentiate tumor from benign
hyperplasia within the gland
• Some cancers (∼50%) are detectable as a focus of contrast
enhancement in the peripheral zone on MDCT.
Benign prostatic hyperplasia
• Hypertrophy and hyperplasia occur in glandular tissue in the
transitional and periurethral zones accompanied by proliferation of
supporting smooth muscle and stromal cells.
• The end result is focal or diffuse enlargement of the prostate
Benign Prostatic Hypertrophy. A. Postcontrast CT scan reformatted into coronal plane reveals marked nodular
enlargement of the prostate gland (P) uplifting the bladder base. Despite marked hypertrophy of the prostate, the
bladder wall is only minimally thickened and the patient had only mild bladder outlet obstruction symptoms,
illustrating the clinical point that it is not the overall size of the prostate that matters but exactly where the hypertrophy
occurs and how much narrowing of the urethra that it causes. B.T2-weighted MR image in axial plane shows marked
diffuse enlargement of the prostate gland (arrows) with heterogeneous signal and cystic change. The normal zonal
anatomy of the prostate is not evident. B, bladder.
• CT findings include:
1. enlargement of the prostate, commonly with lobulated contour
and visible high- and low-attenuation nodules
2. coarse calcifications
3. cystic degeneration
4. bladder wall thickening and trabeculation. 
• MR shows prostate enlargement with heterogeneous central gland
on T2WI

• Areas of cystic degeneration are low signal on T1WI and high signal
on T2WI.
• us
• The transitional zone becomes enlarged and heterogeneous and
compresses the urethra and the central zone
• Discrete nodules, some with cystic changes, may be visualized. The
enlargement is often marginated circumferentially by a pseudocapsule.
• The size of the prostate exceeds 30 g (cc).
• The prostatic urethra becomes elongated, tortuous, and
compressed, causing bladder outlet obstruction. Stasis of urine
may lead to the formation of bladder stones. The bladder base is
commonly elevated and the bladder wall is often thickened.
Benign Prostatic Hypertrophy. A. Postcontrast CT scan reformatted into coronal plane reveals marked nodular
enlargement of the prostate gland (P) uplifting the bladder base. Despite marked hypertrophy of the prostate, the
bladder wall is only minimally thickened and the patient had only mild bladder outlet obstruction symptoms,
illustrating the clinical point that it is not the overall size of the prostate that matters but exactly where the hypertrophy
occurs and how much narrowing of the urethra that it causes. B.T2-weighted MR image in axial plane shows marked
diffuse enlargement of the prostate gland (arrows) with heterogeneous signal and cystic change. The normal zonal
anatomy of the prostate is not evident. B, bladder.
Benign Prostatic
Hypertrophy. Transrectal US
images of the prostate are
routinely viewed inverted. The
transducer is at the bottom, rather
than the top of the image.
Transrectal axial US view through
the midprostate demonstrates
excellent differentiation of a
normal peripheral zone (pz, solid
arrows). The inner gland (IG)
demonstrates mild enlargement
and heterogeneity that is
characteristic of benign prostatic
hypertrophy. A small prostatic cyst
is evident (open arrow). The
hypoechoic fibromuscular zone
(FM) is
anterior. A, anterior; P, posterior.
• Prostatic calcifications occur with increasing frequency in older
men.
• Corpora amylacea refers to echogenic proteinaceous debris within
dilated prostatic ducts.
• Calcifications occur with prostatitis and benign hypertrophy and
are of no clinical significance.
Acute prostatitis
• Acute prostatitis is usually caused by E. coli infection.
• The gland is swollen and edematous.
• Prostatic abscess is demonstrated by US as a focal collection of
echogenic fluid within the gland.
• Septations may be present.
• Transrectal US may be used to direct needle aspiration of a
suspected abscess.
Prostate Abscess. Transverse
transrectal US reveals an
abscess (arrows) in the right
side of the prostate gland in a
patient with fever, pelvic pain,
and pyuria. The abscess
contained purulent debris
seen on US as floating
particulate matter.
Cystic lesions
• Cystic lesions of the prostate and periprostatic tissues are
uncommon but often prominent findings on prostate imaging (51).
Congenital lesions include Müllerian duct and prostatic utricle cysts
that occur in the midline in the upper half of the prostate
• While these are separate entities, they are indistinguishable by
imaging
• Small cysts are incidental findings. Larger cysts may cause bladder
outlet obstruction symptoms, pain, and hematuria.
CYSTIC LESIONS OF THE PROSTATE
• CT shows a well-defined midline cyst of variable size. These cysts are high
signal on T2WI.
• Prostate retention cysts result from the obstruction of the prostatic
ductule. They may occur anywhere in the gland and are usually small and
asymptomatic.
• Cysts associated with benign prostatic hyperplasia are the most common
cysts of the prostate.
• Cystic appearance of prostatic carcinoma is rare but may be suspected if a
cystic lesion shows rapid growth.
• Abscesses may complicate bacterial prostatitis and may be drained using
transrectal US guidance.
Benign Prostatic Hypertrophy. A. Postcontrast CT scan reformatted into coronal plane reveals marked nodular
enlargement of the prostate gland (P) uplifting the bladder base. Despite marked hypertrophy of the prostate, the
bladder wall is only minimally thickened and the patient had only mild bladder outlet obstruction symptoms,
illustrating the clinical point that it is not the overall size of the prostate that matters but exactly where the hypertrophy
occurs and how much narrowing of the urethra that it causes. B.T2-weighted MR image in axial plane shows marked
diffuse enlargement of the prostate gland (arrows) with heterogeneous signal and cystic change. The normal zonal
anatomy of the prostate is not evident. B, bladder.
Utricle/Müllerian Duct Cyst. Axial CT without contrast shows a well-defined cyst (arrow) exactly in the midline
of the prostate (between arrowheads). The patient was asymptomatic. This is an incidental finding of utricle
cyst/Müllarian duct cyst.
Utricle Cyst. Transverse
view of the prostate
(between arrows)
through the urine-filled
bladder (B) shows a
midline cystic mass
(arrowhead) within the
prostate. This is the
typical location and
appearance of a utricle
cyst.
Seminal Vesicles
• While primary tumors are rare, the seminal vesicles are commonly
involved by tumors of the bladder, prostate, and rectum
• Cysts and absence of the seminal vesicles are associated with
ipsilateral renal dysgenesis or agenesis.
Anatomy
• The seminal vesicles are paired elongated saclike glands located in the posterior
groove between the bladder base and the prostate.
• The dilated ampulla portion of the vas deferens courses just superior to the seminal
vesicles. The vas deferens joins the ducts of the seminal vesicles to form the
ejaculatory duct, which courses through the prostate gland to empty into the urethra
at the level of the verumontanum.
• Normal seminal vesicles are 3 cm in length and 8 mm in diameter. Slight asymmetry
is common. They contain fluid that is low to intermediate signal on T1WI and very
high signal on T2WI. The wall of the glands is 1 to 2 mm thick .
• The vas deferens is 3 to 5 mm in diameter. CT shows the fluid containing seminal
vesicles as “bow-tie” in appearance on axial imaging. The seminal vesicles serve as a
landmark for the lowest extent of the peritoneal cavity and for the location of the
ureteral junctions with the bladder.
Pathology
• Unilateral agenesis of the seminal vesicles is highly associated with ipsilateral renal
agenesis (80% of cases) .
• Bilateral seminal vesicle agenesis may be seen in some patients with cystic fibrosis.
Hypoplasia occurs in association with cryptorchidism and hypogonadism.
• Cysts occur in patients with autosomal dominant polycystic disease and in
association with developmental anomalies of the genitourinary tract. The extremely
rare primary neoplasms include cystadenoma, cystadenocarcinoma, and sarcomas
• Tumor involvement by prostate, bladder, or rectum carcinoma appears as
contiguous solid tumor extending from the organ of origin to the seminal vesicles
obliterating intervening fat planes
• Bilateral calcification of the vas deferens is very highly associated with the presence
of diabetes
Calcification of the Vas Deferens. CT without contrast shows calcification of the
bilateral vas deferens (arrowheads). This finding is almost universally associated with
the presence of diabetes mellitus.
Prostate imaging-reporting and data
system (PIRADS)
• T2 signal:
• for the peripheral zone (PZ)
• a. uniform high signal intensity (SI) - 1 (point)
• b. linear, wedge shaped, or geographic areas of lower SI, usually not well
demarcated - 2
• c. intermediate appearances not in categories a/b or d/e -3
• d. discrete, homogeneous low signal focus/mass confined to the prostate -
4
• e. discrete, homogeneous low signal intensity focus with extracapsular
extension/invasive behaviour or mass effect on the capsule (bulging), or
broad (>1.5 cm) contact with the surface - 5 
• for the transition zone (TZ)
• a. heterogeneous TZ adenoma with well-defined margins: “organised
chaos” - 1
• b. areas of more homogeneous low SI, however well marginated,
originating from the TZ/BPH - 2
• c. intermediate appearances not in categories a/b or d/e
• d. areas of more homogeneous low SI, ill defined: “erased charcoal sign” -
4
• e. same as d, but involving the anterior fibromuscular stroma or the
anterior horn of the PZ, usually lenticular or water-drop shaped - 5
diffusion weighted imaging (DWI)
• a. no reduction in ADC compared with normal glandular tissue. No
increase in SI on any high b-value image (≥b800) - 1
• b. diffuse, hyperintensity on ≥b800 image with low ADC; no focal
features, however, linear, triangular or geographical features are
allowed - 2
• c. intermediate appearances not in categories a/b or d/e - 3
• d. focal area(s) of reduced ADC but isointense SI on high b-value
images (≥b800) - 4
• e. focal area/mass of hyperintensity on the high b-value images
(≥b800) with reduced ADC - 5
dynamic contrast enhanced (DCE)-MRI
• type 1 enhancement curve: 1
• type 2 enhancement curve: 2
• type 3 enhancement curve: 3
• +1 point for for focal enhancing lesion with curve type 2–3
• +1 point for asymmetric lesion or lesion at an unusual place with
curve type 2–3
• Additional scoring can be done with MR spectroscopy for a 1.5T
scanner using the citrate and choline peak (3 voxels)
• citrate peak height exceeds choline peak height >2 times - 1 point
• citrate peak height exceeds choline peak height times >1, <2 times
- 2 points
• choline peak height equals citrate peak height - 3 points
• choline peak height exceeds citrate peak height >1, <2 times -  4
points
• choline peak height exceeds citrate peak height >2 times - 5 points
• PI-RADS I - most probably benign - 
• total score with T2, DCE, DWI = 3,4
• total score with T2, DCE, DCE and MRS = 4,5 
• PI-RADS II - probably benign
• total score with T2, DCE, DWI = 5,6
• total score with T2, DCE, DCE and MRS = 6-8 
• PI-RADS III - indeterminate
• total score with T2, DCE, DWI = 7-9
• total score with T2, DCE, DCE and MRS = 9-12 
• PI-RADS IV - probably malignant
• total score with T2, DCE, DWI = 10-12
• total score with T2, DCE, DCE and MRS = 13-16 
• PI-RADS V - highly suspicious of malignancy
• total score with T2, DCE, DWI = 13-15
• total score with T2, DCE, DCE and MRS = 17-20 
• In addition to the PI-RADS score for the probability of a lesion to be
significant, extra-prostatic involvement should also be scored on a
five-point scale
• extracapsular extension
• abutment - 1
• irregularity - 3
• neurovascular bundle thickening - 4
• bulge, loss of capsule - 4
• measurable extra-capsular disease - 5
• seminal vesicles
• expansion - 1
• low T2 signal - 2
• filling in of angle - 3
• enhancement and impeded diffusion - 4
• distal sphincter
• adjacent tumour - 3
• effacement of low signal sphincter muscle - 3
• abnormal enhancement extending into sphincter - 4
• bladder neck
• adjacent tumour - 2
• loss of low T2 signal in bladder muscle - 3
• abnormal enhancement extending into bladder neck - 4