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Multiparametric magnetic resonance imaging characteristics of normal, benign and malignant conditions in the prostate

  • Magnetic Resonance
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Abstract

Objectives

To identify the multiparametric magnetic resonance imaging (mpMRI) characteristics of normal, benign and malignant conditions in the prostate.

Methods

Fifty-six histopathological whole-mount radical prostatectomy specimens from ten randomly selected patients with prostate cancer (PC) were matched with corresponding transverse mpMRI slices. The mpMRI was performed prior to biopsy and consisted of T2-weighted imaging (T2-WI), diffusion-weighted imaging (DWI), dynamic contrast-enhanced imaging (DCE) and magnetic resonance spectroscopic imaging (MRSI).

Results

In each prostate specimen, a wide range of histopathological conditions were observed. They showed consistent but overlapping characteristics on mpMRI. Normal glands in the transition zone showed lower signal intensity (SI) on T2-WI, lower ADC values and lower citrate peaks on MRSI as compared to the peripheral zone (PZ) due to sparser glandular elements and more prominent collagenous fibres. In the PZ, normal glands were iso-intense on T2-WI, while high SI areas represented cystic atrophy. Mimickers of well-differentiated PC on mpMRI were inflammation, adenosis, HG-PIN and post-atrophic hyperplasia.

Conclusion

Each prostate is a unique mix of normal, benign and/or malignant areas that vary in extent and distribution resulting in very heterogeneous characteristics on mpMRI. Understanding the main concepts of this mpMRI-histopathological correlation may increase the diagnostic confidence in reporting mpMRI.

Keypoints

• In each prostate specimen a wide range of histopathological conditions was observed.

• Interpretation of mpMRI may be difficult because benign conditions may mimic PC.

• High signal intensity areas in the PZ on T2-WI represented cystic atrophy.

• The TZ showed sparser glands and more collagenous fibres than the PZ.

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Abbreviations

ADC:

Apparent diffusion coefficient

BCH:

Basal cell hyperplasia

CyA:

Cystic atrophy

DCE:

Dynamic contrast-enhanced imaging

DWI:

Diffusion weighted imaging

FMH:

Fibromuscular hyperplasia

FMS:

Fibromuscular stroma

HG-PIN:

High-grade prostatic intra-epithelial neoplasia

mpMRI:

Multiparametric magnetic resonance imaging

MRSI:

Magnetic resonance spectroscopic imaging

PA:

Partial atrophy

PAH:

Post-atrophic hyperplasia

PC:

Prostate cancer

PZ:

Peripheral zone

SA:

Simple atrophy

SI:

Signal intensity

T2-WI:

T2-weighted imaging

TZ:

Transition zone

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Acknowledgments

An abstract of this paper won the 3rd prize for best oral presentation at the 22nd European Symposium on Urogenital Radiology of the ESUR (European Society of Urogenital Radiology) annual meeting held in Copenhagen, Denmark, September 2015.

The scientific guarantor of this publication is Geert Villeirs. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was not required for this study because it was a retrospective study. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, observational, performed at one institution.

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Author notes

    Authors and Affiliations

    1. Department of Radiology, Ghent University Hospital, 0DPP, De Pintelaan 185, 9000, Ghent, Belgium

      Pieter J. L. De Visschere, Eva Pattyn & Geert M. Villeirs

    2. Department of Basic Medical Sciences, Ghent University Hospital, Ghent, Belgium

      Anne Vral & Gianpaolo Perletti

    3. Clinical Pharmacology, Medical and Surgical Sciences Section, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy

      Gianpaolo Perletti

    4. Department of Pathology, Ghent University Hospital, Ghent, Belgium

      Marleen Praet

    5. Urology Clinic, Instituti Clinici di Perfezionamento, Milano, Italy

      Vittorio Magri

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    1. Pieter J. L. De Visschere
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    Correspondence to Pieter J. L. De Visschere.

    Additional information

    Pieter J. L. De Visschere and Anne Vral contributed equally to this work.

    Electronic supplementary material

    Below is the link to the electronic supplementary material.

    Supplemental Figure 1

    Photograph of a macroslide (Patient 1) showing how the different histological conditions were delineated, based on the observations on the high magnification views. This scheme was used for evaluating the imaging characteristics of the different histological conditions on the corresponding T2-WI, DWI, DCE and MRSI images of the mpMRI. (GIF 10.2 MB)

    High resolution image (TIFF 1.22 MB)

    Supplemental Figure 2

    prostate glands (Patient 4, 12.5x), B. Basal cell hyperplasia (Patient 4, 12.5x), C. Simple atrophy (Patient 4, 12.5x), D. Partial atrophy (Patient 4, 12.5x), E.Post-atrophic hyperplasia (Patient 4, 3.2x), F. Cystic atrophy (Patient 10, 3.2x). (GIF 11.4 MB)

    High resolution image (TIFF 19.9 MB)

    Supplemental Figure 3

    High magnification histopathological images of PC, HG-PIN and benign mimickers of PC. A. Poorly-differentiated PC (Patient 10, 25x), B. Well-differentiated PC (Patient 7, 25x), C. HG-PIN, tufted phenotype (Patient 2, 25x), D. Adenosis (Patient 2, 3.2x), E. Severe stromal and periglandular inflammation (Patient 5, 3.2x), F. Well-defined, pale-stained nodule of fibromuscular hyperplasia embedded within a peri-urethral area of stroma (Patient 2, 3.2x). (GIF 3.68 MB)

    High resolution image (TIFF 22.5 MB)

    Supplemental Figure 4

    A. Photograph of macroslide, B. T2-WI, C. ADC map of DWI, D. subtraction image of DCE, E. MRSI of CyA, F. MRSI of SA (Patient 3). Cystic atrophy (dashed line) and simple atrophy (dotted line) both show a high SI on T2-WI (B) and high ADC values on DWI (C). SA is however ill defined and lacks the black rims of FMS that are typical for CyA (B). CyA shows no contrast enhancement whereas simple atrophy shows minimal contrast enhancement (D). On MRSI both show high citrate peaks and low choline peaks, but in CyA (E) the citrate peaks are lower than in SA (F). (GIF 3.43 MB)

    High resolution image (TIFF 4.28 MB)

    Supplemental Figure 5

    A. Photograph of macroslide, B. T2-WI, C. ADC map of DWI, D. subtraction image of DCE, E. MRSI map, F. MRSI of FMH, G. MRSI of mixture of simple and cystic atrophy (Patient 3). Fibromuscular hyperplasia (dotted line) is a common finding in the TZ and appears as a very hypointense round nodule on T2-WI (B). On DWI it has a low ADC value (C) and on DCE it shows moderate contrast enhancement (D). On MRSI it demonstrates low peaks of all metabolites (G). There is a big contrast with a mixture of simple atrophy and cystic atrophy (dashed line) that shows a moderately high SI on T2-WI (B), high ADC values on DWI (C), low contrast enhancement on DCE (D) and high citrate peaks on MRSI (E, G). (GIF 4.40 MB)

    High resolution image (TIFF 4.66 MB)

    Supplemental Figure 6

    A. Photograph of macroslide, B. T2-WI, C. ADC map of DWI, D. subtraction image of DCE, E. MRSI (Patient 2) Post-atrophic hyperplasia (black line) is usually tiny or very small in size but in this patient a larger nodule was observed histologically, large enough to correlate with the corresponding axial slices of mpMRI, but it showed no specific features: it was isointense on T2-WI (B), showed no restricted diffusion (C) and minimal contrast enhancement (D). Cystic atrophy (dashed line) could be recognized easily in this patient as a kidney-shaped lesion with very high SI on T2-WI (B), high ADC value on DWI (C) and absent contrast enhancement (D). Poorly differentiated PC (white line) in the TZ is demonstrated as an ill-defined irregular homogeneous hypointense lesion on T2-WI (B), with low ADC value on DWI (C) and strong contrast enhancement (D). On MRSI the citrate peaks are decreased (E). Fibromuscular stroma (dotted line) also has low SI on T2-WI (B), with low ADC value on DWI (C) but with fewer contrast enhancement as compared to poorly differentiated PC (D). (GIF 3.21 MB)

    High resolution image (TIFF 5.74 MB)

    Supplemental Figure 7

    A. Photograph of macroslide, B. T2-WI, C. ADC map of DWI, D. high b-value image of DWI, E. subtraction image of DCE, F. DCE enhancement curve of poorly differentiated PC, G. DCE enhancement curve of cystic atrophy, I. MRSI (Patient 3). Poorly differentiated PC (dotted line) is demonstrated as a very low SI nodule on T2-WI (B) with restricted diffusion (C, D) and strong contrast enhancement (E) with high initial contrast peak and wash out shape of the DCE curve (F). On MRSI the citrate peaks are low (I). Cystic atrophy (dashed line) and simple atrophy (white line) show high SI on T2-WI (B) with on DWI high ADC value (C) and low signal on high-b-value image (D). They show absent or minimal contrast enhancement (E) with linear shape of the enhancement curve of DCE (G). On MRSI the citrate peaks are moderately high (G). (JPEG 708 kb)

    High resolution image (TIFF 4.11 MB)

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    De Visschere, P.J.L., Vral, A., Perletti, G. et al. Multiparametric magnetic resonance imaging characteristics of normal, benign and malignant conditions in the prostate. Eur Radiol 27, 2095–2109 (2017). https://doi.org/10.1007/s00330-016-4479-z

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