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Real-Time and Delayed Imaging of Tissue and Effects of Prostate Tissue Ablation

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Abstract

Purpose of Review

Prostate ablation is increasingly being utilized for the management of localized prostate cancer. There are several energy modalities with varying mechanism of actions which are currently used for prostate ablation. Prostate ablations, whether focal or whole gland, are performed under ultrasound and/or MRI guidance for appropriate treatment plan execution and monitoring. A familiarity with different intraoperative imaging findings and expected tissue response to these ablative modalities is paramount. In this review, we discuss the intraoperative, early, and delayed imaging findings in prostate from the effects of prostate ablation.

Recent Findings

The monitoring of ablation both during and after the therapy became increasingly important due to the precise targeting of the target tissue. Recent findings suggest that real-time imaging techniques such as MRI or ultrasound can provide anatomical and functional information, allowing for precise ablation of the targeted tissue and increasing the effectiveness and precision of prostate cancer treatment. While intraprocedural imaging findings are variable, the follow-up imaging demonstrates similar findings across various energy modalities.

Summary

MRI and ultrasound are two of the frequently used imaging techniques for intraoperative monitoring and temperature mapping of important surrounding structures. Follow-up imaging can provide valuable information about ablated tissue, including the success of the ablation, presence of residual cancer or recurrence after the ablation. It is critical and helpful to understand the imaging findings during the procedure and at different follow-up time periods to evaluate the procedure and its outcome.

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Authors and Affiliations

  1. Division of Urology, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Shima Tayebi & Abhinav Sidana

  2. Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Sadhna Verma

  3. Division of Urology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0589, Cincinnati, OH, 45267, USA

    Abhinav Sidana

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  1. Shima Tayebi
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Appendix

Appendix

Fig. 1
figure 1

Examples of real-time HIFU transrectal ultrasound images. A–B shows the procedure development and changes during the procedure. The ablation field is marked as a blue band and the site of ablation is orange. The popcorn effect is seen as a hyperechoic area in the region of the ablation (green circle). C–D Shows the corresponding axial view of A and B

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Fig. 2
figure 2

HIFU. pre-treatment T2 MRI (A), pre-treatment ADC MRI (B) demonstrating a lesion in the left apical posterior peripheral zone (white arrows), biopsied as 3 + 4 prostate cancer. 6-month post-treatment T2 MRI (C) and ADC MRI (D) demonstrating tissue changes post-treatment including volume loss, fibrosis, and capsular retraction (red arrows)

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Fig. 3
figure 3

The changes seen in imaging after focal ablation of the prostate based on the duration. On left, it shows early changes happening in the first days-weeks after the ablation, while the pictures come toward the right show late changes happening more than 6 months after the ablation in the gland

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Fig. 4
figure 4

Contrast-enhanced transrectal ultrasound. A A pre-treatment split-screen grayscale image and B a pre-treatment contrast-enhanced transrectal ultrasound image showing a lesion in the left lobe of the prostate gland with increased enhancement (white arrow). C An immediate post-HIFU split-screen grayscale image and D a post-HIFU contrast-enhanced transrectal ultrasound image showing post-treatment changes in the ablation area as a non-enhancing area (white arrow). Figure adapted with permission from reference [25] (reused with permission from Abreu, Journal of Ultrasound in Medicine, published by Springer, 2018, License number: 5477200383530)

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Fig. 5
figure 5

Transrectal ultrasound ablation (TULSA). A MRI real-time thermometry images of the prostate during TULSA shows the real-time temperature of the different parts of the gland during ablation with the maximum temperature at the site of the ablation. B MRI T1 images of the prostate show left hemiablation of the prostate gland with a non-enhancing area on the left side of the prostate indicating ablation necrosis. Figure adapted with permission from reference [31•] (Wimper, journal of MDPI, published by Life, 2022)

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Fig. 6
figure 6

Examples of cryotherapy images. A shows the prostate gland with hyperechoic lines manifesting cryoneedles inside the gland (blue arrows). B–C are pictures of real-time cryotherapy showing the edge of the iceball seen as a hyperechoic thin line (red arrows) with the posterior shadow (hypoechoic area)

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Fig. 7
figure 7

Cryotherapy. Pre-treatment prostate MRI T2 (A) and DWI (B) demonstrating a lesion in the right anterior paramedian prostate (white arrow). Post-treatment MRI T2 (C) and DWI (D) demonstrating tissue changes post-treatment (red arrows) including prostate atrophy, fibrosis, and capsular retraction with no diffusion restriction in the area of the ablation

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Fig. 8
figure 8

Examples of IRE images. A During the ablation. Hyperechoic areas around the electrodes during ablation; (electrodes marked by red circles were active during this image capture) B post ablation image. Area of hyperechogencity in the ablation zone and obscuration of prostate anterior to the ablation zone

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Fig. 9
figure 9

Irreversible electroporation. Pre-treatment prostate MRI T2 (A) and DWI (B) demonstrating PIRADS 5 lesion in the left mid-anterior transitional zone (white arrows). Post-treatment prostate MRI T2 (C), DWI (D), and ADC (E) demonstrating post-treatment necrosis (yellow arrows). There is a restricted diffusion on DWI (D) and mild enhancement on DCE (E), concerning possible residual disease (red arrows)

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Tayebi, S., Verma, S. & Sidana, A. Real-Time and Delayed Imaging of Tissue and Effects of Prostate Tissue Ablation. Curr Urol Rep 24, 477–489 (2023). https://doi.org/10.1007/s11934-023-01175-4

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