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european urology supplements 6 (2007) 525–532
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Dynamic Contrast-Enhanced MRI for Preoperative
Identification of Localised Prostate Cancer
Arnauld Villers a,*, Philippe Puech b, Xavier Leroy c, Jacques Biserte a,
Jean-Christophe Fantoni a, Laurent Lemaitre b
a
Department of Urology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
Department of Radiology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
c
Department of Pathology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
b
Article info
Abstract
Keywords:
Prostate neoplasms
Magnetic resonance imaging
Magnetic resonance
Contrast enhancement
Prognosis
Radical prostatectomy
Objectives: To assess the value of pelvic-phased array (PPA) dynamic
contrast-enhanced magnetic resonance imaging (DCE-MRI) in predicting
intraprostatic tumour location and volume for clinically localised
prostate cancers.
Methods: Suspicious areas on prospective prebiopsy MRI were located
with respect to anatomic features, gland side, and transition zone (TZ)
and peripheral zone (PZ) boundaries. These MRI findings were compared
with histopathology findings for the radical prostatectomy specimens.
Literature review of original studies correlating MRI and histologic
results was performed.
Results: DCE-MRI with a PPA is superior to T2-weighted sequences for
the detection and depiction of intraprostatic prostate cancer. In a series
of 24 cases with 56 separate cancer foci, sensitivity, specificity, and
positive and negative predictive values for cancer detection by MRI
were, respectively, 77%, 91%, 86%, and 85% for foci >0.2 cc, and 90%,
88%, 77%, and 95% for foci >0.5 cc. Median focus volume was 1.37 cc
(range: 0.338–6.32) for foci >0.2 cc detected by MRI in PZ, and 0.503 cc
(range: 0.337–1.345) for those not detected by MRI ( p < 0.05). The
corresponding values for TZ foci were 2.54 (range: 0.75–16.87) and
0.435 (range: 0.26–0.58).
Conclusions: Prebiopsy PPA DCE-MRI is an accurate technique for detecting and quantifying intracapsular TZ or PZ tumour foci >0.2 cc. It has
several applications, such as screening for prostate cancer and excluding
cancer in patients with a raised PSA level, targeting of biopsies, estimating cancer volume and prognosis, and, in the future, monitoring of
disease both during active surveillance and after focal therapy.
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# 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, Hospital Claude Huriez, CHRU 59037,
Lille, France. Tel. +33 3 20 44 42 35; Fax: +33 3 20 44 51 43.
E-mail address: [email protected] (A. Villers).
1569-9056/$ – see front matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eursup.2007.01.024
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1.
european urology supplements 6 (2007) 525–532
Introduction
Preoperative identification of localised prostate
cancer for early detection and staging are issues
of major concern. Whether the tumour originates in
the transition or peripheral zone has important
implications regarding detection, prognosis, and
therapy [1,2]. Tumour volume, when combined with
Gleason differential (or percentage of Gleason 4 and
5), is a powerful predictor of metastasis, although its
usefulness in routine clinical practice has not been
validated [3,4]. Among the various prostate-imaging
modalities, magnetic resonance imaging (MRI) has
the potential to improve the identification of
prostate cancer at an early stage. A recent review
concluded that the addition of dynamic contrast
enhancement, spectroscopy, and diffusion-weighted
imaging to standard T2-weighted sequences is
practical, and has the potential to improve MRI of
the prostate to the point at which it has several new
applications: the targeting of biopsies, monitoring of
disease burden both during active surveillance and
after focal therapy, and excluding cancer in patients
with a raised prostate-specific antigen (PSA) level [5].
The precise benefit of each technique in a multisequence scan remains to be quantified.
To improve MRI identification of localised prostate
cancer within the prostate gland, we prospectively
investigated the value of dynamic contrast-enhanced
magnetic resonance imaging (DCE-MRI) with pelvicphased array (PPA) coils performed before biopsies.
PPA coils may represent a valuable alternative to
endorectal (ER) coils. PPA coils provide excellent
image quality in prostate MRI because of high spatial
resolution. These coils offer an excellent signal-tonoise ratio, minimizing distortion and flare artefact
[6,7]. We showed that ER and high-resolution PPA
coils provide similar prostate-imaging quality and
cancer detection rates in T2-weighted sequences at
1.5 T (Puech, personal communication). If we compare our results at 1.5 T with published results at 3 T,
we find that our qualitative results for prostate
capsule delineation are very similar to those of
Sosna et al who used either a single PPA coil or
combined ER-PPA coils [8–10], and that our cancer
detection performance is very similar to that
reported by Kim et al [11]. Our specificity and
accuracy are even better, suggesting that 1.5 T
prostate imaging remains competitive with 3 T
imaging, provided that suitable coils are used.
DCE-MRI is best interpreted with PPA coils. ER
coils lead to a loss of signal in the anterior prostate.
Unlike PPA coils, ER coils do not provide a homogenous signal, thus preventing accurate DCE. Gland
deformation due to the balloon may hinder prostate volume estimation and subsequent data use
(eg, for TRUS-guided biopsy with or without image
fusion or radiation treatment planning). DCE-MRI
with a PPA was reported to be superior to T2weighted sequences for the detection and depiction
of intraprostatic prostate cancer. In one study using
DCE-MRI with a PPA, prostate cancer was enhanced
Table 1 – MRI protocol using a 1.5 T unit* with a dedicated five-element receive-only pelvic-phased array coil** [15]
Sequences
T2-w turbo spin echo
Protocol
Slice count and thickness
Acquisition duration
Phase-encoding direction
Field of view
Acquisition matrix
Acquired
Reconstructed voxel size
Percent sampling
Number of repetitions
TR/TE
Turbo factor
Flip angle
12 slices, 4 mm, no intersection gap
4:30
No breath holding
Anteroposterior
160 160 mm
272 231
0.59 0.71 4 mm
0.31 0.31 4 mm
85%
6
3200/110 ms
16
908
T1-w gradient echo DCE MRI
6 identical sequences of 14 slices every 15 s started
immediately after 0.1 mmol/kg IV bolus of gadoteric acid***
at 2 ml/s, followed by 20 ml flush of normal saline****
Same as axial T2 sequence
0:15 per dynamic
No breath holding
Same as axial T2 sequence
160 160 mm
128 109
1.25 1.79 4 mm
0.31 0.31 4 mm
70%
2
120/4.6 ms
508
T2-w = T2-weighted; T1-w = T1-weighted; DCE = dynamic contrast-enhanced; MRI = magnetic resonance imaging; IV = intravenous;
TR = repetition time; TE = time to echo.
*
Intera; Philips Medical System, Best, Netherlands.
**
Syn-cardiac coil; Philips Medical Systems.
***
Dotarem; Guerbet, Roissy CdG, France.
****
Spectris SHS 200; Medrad, Indianola, IA, USA.
european urology supplements 6 (2007) 525–532
more and earlier than normal PZ and adenoma, and
was well visualised in PZ but not in adenoma [12]. In
others studies using DCE-MRI with a PA body coil
prior to biopsy, tumours could be precisely located,
depicted, and staged [11,13]. Girouin et al [14]
showed that DCE-MRI with PPA and simple visual
diagnostic criteria is more sensitive for tumour
localization than T2-weighted imaging. To assess
the accuracy of DCE-MRI in detecting intraprostatic
cancer foci, in patients with clinically localised
prostate cancer, we compared MRI results with
those obtained on pathologic examination of the
radical prostatectomy (RP) specimens [15].
2.
Materials and methods
2.1.
MRI protocol
MRI was performed immediately before transrectal ultrasound (TRUS) biopsy to avoid haemorrhagic and inflammatory
lesions that might hinder interpretation of gland signals. (The
protocol is described in Table 1.) An axial oblique reference
plane perpendicular to the rectal surface of the prostate was
used, similar to the sectioning plane of prostatectomy specimens according to the Stanford technique (Fig. 1). MRI findings
from 24 patients with biopsy-proven cancer were classified as
suspicious if the sum of the subscores was 3, 4, or 5, and not
suspicious if the sum was 0, 1, or 2. The zone of origin of each
suspicious area was determined by locating the area in
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relation to the TZ boundary. These MRI findings were
compared with histopathology findings for the RP specimens.
3.
Results
Histopathology maps of the 24 patients detected 56
separate cancer foci. The largest tumour focus
was located in PZ in 14 patients and in TZ in 10
patients. T1-weighted DCE-MRI identified 30 of the
39 tumour foci >0.2 cc and 27 of the 30 foci >0.5 cc.
T2-weighted sequences were suspicious in 22 of 30
foci >0.2 cc identified by T1-weighted DCE-MRI
sequences. Sensitivity, specificity, and positive
and negative predictive values for cancer detection
by MRI were, respectively, 77%, 91%, 86%, and 85%
for foci >0.2 cc, and 90%, 88%, 77%, and 95% for
foci >0.5 cc. Median focus volume was 1.37 cc
(0.338–6.32) for foci >0.2 cc detected by MRI in PZ,
and 0.503 cc (0.337–1.345) for those not detected by
MRI ( p < 0.05). The corresponding values for TZ foci
were 2.54 (0.75–16.87) and 0.435 (0.26–0.58). MRI
results of six cases from our current series are
depicted in Figs. 2–7.
4.
Discussion
The results for DCE-MRI with PPA have shown that it
is an accurate method for depicting intracapsular
Fig. 1 – MR1 T2-weighted sections: (A) Sagittal section showing oblique reference plane perpendicular to the rectal surface of
the prostate similar to the section plane used to obtain RP specimens by the Stanford technique; (B) coronal section; (C) axial
section. MRI = magnetic resonance imaging; RP = radical prostatectomy.
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european urology supplements 6 (2007) 525–532
Fig. 2 – Case 1: PSA 7.5 ng/ml, cT2. MRI T2-weighted (A) and DCE T1-weighted (B). Axial sections at midgland showing
suspicious area in right PZ (arrow). (A) Low signal intensity; (B) early enhancement at 30 s with high signal intensity.
Systematic and targeted biopsies were positive on 10 mm in length for adenocarcinoma (3+4 = 7). PSA = prostate-specific
antigen; MRI = magnetic resonance imaging; DCE = dynamic contrast-enhanced; PZ = peripheral zone.
cancers, especially cancers located in the anterior
zone of the prostate. Tumour site (TZ vs. PZ) has
important implications for tumour incidence, natural history, detection, prognosis, and treatment
[16]. The contours of the tumour foci and their
location with respect to the TZ boundary on DCEMRI were in agreement with the patterns of spread
observed in histopathology maps by McNeal and
Haillot [17]. Recently, Koppie et al [18] assessed 1290
consecutive open and laparoscopic RPs. A total of
259 patients were in the pure-anterior cancer group;
594 patients were in the pure-posterior cancer
group. Anterior cancers have lower Gleason grade
and lower rates of extraprostatic extension, yet
Fig. 3 – Case 2: PSA 4.5 ng/ml, cT1c. MRI T2-weighted (A) and DCE T1-weighted (B). Axial sections at midgland showing
suspicious area in left PZ (arrow). (A) Low signal intensity; (B) early enhancement at 30 s with high signal intensity.
Systematic biopsies were negative, and targeted biopsies were positive on 7 and 9 mm in length for adenocarcinoma
(3+4 = 7). PSA = prostate-specific antigen; MRI = magnetic resonance imaging; DCE = dynamic contrast-enhanced;
PZ = peripheral zone.
european urology supplements 6 (2007) 525–532
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Fig. 4 – Case 3: PSA 7.5 ng/ml, cT1c. MRI T2-weighted (A) and DCE T1-weighted (B). Axial sections at apex showing suspicious
area anterior to urethra (arrow). (A) No suspicious area; (B) suspicious area with early enhancement at 30 s with high signal
intensity. Systematic biopsies were negative, and targeted biopsies were positive on 7 mm in length for adenocarcinoma
(3+3 = 6). PSA = prostate-specific antigen; MRI = magnetic resonance imaging; DCE = dynamic contrast-enhanced.
patients with anterior tumours have higher overall
tumour volumes and higher rates of positive surgical
margins. The authors concluded that because current
tools for detecting and staging prostate cancer
can underestimate the extent of anterior prostate
disease, improved methods are needed for localizing
and characterizing anterior cancers. Results from
different studies, including our study, showed that
DCE-MRI is one of the tools that help in preoperative
identification of these anterior cancers. It was also
confirmed [19,20].
ER T2 imaging is considered the best technique
for prostate cancer local staging and can be
combined with H spectroscopic imaging to improve
cancer localization and characterization. However,
in a literature review, Kirkham et al [5] showed
that the few studies that have attempted to quantify
the benefit of adding a new technique to standard unenhanced sequences showed an increase of
16% in sensitivity with dynamic contrast-enhanced
sequence and similar improvements in either
sensitivity or specificity with spectroscopy. Overall,
it seems reasonable to hope that an approach using
T2 sequences, dynamic contrast enhancement,
spectroscopy, and, possibly, diffusion imaging will
achieve sensitivity for significant cancers of around
Fig. 5 – Case 4: PSA 22 ng/ml, cT1c. MRI T2-weighted (A) and DCE T1-weighted (B). Axial sections at midgland showing
suspicious area in the right TZ (arrow). (A) No suspicious area; (B) suspicious area with early enhancement at 30 s with high
signal intensity. Four of 5 right systematic biopsies were positive on maximum 8 mm in length, and 3 of 3 targeted biopsies
were positive on 15 mm in length for adenocarcinoma (4+3 = 7). PSA = prostate-specific antigen; MRI = magnetic resonance
imaging; DCE = dynamic contrast-enhanced; TZ = transitional zone.
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Fig. 6 – Case 5: PSA 8.6 ng/ml, cT1c. MRI T2-weighted (A) and DCE T1-weighted (B). Whole-mounted section at midgland (C).
Axial sections at apex showing suspicious area in the anterior fibromuscular stroma (arrow). (A) Suspicious area; (B)
suspicious area with early enhancement at 30 s with high signal intensity. One apex systematic biopsy was positive on
1 mm in length, and one targeted biopsy was positive on 7 mm in length for adenocarcinoma (3+3 = 6). Cancer areas
correlated with MRI suspicious areas. PSA = prostate-specific antigen; MRI = magnetic resonance imaging; DCE = dynamic
contrast-enhanced.
Fig. 7 – Case 6: PSA 12 ng/ml, cT1c. MRI T2-weighted (A) and DCE T1-weighted (B). Axial sections at apex showing suspicious
area anterior to urethra (arrow). (A) No suspicious area; (B) suspicious area with early enhancement at 30 s with high signal
intensity. Systematic biopsies were negative, and targeted biopsies were positive on 12 mm in length for adenocarcinoma
(3+3 = 6). PSA = prostate-specific antigen; MRI = magnetic resonance imaging; DCE = dynamic contrast-enhanced.
european urology supplements 6 (2007) 525–532
90%, with acceptable specificity. Our results showed
that prebiopsy PPA DCE-MRI is an accurate technique for detecting and quantifying intracapsular
anterior (TZ) or posterior (PZ) tumour foci >0.2 cc
with a sensitivity and a specificity, respectively,
of 77% and 91%. These results suggest that cancers
missed would be of limited clinical significance
and allow a cautious optimism about the potential
adequacy of MRI to exclude cancer in a screening
setting. Forty-four prostate cancers were detected
by biopsy in a series of 83 patients who had
prebiopsy diffusion-weighted imaging and dynamic
MRI in combination with T2-weighted imaging. The
sensitivity, specificity, accuracy, and area under the
receiver operator curve (Az) for the detection of
the prostate cancer were 95%, 74%, 86%, and
0.966, respectively. The sensitivity, specificity, and
accuracy were significantly better than those of T2weighted imaging alone [21]. In a series of 46 patients
in which DCE-MRI with PPA was correlated against
RP specimens, it was shown that, of tumours >0.3
cc, 50–60% and 78–81% were correctly depicted with
T2-weighted and DCE imaging, respectively. For
both techniques, the depiction rate of tumours >0.3
cc was significantly influenced by the Gleason score
(most Gleason 6 tumours were overlooked), but not
by the tumour volume [14].
5.
Conclusions
Prebiopsy PPA DCE-MRI is an accurate technique
for detecting and quantifying intracapsular TZ or
PZ tumour foci >0.2 cc. It has several applications,
such as the screening for prostate cancer and excluding cancer in patients with a raised PSA level,
targeting of biopsies, estimating cancer volume
and prognosis, and, in the future, monitoring of
disease both during active surveillance and after
focal therapy.
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
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