P t t CP t t CProstate Cancer Prostate Cancer MR R tMR R tMR ReportMR Report

Vik K d M D Ph DVikas Kundra, M.D., Ph.D.

Disclosure InformationDisclosure InformationDisclosure InformationDisclosure InformationVikas Kundra, M.D, Ph.D.Vikas Kundra, M.D, Ph.D.

I have no financial relationships to disclose.

I WILL NOT include discussion of investigational or off-label use of a gproduct in my presentation.

MR ReportMR Report Location in the gland Location in the gland

– Right, Left, Bilateral– Apex, Mid gland, Basep g

Extracapsular extension Neurovascular bundle invasionT Neurovascular bundle invasion Seminal vesicle invasion Adjacent organs Adjacent organs Lymph node metastasis B t t i

NM Bone metastasis

Prostate size in three dimensionsM

Periprostatic vessels Useful term: Organ confined disease

Vikas Kundra, M.D., Ph.D.

MR ReportMR Report

Location in the gland– European Consensus Meeting Recommendationsp g

Dickinson L et al. European Urology 59 (2011) 477-494Divide prostate into multiple regions Divide prostate into multiple regions

– 16 regions– 27 regions– Each region is assigned a number

Vikas Kundra, M.D., Ph.D.

Prostate CancerProstate Cancer -- AnatomyAnatomyProstate Cancer Prostate Cancer AnatomyAnatomy Imaging Anatomic % glandular % of Imaging Anatomic % glandular % of

tissue prostate cancer in the glandg

Central Transition 5% 25%

Central 20% 5%

Peripheral Peripheral 75% 70%p p

Fibromuscular Fibromuscular 0% 0% Stroma StromaStroma Stroma

Vikas Kundra, M.D., Ph.D.

A

AB

B

B

C

C

Vikas Kundra M D Ph D

Prostate Prostate -- AnatomyAnatomy

Central zone

Peripheral

Urethra

pzone

ilProstate coil

T2-weighted MR Vikas Kundra, M.D., Ph.D.

Prostate Prostate -- AnatomyAnatomy

Neurovascular

Prostate

bundle at 5 and 7 o’clockP t t ilProstate coil

T1-weighted MR Vikas Kundra, M.D., Ph.D.

Prostate Cancer Prostate Cancer -- StagingStaging Based on Tumor-Node-Metastasis (TNM) system

– (T) Primary Tumour E l t t ll t d b i i T fi d t Early tumors are not well staged by imaging: Tumor confined to gland

– TX. Cannot be assessed – T0 NoneT0. None– T1. Clinically inapparent by palpation or imaging

• Incidentally noted tumorT1a. in < 5% of histologic specimen T1b i 5% f hi l i iT1b. in >5% of histologic specimen • Tumor soughtT1c. Tumour identified by needle biopsy (e.g., because of elevated PSA)

MR becomes importantMR becomes important T2. Clinically apparent

– T2a. <1/2 of a lobe T2b >1/2 of a lobe but not both lobesT2b. >1/2 of a lobe, but not both lobes T2c. Both lobes involved

(TNM online ©2005 by John Wiley & Sons, Inc.)Vikas Kundra, M.D., Ph.D.

T2 Prostate Carcinoma i l i th l ft id l d

T1T2involving the left mid gland

Vikas Kundra, M.D., Ph.D.

T2 Prostate Carcinoma left id l d PZ d CZmid gland PZ and CZ

ADCT2 ADC T2

Vikas Kundra, M.D., Ph.D.

Multifocal Prostate Cancer Multifocal Prostate Cancer T1 T2

T2 T2T2 T2

Vikas Kundra, M.D., Ph.D.

Prostate Cancer Prostate Cancer -- StagingStagingBased on Tumor-Node-Metastasis (TNM) system

– (T) Primary Tumour– (T) Primary TumourBetter staged by imaging (MR and CT)

T3 T d h h h i l T3. Tumour extends through the prostatic capsule– T3a. Extracapsular extension

T3b Seminal vesicle(s) invasionT3b. Seminal vesicle(s) invasion

T4. Invasion of adjacent structures other than seminal vesiclesvesicles

– bladder neck, external sphincter, rectum, levator muscles, or pelvic wall

(TNM online ©2005 by John Wiley & Sons, Inc.)

Vikas Kundra, M.D., Ph.D.

Focal prostate carcinoma on the right with b l d l i l i l fbulge and capsular irregularity at left apex

Periprostatic vesselsT2 T1

Periprostatic vessels

Vikas Kundra, M.D., Ph.D.

Neurovascular Bundle InvasionNeurovascular Bundle Invasion

Vikas Kundra, M.D., Ph.D.

Seminal Vesicle InvasionSeminal Vesicle InvasionSeminal Vesicle InvasionSeminal Vesicle Invasion

Vikas Kundra, M.D., Ph.D.

Biopsy related hemorrhage is hyperintense on T1 and hypointense on T2. Hemorrhage can mask an

T1 T2

yp gunderlying tumor in the prostate and seminal vesicles.

Vikas Kundra, M.D., Ph.D.

T4 Prostate CarcinomaT1 T2

Vikas Kundra, M.D., Ph.D.

Prostate Cancer Prostate Cancer -- StagingStaging( ) i ( C ) (N) Regional Lymph Nodes (MR and CT)– NX. Cannot be assessed

N0. None N1. Regional lymph node metastasis (external iliac, internal iliac, and presacral chains)

(M) Distant Metastasis (Bone scan, MR and CT)– MX. Cannot be assessed

M0 None– M0. None– M1. Distant metastasis present

M1a. Non-regional lymph node(s) (not in true pelvis, includes common iliac and para-aortic)and para aortic)

Up to 50% of nodal metasasis are para-aortic without concurrent pelvic nodal metasasis – suggests hematogenous spread and suggests imaging of the abdomen for staging

M1b Bone(s)M1b. Bone(s)M1c. Other locations

(TNM online ©2005 by John Wiley & Sons, Inc.)Vikas Kundra, M.D., Ph.D.

Lymph Node MetastasisLymph Node Metastasisy py p

N1 M1N1 M1a

Vikas Kundra, M.D., Ph.D.

Osseous MetastasisOsseous Metastasis

M1

Vikas Kundra, M.D., Ph.D.

MR ReportMR Report Location in the gland Location in the gland

– Right, Left, Bilateral– Apex, Mid gland, Basep g

Extracapsular extension Neurovascular bundle invasionT Neurovascular bundle invasion Seminal vesicle invasion Adjacent organs Adjacent organs Lymph node metastasis B t t i

NM Bone metastasis

Prostate size in three dimensionsM

Periprostatic vessels Useful term: Organ confined disease

Vikas Kundra, M.D., Ph.D.

Th kTh kThank youThank you

Vikas Kundra, M.D., Ph.D.