Radiologic Evaluation of Prostate Cancer

Size: px

Start display at page:

Download "Radiologic Evaluation of Prostate Cancer"

희원 천
5 years ago
Views:

1 Transrectal Ultrasonography of Prostate 오영택 연세대학교의과대학 영상의학과

2 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

3 Prostate Anatomy McNeal zonal anatomy Glandular zones (70%) Central gland Transitional zone (5%, BPH) Periurethral glandular tissue(1%) Central zone (25%) Peripheral zone (70%) Peripheral gland Central zone (25%) Non-glandular region (30%) Anterior fibromuscular stroma Cancer 20% 10% 70%

4 McNeal Zonal Anatomy Ref. McNeal JE. Am J Surg Pathol 1988;12:

5 TRUS of Prostate Probe Side-,, end-firing endocavitary probe Axial scan : oriented more coronally at base than apex in end-firing probe 8 12 MHz Rubber cover Position Lateral decubitus Gently insert through sphincter with sufficient lubricant gel

6 Transrectal Ultrasonography

7 Transrectal Ultrasonography

Transitional zone Coarse & slightly hypoechoic Increasing

8 BPH TRUS: Normal Appearance Prostate Peripheral zone No clear differentiation from central zone Homogeneous Iso/hyperechoic Transitional zone Coarse & slightly hypoechoic Increasing volume in BPH Surgical capsule Santorini s venous plexus Normal

9 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

10 Volume TRUS: Measurement of Prostate Volumes Normal : 20 g (> 40 g : enlargement) Evaluation of lower urinary tract symptoms Diagnosis Procedure selection Response to treatment Interpretation of serum prostate specific antigen (PSA) levels Determination of PSA density

11 Method TRUS: Measurement of Prostate Volumes Digital rectal exam (DRE), cystourethrography urethrocystoscopy,, urethral pressure profile inaccurate TRUS, CT, MR more accurate Planimetry volume (PV) calculation Prolate ellipse volume (PEV) calculation Ellipsoid volume measurement technique

523 For three unequal axes Practical for routine

12 TRUS: Measurement of Prostate Volumes Prolate ellipse volume (Width x Height x Length) x For three unequal axes Practical for routine clinical application Fast and relatively precise Universal availability H W L

13 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

14 TRUS: Benign Prostatic Hyperplasia Periurethral & transitional zone Stromal nodule formation Continued growth Compressed peripheral gland Surgical capsule fibrous cleavage plane between two glands bladder-outflow obstruction Compression of urethra or occlusion of bladder neck

15 TRUS: Benign Prostatic Hyperplasia TRUS finding Diffuse or nodular enlargement of central gland In early, low echoic discrete nodular appearance Progression, nodules increase in size and number mixed variable echogenicity (hypo, iso, hyperechoic) Surgical capsule formation Calcification Increase in frequence with age Usually along the surgical capsule

16 TRUS: Benign Prostatic Hyperplasia TRUS finding Prostatic or periprostatic cysts Abnormality in digital rectal exam (DRE) Ddx.. from malignancy by TRUS Cancer mimic Contour bulging Peripheral zone Ingrowths to bladder neck (median lobe)

17 TRUS: Benign Prostatic Hyperplasia

18 Calcification along Surgical Capsule

19 BPH Nodule Growing into Bladder Neck

20 BPH nodule on peripheral zone

21 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

22 TRUS: Prostate Cancer Prostate Cancer on TRUS Hypoechoic in peripheral zone: 60-70%, typical Overlap with benign lesions prostatitis,, atrophy, infarction positive predictive value (25-30%) Isoechoic : 25-40%, not detected Hyperechoic : 1-2% 1

23 TRUS: Prostate Cancer Isoecohic cancer

24 TRUS: Prostate Cancer Prostate cancer in transitional zone Very difficult to detect Underlying heterogeneity of BPH Cancer screening Using only TRUS, not appropriate method Combination with DRE, PSA

25 TRUS: Prostate Cancer Prostate Cancer Staging Detection of lesion Not accurate Extracapsular extension Sensitivity < 60% Contour bulging Focal area of periprostatic fat plane obliteration Thickening or asymmetricity of seminal vesicle

26 Extracapsular Extension of Prostate Cancer SV invasion

27 Benign Lesions mimicking Cancer

28 TRUS: Prostate Cancer Color/Power Doppler TRUS May improve detection of prostate cancer (10% more) Increased Doppler flow, associated Increased Gleason score Seminal vesicle invasion Higher rate of post-therapy therapy relapse Increased microvessel density, associated Presence of the cancer Metastases Stage of disease Disease specific survival Drawback Increased vascualrity in Inflammation Contrast-enhanced TRUS

29 Doppler US: Prostate Cancer

30 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

31 TRUS guided Biopsy Advantage More accurate than DRE Distributed throughout prostate in standard geometric pattern Minimize risk of damage to midline structure and bladder Positioning along peripheral zone without damage to neurovascular bundle Detect more abnormality than DRE

32 TRUS guided Biopsy Indication Elevated prostate specific antigen (PSA) > 4.0 ng/ml : PPV 17 ~ 28% > 10 ng/ml : PPV 42 ~ 64% Age-adjusted PSA, PSA density, free PSA ratio, PSA velocity ( > 0.75 ng/ml/year) Abnormal Digital Rectal Examination (DRE) Abnormal TRUS findings Evaluation treatment result or recurrence

33 TRUS guided Biopsy Preparation Stop some medications Anticoagulation, aspirin, NSAID, herbal medication Cleansing enema Antiobiotic prophylaxis Complication Hematuria (23.6%), hematospermia (45.3%) Fever (5%), voiding difficulty(13%) Severe hemorrage or sepsis (<1%): life- threatening

34 TRUS guided Biopsy Local anesthesia The more number of biopsies the better chance of diagnosing prostate cancer the more pain induced Local anesthesia makes it possible to obtain many tissues with acceptable range of pain Nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient Nash, P.A. J Urol 1996;155:607 Periprostatic infiltration of lidocaine,, injection into Denonviller s fascia, lidocaine gel infusion into rectum

TRUS guided Biopsy Strategy (I) Directed biopsy TRUS and/or DRE Sextant biopsy technique Hodge KK et al, J Uro 1989.

35 TRUS guided Biopsy Strategy (I) Directed biopsy TRUS and/or DRE Sextant biopsy technique Hodge KK et al, J Uro Three core ( base, mid, apex) on both side Improve detection of prostate cancer than targeted biopsy Significant minority of cancers were not detected by sextant biopsy

36 TRUS guided Biopsy Strategy (II) Modified sextant biopsy Laterally directed sextant 8, 10, 12 biopsy cores, even more Optimal number and location Need extensive research Transitional zone biopsy Routine biopsy is controversy Recommended : >10ng/ml with previous negative biopsy

37 TRUS guided Biopsy

38 Transrectal Ultrasonography (TRUS) of Prostate Anatomy of Prostate Measurement of Prostate Volume Benign Prostatic Hyperplasia Prostate Cancer Prostate Biopsy Guiding Inflammatory Disease

39 TRUS: Inflammatory Disease Acute bacterial prostatitis/abscess Diagnosed clinically & treated without need for imaging Indication Unresponsive to Tx., abscess drainage Risk for sepsis E coli : usual infecting agent TRUS Generalized enlargement and more rounded symmetrical contour Decreased echogenicity Multifocal hypoechoic area Fluid-filled abscess cavity Extension of abscess to seminal vesicle & extracapsule

40 TRUS: Inflammatory Disease Chronic bacterial/nonbacterial prostatitis Symptomatic/asymmtomatic asymmtomatic Abnormal DRE, elevated PSA with fluctuation Granulomatous Prostatitis Malakoplakia TRUS finding Hypoechoic change of PZ (focal, multifocal,, diffuse) mimic cancer, need biopsy Increased vascularity Calcification Periprostatic venous engorgement Seminal vesicle abnormality dilatation, loculation, septal thickening

41 TRUS: Chronic Prostatitis

42 TRUS: Seminal Tracts Seminal vesicle (SV) Length : cm (TRUS : cm) Width : (TRUS: cm) Mucoid,, alkaline secretion help activate spermatozoa 70% of male ejaculate vas deference Continuation of tail of epididymis Ampullary segment join with excretory duct of SV -> ejaculatory duct -> > open into the prostatic urethra on either side of verumontanum TRUS Symmetrically hypoechogenicity Fine internal echoes or septation by convolution

43 TRUS: Seminal Tracts Ejaculatory duct VD VD SV SV

44 TRUS: Seminal Tracts Congenital anomaly Agenesis Seminal vesicle cyst Combined renal anomaly Mid line cyst Utricular cyst, mullerian duct cyst, ejaculatory duct cyst May cause obtruction of ejaculatory duct

45 Mid Line Cyst

46 TRUS: Seminal Tracts Acquired disease Inflammation Neoplasms Adenocarcinoma,, sarcoma, seminoma, leiomyoma, Metastasis from malignancy of prostate, rectum, bladder Infertility & hematospermia evaluation Ejaculatory duct obstruction, anomaly Inflammation, stone, prostate cancer

47 Ejaculatory Duct Obstruction with Seminal Vesicle dilatation Ejaculatory duct

48 Acquired Disease Chronic inflammation Invasion of prostate cancer

슬라이드 1

슬라이드 1 Proposed Korean guideline for the diagnosis of BPH Hyun Woo Kim The Catholic University of Korea BPH Guideline AHCPR guideline on BPH (1994) AUA guideline on BPH (2003) EAU guideline on BPH (2004) International