BODY APPLICATIONS OF MRI 89

Chapter Seven

Tom Schrack, BS, ARMRIT

Fairfax Radiological Consultants
Fairfax, VA
CHAPTER SEVEN

Prostate MRI
After completing this chapter, the reader will be able to:
■ Identify the anatomy and function of the prostate gland
■ Respond appropriately to the patient, given the sensitive

nature of the prostate MRI exam

■ Explain the basic imaging procedures for the prostate gland

Pelvic imaging is virtually the same for men as for women. Obviously, the internal organs of
the male and female pelvis are different, but imaging protocols, pulse sequences, and imaging
weighting vary little by gender. The most obvious and significant role for MRI in a male-specific
pelvic application is the prostate gland, and prostate cancer is by far the most common indication
for pelvic MRI.

OVERVIEW A private, reserved bathroom must be avail-

able to the patient immediately following the
One in 35 men will die of prostate cancer,
exam. While this is a fast, virtually pain-free,
and prostate cancer is the second most
and highly-diagnostic exam, few MR facilities
common cancer after skin cancer. It is the
offer this application because of the nature of
second leading cancer death in men after lung
the exam.
cancer. In 2009, it is estimated that more than
190,000 men will be diagnosed with prostate
cancer. However, due in part to advances in
early detection, the five-year survival rate for POINTS FOR PRACTICE
men with prostate cancer is nearly 100%. The
relative 10-year survival rate is nearly 91%, 1. The prostate gland is segmented into what
while the 15-year survival rate is approximately three zones?
76%.1 For men diagnosed today with prostate
2. Which condition is typically associated with
cancer, the long-term outlook is even better. the central zone?
As with pelvic floor imaging, this exam
3. What is the role of SER?
requires the utmost sensitivity to the patient
to guarantee privacy and maintain dignity. 4. Name some advantages of using MR
The exam needs to be explained in detail spectroscopy.
prior to the beginning of the evaluation.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
90

Bladder

A
B B
C
C

Prostate

Figure 90. Bladder and prostate anatomy.

The prostate has a variable position, some- Figure 92. Coronal prostate anatomy.
times leaning anteriorly or slightly posterior- A = transitional zone
ly. Coronal MR imaging is best performed in B = central zone
the oblique coronal plane, tilted to coincide C = peripheral zone
with the vertical axis of the prostate. D = seminal vesicles

ANATOMY
The purpose of the prostate gland is to secrete
seminal fluid (approximately 30% in total),
A B mixing with sperm and fluids from the seminal
B vesicles to make up the components of semen.
C C
The area of interest in prostate MRI includes
the prostate gland itself, which is segmented
into 3 zones: the central zone, the transi-
tional zone, and the peripheral zone, as
D well as the seminal vesicles. The role of MRI
is to evaluate tumor extension, either extra-
capsular or direct seminal vesicle invasion
(Figures 90, 91, and 92).

Figure 91. Axial prostate anatomy. IMAGING PROTOCOL

A = transitional zone
B = central zone The prostate gland is optimally imaged using
C = peripheral zone an inserted endorectal coil in conjunction with
D = air-filled rectum the pelvic phased-array coil, allowing for eval-

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 PROSTATE MRI 91
Chapter Seven

may be altered by therapy.

Standard Imaging Protocol

The typical prostate protocol consists of axial,
sagittal, and coronal T2 imaging without fat
suppression. Because high spatial resolution
is required, the slice thickness is thin, usually
3.0 mm or less. See Table 14 on page 97.

Diffusion-Weighted Imaging
There is growing interest in the utility of
diffusion-weighted imaging of the prostate.
Apparent diffusion coefficient (ADC) maps
show promise in demonstrating cancerous
Figure 93. Axial T1 of a patient 4 weeks diffusion (Figure 94b). The use of parallel
post-biopsy. Note the residual blood in the
imaging and multi-direction diffusion tensor
left peripheral zone (circle). The exam did
not proceed and was re-scheduled for 4 imaging (DTI) greatly decreases potential
weeks later. geometric distortion common in some DWI
imaging, as well as increasing SNR (Figure
94a).

Endorectal Coil
uation of the entire pelvis for possible cancer
Just as with female breast MRI and pelvic floor
involvement and providing high spatial resolu-
imaging, special considerations for the patient
tion images of the prostate with high SNR.
should be made for the prostate patient. The
endorectal coil uses an inflated bulb to hold it
History of Biopsy in place. A water-soluble lubricant must be
used for insertion, but care must be taken in
If the patient has had a previous biopsy, a
determining how much to use because the
minimum of six to eight weeks should sepa-
gel lubricant produces a bright signal profile.
rate biopsy and MR imaging to allow any
Using too much lubricant can result in exces-
residual blood from the biopsy to resolve.
sive ghosting caused by rectal spasms; using
Blood in the prostate can obscure, or worse,
too little makes insertion painful.
mimic carcinoma (Figure 93).
The coil should be inserted so that the coil
At the time of the exam, the patient’s PSA
element is seated just posterior to the prostate.
(prostate-specific antigen) level, Gleason
The bulb should be inflated to the patient’s
score, biopsy date, and whether radiation
tolerance level, usually 90-110 mL of air but
or hormonal therapy has been administered
no more than 120 mL.
should be noted. This information is extremely
useful for the radiologist when interpreting the
MR images as prostate gland image contrast

©2009, International Center for Postgraduate Medical Education. All rights reserved.
92

a b

Figure 94. Axial diffusion-weighted images of the prostate. (a) 6-direction diffusion tensor-weighted
image indicating possible lack of normal perfusion in the left peripheral zone (circle). (b) The
apparent diffusion coefficient (ADC) map of the same location. Dark area (circle) confirms diffusion
deficit.

MRI FINDINGS through the pelvis is useful for evaluating

adenopathy related to prostate cancer
(Figures 95 and 96).
Benign Prostate Hyperplasia (BPH)
Most prostate cancers occur in the peripheral
Seminal Vesicle Invasion
zone but are not uncommon in other zones.
The central zone is most commonly associated Cancerous invasion of the seminal vesicles
with benign prostate hyperplasia (BPH). typically demostrates as hypointense signal on
This condition often results in an acute need to T2-weighted imaging as with prostate cancer
urinate but with low yield. BPH is not always within the zonal areas as discussed above.
associated with cancer; however, cancer of Moreover, the cancerous invasion usually
the prostate can result in the same urinary appears as a “mass-effect” as it displaces
dysfunction, so it is important to have this normal seminal vesicle tissue as shown in
condition medically evaluated without delay. Figure 97.

Prostate Cancer Prostatitis

Prostate cancer (PCa) typically demonstrates Prostatitis is an inflammation of the prostate
as hypointense signal on T2-weighted imaging gland and can be chronic or acute. MR
and is usually performed in all three planes to imaging of the prostate in an attempt to
the prostate. This sequence is also essential for differeniate between prostate cancer and
BPH evaluation. Axial T1-weighted imaging noncancerous prostatitis can be challenging

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 PROSTATE MRI 93
Chapter Seven

a b

Figure 95. (a) Axial T1 of the prostate. Large central zone cancer of the prostate in a 65-year-old
male. The circle indicates a large, hypointense tissue along the anterior wall of the prostate.
(b) Axial post-contrast. Post-dynamic gadolinium contrast injection of the same patient. Circle
indicates rapid contrast uptake indicative of a cancerous prostate gland.

a b

Figure 96. (a) Axial T2 of the prostate of a 77-year-old male. The circle indicates a recurrence in the
mid-left peripheral zone posterior and lateral. (b) Axial post-dynamic gadolinium enhancement of
the same patient. The circle indicates strong contrast uptake indicative of prostate gland carcinoma.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
94

a b

Figure 97. Axial (a) and coronal (b) T2- weighted images of a 64-year-old male with prostate
carcinoma with seminal vesicle invasion (circles).

as prostatitis demonstrates many of the same

signal characteristics as prostate cancer. Low
signal intensity of homogeneous tissue in the
peripheral zone is present in both prostate
cancer and prostatitis. Focal hypointense tissue
signal that is not specfic for cancer is the most
common MR finding in chronic prostatitis.2

SIGNAL ENHANCEMENT RATIO

The role of IV gadolinium contrast in prostate
MRI is not well-defined, as studies thus far
have yielded differing results as to the utility
of using a GBCA. A normal, noncancerous
prostate gland will show modest contrast
uptake enhancement. However, a cancerous
Figure 98. Signal Enhancement Ratio map
gland also enhances. Use of Signal Enhance- showing the maximum rate of contrast
ment Ratio (SER) maps can be useful for uptake. Large dark area (white arrow) in the
determining contrast-uptake differences left peripheral zone is much larger and
between normal and cancerous tissue where a darker compared to the smaller, less dark
normal gland enhances slower than a cancer- areas of the central zone (black arrows).
ous gland (Figures 98 and 99).

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 PROSTATE MRI 95
Chapter Seven

5210 MR Units a b
5000 3
3

4000
#3
2
1
Cho
1:0.243 c Ci
1:0.409
d
3000
0.03
2
1
0.03

0.02
Ci
2000 0.02 1:0.140

Cho
1:0.0865
0.01
0.01 Cr
Cr 1:0.0714
1:0.0182

1000 0.00 0.00

729
1 2 3 4 5 6 7 8 9 10 ppm
4 3 2 4 3 2 1

Figure 99. Signal Enhancement Ratio curve. Figure 101. Prostate spectroscopy. (a) Axial
Contrast update map of the ROI shown in T2-weighted image. (b) Apparent diffusion
Figure 98 indicating volume and rate of coefficient map. (c, d) Spectrums of the
enhancement. ROI #3 shows a visibly areas indicated by the arrows. Note the high
greater rate and volume of enhancement choline (c) and citrate (d) peaks, indicating
versus ROI #1 and 2, consistent with prostate carcinoma. Courtesy of UCLA.
prostate carcinoma.

MRI findings of extracapsular extension

include irregular bulge of the prostate margin,
contour deformity with step-off or angulated
margin, breach of the capsule with direct
tumor extension, obliteration of rectoprostatic
angle, and asymmetry of neurovascular
bundles. Axial images are essential in the
evaluation of extracapsular invasion.

MR SPECTROSCOPY
MR spectroscopic (MRS) imaging has recently
expanded the diagnostic assessment of the
prostate beyond simple anatomic information.
MRS provides metabolic information specific
Figure 100. Prostate spectroscopy metabo- to the prostate through the detection of the
lite map showing high concentrations of
cellular metabolites citrate, creatine, and
choline. Courtesy of GE Healthcare.
choline. Information obtained from MRS

©2009, International Center for Postgraduate Medical Education. All rights reserved.
96

allows an expanded assessment of tumor SUMMARY

aggressiveness and risk of disease progression.
When performed with close attention to high
Typically, high concentrates of choline and
spatial resolution and signal-to-noise ratio,
low concentrates of citrate are indicative of
MRI of the prostate provides highly detailed
prostate gland carcinoma. However, normal
and useful information in the detection and
prostate gland may display lower citrate
staging of prostate cancer and benign prostate
concentrations following some hormonal ther-
hyperplasia. However, high-quality prostate
apies, such as androgen deprivation therapy3
imaging is invasive in that it requires the use
(Figures 100 and 101).
of an endorectal prostate coil, which may be
In the localization of PCa, combined MRI and uncomfortable for the patient. Emerging tech-
MRS demonstrate 91% specificity, the highest niques such as prostate spectroscopy, diffusion
value obtained by a noninvasive method.4 The tensor imaging, and functional post-processing
combined use of MRI and MRS significantly of dynamic contrast images into signal
improves evaluation of extracapsular spread enhancement maps may be useful additional
and decreases interobserver variability, signifi- tools in cancer evaluation of the prostate.
cantly increasing the value of MRI in the
evaluation of prostate cancer.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 PROSTATE MRI 97
Chapter Seven

Table 14.
SAMPLE PROSTATE SCAN PROTOCOL USING ENDORECTAL PROBE
3 Plane
Parameter Localizer Axial T1 Axial T2 Coronal T2 Sagittal T2
Patient Position
Orientation Feet first, Feet first, Feet first, Feet first, Feet first,
Supine Supine Supine Supine Supine
Coil Torso phased Torso phased Torso phased Torso phased Torso phased
array array array and array and array and
endorectal endorectal endorectal
Plane 3 Planes Axial Axial Oblique Sagittal
Imaging Parameters
Pulse Sequence GRE SE FSE FSE FSE
Scan Timing
Number of Shots
TE (msec) Minimum 120 120 120
TR 600 6,000 4,500 5,500
TI
FA 90 90 90
ETL 12 12 20
Options Resp Comp, Flow Flow Flow
NPW Comp, NPW, Comp, NPW, Comp, NPW,
VBw VBw VBw
Scanning Range
FOV (cm) 48 24-28 14 14 16
Slice Thickness (mm) 8 5 3 3 4
Slice Spacing (mm) 2 1 0 0 1
SAT Bands Inferior/Superior Inferior/Superior Inferior/Superior Inferior/Superior
Anterior/Posterior Anterior/Posterior
Acquisition Time
Acquisition Matrix Frequency 256 256 256 256 256
Acquisition Matrix Phase 128 192 192 192 256
NEX 2 1 4 4 3
Phase FOV 1 1 1 1 1
Frequency Direction R/L A/P S/I S/I
Auto Center Frequency Water Water Water Water Water
Autoshim Yes Yes Yes Yes Yes

Notes
• When using a probe, be sure the probe lies flat against the prostate; if it is rotated make the proper
adjustments before continuing past the localizer.
• The T1 axials should be placed from the bifurcation of the iliac arteries to the pubis symphysis.
• The T2s should cover from just above the seminal vesicle to just below the prostate gland.
• The use of a compression belt will help reduce respiratory artifact.
• Make the patient as comfortable as possible, offer music, elevate knees with a wedge or pillow.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
98

POINTS FOR PRACTICE

1. The prostate gland is segmented into what three zones?

The gland is comprised of the central zone, the transitional zone, and the peripheral zone, as
well as the seminal vesicles. The role of MRI is to evaluate tumor extension, either extracapuslar
or direct seminal vesicle invasion.

2. Which condition is typically associated with the central zone?

BPH – benign prostate hyperplasia – is most commonly associated with the central zone. BPH
is a condition that often results in the frequent need to urinate but with low yield. Urinary
dysfunction can also be a result of prostate cancer, making it imperative to have this condition
medically evaluated.

3. What is the role of SER?

A Signal Enhancement Ratio Map can be useful in determining contrast-uptake differences
between normal and cancerous tissue as a normal gland will enhance more slowly than a
cancerous gland.

4. Name some advantages of using MR spectroscopy.

In the localization of prostate cancer, combined MRI and MRS demonstrate 91% specificity, the
highest value obtained by a non-invasive method. This significantly improves the evaluation of
extracapsular spread while reducing inter-observer reliability.

REFERENCES
1. US National Institutes of Health. National Cancer Institute. Prostate Cancer. Available at:
[Link] Accessed July 9, 2009
2. Shukla-Dave A, Hricak H, Eberhardt SC, et al. Chronic prostatitis: MR imaging and 1H MR spectroscopic imaging
findings – initial observations. Radiology. 2004;231:717-724.
3. Noworolski S. Prostate MR Imaging. Paper presented at Annual Scientific Assembly and Annual Meeting of the
Radiological society of North America, December 2, 2009; Chicago.
4. Kurhanewicz J, Sotto CK, Coakley F. Magnetic resonance anatomic and spectroscopic imaging of prostrate cancer –
current status. PCRI Insights. 2006; 9(4).

All images, tables, and protocols courtesy of Fairfax Radiological Consultants, Fairfax, VA, unless otherwise noted.

©2009, International Center for Postgraduate Medical Education. All rights reserved.