Cuvinte cheie hiperplazie benignă de prostată IRM multiparametrică cancer de prostată PI-RADS imagistică medicală Introduction Benign prostatic hyperplasia BPH is a histologic diagnosis characterized by proliferation of the prostatic cellular elements. Benign hyperplastic nodules are most commonly seen in the transition zone, but they can also protrude into the peripheral zone or even beyond the prostatic capsule, normal volume of prostate in ml as an exophitic pelvic mass normal volume of prostate in ml as a mass within the bladder 2.
Usually, there is a direct relationship between prostate enlargement and symptoms severity, although many patients with small prostates also present urinary obstruction, because of the strategically position of the adenoma, sitting right on the bladder outlet 2.
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The initial evaluation should asses the frequency and severity of symptoms by using the International Prostate Symptom Score IPSS 4 and it should also include a digital rectal examination and urinalysis. Enlargement of the prostate associated with a palpable nodule and elevated PSA prostate specific antigen level requires imaging methods of diagnosis, such as transrectal ultrasonography which provides a more accurate assessment of prostate volume than digital rectal examination does 5 and MRI for the characterization of the prostatic tissue, due to its excellent contrast resolution.
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- Antigenul specific prostatic (PSA)
Case report We present the case of a year-old patient who was referred to the urology department of our clinical institute three years ago, with lower urinary tract symptoms LUTS.
PSA value was Digital rectal examination and transrectal ultrasonography revealed an increased prostate. The patient was directed to our department, where we performed an MRI investigation, in order to rule out prostate cancer, possibly associated with BPH. A written consent was taken from the patient before entering normal volume of prostate in ml scanner room, after he was interviewed about his medical history, possible allergies, previous examinations and MRI contraindications.
An intravenous antispasmodic agent is routinely used, in order to decrease the artifacts generated by intestinal motility, after a venous line is secured. He was investigated on a Toshiba 1. High-resolution multiplanar T2 WI are morphological sequences ideal for the prostate anatomy evaluation.
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Dynamic contrast enhancement DCE and diffusion-weighted DWI are functional sequences, corresponding to angiogenesis and cellular density, respectively. MR-spectroscopy MRS is another functional sequence that correlates with cellular turnover, but we do not perform it routinely. The scanning protocol is listed in Table 1. Contrast media is injected in a volume of 0.
Prostate Size and Cancer
Table 1. The routine multiparametric MRI protocol for prostate imaging used for the patient Imaging findings showed an enlarged prostate, with its three diameters of 51 mm, 61 mm and 41 mm longitudinal normal volume of prostate in ml, axial diameter and anteroposterior diameter, respectivelywith an estimated total volume of The transitional zone TZ appeared asymmetrically enlarged, predominantly on the right half of the prostate, which led to the compression of the urethra being displaced to the left and thinning the peripheral zone PZespecially on the right side of the base.
The PZ showed diffuse decreased signal intensity on T2WI alimente condimentate prostatita no restricted diffusion, typical aspect for chronic inflammatory lesions. The TZ presented multiple small cystic areas and a multinodular structure because of the presence of stromal and glandular nodulesthe biggest one being located in the right middle third and apex of the TZ, with an axial diameter of 38 mm.
We noticed a bulging aspect of the macronodule described in the right TZ, protruding into the neighboring PZ, with a central area of increased signal intensity on diffusion WI and decreased signal intensity on ADC map, but a negative dynamic contrast enhancing DCE curve Figures 1 and 2. Figure 1.
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This particular right TZ nodule has been marked with a final PI-RADS score of 3, which means that the presence of clinically significant cancer is equivocal. Discussion BPH nodules appear as a mixture of signal intensities, ranging from hypointense to hyperintense on T2 WI, depending on the proportion of their stromal and glandular components.
They are well-delineated nodules that arise in the TZ, involving the periurethral regions, but sometimes they can bulge the surgical capsule, so they can be found in the PZ.
The patient was referred for prostatic biopsy one month after the MR examination, considering the elevated PSA value, which revealed a benign appearance of the sample: polymorphic aspect on account of a chronic inflammatory, non-specific process. Retrospectively, we can conclude that DWI changes and elevated PSA value may be due to this chronic inflammatory, non-specific process. The patient received anti-inflammatory treatment and remained under urological surveillance.
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Conclusions Multiparametric MRI is a precious tool in prostate tissue characterization, completing clinical and biological information, but in case of BPH, a suspected prostate carcinoma in the TZ may represent a real challenge for the radiologist. Often, biopsy is mandatory for a definitive differentiation between inflammatory lesions and prostate cancer. Bibliografie Lim KB. Epidemiology of clinical benign prostatic hyperplasia.
Asian J Urol. Foo KT. Diagnosis and treatment of benign prostate hyperplasia in Asia. Transl Androl Urol.
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Emberton M, et al. Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management.
Int J Clin Pract.
Liao CH, et al. Diagnostic value of International Prostate Symptom Score voiding-to-storage subscore ratio in male lower urinary tract symptoms. Edwards JL.