前列腺MRI诊断再认识ppt课件

前列腺MRI诊断再认识20161203,前列腺癌MRI诊断再认识,2016-12-04,前列腺MRI诊断再认识20161203,2012年首次发表前列腺影像报告和数据系统（prostateimagingreportinganddatasystem,PI-RADS）。采用PI-RADS规范了前列腺MRI报告，具有良好的临床应用价值。2014年的北美放射学年会上，美国放射学会、欧洲泌尿生殖放射学会和AdMeTech基金会合作开发并发布了第二版PI-RADS（PI-RADSV2）,PI-RADS(前列腺影像报告和数据系统),前列腺MRI诊断再认识20161203,PI-RADSV2中将有临床意义的前列腺癌定义为Gleason评分7分，伴或不伴体积0.5cm3【直径约0.8cm】、包膜外侵犯。PI-RADSV2根据前列腺T2WI、DWI及DCE的综合表现，对出现有临床意义前列腺癌的可能性给出了评分方法：1分：非常低，极不可能存在；2分：低，不可能存在；3分：中等，可疑存在；4分：高，可能存在；5分：非常高，极有可能存在。PI-RADS评分4或5分应考虑活检。对于前列腺外周带疾病以DWI结果为主，例如DWI评分为4分，T2WI评分为2分，则PI-RADS评分为4分；前列腺移行带疾病以T2WI结果为主。,前列腺MRI诊断再认识20161203,1.1移行带T2WI,【大小、形态、信号均匀度/强度、边缘】,前列腺MRI诊断再认识20161203,移行带T2WI,T2:PI-RADS=1,T2:PI-RADS=4,前列腺MRI诊断再认识20161203,1.2外周带T2WI,【大小、形态、信号均匀度/强度、边缘】,前列腺MRI诊断再认识20161203,外周带T2WI,T2:PI-RADS=1,T2:PI-RADS=2,T2:PI-RADS=4,T2:PI-RADS=5,T2:PI-RADS=4,前列腺MRI诊断再认识20161203,2.DWI,良恶性ADC阈值0.75-0.95【MR750建议0.9】，最重要的一个阈值！,前列腺MRI诊断再认识20161203,3.1动态增强（DCE）-V1（弃用）,2和3型曲线，局灶性病变+12和3型曲线，病变不对称+1个人建议：加入早期增强速率有一点参考价值,前列腺MRI诊断再认识20161203,DCE-MRI-V1,DCE:PI-RADS=1,DCE:PI-RADS=2,DCE:PI-RADS=3,前列腺MRI诊断再认识20161203,3.2动态增强（DCE）-V2,【自己：增强形态学被忽视，如移行带结节强化内部“黑白错落有致征”与“黑白涂抹征”有价值】,前列腺MRI诊断再认识20161203,增生结节,腺癌,“黑白错落有致征”,“黑白涂抹征”,前列腺MRI诊断再认识20161203,4.MRS定性分析-V1（V2未纳入）,前列腺MRI诊断再认识20161203,B值：如果信噪比足够高，b值取16002000或更高，更有利于诊断。PI-RADSV2中建议，最小b值取100（而不是0），以便减少血流灌注对ADC值的影响。我院MR750：B值取100、1500、2100三个B值。无临床意义的前列腺癌不在V2评分范围（指病理Gleason评6分以下、体积0.5cm3、无包膜外侵犯），为潜伏癌或偶发癌，大多漏诊：外周带T2WI/DWI/DCE均可能显示，移行带仅靠DWI，故选择B值很重要，要1500以上，较低B值如800的T2透过效应严重。相当数量潜伏癌不发展成临床癌。,PI-RADS,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,PI-RADS与“七剑术”对比,PI-RADS标准很重要，但有缺陷！综合分析法可解决,前列腺MRI诊断再认识20161203,如何将PI-RADS融入自己的思维架构,一、概述、解剖基础（解剖细节）、检查技术二、将PI-RADS精髓融入自己的“七剑术”,前列腺MRI诊断再认识20161203,一、概述、解剖基础（解剖细节）、检查技术,前列腺MRI诊断再认识20161203,概述,前列腺癌是男性常见的恶性肿瘤之一。世界范围内，PCa患病率居男性恶性肿瘤第2位。我国PCa的患病率虽然远低于欧美国家，但近年来呈显著增长趋势。根据2013年的调查结果，1998年至2008年我国男性PCa患病率年均增加12.07%，这与人口的老龄化、生活水平的提高有关。近来泌尿学专家对活检前的前列腺MRI检查和MRI导引下前列腺穿刺活检非常热门。约30%前列腺癌PSA在正常范围内。个人建议3T-MRI平扫可作为筛查项目之一，有可疑异常，马上增强。,前列腺MRI诊断再认识20161203,解剖基础,基础决定高度！权威书籍或论文的解剖概念也混乱强调前列腺的解剖细节（如下面一组病例）3T-MR750高分辨率提供了最先进的武器,一组病例提示：T2WI+DWI+DCE与单纯T2WI相比，并不能提高前列腺移行带癌的检出率和定位准确率。,前列腺MRI诊断再认识20161203,PI-RADSv2,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,刘树伟主编的断层解剖学仅用“区”，未用“带”,前列腺MRI诊断再认识20161203,个人建议：仅用“带”细分。如要用中央带+移行带，则两者=中央区？但少数论著中央区=中央带。中央腺体=内腺=移行带（+尿道周围腺），中央腺体易误为含有中央带（如上文）。,前列腺MRI诊断再认识20161203,ExvivoT2-weightedimage(4700/42)ofthespecimen,obtainedat9.4T,showshighlycellular,compactdarktissueinthecentralgland(arrows)surroundingtheurethra(U).(h)Photographofawhole-mountreconstructedhistologicsection(originalmagnification,2;hematoxylin-eosinHEstain)ofthemidglandshowsalargevolumeoftumorinthetransitionzone(outlinedingreen).Notetheexcellentcorrelationwiththeexvivoimageingandtheinvivoimageinc,whichshowcancerofhighcellulardensityinthetransitionzone,前列腺MRI诊断再认识20161203,前列腺小囊为苗勒氏管盲端,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,P-周围带C-中央带T-移行带A-前肌纤维质U-尿道S-精囊e-射精管V-精阜,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,冠状层面，中央带呈八字形，更后层面呈Y字形,前列腺MRI诊断再认识20161203,外周带明显高信号提示早期增生？因前列腺小管受压、分泌液潴留,前列腺MRI诊断再认识20161203,精阜射精管,前列腺MRI诊断再认识20161203,前列腺分区（本科室应统一，建议只用“带”）,前列腺MRI诊断再认识20161203,前列腺组织结构,纤维肌肉基质区1/3,腺体部分2/3,外周带70%,中央带25%,移行带5%-10%,尿道周围区1%,前列腺MRI诊断再认识20161203,中央带起于精阜水平，向头侧方向扩展，直径逐渐增大，是前列腺基底部主要构成成分。由于中央带内含较多致密的平滑肌组织，信号较低且均匀，注意与MT鉴别。移行带位于尿道的前、外侧，从精阜水平伸到膀胱颈水平，在横轴位上呈马蹄形。正常前列腺外周带的腺泡沿着尿道呈放射状分布，腺体和腺管结构丰富。诸前列腺管开口于精阜周围的尿道。前列腺表面覆盖有两层被膜，内层称前列腺囊，为一坚韧的纤维肌性组织，紧包于前列腺表面。外层称前列腺筋膜，为盆脏筋膜在前列腺囊周围增厚而成。,前列腺MRI诊断再认识20161203,前列腺血管,动脉：膀胱下A、阴部内A、直肠下A.膀胱下动脉是前列腺的主要血液供应来源。膀胱下动脉在进入前列腺前又分为支，即前列腺被膜动脉和尿道前列腺动脉。前列腺外腺组的血供，主要由前列腺被膜动脉承担；尿道周围的腺体组织和前列腺深部组织，由尿道前列腺动脉供给。静脉：髂内V；与骶骨、腰椎和髂翼的静脉有交通；通过直肠上V汇入肝门静脉（可肝转移），因此，前列腺癌有腰骶部和髂部浸润时，为早期转移表现。淋巴：髂内、髂外,前列腺MRI诊断再认识20161203,T2WI：中央带及移行带腺体少，肌肉及间质致密，信号低；外周带腺体丰富，呈高信号外科假包膜:移行带与外周带之间有时可见低信号条状影，为受压的外周带和中央带形成。前列腺包膜：外周带外周低信号、厚度约1mm的、由纤维肌肉组织构成的T1中等信号包膜。,影像解剖前列腺MR,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,正常前列腺的MRI表现,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,中央带T2WI呈低信号，部分等信号；【自己观察到：多数情况下，DWI及DCE与外周带相似】。尿道周围腺体T2WI呈低信号。,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,前肌纤维质,移行带,周围带,中央带与CA鉴别,SLICE-5,前列腺MRI诊断再认识20161203,周围带（P）,中央带（C）,精囊（S）,前肌纤维质,尿道,正中矢状面,C,P,S,前列腺MRI诊断再认识20161203,中央带C,周围带P,移行带T,C,P,T,B,旁正中矢状面,前列腺MRI诊断再认识20161203,周围带,中央带,精阜,精囊,冠状面,P,C,前列腺MRI诊断再认识20161203,中央带,前列腺MRI诊断再认识20161203,注意：中央带ADC值低，约1.0，与癌有交叉,前列腺MRI诊断再认识20161203,正常前列腺T1WI,前列腺MRI诊断再认识20161203,检查技术,前列腺MRI诊断再认识20161203,前列腺MRI扫描前准备,患者适度充盈膀胱。膀胱过度充盈会引起波动伪影，膀胱排空后不利于观察前列腺与膀胱壁的关系及膀胱壁受累情况。胃肠道内容物对前列腺图像质量影响严重,保证检查时直肠内清洁。若先行前列腺穿刺活检，则穿刺活检与MRI检查至少间隔6周以上。线圈的中心正对耻骨联合，下腹部垫以海绵垫，并束紧前后片线圈压迫小腹以抑制呼吸运动，不需要前片线圈的支架。,前列腺MRI诊断再认识20161203,男性前列腺规范化扫描方案,邻近前列腺包膜有异常信号时，应加扫轴位T2WI不压脂序列。,前列腺MRI诊断再认识20161203,不压脂T2WI：Histopathologicfindingsconfirmedextracapsularextension,前列腺MRI诊断再认识20161203,AxDWI技术：,PI-RADSV2中建议，最小b值取100s/mm2（而不是0），以便减少血流灌注对ADC值的影响常规B值1500，或增加一个更高B值（2000以上，只要信噪比允许），有利诊断。一般情况下复制横断面T2定位像，注意，由于弥散序列使用ASSET，必须手动调节FOV大小，超过盆腔结构大小。必须添加局部匀场。频率编码为左右方向。若膀胱充满尿液，将会引起弥散图像伪影。早期病灶最好用HR-DWI-小FOV,前列腺MRI诊断再认识20161203,PitfallIX(lackofsuppressionofbenignprostatetissueonstandardhigh-b-valuediffusion-weightedimages):Impactofultrahighbvaluesfortumorconspicuityin61-year-oldmanwhounderwentprostateMRIafterpreviousprostatebiopsyshowingGleason3+4tumorinonecorefromleftmidglandperipheralzone.A,T2-weightedimageshowsfocalregionofdecreasedsignalintensity(arrow)inregionofbiopsy-proventumorinleftperipheralzone.B,Diffusion-weightedimageatb=1000s/mm2showsdiffusehyperintensitythroughoutperipheralzonebilaterally(arrows).Leftperipheralzonelesionisthereforenotreadilyapparent.C,Diffusion-weightedimageatb=1500s/mm2showsgreatersuppressionofsignalintensitythroughoutperipheralzonewithsubsequentgreaterconspicuityofareaofhyperintensityinregionofleftperipheralzonetumor(arrow),几年前上海市一3T-HDxt用B值800，太多良性也明显高信号，MR750已改用1500,前列腺MRI诊断再认识20161203,扫描其他注意事项,矢状位：尖部是前列腺癌的好发部位，底部的精囊腺根部是前列腺癌包膜外侵犯的好发部位。动态增强扫描一般不建议使用SCIC信号强度均匀性纠正技术。T2WI也不用SCIC,前列腺MRI诊断再认识20161203,二、将PI-RADS精髓融入自己的“七剑术”,前列腺MRI诊断再认识20161203,、临床,前列腺MRI诊断再认识20161203,PSA值,正常:10ng/ml可疑者1/3有癌，异常者2/3有癌PSA20ng/ml很少能幸免于前列腺癌结合TPSA、FPSA、FPSA/TPSA、PSAD等诊断PCa的敏感性为75%，而特异性仅40%约30%前列腺癌PSA在正常范围内,前列腺MRI诊断再认识20161203,游离前列腺特异抗原（fPSA）,近来研究发现血清中PSA以不同的分子形式存在，血清中有少量未结合的PSA称游离PSA。它对区分BPH和前列腺癌有重要意义，测定fPSA可提高PSA诊断前列腺癌的特异性，结果认为fPSA比率25，则可基本排除前列腺癌。如tPAS小于4，则fPSA比率无意义。,前列腺MRI诊断再认识20161203,、部位,前列腺癌来源于前列腺的腺泡或导管上皮前列腺癌：外周带68%，移行带24%，中央带8%病变分布对称否大约有83-85%的前列腺癌呈多发性。PI-RADS将移行带和外周带分开独立评分（见前）,前列腺MRI诊断再认识20161203,Prostatecancerina43-year-oldmanwithaGleasonscoreof4+3andaPSAlevelof90.5ng/mL.EndorectalMRimagingwasperformedat3.0T.(a)T2-weightedimage(4860/109)showsavoxelofinterest(square)intheleftperipheralzone.Althoughtheleftperipheralzoneisenlargedcomparedwiththerightperipheralzone,ithasnofocaldarkareas.Therearepatchydarkabnormalitiesintherightperipheralzone.(b)MRspectroscopicspectrumfromthevoxelofinterestshowsamarkedlyelevatedlevelofcholine(Cho)(arrow)thatisalmostequaltothecitrate(Ci)peak.Elevationofcholinelevelwithadecreaseincitratelevelisthespectralsignatureofprostatecancer.Cr=creatine.(c)ColorDCEMRmapshowsalargeareaofhighpermeability(Ktrans)occupyingtheentireleftperipheralzone(arrows).(d)AxialimagefromaSPECTstudywith111Inlabeledprostatemonoclonalantibody(capromabpendetideProstaScint;Cytogen,Princeton,NJ)showsaviduptakeintheentireleftprostate(arrow),afindingcompatiblewithalarge-volumeprostatecancer.Asseeninthiscase,someaggressiveprostatecancers,evenoflargevolume,mayappearisointenseonT2-weightedimages;thus,morphologicimagingalonemaynotbeabletoshowthesetumors.FunctionalMRimagingMRspectroscopyandDCEMRimagingaswellasantibodyimagingaccuratelydepictedthislargeprostatecancer.,外周带两侧不对称提示病变,前列腺MRI诊断再认识20161203,多发性,前列腺MRI诊断再认识20161203,、影像（PI-RADS的应用；解剖细节）,1、PI-RADS的应用：大小、形态、信号均匀度与强度、边缘（见前述评分法）。癌的信号改变：细胞密度增加、腺管结构消失。2、解剖细节（3T-MR的最大优势）破坏,前列腺MRI诊断再认识20161203,外周带低信号的形态,线状、楔形、地图状、弥漫性倾向于良性下例T2WI外周带基本对称弥漫不均匀信号减低（部分中度减低），DWI等及少部分轻度高信号（3分），DCE中度强化（+）。【PI-RADS4分】。病理为腺癌。自己认为：外周带弥漫性伴有中度以上强化应为待定、或可疑（+）。,前列腺MRI诊断再认识20161203,前列腺腺癌：本例67岁，DWI呈等信号少部分轻度高信号，ADC1.0，TIC呈2型,前列腺MRI诊断再认识20161203,(a)Transverseand(b)coronalT2-weightedMRimagesin59-year-oldpatienttreatedwithhigh-intensityfocusedultrasoundshowsthickenedprostaticcapsule(arrow)andextensivetissuefibrosisaroundtheprostate(arrowhead).Thereisdiffuselydecreasedvolumeintheperipheralzonewithbenignprostatichyperplasiainthetransitionzone.,前列腺外周带也可见增生,前列腺MRI诊断再认识20161203,60-year-oldmanwithperipheralprostatecancer,withnegativeMRspectroscopy(MRS)imagingresultsandpositivefindingsfromT2-weightedimaging(T2WI),diffusion-weightedimaging(DWI),anddynamiccontrast-enhanced(DCE)MRIimages.Patientsprostate-specificantigen(PSA)levelwas3.90ng/mL,andhisfree-to-totalPSAratiowas7.5%.A,AxialT2WIscanshowslow-signal-intensitynodularlesion(arrow)withinleftperipheralzone,suspiciousforcancer.B,DCE-MRIimagesshowscurvetype3fromregionofinterestoflesion(arrow)suspiciousforcancer.C,MRSimageshowsnormalmetaboliccurvewithinvoxelfromlesion(arrow).D,ApparentdiffusioncoefficientmapfromDWIshowsrestricteddiffusionfromlesion(arrow),suspiciousformalignanttumor.Biopsywaspositiveforprostatecancerwithinperipheralzone.,不典型类楔形MRS正常ADC明显低信号,前列腺MRI诊断再认识20161203,59-year-oldmanwithprostatecancer.A,AxialT2-weightedMRimageshowssubtledecreaseinrightperipheralzonesubcapsularT2signalintensity(arrow).B,Apparentdiffusioncoefficient(ADC)mapfromdiffusion-weightedimagingshowsdecreasedADC(arrow)correspondingtoareainA,aidingvisualizationofabnormality.MRI-ultrasoundfusionbiopsyshowedGleason3+4tumorinthisregion.,少见区域发生的Pca,前列腺MRI诊断再认识20161203,2、解剖细节破坏-破坏具动态感，特异性强,真包膜：外隆/外侵，包膜增厚/僵直/接触面积，向内收缩外科包膜：跨界前肌纤维质：受侵中央带：受侵。其它结构破坏：含典型增生结节的假包膜破坏、纤维肌性分隔破坏、尿道、精阜、射精管、精囊腺根部、中央沟、苗勒氏管囊肿、血管神经束等巨大的移行带增生结节，压迫中央带变薄，使之参与形成外科包膜。外周带低信号分隔：呈放射状围绕尿道排列+少量网状分布，窄窗宽容易观察。,前列腺MRI诊断再认识20161203,前列腺MRI诊断再认识20161203,移行带的解剖细节应用,癌与增生难鉴别时，反过来研究增生。常规窗+窄窗（移行带与外周带用不同的窄窗）。移行带增生内部信号：高信号腺体增生与坏死的区别；低信号间质增生（纤维平滑肌增生）与瘤实质的区别。移行带增生：边缘T2WI无“擦木炭画征”，内部有“黑白错落有致征”。DCE结节内部强化有“黑白错落有致征”,前列腺MRI诊断再认识20161203,正常及增生的解剖细节应用,移行带均匀低信号结节：边缘是否规则完整、模糊，与其他间质增生信号是否一样；内部低信号的程度，用窄窗宽观察【注意不同设备不同参数的正常表现】外周带：轻度低信号、边缘模糊，似磨玻璃样（窄窗宽可见更低信号分隔）：慢性炎症间质增生结节：DWI轻中度高信号（ADC多在0.9-1.3），而癌DWI明显高信号、ADC多小于0.9,前列腺MRI诊断再认识20161203,手术病理证实为前列腺增生窄窗宽更好显示结节内部细节低信号间质（平滑肌为主）增生结节周边环绕高信号提示良性高些？主要应结合DWIADC本例该结节DWI中等高S，ADC约1.0。T2WI+DWI应评3分,低信号结节与同侧增生间质信号相似或轻度降低，偏向良性，如中度降低则偏向MT,前列腺MRI诊断再认识20161203,T2WI评3分DWI评5分，总的T2WI应升为4分,前列腺MRI诊断再认识20161203,移行带癌T2WI：较均匀低信号边缘模糊擦木炭画征DWI高信号，ADC降低DCE流出型平台型MRSCho/Cr升高，Cit降低,前列腺MRI诊断再认识20161203,擦木炭画征,前列腺MRI诊断再认识20161203,前列腺前部穿刺活检易漏诊,61-year-oldmanwithprostatecancer(prostate-specificantigenlevel,6.6ng/mL).A,AxialT2-weightedimageshowsfainthypointenselesion(arrow)inrightanteriorprostategland.Scoreof3wasassignedonT2-weightedimagealonebecauselesionisindistinguishablefromanteriorfibromuscularstroma.B,Onapparentdiffusioncoefficient(ADC)map,lesion(arrow)showshypointensity.Consequently,scoreof5wasassignedtointerpretationofT2-weightedimageandADCmap.C,Photographofhistologicstepsectionrevealsprostatecancer(outlinedareas)inrightanteriorprostategland.,前列腺MRI诊断再认识20161203,Comparisonofcancerousanteriorfibromuscularstromaandnoncancerousanteriorfibromuscularstroma.AandB,67-year-oldmanwithanteriorprostatecancer.T2-weightedimage(A)andapparentdiffusioncoefficient(ADC)map(B)showhypointenselesions(arrows)inmiddleofanteriorprostategland.CandD,68-year-oldmanwithnoncancerousanteriorfibromuscularstroma.AlthoughT2-weightedimage(C)showshypointenselesion(arrows,C)inmiddleofanteriorprostategland,ADCmap(D)doesnotshowhypointensityincorrespondingarea(arrows,D).,前列腺MRI诊断再认识20161203,71-year-oldmanwithbilateralperipheralandtransitionzonecancerwithextracapsularextension(Gleasonscore,7;baselineprostate-specificantigenlevel,5.64ng/mL).A,Photographofhistopathologicspecimenshowscancer(outlinedarea)inbilateralanteriorperipheralandtransitionzones.Extensiveextracapsularextension(blue)wasfound.B,OnaxialT2-weightedimage,cancer(arrow)withhomogeneouslylowsignalintensityisseeninanterioraspectofprostate.Associatedfindingsofcontourbulgingandindistinctmarginindicatepossibilityofextracapsularextension.C,Onaxialapparentdiffusioncoefficient(ADC)map,ADCvalueofcancer(outlinedarea)is0.77103mm2/S.,前列腺MRI诊断再认识20161203,移行带低信号结节：BPH与Pca,内部：窄窗观察（与同侧邻近结节信号接近或仅轻度降低，或存在黑白相间），增强黑白错落有致征，为BPH。均匀则待定假包膜：完整更倾向于BPH，少数Pca也可。周围高信号环绕：更倾向于BPH？Pca也可。周围解剖细节破坏，则为Pca。DWI：Pca的DWI高信号大于BPH，ADC有交叉，间质增生结节ADC多为0.9-1.3Dyn-CE：只分阳性与阴性。减少活检，保护前列腺，应避免检出无临床意义的前列腺癌,前列腺MRI诊断再认识20161203,移行带Pca的MRI平扫表现,早期移行带前列腺癌，所示病灶呈弥漫性低信号，外周带信号依然正常。这一例病灶已经出现了膀胱和精囊的侵犯征象。,前列腺MRI诊断再认识20161203,Biopsy-provedadenocarcinomaina72-year-oldman.(a)AxialT2-weightedMRimageshowsalow-signal-intensitylesionintherightlobeoftheprostate(arrow).(b)ADCmapshowsalowADCvalueinthelesion(arrow),afindingindicativeofdecreaseddiffusion.Atargetedbiopsywasperformed.,前列腺MRI诊断再认识20161203,Prostaticcancerin68-year-oldmanwithprostate-specificantigenlevelof19.3ng/mLandnegativefindingsonendorectalsonography-guidedbiopsy.StageisT2b.Nosuspiciousfindingswereseenondigitalrectalexaminationorendorectalsonography.AandB,AxialandsagittalT2-weightedimages(TR/TE,5,000/155and4,700/119;echo-trainlength,8)showuniformhypointenseareawithirregularmargininanteriorlocationofinnergland,whichextendstowardanteriorfibromuscularstroma(arrows).Heterogeneousdecreasedintensityareaisseeninrightperipheralzone.C,Contrast-enhancedT1-weightedimage(600/20)withfatsuppressionshowshomogeneousenhancementoflesionatinnerglandandenhancementofbothperipheralzones.D,Histopathologicspecimenobtainedatcorrespondinglevelrevealsmoderatelydifferentiatedadenocarcinomainanteriorpositionofinnergland(arrow).Tumorsizeis3515mm.Twosmalltumorfociindicatingprostaticintraepithelialneoplasiaareseeninbackgroundofbothperipheralzones(arrowheads),前列腺MRI诊断再认识20161203,70-year-oldmanwithstageT2bcancer.Prostate-specificantigenis11.8ng/mL.A,AxialT2-weightedimage(TR/TE,5,550/137;echo-trainlength,8)illustratesuniformlow-intensityabnormalityininnerglandatright(arrows).B,Contrast-enhancedT1-weightedimage(550/12)withfatsuppressionshowshomogeneousenhancementconfinedtoinnergland.C,Histopathologicspecimenatleveloftumorshowsadenocarcinomapresentatinnergland.Tumorsizeis2416mm(originalmagnification,HandEstaining).,前列腺MRI诊断再认识20161203,68-year-oldmanwithstageT2bcancer.Prostate-specificantigenwas17ng/mL.AandB,AxialandsagittalT2-weightedimages(TR/TE,4,500/132and4,500/136,respectively;echo-trainlength,8)showband-shapedhypointenseareainanteriorofinnergland(arrows).C,Hypointenseareashowshomogeneousenhancementwithirregularmarginoncontrast-enhancedT1-weightedimagewithfatsuppression(517/18).D,Histopathologicsectionrevealsmoderatelydifferentiatedadenocarcinoma.Anteriorfibromuscularstromaisruptured(arrow),前列腺MRI诊断再认识20161203,59-year-oldmanwithstageT2acancer.Prostate-specificantigenwas71.4ng/mL.A,AxialT2-weightedimage(TR/TE,4,617/102;echo-trainlength,8)showslargeheterogeneouslowsignalintensityonrightsideofinnergland(arrows).B,Aftercontrastmaterialadministration,homogeneousenhancementisshowninanterioroflesion(arrowheads)andinhomogeneousenhancementinposterioroflesion(arrows)(617/12).C,Histopathologicspecimenobtainedatcorrespondinglevelrevealsmoderatelydifferentiatedadenocarcinomaoriginatingfrombenignprostatichyperplasianodulesurroundedbycapsuleofbenignprostatichyperplasia(arrowheads).Anteriorfibromuscularstromaisruptured.Tumorsizeis3428mm(originalmagnification,HandEstaining).,前列腺MRI诊断再认识20161203,73-year-oldmanwithstageT2bcancerandfalse-negativeinterpretationofbenignlesion.Prostate-specificantigenis10ng/mL.A,Regularmarginofintermediate-signal-intensitynodule(arrows)isshownininnerglandonleftonaxialT2-weightedimage(TR/TE,4,000/120;echo-trainlength,12).B,PostcontrastT1-weightedimagewithfatsuppression(TR/TE,672/17)showsnoenhancementwithregularmargin.CandD,Histopathologicspecimensshowhypernephroidpatternofadenocarcinoma.Leftofanteriorfibromuscularstromaisruptured(arrowhead,C)(originalmagnification,10;HandEstain).,不典型易漏诊，无强化之Pca，应做DWI,前列腺MRI诊断再认识20161203,70-year-oldmanwithstageT2bcancer.Prostate-specificantigenis5.9ng/mL.A,AxialT2-weightedimage(TR/TE,4,400/103;echo-trainlength8)showslowintensityarea(arrows)ininnerglandatright.B,PostcontrastT1-weightedimagewithfatsuppression(550/12)showsnoenhancementwithclearmargininterpretedasbenignprostatichyperplasianodule(arrows).C,Histopathologicspecimenatleveloflesionshowspseudohyperplasticadenocarcinomapresentatrightinnergland(arrowheads)(originalmagnification,HandEstain).,不典型易漏诊，无强化之Pca，T2WI较典型，应做DWI,前列腺MRI诊断再认识20161203,73-year-oldmanwithstageT2bcancer.Prostate-specificantigenis13ng/mL.A,AxialT2-weightedMRimage(TR/TE,4,467/120;echo-trainlength,8)showstwohypointenseareasininnergland(arrowsandarrowheads).B,Contrast-enhancedT1-weightedimage(TR/TE,517/13)withfatsuppressionandanteriorlesionshowshomogeneousenhancementwithirregularmargin(arrows).Posteriorlesionshowsnoenhancementwithregularmargin(arrowheads).C,Histopathologicsectionshowswell-differentiatedadenocarcinomainanterior(arrows)andnodulebenignprostatichyperplasiasurroundedbycapsuleinposterior(arrowheads)(originalmagnification,HandEstain).,前列腺MRI诊断再认识20161203,中央带的解剖细节应用,Thecentralzonewasvisualizedinmostpatients.Cancersinvolvingthecentralzonewereassociatedwithmoreaggressivediseasethanthosewithoutcentralzoneinvolvement,前列腺MRI诊断再认识20161203,(a)Axialand(b)coronalT2-weightedMRimages(4750/119)ina64-year-oldpatientwithprostatecancershowingthetypicalhomogeneouslowsignalintensityandsymmetricalappearanceoneithersideofejaculatoryducts(dashedarrowona)ofthecentralzone(arrows).B=bladder,ERC=endorectalcoil,PZ=peripheralzone.,前列腺MRI诊断再认识20161203,(a)Axialand(b)coronalT2-weightedMRimages(3500/100.7)and(c)ADCmap(4000/100.1;bvalueswere0and700sec/mm2)obtainedat1.5Tina58-year-oldpatientwithprostatecancerdemonstrateareassuspiciousforcancerinvolvingtherightcentralzone(arrows),adjacenttotheejaculatoryducts(dashedarrow).(d)Representativeimagefromstep-sectionpathologicmapdemonstratesmultifocalprostatecancer(greenandblacklines),withthedominanttumorinvolvingtherightcentralzoneandcorrespondingtotheabnormalityonMRimages.Thelocationofabenignhyperplasticnodule(star)intherighttransitionzone