Elsevier

Clinical Radiology

Volume 74, Issue 11, November 2019, Pages 831-840
Clinical Radiology

Review
Optimising prostate mpMRI: prepare for success

https://doi.org/10.1016/j.crad.2018.12.003Get rights and content

Highlights

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    Routine use of antiperistaltic agents prior to mpMRI is recommended.

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    Rectal distension significantly distorts DWI and should be minimized prior to mpMRI.

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    3 days refraining from ejaculation may improve the evaluation of seminal vesicles.

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    PROPELLER DWI significantly improves DW image quality in patients with hip metalwork.

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    Acquisitions in the plane axial to the patient are recommended.

Multiparametric magnetic resonance imaging (MRI) now plays an essential role in prostate cancer diagnosis and management. The increasing use of MRI before biopsy makes obtaining images of the highest quality vital. The European Society of Urogenital Radiology (ESUR) 2012 guidelines and subsequent Prostate Imaging –Reporting Data System (PI-RADS) version 2 recommendations in 2015 address the technical considerations for optimising MRI acquisition; however, the quality of the multiparametric sequences employed depends not only on the hardware and software utilised and scanning parameters selected, but also on patient-related factors, for which current guidance is lacking. Patient preparation factors include bowel peristalsis, rectal distension, the presence of total hip replacement (THR), post-biopsy haemorrhage, and abstinence from ejaculation. New evidence has been accrued since the release of PI-RADS v2, and this review aims to explore the key issues of patient preparation and their potential to further optimise the image quality of mpMRI.

Introduction

Prostate cancer (PCa) is the commonest malignancy in Western men and is the second leading cause of cancer-related mortality,1 with the incidence forecasted to double by 2030.2 Diagnosis of PCa has traditionally relied on prostate-specific antigen (PSA) levels, digital rectal examination (DRE), and systematic transrectal ultrasound (TRUS)-guided biopsy3; however, there is increasing evidence that the pre-biopsy multiparametric (mp) magnetic resonance imaging (MRI) outperforms systematic TRUS-guided biopsy and can lead to an increased detection of clinically significant (cs)PCa whilst at the same time reducing over-diagnosis of clinically insignificant cancer.4, 5 MpMRI in combination with clinical risk assessment can potentially obviate the need for biopsy in 25–30% of men4, 5 due to its high negative predictive value in diagnosing csPCa.6 As a result, there has been a steady increase in the use of mpMRI, and particularly pre-biopsy mpMRI, which is now being performed in up to 75% of men with suspicion of PCa in the UK.7

Given the central role of mpMRI in PCa management pathway, imaging of the highest quality is essential. In order to achieve this, in 2015, the European Society of Urogenital Radiology (ESUR) and American College of Radiology (ACR) published a second, extended version of the Prostate Imaging – Reporting Data System (PI-RADS) recommendation guidelines, which aim to standardise MRI acquisition and interpretation.8 Detailed guidance is given on technical considerations and diagnostic evaluation; however, no definite recommendation is given regarding patient preparation, mainly due to the lack of sufficient evidence available at the time. mpMRI consists of three key sequences: T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) imaging.8 The quality of these sequences depends on the hardware and software utilised and scanning parameters selected, but also on several other factors including bowel peristalsis, rectal distension, the presence of total hip replacement (THR), post-biopsy haemorrhage, and abstinence from ejaculation. Since the publication of PI-RADS v2, several new studies exploring these areas have been performed giving us additional insight on how to better overcome these challenges.

The aim of this review is therefore to briefly summarise technical considerations and highlight the key issues of patient preparation in order to further optimise imaging quality of mpMRI.

Section snippets

Technical considerations

Prostate mpMRI at both 1.5 and 3 T can provide satisfactory and reliable diagnostic examinations when appropriate contemporary technology is employed and acquisition parameters are optimised.8 Three tesla is generally considered superior8, 9 due to increased signal-to-noise ratio (SNR), superior spatial resolution, and decreased acquisition times.8, 9, 10 Performing mpMRI at magnetic field strengths below 1.5 T is not recommended.

The use of an endorectal coil (ERC) provides an increase in SNR,

Sequences

PI-RADS v2 recommends that T2WI, T1WI, DWI, and DCE pulse sequences are included for all prostate MRI examinations.8 A full review of the PI-RADS guidelines for technical parameters is beyond the scope of this article; however, a summary of key recommendations is outlined in Table 1.

Abstinence from ejaculation

PI-RADS v28 makes no recommendation on abstinence from ejaculation prior to prostate MRI, given the limited available evidence at the time; however, some institutions instruct the patients to refrain from ejaculation for 3 days prior to MRI examination in order to achieve maximal distension.40, 41 Several recent studies support this practice, demonstrating a significant decrease in SV volume after ejaculation, which could theoretically hinder interpretation of SV invasion (T3b disease; Fig 7).42

Anti-Spasmodic agents

Bowel peristalsis is known to cause motion artefact at MRI; however, it has been suggested that the low pelvic location of the gland, remote from the small bowel, may limit the benefit of anti-speristaltic agents in prostate MRI.46, 47 All studies to date have investigated the use of hyoscine butylbromide (HBB); however, this could be substituted by glucagon (1 mg) depending on local preference, or if HBB is contraindicated. HBB administration does carry a risk of side-effects, mainly related

Bowel preparation

Increased rectal loading has been shown to significantly correlate with increased DWI distortion and reduced DWI image quality by inducing susceptibility artefacts57 (Fig 8). These especially affect echo planar imaging (EPI) sequences, which are currently the most commonly used DWI sequence in abdominal and pelvic imaging, and these effects are further magnified at higher 3 T field strengths.58, 59, 60 Susceptibility artefacts occur in areas around the air–tissue interfaces,58, 59, 60 such as

Implanted devices and THR

Although it is often safe to image at 3 T, THR patients should be imaged a 1.5 T due to significant distortion artefact, which compromises image quality and will likely render the study non-diagnostic58, 59, 72 (Fig 9). THR is an established standard treatment for end-stage hip disease,73 the typical patient age group overlaps with that of PCa, and the number of procedures is expected to double by 2030,74 making this more of an issue. DWI is the dominant sequence for PZ assessment8; however, it

Conclusion

MpMRI has become established for the detection, local staging, and treatment planning of PCa, emphasising the need for high-quality studies. Image quality depends on the acquisition parameters employed, but also other factors including bowel peristalsis, rectal distension, post-biopsy haemorrhage, post-ejaculatory status, and presence of metalwork. Increasing evidence exploring aspects of patient preparation has been accrued since the release of the PI-RADS v2 guidelines in 2015; however,

Acknowledgements

T.B. acknowledges support from Cancer Research UK, National Institute of Health Research Cambridge Biomedical Research Centre, Cancer Research UK, and the Engineering and Physical Sciences Research Council Imaging Centre in Cambridge and Manchester, and the Cambridge Experimental Cancer Medicine Centre.

References (76)

  • R.A. Slough et al.

    Effect of hyoscine butylbromide on prostate multiparametric MRI anatomical and functional image quality

    Clin Radiol

    (2018)
  • W. Johnson et al.

    The value of hyoscine butylbromide in pelvic MRI

    Clin Radiol

    (2007)
  • I. Caglic et al.

    Evaluating the effect of rectal distension on prostate multiparametric MRI image quality

    Eur J Radiol

    (2017)
  • B.J. Soher et al.

    A review of MR physics: 3 T versus 1.5 T, magn reson imaging

    Clin N Am

    (2007)
  • O. Dietrich et al.

    Artifacts in 3-T MRI: physical background and reduction strategies

    Eur J Radiol

    (2008)
  • A.R. Padhani et al.

    Evaluating the effect of rectal distension and rectal movement on prostate gland position using cine MRI

    Int J Radiat Oncol Biol Phys

    (1999)
  • H.A. McNair et al.

    A systematic review: effectiveness of rectal emptying preparation in prostate cancer patients

    Pract Radiat Oncol

    (2014)
  • N. Korn et al.

    Reduced-FOV excitation decreases susceptibility artifact in diffusion-weighted MRI with endorectal coil for prostate cancer detection

    Magn Reson Imaging

    (2015)
  • Y.L. Thian et al.

    Readout-segmented echo-planar imaging for diffusion-weighted imaging in the pelvis at 3 T—a feasibility study

    Acad Radiol

    (2014)
  • D. Holland et al.

    Efficient correction of inhomogeneous static magnetic field-induced distortion in echo planar imaging

    Neuroimage

    (2010)
  • R.A. Rakow-Penner et al.

    Prostate diffusion imaging with distortion correction

    Magn Reson Imaging

    (2015)
  • L. Shan et al.

    Total hip replacement: a systematic review and meta-analysis on mid-term quality of life

    Osteoarthritis Cartilage

    (2014 Mar)
  • A.B. Rosenkrantz et al.

    Use of reduced field-of-view acquisition to improve prostate cancer visualization on diffusion-weighted magnetic resonance imaging in the presence of hip implants: report of 2 cases

    Curr Probl Diagn Radiol

    (2018)
  • M. Czarniecki et al.

    Role of PROPELLER-DWI of the prostate in reducing distortion and artefact from total hip replacement metalwork

    Eur J Radiol

    (2018)
  • L.A. Torre et al.

    Global cancer statistics, 2012

    CA Cancer J Clin

    (2015)
  • J. Maddams et al.

    Projections of cancer prevalence in the United Kingdom, 2010-2040

    Br J Cancer

    (2012)
  • M.S. Litwin et al.

    The diagnosis and treatment of prostate cancer: a review

    JAMA

    (2017)
  • V. Kasivisvanathan et al.

    PRECISION Study Group Collaborators. MRI-targeted or standard biopsy for prostate-cancer diagnosis

    N Engl J Med

    (2018)
  • The Royal College of Surgeons of England. reportNational Prostate Cancer Audit Fourth Year Annual Report – Results of...
  • B. Turkbey et al.

    Comparison of endorectal coil and non-endorectal coil T2W and DW MRI at 3T for localizing prostate cancer: correlation with whole-mount histopathology

    J Magn Reson Imaging

    (2014)
  • O. Rouviere et al.

    Prostate MR imaging at high-field strength: evolution or revolution?

    Eur Radiol

    (2006)
  • M.A. Haider et al.

    Prostate imaging: evaluation of a reusable two-channel endorectal receiver coil for MR imaging at 1.5 T

    Radiology

    (2014)
  • S.W. Heijmink et al.

    Prostate cancer: body- array versus endorectal coil MR imaging at 3 T—comparison of image quality, localization, and staging performance

    Radiology

    (2007)
  • J.J. Futterer et al.

    Prostate cancer: comparison of local staging accuracy of pelvic phased-array coil alone versus integrated endorectal-pelvic phased-array coils. Local staging accuracy of prostate cancer using endorectal coil MR imaging

    Eur Radiol

    (2007)
  • B.K. Park et al.

    Comparison of phased- array 3.0-T and endorectal 1.5-T magnetic resonance imaging in the evaluation of local staging accuracy for prostate cancer

    J Comput Assist Tomogr

    (2007)
  • D. Beyersdorff et al.

    MRI of prostate cancer at 1.5 and 3.0 T: comparison of image quality in tumor detection and staging

    AJR Am J Roentgenol

    (2005)
  • J.O. Barentsz et al.

    ESUR prostate MR guidelines 2012

    Eur Radiol

    (2012)
  • M. Brizmohun Appayya et al.

    National implementation of multi-parametric magnetic resonance imaging for prostate cancer detection — recommendations from a UK consensus meeting

    BJU Int

    (2018)

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