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Differential Diagnosis of Uncommon Prostate Diseases: Combining Mpmri and Clinical Information

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Differential Diagnosis of Uncommon Prostate Diseases: Combining Mpmri and Clinical Information Han et al. Insights Imaging (2021) 12:79 https://doi.org/10.1186/s13244-021-01024-3 Insights into Imaging EDUCATIONAL REVIEW Open Access Diferential diagnosis of uncommon prostate diseases: combining mpMRI and clinical information Chao Han1, Lina Zhu2, Xiang Liu1, Shuai Ma1, Yi Liu1 and Xiaoying Wang1* Abstract The diferential diagnosis of abnormalities in the prostate is broad, covering common (acinar adenocarcinoma, benign prostatic hyperplasia, chronic prostatitis, hemorrhage, cysts, calcifcations, atrophy and fbrosis) and less common con- ditions (tumors other than acinar adenocarcinoma, granulomatous prostatitis containing tuberculosis, abscesses and other conditions, and idiopathic disorders such as amyloidosis and exophytic benign prostatic hyperplasia). Recent advances in magnetic resonance imaging (MRI) of the prostate gland and imaging guidelines, such as the Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1), have dramatically improved the ability to distinguish common abnormalities, especially the ability to detect clinically signifcant prostate cancer (csPCa). Overlap can exist in the clinical history and imaging features associated with various common/uncommon prostate abnormalities, and biopsy is often required but is invasive. Prostate abnormalities can be divided into two categories: category 1, diseases for which PI-RADS scores are suitable for use, and category 2, diseases for which PI-RADS scores are unsuitable for use. Radiologists must have an intimate knowledge of other diseases, especially uncommon conditions. Past relevant history, symptoms, age, serum prostate-specifc antigen (PSA) levels, MRI manifestations, and the applicability of the PI-RADS assessment should be considered when diagnosing prostate abnormalities. Keywords: Prostate, Magnetic resonance imaging, Uncommon prostatic diseases Key Points Background Diseases of the prostate make up a large proportion of • Prostate abnormalities can be divided into two cat- male urologic diseases. In the clinic, individuals usu- egories, PI-RADS suitable and PI-RADS unsuitable. ally visit the hospital with overlapping symptoms of • Radiologists must have an intimate knowledge of prostatic diseases or elevated serum prostate-specifc uncommon prostate abnormalities. antigen (PSA) levels. Currently, advances in multipara- • Granulomatous prostatitis adds a diagnostic chal- metric magnetic resonance imaging (mpMRI) of the lenge as it usually mimics PCa radiologically. prostate gland and the Prostate Imaging Reporting and • Most sarcomas appear as well-circumscribed masses Data System version 2.1 (PI-RADS v2.1) have remarkably with a complete or incomplete pseudocapsule. improved the ability to detect and stage clinically signif- cant prostate cancer (csPCa) [1–4]. PI-RADS v2.1 suggests the use of the mpMRI proto- col, including T2-weighted imaging (T2WI), difusion- weighted imaging (DWI), apparent difusion coefcient *Correspondence: [email protected] (ADC) maps and dynamic contrast-enhanced (DCE) 1 Department of Radiology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China imaging, to provide both imaging and functional infor- Full list of author information is available at the end of the article mation of the prostate. In addition, radiologists use © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Han et al. Insights Imaging (2021) 12:79 Page 2 of 17 PI-RADS v2.1 assessment categories, a 5-point scale from Common prostatic diseases other than typical PI-RADS 1 to5, to express the probability of the presence benign lesions of csPCa for each lesion in the prostate gland [3]. Tere- Common prostatic diseases other than typical benign fore PI-RADS v2.1 is widely applied in the clinic to dis- lesions, such as acinar adenocarcinoma, BPH and pros- tinguish csPCa from benign prostatic hyperplasia (BPH), tatitis, are usually inert or chronic, with varying degrees chronic prostatitis, or other common prostatic diseases. of elevated serum PSA levels or disturbing symptoms However, unusual diseases involving the prostate, such as such as lower urinary tract symptoms (LUTS), and uncommon prostatic neoplasms, are classifed into mul- interfere with the quality of life as a long-term prob- tiple classes. As a result of their relative rarity and diverse lem for males, particularly elderly males, as BPH and of imaging presentations [5], many radiologists might prostate cancer are age-related conditions [6]. PSAs not be familiar with their characteristics or situations in are proteinases produced mainly in the epithelial cells which the use of the PI-RADS assessment is appropriate. of the prostate [7]. When various factors cause destruc- Therefore, in this article, prostatic diseases are tion of the epithelial cells or the blood-epithelial bar- divided into two categories: category 1, diseases for rier, a substantial increase in PSA secretion from tumor which the PI-RADS assessment is suitable for use, and cells, or increasing entry of PSAs into the blood, serum category 2, diseases for which PI-RADS assessment PSA levels are increased. is not suitable for use. The characteristics of com- PCa is one of the most common group of malignan- mon prostatic diseases are simply reviewed, followed cies occurring in the male population after lung cancer by a focus on the characteristics of unusual prostatic [8], among which acinar adenocarcinoma is the most diseases. In addition, we summarize the clinical MRI common malignancy observed. On MRI, csPCa pre- diagnostic workflow for prostatic diseases. sents with homogeneous and moderate hypointensity on T2WI, hyperintensity on high b-value DWI, a low ADC, and early enhancement, without capsules and Classifcation of prostatic diseases easily forming extraprostatic extensions (EPEs). Tese Common diseases of the prostate include acinar ade- fndings result in a PI-RADS 4–5 classifcation. nocarcinoma, BPH, chronic prostatitis, hemorrhage, BPH is the ffth most prevalent non-cancer-related cysts, calcifications, atrophy and fibrosis. Uncommon disorder among 50-year-old or elderly men [9]. By the diseases of the prostate include tumors other than age of 60, the prevalence of BPH is 50%, and it increases acinar adenocarcinoma, granulomatous prostatitis to 80% by the age of 80. BPH tissue produces PSA and containing tuberculosis, abscesses and so on, and idi- primarily arises in the TZ. BPH consists of glandular opathic disorders such as amyloidosis and exophytic hyperplasia and stromal hyperplasia. Predominantly BPH. glandular BPH nodules exhibit moderate hyperinten- Many conditions that yield abnormal signals within sity on T2WI with hypointense capsules, while pre- the prostate, including hemorrhage, cysts, calcifica- dominantly stromal nodules present hypointensity on tions, atrophy and fibrosis, are benign and highly rec- T2WI. A mixture of stromal and glandular hyperpla- ognizable on mpMRI [3]. In addition to these benign sia may appear as band-like areas and/or encapsulated signal abnormalities and based on the applicability round nodules with circumscribed or encapsulated of PI-RADS assessment, we divide other focal signal margins. Many BPH nodules display a mixture of signal abnormalities involving the prostate into two catego- intensities on T2WI and may be remarkably enhanced ries according to the patient’s age, serum PSA level, on DCE imaging [3]. Te PI-RADS assessment is suita- symptoms and mpMRI findings: category 1, diseases ble for use and PI-RADS scores of 1–2 may be assigned for which the PI-RADS assessment is suitable for to typical BPH. use, and category 2, diseases for which the PI-RADS Chronic prostatitis is often subclinical and presents assessment is not suitable for use. Category 1 includes as an immune infltrate. On T2WI and ADC maps, prostate cancer (PCa), typical BPH in the transitional chronic prostatitis often presents with decreased sig- zone (TZ), and some types of prostatitis/granuloma- nals that are band-like, wedge-shaped, or difuse in tous prostatitis, which overlap in terms of clinical and the peripheral zone (PZ). On DCE imaging, they may mpMRI findings, while category 2 includes tumors exhibit early enhancement. Te PI-RADS assessment except for PCa, exophytic BPH nodules, and some is suitable for use and a PI-RADS score of 2 may be types of granulomatous prostatitis (abscesses and assigned to typical chronic prostatitis. tuberculosis), for which PCa may be excluded accord- ing to the clinical and MRI findings. Han et al. Insights Imaging (2021) 12:79 Page 3 of 17 Uncommon prostatic diseases types: idiopathic (nonspecifc), infective, iatrogenic (after BPH nodules outside the TZ surgical operation), malakoplakia, and cases
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