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Published online before print July 24, 2007, 10.1148/radiol.2443061063
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Prostate Cancer: Sextant Localization with MR Imaging, MR Spectroscopy, and 11C-Choline PET/CT1

Claudia Testa, PhD, Riccardo Schiavina, MD, Raffaele Lodi, MD, Eugenio Salizzoni, MD, Barbara Corti, MD, Mohsen Farsad, MD, John Kurhanewicz, PhD, Fabio Manferrari, MD, Eugenio Brunocilla, MD, Caterina Tonon, MD, Nino Monetti, MD, Paolo Castellucci, MD, Stefano Fanti, MD, Manuela Coe, MD, Walter F. Grigioni, MD, Giuseppe Martorana, MD, Romeo Canini, MD, and Bruno Barbiroli, MD

1 From the Department of Clinical Medicine and Applied Biotechnology "D. Campanacci" (C. Testa, R.L., C. Tonon, B.B.), Department of Urology (R.S., F.M., E.B., G.M.), Clinical Department of Radiologic and Histopathologic Science, Diagnostic Imaging Section "V. Bollini" (E.S., M.C., R.C.), Pathologic Anatomy Unit, Institute of Oncology "F. Addarii" (B.C., W.F.G.), and Department of Nuclear Medicine, P.E.T. Center (M.F., N.M., P.C., S.F.), Policlinico S. Orsola-Malpighi, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; and Department of Radiology, University of California-San Francisco, San Francisco, Calif (J.K.). Received June 19, 2006; revision requested August 21; revision received November 9; accepted December 18; final version accepted January 16, 2007. Address correspondence to R.L. (e-mail: raffaele.lodi{at}unibo.it).


Figure 1
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  		Figure 1: Flowchart of study profile. Final study group consisted of 26 patients who underwent radical prostatectomy. MRSI = MR spectroscopic imaging.

 

Figure 2A
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  		Figure 2a: Patient 21. (a) Transverse T2-weighted MR image (fast spin-echo sequence, 5000/102) with 3D MR spectral grid and corresponding 3D MR spectroscopic spectra of midgland: MR image shows wide area of low signal intensity in posterior peripheral zone of gland, bilateral with capsular irregularity; 3D MR spectroscopic spectra shows low citrate content and high choline peak in corresponding voxels (mean CC/C ratio = 1.81 on right side, 1.64 on left). (b) Corresponding PET/CT fusion images show pathologic uptake of 11C-choline extending outside rim of gland in posterior right side (maximum SUV = 7); on left side of posterior gland, another area of focal uptake of 11C-choline (maximum SUV = 5.9) is depicted; in anterior transitional zone, lower 11C-choline focal uptake (maximum SUV = 4.9) is depicted. Black arrow = cursor. (c) Corresponding histologic specimen shows bilateral posterior adenocarcinoma (T3bN1MX, Gleason score = 4 + 3) with infiltration of anterior transition zone and bilateral extracapsular extension (*). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 2B
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  		Figure 2b: Patient 21. (a) Transverse T2-weighted MR image (fast spin-echo sequence, 5000/102) with 3D MR spectral grid and corresponding 3D MR spectroscopic spectra of midgland: MR image shows wide area of low signal intensity in posterior peripheral zone of gland, bilateral with capsular irregularity; 3D MR spectroscopic spectra shows low citrate content and high choline peak in corresponding voxels (mean CC/C ratio = 1.81 on right side, 1.64 on left). (b) Corresponding PET/CT fusion images show pathologic uptake of 11C-choline extending outside rim of gland in posterior right side (maximum SUV = 7); on left side of posterior gland, another area of focal uptake of 11C-choline (maximum SUV = 5.9) is depicted; in anterior transitional zone, lower 11C-choline focal uptake (maximum SUV = 4.9) is depicted. Black arrow = cursor. (c) Corresponding histologic specimen shows bilateral posterior adenocarcinoma (T3bN1MX, Gleason score = 4 + 3) with infiltration of anterior transition zone and bilateral extracapsular extension (*). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 2C
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  		Figure 2c: Patient 21. (a) Transverse T2-weighted MR image (fast spin-echo sequence, 5000/102) with 3D MR spectral grid and corresponding 3D MR spectroscopic spectra of midgland: MR image shows wide area of low signal intensity in posterior peripheral zone of gland, bilateral with capsular irregularity; 3D MR spectroscopic spectra shows low citrate content and high choline peak in corresponding voxels (mean CC/C ratio = 1.81 on right side, 1.64 on left). (b) Corresponding PET/CT fusion images show pathologic uptake of 11C-choline extending outside rim of gland in posterior right side (maximum SUV = 7); on left side of posterior gland, another area of focal uptake of 11C-choline (maximum SUV = 5.9) is depicted; in anterior transitional zone, lower 11C-choline focal uptake (maximum SUV = 4.9) is depicted. Black arrow = cursor. (c) Corresponding histologic specimen shows bilateral posterior adenocarcinoma (T3bN1MX, Gleason score = 4 + 3) with infiltration of anterior transition zone and bilateral extracapsular extension (*). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 3A
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  		Figure 3a: Patient 5. (a) Transverse T2-weighted MR image of midgland (fast spin-echo sequence, 5000/102) shows bilateral signal hypointensities and corresponding 3D MR spectroscopic spectra show bilateral abnormalities (mean CC/C ratio = 0.95 on right side and 1.10 on left) indicative of cancer, while (b) corresponding PET/CT transverse images do not show any relevant pathologic focal accumulation of 11C-choline (background maximum SUV = 2.5). (c) Corresponding pathologic specimen (T3aNXMX, Gleason score = 4 + 3) shows bilateral posterior adenocarcinoma with right extracapsular extension (**). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 3B
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  		Figure 3b: Patient 5. (a) Transverse T2-weighted MR image of midgland (fast spin-echo sequence, 5000/102) shows bilateral signal hypointensities and corresponding 3D MR spectroscopic spectra show bilateral abnormalities (mean CC/C ratio = 0.95 on right side and 1.10 on left) indicative of cancer, while (b) corresponding PET/CT transverse images do not show any relevant pathologic focal accumulation of 11C-choline (background maximum SUV = 2.5). (c) Corresponding pathologic specimen (T3aNXMX, Gleason score = 4 + 3) shows bilateral posterior adenocarcinoma with right extracapsular extension (**). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 3C
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  		Figure 3c: Patient 5. (a) Transverse T2-weighted MR image of midgland (fast spin-echo sequence, 5000/102) shows bilateral signal hypointensities and corresponding 3D MR spectroscopic spectra show bilateral abnormalities (mean CC/C ratio = 0.95 on right side and 1.10 on left) indicative of cancer, while (b) corresponding PET/CT transverse images do not show any relevant pathologic focal accumulation of 11C-choline (background maximum SUV = 2.5). (c) Corresponding pathologic specimen (T3aNXMX, Gleason score = 4 + 3) shows bilateral posterior adenocarcinoma with right extracapsular extension (**). (Hematoxylin-eosin stain; original magnification, x1.)

 

Figure 4
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  		Figure 4: Receiver operating characteristic curve for prediction of sextant tumor involvement on the basis of maximum SUV measurement (area under receiver operating characteristic curve = 0.72, 95% confidence interval: 0.639, 0.786).

 

Figure 5
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  		Figure 5: Scatterplot depicts maximum SUVs in sextants with tumors compared with those in sextants with benign lesions (including HGPIN). PET/CT results show sensitivity of 72% and specificity of 65% by using a maximum SUV threshold greater than 2.9.

 




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