presentation1.pptx, ultrasound examination of the urinary bladder and prostate
TRANSCRIPT
Ultrasound examination of the urinary bladder and prostate
Dr ABD ALLAH NAZEER MD
ULTRASOUND OF THE BLADDER ndash Normal
Longitudinal Bladder View Longitudinal Bladder Image
Transverse Scan Plane Transverse Bladder Image
Ultrasound of the Bladder - ProtocolRole of UltrasoundUltrasound is an important tool for assessing the bladder wall for wall thickening trabeculation masses and diverticulae Pre and post micturition volumes Vesico-ureteric junctions also can be visualized Bladder calculi amp foreign bodies Use the full bladder as an acoustic window to assess the prostate in males and gynecological structures in females
Common PathologyTrabeculationDiverticulumCalculusUreteroceleUrinary bladder infectionAdenocarcinomaTransitional Cell carcinoma
Scanning TechniquePatient supine with suprapubic area exposedExamine the bladder sagittally in the midline Now angle laterally amp sweep the probe both left and right to check the lateral marginsRotate 90degrees into the axial(transverse) plane Sweep through from the superior dome to the bladder base Ensure the ultrasound beam is projected as close to perpendicular to the bladder wall as possibleLook for ureteric jets at the bladder base This confirms bilateral renal function and ureteric patency To do this in transverse angle inferiorly using power Doppler (or colour Doppler with low PRF amp wall filter settings) You may need to be patient to wait for the ureteric jet depending on renal function and degree of hydrationDocument the normal anatomy and any pathology found (including measurements and vascularity if indicated) Measure the bladder volume pre and post micturition As a rule of thumb the bladder should empty to approximately 10 of the pre-micturition volume If the initial post-void volume is greater than 100mL encourage the patient to try again because a large residual volume may be artefactual following a very full bladder
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
ULTRASOUND OF THE BLADDER ndash Normal
Longitudinal Bladder View Longitudinal Bladder Image
Transverse Scan Plane Transverse Bladder Image
Ultrasound of the Bladder - ProtocolRole of UltrasoundUltrasound is an important tool for assessing the bladder wall for wall thickening trabeculation masses and diverticulae Pre and post micturition volumes Vesico-ureteric junctions also can be visualized Bladder calculi amp foreign bodies Use the full bladder as an acoustic window to assess the prostate in males and gynecological structures in females
Common PathologyTrabeculationDiverticulumCalculusUreteroceleUrinary bladder infectionAdenocarcinomaTransitional Cell carcinoma
Scanning TechniquePatient supine with suprapubic area exposedExamine the bladder sagittally in the midline Now angle laterally amp sweep the probe both left and right to check the lateral marginsRotate 90degrees into the axial(transverse) plane Sweep through from the superior dome to the bladder base Ensure the ultrasound beam is projected as close to perpendicular to the bladder wall as possibleLook for ureteric jets at the bladder base This confirms bilateral renal function and ureteric patency To do this in transverse angle inferiorly using power Doppler (or colour Doppler with low PRF amp wall filter settings) You may need to be patient to wait for the ureteric jet depending on renal function and degree of hydrationDocument the normal anatomy and any pathology found (including measurements and vascularity if indicated) Measure the bladder volume pre and post micturition As a rule of thumb the bladder should empty to approximately 10 of the pre-micturition volume If the initial post-void volume is greater than 100mL encourage the patient to try again because a large residual volume may be artefactual following a very full bladder
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Transverse Scan Plane Transverse Bladder Image
Ultrasound of the Bladder - ProtocolRole of UltrasoundUltrasound is an important tool for assessing the bladder wall for wall thickening trabeculation masses and diverticulae Pre and post micturition volumes Vesico-ureteric junctions also can be visualized Bladder calculi amp foreign bodies Use the full bladder as an acoustic window to assess the prostate in males and gynecological structures in females
Common PathologyTrabeculationDiverticulumCalculusUreteroceleUrinary bladder infectionAdenocarcinomaTransitional Cell carcinoma
Scanning TechniquePatient supine with suprapubic area exposedExamine the bladder sagittally in the midline Now angle laterally amp sweep the probe both left and right to check the lateral marginsRotate 90degrees into the axial(transverse) plane Sweep through from the superior dome to the bladder base Ensure the ultrasound beam is projected as close to perpendicular to the bladder wall as possibleLook for ureteric jets at the bladder base This confirms bilateral renal function and ureteric patency To do this in transverse angle inferiorly using power Doppler (or colour Doppler with low PRF amp wall filter settings) You may need to be patient to wait for the ureteric jet depending on renal function and degree of hydrationDocument the normal anatomy and any pathology found (including measurements and vascularity if indicated) Measure the bladder volume pre and post micturition As a rule of thumb the bladder should empty to approximately 10 of the pre-micturition volume If the initial post-void volume is greater than 100mL encourage the patient to try again because a large residual volume may be artefactual following a very full bladder
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Ultrasound of the Bladder - ProtocolRole of UltrasoundUltrasound is an important tool for assessing the bladder wall for wall thickening trabeculation masses and diverticulae Pre and post micturition volumes Vesico-ureteric junctions also can be visualized Bladder calculi amp foreign bodies Use the full bladder as an acoustic window to assess the prostate in males and gynecological structures in females
Common PathologyTrabeculationDiverticulumCalculusUreteroceleUrinary bladder infectionAdenocarcinomaTransitional Cell carcinoma
Scanning TechniquePatient supine with suprapubic area exposedExamine the bladder sagittally in the midline Now angle laterally amp sweep the probe both left and right to check the lateral marginsRotate 90degrees into the axial(transverse) plane Sweep through from the superior dome to the bladder base Ensure the ultrasound beam is projected as close to perpendicular to the bladder wall as possibleLook for ureteric jets at the bladder base This confirms bilateral renal function and ureteric patency To do this in transverse angle inferiorly using power Doppler (or colour Doppler with low PRF amp wall filter settings) You may need to be patient to wait for the ureteric jet depending on renal function and degree of hydrationDocument the normal anatomy and any pathology found (including measurements and vascularity if indicated) Measure the bladder volume pre and post micturition As a rule of thumb the bladder should empty to approximately 10 of the pre-micturition volume If the initial post-void volume is greater than 100mL encourage the patient to try again because a large residual volume may be artefactual following a very full bladder
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Scanning TechniquePatient supine with suprapubic area exposedExamine the bladder sagittally in the midline Now angle laterally amp sweep the probe both left and right to check the lateral marginsRotate 90degrees into the axial(transverse) plane Sweep through from the superior dome to the bladder base Ensure the ultrasound beam is projected as close to perpendicular to the bladder wall as possibleLook for ureteric jets at the bladder base This confirms bilateral renal function and ureteric patency To do this in transverse angle inferiorly using power Doppler (or colour Doppler with low PRF amp wall filter settings) You may need to be patient to wait for the ureteric jet depending on renal function and degree of hydrationDocument the normal anatomy and any pathology found (including measurements and vascularity if indicated) Measure the bladder volume pre and post micturition As a rule of thumb the bladder should empty to approximately 10 of the pre-micturition volume If the initial post-void volume is greater than 100mL encourage the patient to try again because a large residual volume may be artefactual following a very full bladder
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Trabeculated bladder a noncompliant hypotonic bladder
resulting from hypertrophy of the muscular coat usually caused by obstruction of the urethra Increasing postvoid residuals and risk of urinary tract infection may ensue
Trabeculation of the bladder wall
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Bladder diverticulum are outpouchings from the bladder wall whereby mucosa herniates through the bladder wall They may be solitary or multiple in nature and can very considerably in size
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Pelvic (Bladder) ultrasound shows a large outpouching (D) of the bladder wall and mucosa projecting from the lumen of the bladder (B)
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
U Bladder Diverticulum
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Bladder calculi occur either from migrated renal calculi or urinary stasis Bladder calculi can be divided into primary and secondary stonesprimary stones form de novo in the bladdersecondary stones are either from renal calculiwhich have migrated down into the bladder or from concretions on foreign material (eg urinary catheters)
UltrasoundSonographically they are mobile echogenic and shadow distally They may be associated with bladder wall thickening due to inflammation
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Large urinary bladder calculus
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Ureteroceles represent congenital dilatation of the distal-
most portion of the ureter The dilated portion of the ureter may herniate into the bladder secondary to the abnormal structure of vesicoureteric junction (VUJ) There are two main types of ureterocele both of which are the result of cystic ectasia of the subepithelial portion of the ureter as it inters the bladdersimple a ureterocele that occurs at a VUJ in a normal positionectopic that which occurs at a VUJ whose site is abnormal
UltrasoundA ureterocele appears as a cystic structure projecting into the bladder often near the normal location of the vesicouretericjunction (VUJ) This is ectopic in the majority of cases and therefore not at the expected location of the ureteric orifice The associated ureter is usually noticeably dilated
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
A bladder infection also called cystitis is caused by an abnormal growth of bacteria inside the bladder the balloon-like organ that stores urine Bladder infections are one of the most common bacterial infections to affect humans with up to one-third of all females having at least one infection at some point in their lives Bladder infections are classified as either simple or complicated Simple bladder infections affect only healthy women with normal urinary systems Bladder infections are rare in men who are otherwise healthy
UltrasonographyThere are many causes of inflammation of the bladder wall including infection radiation drugs (eg cyclophosphamide) and trauma (eg indwelling catheter surgery) The bladder appears sonographically normal in most cases but may show thickening of its wall as a result of edema The bladder mucosa is normally less than 2mm thick when measured at full distention and less than 5mm thick when non-distended
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Acute cystitis
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Acute and chronic cystitis Neurogenic bladder Gray-scale ultrasound on axial (a) and sagital (b) planes showed a focal tissular thickening in postero-superior bladder wall (arrows) (c d) CEUS showed preservation of the lineal enhancement in the mucosa-submucosa layer (arrows) and a marked thickening of muscular layer (double head arrow) therefore neoplasia could be excluded Biopsy confirmed acute and chronic cystitis
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Follicular cystitis Ultrasound showed irregular thickening tissue on the right trigone (arrows)
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Cystitis glandularis A 72 year-old man with paraplegia and obesity (a) Gray-scale ultrasound showed an irregular echogenic tissue thickening at bladder base simulating urothelial carcinoma (b) CEUS showed enhancement similar to urothelial neoplasia with effacement of the mucosa-submucosa line that correlates with mucosal denudation in pathologic analysis
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Eosinophilic cystitis A 50 year-old woman presenting with hematuria (a) Gray-scale ultrasound showed an intravesical mass (asterisk) non-enhancing on CEUS (b) that corresponds to blood clot and a hyperenhanced focus of 13 cm on the right lateral bladder wall (arrow) simulating neoplastic lesion On pathologic study this lesion corresponded to eosinophilic cystitis
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Acute cystitis A paraplegic 20 year-old man presenting with hematuria (a) Gray-scale ultrasound showed irregular tissue thickening on the right bladder wall (arrows) (b) CEUS showed marked enhancement on the preserved mucosa-submucosa line (arrows) with a less-enhanced and thickened muscular layer (discontinues arrow) with delayed wash-out (c) Pathologic study revealed intense acute inflammatory change
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Bladder wall abscess secondary to Crohn disease Crohn disease presenting with pyuria and hematuria (a) Gray-scale ultrasound showed a mass protruding intraluminally (arrows) (c) CEUS excluded neoplasia revealing preservation of the mucosa-submucosa line with a non-enhancing collection inside the bladder wall corresponding to an abscess secondary to a fistulizing Crohn disease as CT (b) confirms (R Rectum)
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Adenomatous hyperplasia A 47 year-old man with hematuria (a) Gray-scale ultrasound showed a hardly distensible bladder with wall thickening and nodular intraluminal projections (arrows) (b) CEUS showed enhancement with effacement of the mucosa-submucosa line (arrow) being the finding indistinguishable from a neoplastic lesion After cystoscopy and biopsy the pathologic diagnosis was adenomatous hyperplasia
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Squamous metaplasia A 66 year-old woman with previous history of bladder lithiasis and hematuria (a) Gray-scale ultrasound showed a scarcely distensible bladder with an intraluminal mass (b) CEUS revealed a non-enhancing clot (asterisk) and hyperenhancing papillary nodules in the right bladder wall (arrow) indistinguishable from neoplastic focus Pathologic study revealed squamous metaplasia with chronic and acute inflammation
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Endometriosis Longitudinal US image shows a solid homogeneous hypoechoic mass protruding into the bladder lumen
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Invasive inflammatory pseudotumor Transverse ultrasonographic (US) large lobulated mass arising from the lateral wall of the
bladder with significant extra-vesicular extension (arrows)
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Schistosomiasis Longitudinal US image through the bladder shows nodular bladder wall thickening (arrows) an appearance more typical in the acute phase of infection
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign urinary bladder tumour benign neoplasms including leiomyoma hemangioma neurofibroma and schwannoma and tumors of uncertain malignant potential including paraganglioma granular cell tumor and perivascular epithelioid cell tumor Common clinical presentations morphological characteristics and immunohistochemical features are described to aid the practicing pathologist in the identification of these entities This review also describes current theories as to the pathogenesis of inflammatory myofibroblastic tumor and postoperative spindle cell nodule and details the current molecular markers identifying several of these lesions
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Leiomyoma of the urinary bladder is a rare benign tumour predominantly found in women although men can also be affected The most common presenting complaints are urinary voiding symptoms such as obstruction and irritation US examination typically shows a smooth-walled homogeneous hypoechoic solid mass in the bladder with thin echogenic surface
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Inverted papilloma of the urinary bladder is a rare entity According to literature data this disease is not malignant and has low recurrence rate
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Echographic appearance of schwannoma bladder
Schwannoma of the urinary bladder is an extremely rare tumor It arises from Schwann cells in nerve sheaths and may be malignant or benign and is often associated with von Recklinghausenacutes disease
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Bladder pheochromocytoma
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Extra-adrenal paragangliomas of the urinary bladder are rare
Typically patients present with symptoms related to catecholamine hypersecretion or mass effect but these tumors can also be encountered incidentally on imaging studies obtained for a different purpose
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Non-functional paraganglioma of the urinary bladder
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Bladder cancer is any of several types of cancer arising from the epithelial lining (ie the urothelium) of the urinary bladder Rarely the bladder is involved by non-epithelial cancers such as lymphoma or sarcoma but these are not ordinarily included in the colloquial term bladder cancer It is a disease in which abnormal cells multiply without control in the bladderThe most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinomaor more properly urothelial cell carcinoma Five-year survival rates in the United States are around 77 Squamous cell carcinoma (4)Worst prognosisAssociated with chronic infection and irritation
In underdeveloped nations associated with bladder infection by Schistosoma haematobiumAdenocarcinoma (1)Most common in bladder exstrophyRespond poorly to radiation therapy
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Infiltrative bladder neoplasm CEUS shows irregular hyperenhancing tissue thickening that effaces mucosa-submucosa line CEUS invading the hypoechogenic muscular layer (arrows-preserved line)pointing to neoplastic origin
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Carcinoma urinary bladder- 3D ultrasound images
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
TRUS ultrasound images of the prostate and bladder
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Urinary bladder carcinoma
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Images for bladder transitional cell carcinoma
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Multiple bladder masses
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Squamous cell carcinoma
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Botryoid rhabdomyosarcoma Transverse US
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
B-cell lymphoma (a) Longitudinal US image shows intraluminal bladder masses (white arrows) involving the posterior wall and ureteral orifice The latter mass is causing obstruction in the form of a hydroureter (black arrows) (b) Axial CT image shows the thickening at the ureteral orifice (arrows)
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
ULTRASOUND OF THE PROSTATE - Normal
Angle the probe caudally and in the midline to get a sagittal view of the prostate Prostate is situated behind the bladder
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Turn the probe 90degrees and anglecaudally to get the transverse view Transverse View Prostate
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)
Prostate Volume Axial Image
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Role of UltrasoundVisualization of the Prostate using the TRUS ( Transrectal Ultrasound) technique has improved the diagnostic ability of the sonologist It plays an important role in most prostatic diseases It is necessary for all prostate biopsiesIf the PSA is elevated or increasing rapidly or there is an abnormal prostate examination then a transrectal ultrasound and prostate biopsy may be indicated to obtain tissue to make the diagnosis of prostate cancerTransabdominal Ultrasound can assess the volume of the prostate but is not reliable to diagnose carcinoma
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Scanning TechniqueTRUS TECHNIQUE
It is ideal to have a small amount of urine in the bladderAsk the patient to try and relax and bear down to open the sphincter as the transducer is inserted slowly Ensure the transducer has a latex free dedicated probe cover with plenty of gel The highest frequency sector probe 7-12MHz should be usedThe scanning begins in the axial plane The seminal vesicles are examined initially As the probe is angled caudally the base of the prostate is seenOnce the prostate is examined in its entirety in this plane the probe is turned 90degrees in a sagittal plane The probe is angled from one side across to the otherA volume is taken by measuring height x length in the sagittal plane and x width in the axial plane and multiply by 052Look for changes in the contours and echogenicity in each zoneTRANSABDOMINAL TECHNIQUE
The patient lies supine The patient should have a half full bladder 500 mls of water 1 hr before the scan if possible is recommendedThe probe is angled approximately 30 degrees caudal using the bladder as a window Slight compression to ensure the inferior portion of the prostate is not obscured by the shadow artifact from the base of the bladder
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Common Pathology
ProstatitisCystsBenign Prostatic Hyperplasia (BPH)Prostate CarcinomaEnlarged seminal vesiclesStones in the seminal vesicles Prostate or ejaculatory ducts
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Acute prostatitis with increased blood flow
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Acute prostatitis with increased blood flow
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Images of acute prostatitis
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Granulomatous prostatitis with multiple hypoechoic area inside
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic abscess
Prostatic abscesses can be a rare complication of prostatitis
Transrectal sonography (TRUS) is considered very reliable imaging method to diagnose a prostatic abscess It usually demonstrates ill-defined hypoechoic areas within an enlarged andor distorted prostate gland They may be inhomogenous echoes within
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic abscess
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Cysts of the prostate gland can be classified into 6 categories including 1) isolated medial cysts 2) cysts of the ejaculatory duct 3) simple or multiple cysts of the parenchyma 4) complicated infectious or hemorrhagic cysts 5) cystic tumors and 6) cysts secondary to parasitic disease Cysts of the prostate are related to atrophy of the prostate gland as well as to other well-known factors such as inflammatory disease benign prostatic hyperplasia ejaculatory duct obstruction and cancer The differential diagnosis and diagnostic criteria are shown for each category A possible limitation of this classification is that the quantitative aspect of the cyst was not evaluated This is the initial step toward a more detailed classification and the basis for further pathological studies
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic utricle cyst
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Images for prostatic cyst
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Large cyst of seminal vesicle
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic calcification is a common finding especially after the age of 50 They may be solitary but usually occur in clusters UltrasoundCalcifications appear as brightly echogenic foci that may or may not show posterior shadowing
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Calcified cyst of the prostatic utricle
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
(C) Ejaculatory duct calcifications (D) Seminal vesicle calcifications (E) Ejaculatory duct dilation
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Seminal vesicle calculi (seminal vesicle calcification)
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign prostatic hypertrophy (BPH) is an extremely common condition in elderly men and is a major cause of outflow obstruction Although the term prostatomegaly is often used interchangeably strictly speaking prostatomegaly may refer to any cause of prostatic enlargement
UltrasoundUltrasound has become the standard first line investigation after the urologists finger Typically there is an increase in volume of the prostate with a calculated volume exceeding 30 cc ((A x B x C)2) The central gland is enlarged and is hypoechoic or of mixed echogenicity Calcification can be seen both within the hypertrophied gland as well as in the pseudocapsule (representing compressed peripheral zone)Post-micturition residual volume is typically elevated
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign prostatic hypertrophy
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign prostatic hyperplasia
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Benign prostatic hyperplasia
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic carcinoma ranks as the most common malignant tumour in men and the second most common cause of cancer-related deaths in men Prostatic adenocarcinoma is by far the most common histological type and is the primary focus of the article
UltrasoundTransrectal ultrasonography (TRUS) is often initially performed in order to detect abnormalities and to guide biopsy usually following an abnormal PSA level or DREUltrasound is used to direct biopsy of suspicious hypoechoic regions usually in the peripheral zone Because of the high incidence of multifocality systematic sextant biopsies are recommendedOn ultrasound prostate cancer is usually seen as a hypoechoic lesion (60-70) in the peripheral zone of the gland but can be hyperechoic or isoechoic (30-40 of lesions)Transrectal ultrasound is also the modality of choice for directing brachytherapy seeds into the prostate gland
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Carcinoma of the prostate
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Carcinoma prostate- Ultrasound and Color Doppler imaging
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Contrast-enhanced ultrasound showing an enhancing prostate cancer
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Grayscale ultrasound showing a hypoechoic nodule in the left peripheral zone (arrow) There is interruption of the normal green band on elastography with a stiff area that corresponds to the nodule Biopsy confirmed Gleason grade 7 prostate cancer
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
A Conventional gray scale image shows a hypoechoic mass extending exophytically from the prostate (arrows) The hypoechoic appearance is the classic description for prostate cancer B Real-time elastography shows reduced tissue elasticity (darker blue color) in the region of the mass (arrows) C Color Doppler shows increased flow within and around the mass (arrows)
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
A Conventional gray scale image shows a hypoechoic area in the left base (arrows) B Power Doppler image shows no significant increase in flow in this hypoechoic area C Harmonic gray scale during contrast infusion shows a clearly defined area of focal enhancement corresponding to the cancer (arrows) D Harmonic gray scale with intermittent imaging shows a less well-defined larger area of parenchymal enhancement around the cancer E Contrast-enhanced color Doppler image shows increased flow associated with the cancer F Contrast-enhanced power Doppler image also shows increased flow associated with the cancer
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Conventional gray scale transverse image does not show any suspicious lesion B Only contrast-enhanced colour Doppler transverse image shows increased flow associated with the cancer
A Conventional gray scale transverse image shows no focal lesion B Contrast-enhanced colour Doppler transverse image shows increased flow in the left base corresponding to the cancer C Also contrast-enhanced power Doppler transverse image shows increased flow corresponding to the cancer
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
A Power Doppler image showed limited blood flux in the central gland of the prostate (arrow) suggesting that this area had not been totally destroyed by the HIFU ablation B Simultaneous acquisition of a low mechanical index ultrasound image (right side of the screen) and of a contrast ultrasound image (left side of the screen) 30sec after bolus injection of 48ml of Sonovue The HIFU-induced coagulation necrosis was clearly seen as a devascularized area with no contrast enhancement (straight arrows) The anterior part of the left lobe showed intense enhancement on contrast image (arrowheads) suggesting it had not been destroyed by HIFU Obtaining biopsy from that anterior territory might increase the sensitivity of residual cancer detection Note that the devascularized area extended into the periprostatic tissues (curved arrow)
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Sarcoma Delayed development of prostatic sarcoma is a rare
complication of prostatic pelvic irradiation The TRUS appearance of this lesion is typified by an irregular hypoechoic prostatic mass with an anechoic area consistent with the echogenicity of muscle andor necrosis This appearance is distinctly dissimilar to prostatic adenocarcinoma The sonographic finding of an irregular hypoechoic prostatic mass with an anechoic area should raise the suggestion of prostatic sarcoma in patients with a history of pelvic irradiation who develop an abnormal prostate found during a rectal examination andor who have worsening voiding symptoms despite a normal serum PSA level Unlike radiation-induced sarcoma involving the prostate which is predominantly hypoechoic the echogenicity of rhabdomyosarcoma is similar to that of the normal prostate TRUS can provide a means of monitoring prostate size and sampling tissue in older patients with prostatic rhabdomyosarcoma but has little value as a diagnostic imaging technique TRUS is inappropriate in children who are more commonly affected with prostatic rhabdomyosarcoma Cystosarcoma phyllodes involving the prostate appear as a large irregular mass containing multiple large anechoic cysts of variable size
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Prostatic involvement by lymphoma and leukemia is rare in
surgical pathology practice In the 2 largest consecutive series leukemialymphoma was identified in less than 1 of prostates
Lymphoma of the prostate
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Melanoma of the prostate with lung metastasis
Metastasis of the prostate from cancer rectum
Thank You
Metastasis of the prostate from cancer rectum
Thank You
Thank You