1. MAGNETOM Flash
The Magazine of MR
Issue Number 2 /2009
ASTRO/ESTRO Edition
Clinical
Prostate Imaging
at 3T
Page 6
IVIM f-maps of
Pancreatic Lesions
Page 26
Nonsecretory
Multiple Myeloma
Page 34
TWIST MRA of Pelvic
Congestion Syndrome
Page 58
Product News
What’s new with
software version
syngo MR B17
Page 92
Xxxxxxx xxxxxxxxx xxxxxxxxxxxxxx

2. Editorial
Matthias Lichy, M.D.
Dear MAGNETOM user,
Diffusion-weighted imaging (DWI) is application for tumor staging and to
currently one of the fastest-emerging improve workflow. However, we can also
applications for the precise detection and improve workflow by using existing
characterisation of lesions in the body. techniques based on our Tim technology,
We explore the integration of this method such as syngo TWIST - a technique for
in a variety of clinical scenarios. Prostate highly temporal resolved MR angiography
imaging, for example, is explored in an (case reports by Merkle et al. on imaging
article on pre-operative local staging at of pelvic congestive syndrome).
3Tesla. The syngo MR B17 software also intro-
In addition, syngo REVEAL enables us to duces non contrast-enhanced MR
obtain information about tumor viability, angiography techniques that provide
as shown in an extensive case report detailed information on vessel diseases
on a patient with nonsecretory multiple in patients who until recently had to be
myeloma. rejected for MRI for several reasons,
DWI techniques can also be used to gather including a high risk of NSF or known
additional information about perfusion severe allergic reactions to former con-
within one scan. Background information trast applications. The first results
about the ‘intravoxel incoherent motion’ revealed in this issue are promising and
(IVIM) technique and its clinical relevance we have great expectations that this
in the differentiation of pancreatic lesions imaging technique will soon establish
are examined in the article by Re et al., itself in our daily clinical routine.
German Cancer Research Center.
We are sure you will enjoy reading this
The introduction of the syngo MR B17 latest edition of Flash!
software offers a variety of new industry-
unique applications with a special focus
on oncology. We have expanded the
capabilities of the continuous table move
technique (syngo TimCT) to include an Matthias Lichy, M.D.
MAGNETOM Flash is part of Life, Siemens’ unique customer care solution that helps you get the
most from your investment. With its programs and services Life sharpens your skills so you can
see optimal clinical value. It provides the support you need to maximize productivity and it assures
that as technology changes, you will always be at the cutting edge.
2 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world

3. Editorial
The Editorial Team
We appreciate your comments.
Please contact us at magnetomworld.med@siemens.com
Matthias Lichy, M.D.
Editor in Chief
Antje Hellwich Dagmar Thomsik-Schröpfer, Okan Ekinci, M.D. Peter Kreisler, Ph.D.
Associate Editor Ph.D., MR Marketing-Products, Segment Manager Collaborations & Applications,
Erlangen, Germany Cardiovascular MRI Erlangen, Germany
Erlangen, Germany
Heike Weh, Bernhard Baden, Ignacio Vallines, Ph.D., Wellesley Were
Clinical Data Manager, Clinical Data Manager, Applications Manager, MR Business Development
Erlangen, Germany Erlangen, Germany Erlangen, Germany Manager
Australia and New Zealand
Milind Dhamankar, M.D. Michelle Kessler, US Gary R. McNeal, MS (BME) Dr. Sunil Kumar S.L.
Sr. Director, MR Product Installed Base Manager, Advanced Application Specialist, Senior Manager Applications,
Marketing, Malvern, USA Malvern, PA, USA Cardiovascular MR Imaging Canada
Hoffman Estates, USA
MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 3

4. Content Content
Content 26
IVIM ƒ-maps
34
Nonsecretory Mulitple Myeloma
40
syngo TimCT Oncology
62
DWI in Mamma Ca
Product News Clinical Whole Body Clinical Clinical
See what is new
Abdomen / Pelvis 34 Case Report: Nonsecretory Multiple Women’s Health k How I do it
with software version Myeloma MRI Monitoring of
6 Assessment of Tumor Extension 58 Case Reports: Time-Resolved MRA 72 The Composer
syngo MR B17. Therapy Response
and Improved Localization for Evaluation of Pelvic -Congestion Sandra Winsor
Marius Horger
Planning of Nerve Sparing Radical Syndrome
Prostatectomy 40 Case Report: Whole-body Oncologic Charles Kim, et al.
Matthias Philipp Lichy, et al. Imaging with syngo TimCT
Technology
Eric Hatfield, et al. 62 Case Report: Role of DWI for
16 Case Reports: MRI-guided 78 32-Channel Head Coil
Lesion Discrimination in Breast
Prostate Biopsies Imaging at 3T
MRI of Multifocal and
88 Karl Engelhard Clinical Contralateral Breast Cancer
Thomas Benner
syngo NATIVE TrueFISP Evelyn Wenkel, et al.
18 Case Report: Echo Planar Diffusion Neurology
Imaging for Detection of Prostate 67 Diffusion-Weighted Imaging for Product News
50 Case Report: Glioblastoma
Cancer Recurrence Otherwise Characterizing Breast Lesions 88 New with syngo MR B17:
Multiforme
Occult to Imaging Prior to Biopsy syngo Native – Non Contrast MR
Masahiro Ida
Sarah Foster, Nick Ferris Mitsuhiro Tozaki, Angiography Techniques
Maruyama Katsuya Peter Weale
20 Characterization of Genitourinary Clinical 92 What’s New for Cardiac in
Lesions Using Diffusion-Weighted
Imaging at 3T MRI Cardiocascular Software Version syngo MR B17
Farhood Saremi, Peter Weale
52 Case Report: Non-Contrast Lower
Helmuth Schultze-Haakh
Limb MR Angiography Using 95 Improved Workflow and
26 Intravoxel Incoherent Motion (IVIM) NATIVE SPACE Performance for Contrast-
ƒ-maps of Pancreatic Lesions Andrew Holden, et al. Enhanced MR Angiography
Thomas Joseph Re, et al. Sequences
54 Pre-Transplant Assessment of
Gary R. McNeal, et al.
Potential Renal Donors with syngo
Native TrueFISP: Case Study and
Initial Experience
Mellena D. Bridges, et al.
4 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 5

5. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
Assessment of Tumor Extension and 3T without endorectal coil is presented
in this case report article. In both shown
4. 3D dynamic contrast en-
hanced T1-weighted imaging:
1 average, 70 measurements, acquisition
time for one data set was 04:58 min;
cases, MRI was able to improve therapy syngo TWIST (GRE with echo sharing): contrast media was injected via a cubital
Improved Localization for Planning and planning and the surgical outcome
clearly. To improve the image quality
TR 3.5 ms, TE 1.4 ms, PAT factor 2, no fat
suppression, slice thickness 3.6 mm,
vein in a standardized flow and dosage
with the start of the first measurement
Nerve Sparing Radical Prostatectomy especially of the diffusion-weighted
imaging (syngo DWI), after a digital rectal
FOV 260 x 260 mm, matrix 144 x 192, (Magnevist, Bayer Schering, Germany).
examination 50 to 100 ml ultrasound
Matthias Philipp Lichy, M.D. 1,4; David Schilling2, M.D; Claus H. von Weyhern3, M.D.; Arnulf Stenzl2, M.D.; gel was administered per rectum in both
Matthias Roehtke, M.D.1; Ralph Strecker, Ph.D.4; Wilhelm Horger4; Berthold Kiefer, Ph.D.4; Claus D. Claussen, M.D.1; cases. Sequence parameters for the k Visit www.siemens.com/magnetom-world
Heinz-Peter Schlemmer, M.D., Ph.D.1 shown MR examinations were: for practical information on MR spectroscopic
imaging of the prostate in clinical routine.
1
University Hospital Tübingen, Department of Diagnostic and Interventional Radiology, Tübingen, Germany 1. T2-weighted MRI Turbo Spin
2
University Hospital Tübingen, Department of Urology, Tübingen, Germany Echo (TSE) sequences:
3
University Hospital Tübingen, Department of Pathology, Tübingen, Germany Transversal T2w TSE:
4
Siemens Healthcare Sector, Erlangen, Germany TR 6330 ms, TE 101 ms, PAT factor 2
(syngo GRAPPA), FOV 200 x 200 mm, Starting on page 64 of the Operator
matrix 310 x 320, slice thickness 3 mm, Manual – Spectroscopy you’ll find
3 averages, acquisition time 3:04 min. ■ positioning of the patient and coil
Coronal T2w TSE: ■ planning the VOI
TR 4440 ms, TE 101 ms, PAT factor 2 ■ measurement and
(syngo GRAPPA), FOV 200 x 200 mm, ■ examples of spectra.
Introduction matrix 310 x 320, slice thickness 3 mm, The manual also includes the evaluation
Prostate cancer (PCa) is the most com- main indication for MRI of the prostate such a purpose. Therefore it seems to 2 averages, acquisition time 3:44 min. of spectroscopic data with the syngo
mon malignancy in men and according in the daily clinical work-up had be only logical to include information Sagittal T2w TSE: Spectroscopy task card and provides
to the update of the National Cancer remained tumor staging for assignment provided by metabolic (MR spectroscopic TR 5000 ms, TE 101 ms, PAT factor 2 detailed information on the workflow
Institute in 2005, the incidence of this of best therapy. However, clinical imaging; MRSI) and functional imaging (syngo GRAPPA), FOV 200 x 200 mm, of a typical 1H MRS examination in the
malignancy in the United States of demands have changed dramatically (diffusion-weighted imaging; syngo DWI matrix 310 x 320, slice thickness 3 mm, head and breast (syngo GRACE).
America is higher than for female breast during the last decade; while prostate- and T1-weighted dynamic contrast 2 averages, acquisition time 2:40 min.
cancer (2004: 165.3 PCa per 100.000 specific antigen (PSA) testing has signifi- enhanced MRI; T1w DCE) to improve the At www.siemens.com/magnteom-world
men; 126.4 breast cancer per 100.000 cantly reduced the amount of advanced diagnostic performance of MRI. 2. Diffusion-weighted imaging you can download the manuals in German
women). Also, with the widespread (T4/T3; N+, M+ stages) PCa at the time With the introduction of the 3T MR scan- (syngo DWI): and English free-of-charge.
introduction of PSA testing a shift point of diagnosis, the refinement of ner and associated increase in signal- Single shot echo planar imaging (EPI):
towards detection of PCa at an early surgical and radiotherapy treatment pro- to-noise (SNR) there is now the potential TR 3800 ms, TE 70 ms, PAT factor 2
stage of disease can be observed. cedures like robot-assisted nerve sparing to acquire all this information without (syngo GRAPPA), SPAIR fat suppression
The potential of magnetic resonance radical prostatectomy and intensity the use of an endorectal coil. Based on technique, FOV 221 x 260 mm, matrix
imaging (MRI) for imaging PCa was modulated radiotherapy have increased literature data, the application of an 102 x 160, 3 scan trace, ADC-mapping
already recognized and evaluated in the demand for a dedicated and accu- endorectal coil at 3T will increase the (Inline), b-values: 0 / 100 / 400 /
the beginning of the wide introduction rate imaging modality to provide all sensitivity for the detection of tumor 800 s/mm2, slice thickness 3.6 mm,
of MRI into clinical practice in the early relevant information about extension penetration of the capsule; nevertheless, 6 averages, acquisition time 2:40 min.
80’s. Until recently, the combination of and localisation of prostate cancer. Of for tumor localization within the gland
T2-weighted Turbo Spin Echo (T2w TSE) course, it has been recognised since the e.g. for planning of radiotherapy or 3. 3D MR spectroscopic
sequences and the application of an early days of prostate MRI that due to MRI-guided biopsies and also for follow- imaging:
endorectal coil had still been considered hyperplasia of the central gland, prosta- up, deformation of the prostate TR 750 ms, TE 145 ms, voxel size (inter-
as state-of-the-art for local tumor titis and bleedings (e.g. caused by for- introduced by the endorectal coil can polated) 0.5 x 0.5 x 1.1 cm, averages 8,
staging, in particular for magnetic field mer biopsies) the diagnostic accuracy of be disadvantageous. Hamming filter, spectral lipid and water
strengths up to 1.5 Tesla, whilst the T2w TSE MRI can be clearly restricted for The potential of state-of-the-art MRI at suppression, acquisition time 9:14 min.
6 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 7

6. 2A
Clinical Abdomen / Pelvis Abdomen/Pelvis Clinical
Cardiovascular
Case 1
Patient with stage T3a prostate cancer
This 61-year-old patient with biopsy to our MRI unit one day before planned to the left dorsal capsule with main
proven prostate cancer and an initial nerve sparing radical prostatectomy. localization in the apico-medial periph-
total PSA level of 5.1 ng/ml was referred MRI revealed a tumor with broad contact eral zone and extension to the base.
1A
2A This figures show the clear restriction of the water diffusion within the tumorous areas. Left: T2-weighted TSE image, middle: original high b-value
image (b = 800 s/mm2), right: overlay of syngo DWI and T2-weighted TSE image, showing perfect match, confirming the extension of the tumor.
2B
1B
1C
1 Exemplary chosen T2-weighted TSE images demonstrating the extent of the tumor suspicious findings (A transversal, B sagittal, C coronal). 2B DCE T1-weighted image demonstrating the difference between the cancer and normal prostate tissue. Left: T1-weighted DCE image subtracted
from a native mask image at the time point of the maximum peak of the signal-intensity-time curves (middle) within the tumor tissue. While
standardized parameter maps do show only a slight side difference (Kep right upper image; right lower image T2-weighted reference), the signal-
intensity-time curves are highly suspicious and correlate clearly with the morphologic changes on T2-weighted image.
8 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 9

7. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
2C 1 3A 3B
No seminal vessel infiltration and suspi-
APEX
cious lymph nodes were found. Despite
the lack of a clear extension beyond
the capsule, the finding was highly
suspicious for a micro penetration of the
capsule, potentially negating a bilateral
2
1 3
2 3
2C Exemplary chosen spectra from the base of the prostate, demonstrating the widespread tumor infiltration. In all voxels, a clear
increase of the (Choline + Creatine) / Citrate ratio can be observed.
BASE
3 A: Macroscopic prostatectomy specimen before fixation, B: HE stained histopathology with marked extension of all tumor foci (blue line).
A high concordance between MR findings and histophatology is obvious.
No seminal vessel infiltration and suspi- neous section. To ensure oncological
cious lymph nodes were found. Despite resection of the tumor, it was not possi-
the lack of a clear extension beyond ble to preserve the left nerve bundle.
the capsule, the finding was highly According to the MRI findings, the
suspicious for a micro penetration of the surgeons could spare the right nerve
capsule, potentially negating a bilateral bundle. The prostate cancer was staged
nerve sparing. The strong suspicion of as pT3a pN0 (0/15) cM0 R0, Gleason
a T3a stage was confirmed during the Score 3 + 4 = 7.
radical prostatectomy by an instanta-
10 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 11

8. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
Case 2 4B 4C 4D
4B–D Exemplary chosen
Patient with stage T3b prostate cancer T2-weighted images (B sagittal,
C coronal) demonstrating the
This 63-year-old patient with biopsy- the patient revealed a urothelium carci- found. The histopathology revealed extent of the tumor suspicious
proven prostate cancer and a total PSA noma (initial diagnosis made 6 years heterotopic ossifications. findings.
D: Corresponding ADC-maps,
level of 7.51 ng/ml at the time point of ago) and approx. one month before the MRI revealed a tumor of the right demonstrating the clear water
surgery was referred to our MRI unit one planed radical prostatectomy, a resec- dorsal gland within the peripheral zone diffusibility restriction also in
day before planned nerve sparing radical tion of suspicious pulmonary findings with broad contact to the capsule. the suspicious area within the
right seminal vessel.
prostatectomy. The medical history of was performed but no malignancy was Additionally, in the right seminal vessel,
4A 4E
4A Exemplary chosen T2-weighted images (transversal) demonstrating the extent of the tumor suspicious findings. D, E: Corresponding ADC-maps, 4E Corresponding ADC-maps, demonstrating the clear water diffusibility restriction also in the suspicious area within the right seminal vessel.
demonstrating the clear water diffusibility restriction also in the suspicious area within the right seminal vessel.
12 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 13

9. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
a T2-weighted hypointense and nodular MRI findings, the instantaneous section (R0 resection). However, lymphadenec- References
configured area was detected. In combi- found capsule penetration with infil- tomy found positive pelvic lymph nodes. 1 Goeb K, Engehausen DG, Krause FS, Hollenbach 10 Fütterer JJ, Engelbrecht MR, Jager GJ, Hartman for predicting insignificant prostate cancer: an
HP, Niedobitek G, Buettner M, Frangou P, RP, King BF, Hulsbergen-Van de Kaa CA, Witjes initial analysis. BJU Int 99(4):786-93.
nation with the clear restriction of the tration of the nerve bundles as well as The prostate cancer was staged as pT3b
Engelhard K (2007) MRI spectroscopy in screen- JA, Barentsz JO (2007) Prostate cancer: compar- 20 JWang L, Zhang J, Schwartz LH, Eisenberg H,
water diffusion, this finding was cate- extension towards the right seminal pN1 (3/14) cMx, R0, L0, V0, Gleason ison of local staging accuracy of pelvic phased- Ishill NM, Moskowitz CS, Scardino P, Hricak H
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gorized as tumor and therefore a stage vessel and therefore no nerve sparing Score 4 + 3 = 7. 687–93. array coil alone versus integrated endorectal- (2007) Incremental value of multiplanar cross-
T3b was assumed. In agreement with prostatectomy could be achieved 2 Lichy MP, Anastasiadis AG, Aschoff P, Sotlar K, Es- pelvic phased-array coils. Local staging accuracy referencing for prostate cancer staging with
chmann SM, Pfannenberg C, Stenzl A, Claussen of prostate cancer using endorectal coil MR endorectal MRI. AJR Am J Roentgenol
CD, Schlemmer HP (2007) Morphologic, func- imaging. Eur Radiol 17(4): 1055–65. 188(1):99–104.
5A 5B tional, and metabolic magnetic resonance imag- 11 Fütterer JJ, Heijmink SW, Scheenen TW, Veltman 21 Akin O, Sala E, Moskowitz CS, Kuroiwa K, Ishill
ing-guided prostate biopsy in a patient with J, Huisman HJ, Vos P, Hulsbergen-Van de Kaa NM, Pucar D, Scardino PT, Hricak H (2006) Tran-
APEX prior negative transrectal ultrasound-guided CA, Witjes JA, Krabbe PF, Heerschap A, Barentsz sition zone prostate cancers: features, detec-
biopsies and persistently elevated prostate-spe- JO (2006) Prostate cancer localization with tion, localization, and staging at endorectal MR
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3 Anastasiadis AG, Lichy MP, Nagele U, Kuczyk MA, proton MR spectroscopic imaging. Radiology 22 White S, Hricak H, Forstner R, Kurhanewicz J,
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Sievert KD, Claussen CD, Stenzl A, Schlemmer 12 Fütterer JJ, Engelbrecht MR, Huisman HJ, Jager Carroll PR (1995) Prostate cancer: effect of
HP (2006) MRI-guided biopsy of the prostate GJ, Hulsbergen-van De Kaa CA, Witjes JA, Bar- postbiopsy hemorrhage on interpretation of MR
increases diagnostic performance in men with entsz JO (2005) Staging prostate cancer with images. Radiology 195(2):385–90.
elevated or increasing PSA levels after previous dynamic contrast-enhanced endorectal MR im- 23 Singh AK, Guion P, Sears-Crouse N, Ullman K,
negative TRUS biopsies. Eur Urol 50(4):738–48; aging prior to radical prostatectomy: experi- Smith S, Albert PS, Fichtinger G, Choyke PL, Xu
discussion 748–9. enced versus less experienced readers. Radiolo- S, Kruecker J, Wood BJ, Krieger A, Ning H
4 Lichy MP, Pintaske J, Kottke R, Machann J, Anas- gy 237(2): 541–9. (2007) Simultaneous integrated boost of biopsy
tasiadis A, Roell S, Hennenlotter J, Diergarten T, 13 Scheenen TW, Klomp DW, Röll SA, Fütterer JJ, proven, MRI defined dominant intra-prostatic
Schick F, Stenzl A, Claussen CD, Schlemmer HP Barentsz JO, Heerschap A (2004) Fast acquisi- lesions to 95 Gray with IMRT: early results of a
(2005) 3D proton MR spectroscopic imaging of tion-weighted three-dimensional proton MR phase I NCI study. Radiat Oncol 18;2:36.
prostate cancer using a standard spine coil at spectroscopic imaging of the human prostate.
1.5 T in clinical routine: a feasibility study. Eur Magn Reson Med 52(1):80–8.
Radiol 15(4):653–60. 14 Engelbrecht MR, Huisman HJ, Laheij RJ, Jager GJ,
5 Kiessling F, Lichy M, Grobholz R, Heilmann M, van Leenders GJ, Hulsbergen-Van De Kaa CA, Contact
Farhan N, Michel MS, Trojan L, Ederle J, Abel U, de la Rosette JJ, Blickman JG, Barentsz JO Matthias Lichy, M.D.
Kauczor HU, Semmler W, Delorme S (2004) Sim- (2003) Discrimination of prostate cancer from Siemens Healthcare
ple models improve the discrimination of pros- normal peripheral zone and central gland tissue MR CRM MK CCA
tate cancers from the peripheral gland by T1- by using dynamic contrast-enhanced MR imag- Tel. +49 (9131) 84-3266
weighted dynamic MRI. Eur Radiol 14(10): ing. Radiology 229(1): 248–54. matthias.lichy@siemens.com
1793–801. 15 Engelbrecht MR, Jager GJ, Laheij RJ, Verbeek AL,
6 Engelhard K, Hollenbach HP, Kiefer B, Winkel A, van Lier HJ, Barentsz JO (2002) Local staging
Goeb K, Engehausen D (2006) Prostate biopsy of prostate cancer using magnetic resonance
in the supine position in a standard 1.5-T scan- imaging: a meta-analysis. Eur Radiol 12(9):
ner under real time MR-imaging control using 2294–302.
a MR-compatible endorectal biopsy device. Eur 16 Jager GJ, Severens JL, Thornbury JR, de La
Radiol 16(6): 1237–43. Rosette JJ, Ruijs SH, Barentsz JO (2000) Prostate
7 Engelhard K, Hollenbach HP, Deimling M, Kreckel cancer staging: should MR imaging be used?--A
M, Riedl C (2000) Combination of signal intensi- decision analytic approach. Radiology 215(2):
ty measurements of lesions in the peripheral 445-51.
zone of prostate with MRI and serum PSA level 17 Bloch BN, Furman-Haran E, Helbich TH, Lenkinski
for differentiating benign disease from prostate RE, Degani H, Kratzik C, Susani M, Haitel A,
cancer. Eur Radiol. 2000;10(12): 1947–53. Jaromi S, Ngo L, Rofsky NM (2007) Prostate
8 Scheenen TW, Heijmink SW, Roell SA, Hulsber- cancer: accurate determination of extracapsular
gen-Van de Kaa CA, Knipscheer BC, Witjes JA, extension with high-spatial-resolution dynamic
Barentsz JO, Heerschap A (2007) Three-dimen- contrast-enhanced and T2-weighted MR imag-
sional proton MR spectroscopy of human pros- ing--initial results. Radiology 245(1):176–85
tate at 3 T without endorectal coil: feasibility. 18 Haider MA, van der Kwast TH, Tanguay J, Evans
BASE Radiology 245(2): 507–16.
9 Heijmink SW, Fütterer JJ, Hambrock T, Takahashi
AJ, Hashmi AT, Lockwood G, Trachtenberg J
(2007) Combined T2-weighted and diffusion-
S, Scheenen TW, Huisman HJ, Hulsbergen-Van weighted MRI for localization of prostate can-
de Kaa CA, Knipscheer BC, Kiemeney LA, Witjes cer. AJR Am J Roentgenol 189(2):323–8.
5 A: Macroscopic prostatectomy specimen before fixation, B: HE stained histopathology with marked extension of all tumor foci (blue line). JA, Barentsz JO (2007) Prostate cancer: body- 19 Shukla-Dave A, Hricak H, Kattan MW, Pucar D,
A high concordance between MR findings and histophatology is obvious. The specimen of the seminal vessels and the lypmph nodes are not array versus endorectal coil MR imaging at 3 T-- Kuroiwa K, Chen HN, Spector J, Koutcher JA,
shown in this stage pT3b pN1case. comparison of image quality, localization, and Zakian KL, Scardino PT (2007) The utility of
staging performance. Radiology 244(1):184–95. magnetic resonance imaging and spectroscopy
14 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 15

10. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
Case Reports:
MRI-guided Prostate Biopsies
Karl Engelhard, M.D.
2A 2B 3
Diagnostic Radiology, Martha-Maria Hospital Nuernberg, Nuernberg, Germany
This article examines two important Coronal (TR 4.000 ms; TE 102 ms; After localization of the tumor-suspi-
clinical cases for a better understanding ST 3 mm; GAP 0.25; FOV 200 mm; cious areas, the endorectal coil was
of potential benefits, but also limita- matrix 256 × 256); removed and the MR visible needle guide
tions, of MRI-guided prostate biopsies. Sagittal (TR 4.560 ms; TE 106 ms; was inserted into the patient’s rectum
All examinations were performed on ST 3 mm; GAP 0.25; FOV 200 mm; and guided to the area to be punctured
a 1.5T system (MAGNETOM Symphony, matrix 230 × 256); close by the prostate capsule. The
Siemens Healthcare, Erlangen, Germany). Subsequently, a T1-weighted axial biopsies were performed by means of an
Prior to the MRI-guided biopsy, an MRI TSE sequence was applied (TR 700 ms; MR-compatible biopsy gun (16 G; MRI
examination with a combined endo- TE 12 ms; ST 4 mm; GAP 0.3; Devices, Schwerin, Germany). Further
2A Transversal T2w TSE MR demonstrating 2B Corresponding sagittal T2w slice. 3 MR image in oblique orientation
rectal body phased-array coil was per- FOV 160 mm; matrix 192 × 256) from information about the procedure can be
a small suspicious lesion within the left during biopsy.
formed. After insertion of the endorectal the prostate apex up to the seminal found in: Engelhard K, Hollenbach HP, lateral zone.
coil, the imaging protocol for localiza- vesicle. In addition, a T1-weighted axial Kiefer B, Winkel A, Goeb K, Engehausen
tion of suspicious areas within the gland TSE sequence (TR 500 ms; TE 13 ms; D. “Prostate biopsy in the supine position
consisted of the following T2-weighted ST 5 mm; GAP 0.3; FOV 300 mm; in a standard 1.5T scanner under real
TSE sequences: Axial (TR 4.000 ms; matrix 256 × 256) was applied through time MR-imaging control using a MR-
TE 102 ms; slice thickness (ST) 3 mm; the regional lymph drain path from compatible endorectal biopsy device.” Case 2
slice distance (GAP) 0.25; field of view the prostate base up to the aorta bifur- Eur Radiol. 2006 Jun;16(6):1237-43. In the T2-weighted image, low-signal shown. Before MRI-guided prostate biopsy of the suspicious hypointense
(FOV) 160 mm; matrix 256 × 256); cation. Epub 2006 Feb 1. lesions within inhomogeneous adenoma biopsy, the patient has undergone three area in the ventral transition zone within
structures could correspond to hyper- negative punch biopsies for evaluation adenoma structures (Figs. 4 and 5).
cellular carcinomas. As a differential of a TRUS-proven tumor (once with Histology revealed sclerotic node forma-
diagnosis, sclerotic adenoma nodes rich 6 samples, twice with 18 samples). The tion with collagen-rich benign prostatic
Case 1 1
in connective tissue also produce low presence of a suspicious lesion was hyperplasia (BPH).
A 60-year-old patient with a PSA elevated signal. In this case, a 70-year-old patient confirmed by T2w MRI and therefore the
to 10 ng/ml is shown. Transrectal ultra- with a PSA elevated to 12 ng/ml is patient was referred to MRI-guided punch
sound (TRUS) did not show a cancer-
suspected lesion (Fig. 1), however, the 4 5
endorectal MRT showed a small but Contact
PD Dr. Karl Engelhard, M.D.
cancer-suspected hypointense lesion in Martha-Maria Hospital Nuernberg
medio-lateral orientation in the middle Dept. of diagnostic Radiology
peripheral gland, left (Fig. 2). MRI- Stadenstraße 58
guided punch biopsy was performed at 90491 Nuernberg
Germany
the suspected site (Fig. 3), histology
k.engelhard@martha-maria.de
revealed an Adeno-Carcinoma (G1,
Gleason 2 + 2 = 4). The patient was
then referred to radical prostatectomy.
Based prostatectomy specimen,
pT3a G3 pN0 pM0, Gleason 3 + 4 = 7 was
diagnosed with tumor cell layers in both
lobes. Therefore it is important to stress
that when the location of the biopsy
4 Transversal T2w TSE demonstrating 5 Corresponding MR image in oblique
site is determined solely by suspicious
irregular and unclear nodule in the ventral orientation taken during biopsy.
areas in the T2-weighted pulse sequence, 1 Transrectal ultrasound, no clear depiction of suspicious lesion possible. right central gland.
not all tumor sites become visible.
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11. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
Case Report: 3 4
Echo Planar Diffusion Imaging for
Detection of Prostate Cancer Recurrence
Otherwise Occult to Imaging
Sarah Foster, M.D.; Nick Ferris, M.D.
Department of Diagnostic Radiology, Peter MacCallum Cancer Center, Melbourne, Australia
Background
Imaging of the “post-treatment” gland The peripheral zone can, however, dem- susceptibility artifacts which obscure fine
for prostate cancer can be especially onstrate focal or diffuse low signal in detail and can impair interpretation of
challenging. Treatment for non-operable a number of clinical situations. Benign certain MRI sequences, such as diffusion
prostate cancer includes various combi- prostatic hypertrophy often results in a imaging or MR spectroscopy, within the
nations of chemotherapy (anti-androgen compressed peripheral zone which may prostate. 3 ADC map demonstrating focal restriction of water diffusion. 4 High b-value image at b = 800 s/mm2.
therapy), targeted radiation therapy, and have altered signal. Treatment for pros- MRI of the post-treatment gland can thus
brachytherapy (implanted seeds). tate cancer with anti-androgen therapy be difficult, as areas of low signal may
The majority of prostate cancers arise can result in diffuse low signal within represent recurrent/residual disease, or
from the peripheral zone. Normal tissue the peripheral zone. Radiation therapy merely be part of the spectrum of therapy
Conclusions
in the peripheral zone has higher signal can also result in low signal, either dif- change. A dilemma thus arises when a post-treat- of 50, 400 and 800, TR 4200 ms,
intensity on T2-weighted imaging than fusely or focally, depending on the radi- Ultrasound detection of prostate cancer can ment patient presents with an increasing TE 85 ms, matrix 192/144, 4 mm slice Diffusion-weighted imaging using the
the central, transitional and periurethral ation port. These changes are thought also be difficult in a hypertrophied gland PSA level, suspicious for recurrence. The thickness; ADC-maps were recon- Siemens 3T MAGNETOM Trio was helpful
zones. Malignancy can be detected on to reflect fibrous replacement of the due to the heterogeneity of tissue, making imaging many times is not sensitive or structed automatically from these with in identifying disease which would oth-
MRI as a low signal region within other- normally glandular tissue. Additionally, location of a discrete lesion challenging. specific enough to confidently locate the the system software. erwise have been occult to imaging.
wise high signal peripheral zone tissue. brachytherapy seeds result in metallic Many lesions are ultrasound-occult. residual or recurrent disease location A region of significantly restricted diffu- This helped guide a successful ultrasound-
to help steer biopsy. sion was detected in the right apex of guided biopsy to confirm disease recur-
We are trialling diffusion-weighted MR the gland. At T2-weighted imaging, only rence. This has significant implications
1 2 imaging at 3T to aid in improving detec- a subtle low signal focus could be seen for the patient’s prognosis, and decisions
tion of disease recurrence. The theory is at this site. The T2-weighted sequences regarding further treatment.
that highly cellular tumor tissue will alone would have been difficult to inter- Diffusion imaging has its limitations.
demonstrate significantly restricted dif- pret, as the peripheral zone demonstrated False positive results can occur in the set-
fusion, compared with normal stromal diffusely low T2 signal intensity, as well ting of haemorrhage, infection or arti-
and glandular tissue. as some artifact at the site of the fact from implanted metal. When the
brachytherapy seeds. findings are taken in the correct clinical
Case scenario The patient went on to have ultrasound setting, however, diffusion-weighted im-
The patient presented with a rising PSA imaging of the prostate, which did not aging may be a powerful adjunct to the
following brachytherapy for stage T2a distinguish a focal lesion in the prostate detection of residual or recurrent disease
N0 M0 Gleason 6 prostate cancer. The apex. in prostate adenocarcinoma.
disease was initially located in the right The prostate was biopsied under ultra-
apex of the gland. The patient had a sound guidance with samples obtained
Contact
repeat MRI for restaging. from the base, mid portion and apex of Sarah Foster, M.D.
We scanned the patient using the the gland, with extra samples from the Department of Diagnostic Radiology
Siemens 3T MAGNETOM Trio. right apex to correlate with the abnor- Peter MacCallum Cancer Center
Sequences included: mal region of restricted diffusion on MRI. St Andrew’s Place
East Melbourne, Victoria 3002
■ T1 TSE transverse The biopsy confirmed recurrent prostate
Australia
1 TRUS guided biopsy. 2 T2-weighted TSE sequence. ■ T2 TSE transverse, coronal and sagittal, adenocarcinoma within the right apex, Sarah.Foster@petermac.org
■ EPI Diffusion transverse with b-values as suspected from the MRI.
18 MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world MAGNETOM Flash · 2/2009 · www.siemens.com/magnetom-world 19

12. Clinical Abdomen / Pelvis Abdomen / Pelvis Clinical
Characterization of Genitourinary Lesions Using 2A 2B
Diffusion-Weighted Imaging at 3T MRI
Farhood Saremi, M.D.1; Helmuth Schultze-Haakh, Ph.D.2
1
Professor of Radiology and Medicine, University of California, Irvine (UCI), USA
2
Siemens Medical Solutions USA, Cypress, CA, USA
There is growing interest in the applica- high performance gradients, phased metric pair of diffusion-sensitizing gradi- b50 b400
tion of diffusion-weighted imaging array multi-channel surface coils, and ents with opposed polarity [8, 9]. In
(DWI) for the evaluation of lesions in the clinical use of higher magnetic field contrast to static molecules, the random 2C 2D
abdomen and pelvis [1–3]. DWI yields strengths [12–17]. Using new tech- displacement of moving water mole-
both qualitative and quantitative infor- niques, breathhold DWI sequences can cules in the period between application
mation that can be helpful in differenti- be appended to existing imaging pro- of the first and second opposed polarity
ating benign from malignant processes. tocols without a significant increase in gradient pulses results in dephasing and
The application of DWI is useful for tumor the total examination time. consequent loss of signal intensity. The
detection, tumor characterization, and In this review, we describe our experi- degree of signal loss is proportional to
in the evaluation of tumor recurrence or ence in using DWI for the characteriza- the degree of water motion (mean diffu-
response to treatment [4–7]. tion of genitourinary tract lesions as sional path length), with the highest
DWI has been widely used in neuroimag- done on our MAGNETOM Trio, A Tim signal attenuation seen with bulk water.
ing [8–11]. However, its application to System with the Body Matrix coils. The MR signal in DWI depends on two
body imaging was initially limited by the factors: the amplitude of random dis-
Basic understanding of DWI b1500 ADC-map
inherent motion sensitivity of the tech- placements of water molecules (related
nique coupled with the presence of bulk technique to the diffusion coefficient) and the 2 Abdominal DWI – Normal Appearance. ADC of the kidney is the highest among all abdominal organs, followed by the liver, pancreas, and
physiologic motion in the abdomen. DWI sequences are designed to detect b-value (the degree of diffusion-weight- spleen. As the b-value increases, the signal of normal kidney drops. The spleen remains bright and liver signal decreases mildly. Note that the
Routine extracranial application of DWI alterations in thermally-induced random ing). The optimal b-values for abdominal signal of the left liver lobe is generally lower than the right lobe (which may be caused by transmitted cardiac pulsations). The center of the
has become feasible following a series (Brownian) motion of water molecules DWI have not yet been determined. abdomen generally has no signal mostly due to susceptibility effect of gasterointestinal air. The bright signal in the ADC-map is stomach con-
tent, not a solid organ.
of technological advancements in MR within tissues also known as diffusion DWI is typically performed using at least
imaging. These developments include [8, 9]. Diffusion effects are very small to two b-values (within a range of 0 to
faster imaging techniques with echo-pla- be visible by conventional MRI. A DWI 1000 s/mm2) to allow the calculation of
nar imaging (EPI) and parallel imaging, sequence requires the addition of a sym- the apparent diffusion coefficient (ADC).
As the b-value is increased, sensitivity with more receiver channels (> 8) can small lesions are better visualized [17]. 3T
to the effects of diffusion increases at compensate for poor SNR [17, 18]. We is particularly useful at higher b-values.
1A 1B 1C
the expense of longer TE and worsened found spectral fat saturation technique However, with 3T we should expect larger
signal-to-noise ratio (SNR) and image more practical than STIR (short TI inver- susceptibility-induced image distortions
distortion. sion recovery) for breathhold studies, and signal loss, and more motion-related
since with STIR the acquisition time is artifacts [18]. Traditionally, most DWI
Imaging protocol at our longer and lesion visibility may be inferior studies have reported b-values of below
institution compared with spectral fat saturation, 1000 s/mm2. However, the use of even
Most of the images shown herein were especially in the center of the abdomen greater b-values may be beneficial. For
obtained using a 3 tesla (T) magnet [19]. Parallel imaging is also essential example, high grade tumors may retain
(MAGNEOM Trio, Siemens Healthcare, for breathhold DW imaging. With parallel their bright signal with b-values above
Erlangen, Germany). We used a breath- imaging, a shorter TE is possible which in 1000 s/mm2, whereas low grade tumors
hold single-shot spin echo EPI combined fact increases the SNR and reduces will lose their signal [23]. High b-values
with parallel imaging and spectral fat susceptibility-induced image distortions have also been used effectively to assess
1 Breathhold diffusion-weighted images at b = 400 are obtained on our MAGNETOM Trio, A Tim System (with software version syngo MR suppression [11–14]. Our DWI protocol [20–22] (Fig. 1). In our experience, early recurrences of a tumor [24].
B15) using fat suppressed single shot echo planar sequence without (A) and with (B) parallel imaging. scan time is 22 sec on both, and the is shown in Table 1. syngo GRAPPA is more advantageous to
field of view is 360 mm. TR is reduced from 3000 ms in A to 2600 ms in B and C. Two different parallel imaging techniques are used, syngo
In breathhold techniques, although the mSENSE given the degree of off reso- Signal of normal tissues in DWI
GRAPPA (A and B) and mSENSE (C). Spectral fat suppression is employed in all. Note the ghost artifact (long arrows) superimposed on the
kidneys on the image without parallel imaging, which is pushed to the periphery following application of syngo GRAPPA and mSENSE. The signal-to-noise ratio (SNR) is inferior nance and motion ghost artifacts associ- The ADC of the kidney is the highest
overall image quality is clearly improved with parallel imaging. syngo GRAPPA is a preferred technique as aliasing artifacts are less frequent compared with multiple averaging meth- ated with mSENSE (Fig. 1). among all solid abdominal organs, fol-
than with mSENSE (small arrows). Note: improved signal intensity in the center of the abdomen with syngo GRAPPA. ods, the use of higher magnetic field It is reported that the DW image quality is lowed by the liver, pancreas, and spleen
strengths (e.g., 3 Tesla) and surface coils superior at 3T compared to 1.5 T and that [16, 25, 26] (Fig. 2). The ADC value of
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