Korean J Radiol.  2015 Apr;16(2):342-348. 10.3348/kjr.2015.16.2.342.

Multiphase Contrast-Enhanced Magnetic Resonance Imaging Features of Bacillus Calmette-Guerin-Induced Granulomatous Prostatitis in Five Patients

• Kawada H
• Kanematsu
• Goshima S
• Kondo H
• Watanabe H
• Noda Y
• Tanahashi
• Kawai N
• Hoshi H

• KMID: 2070178
• DOI: http://doi.org/10.3348/kjr.2015.16.2.342

Abstract

OBJECTIVE
To evaluate the multiphase contrast-enhanced magnetic resonance (MR) imaging features of Bacillus Calmette-Guerin (BCG)-induced granulomatous prostatitis (GP).
MATERIALS AND METHODS
Magnetic resonance images obtained from five patients with histopathologically proven BCG-induced GP were retrospectively analyzed for tumor location, size, signal intensity on T2-weighted images (T2WI) and diffusion-weighted images (DWI), apparent diffusion coefficient (ADC) value, and appearance on gadolinium-enhanced multiphase images. MR imaging findings were compared with histopathological findings.
RESULTS
Bacillus Calmette-Guerin-induced GP (size range, 9-40 mm; mean, 21.2 mm) were identified in the peripheral zone in all patients. The T2WI showed lower signal intensity compared with the normal peripheral zone. The DWIs demonstrated high signal intensity and low ADC values (range, 0.44-0.68 x 10(-3) mm2/sec; mean, 0.56 x 10(-3) mm2/sec), which corresponded to GP. Gadolinium-enhanced multiphase MR imaging performed in five patients showed early and prolonged ring enhancement in all cases of GP. Granulomatous tissues with central caseation necrosis were identified histologically, which corresponded to ring enhancement and a central low intensity area on gadolinium-enhanced MR imaging. The findings on T2WI, DWI, and gadolinium-enhanced images became gradually obscured with time.
CONCLUSION
Bacillus Calmette-Guerin-induced GP demonstrates early and prolonged ring enhancement on gadolinium-enhanced MR imaging which might be a key finding to differentiate it from prostate cancer.

Keyword

Granulomatous prostatitis; Multiphase contrast-enhanced MR imaging; BCG; Ring enhancement

MeSH Terms

Aged
Gadolinium/*diagnostic use
Humans
Image Enhancement
Immunotherapy/*adverse effects
Magnetic Resonance Imaging/*methods
Magnetic Resonance Spectroscopy
Male
Middle Aged
Mycobacterium bovis/*pathogenicity
Prostate-Specific Antigen/blood
Prostatic Neoplasms/diagnosis
Prostatitis/*diagnosis
Retrospective Studies
Urinary Bladder Neoplasms/drug therapy
Gadolinium
Prostate-Specific Antigen

Figure

• 

  Fig. 1 75-year-old man after Bacillus Calmette-Guérin immunotherapy for bladder carcinoma. A. Transverse T2-weighted magnetic resonance (MR) image demonstrating heterogeneous signal mass (white arrow) in left peripheral zone of prostate extending to transition zone. B. Transverse T1-weighted MR image showing high signal spot (white arrow) in mass. C. Transverse diffusion-weighted image demonstrating restricted water diffusion in mass. Gadolinium-enhanced sagittal images obtained in arterial (D), venous (E), and equilibrium phases (F) showing early and prolonged ring enhancement in mass. G. Pathological specimen obtained at biopsy (hematoxylin and eosin staining, × 100) showing granulomatous (straight arrow) and epithelioid cell (curved arrow) proliferation with central caseous necrosis (*). Transverse T2-weighted magnetic resonance (MR) image and diffusion-weighted image obtained 6 (H, I) and 49 months (J, K) after initial MR image. Mass (white arrows) shrunk in size, and diffusion signal (white arrows) decreased over time.

• 

  Fig. 2 61-year-old man after Bacillus Calmette-Guérin (BCG) immunotherapy for prophylaxis of recurrence. A. Transverse T2-weighted magnetic resonance (MR) image demonstrating heterogeneous signal mass in right peripheral zone of prostate. B. Transverse T1-weighted MR image showing low signal spot (white arrowhead) in high signal mass. C. Transverse diffusion-weighted image demonstrating restricted water diffusion in mass. Gadolinium-enhanced sagittal images obtained in arterial (D), venous (E), and equilibrium phases (F) showing early and prolonged ring enhancement in mass (white arrowheads). Transverse contrast enhanced T1-weighted MR images at 1 (G), 4 (H), 13 (I), and 17 months (J) after BCG therapy show that tumor shrank gradually while ring enhancement remained.

• 

  Fig. 3 77-year-old man after Bacillus Calmette-Guérin immunotherapy for treatment of carcinoma in situ recurrence. A. Transverse T2-weighted magnetic resonance (MR) image demonstrating heterogeneous signal mass in left peripheral zone of prostate extending to transition zone. B. Transverse T1-weighted MR image showing low signal intensity mass surrounded with slightly high signal rim (white arrowheads). C. Transverse diffusion-weighted image demonstrating restricted water diffusion corresponding to mass, particularly low signal area on T1-weighted image. Gadolinium-enhanced sagittal images obtained in arterial (D), venous (E), and equilibrium phases (F) showing early and prolonged ring enhancement in mass.

Reference

1. Morales A, Eidinger D, Bruce AW. Intracavitary Bacillus Calmette-Guerin in the treatment of superficial bladder tumors. J Urol. 1976; 116:180–183.

2. Lamm DL, Stogdill VD, Stogdill BJ, Crispen RG. Complications of bacillus Calmette-Guerin immunotherapy in 1,278 patients with bladder cancer. J Urol. 1986; 135:272–274.

3. Oates RD, Stilmant MM, Freedlund MC, Siroky MB. Granulomatous prostatitis following bacillus Calmette-Guerin immunotherapy of bladder cancer. J Urol. 1988; 140:751–754.

4. Miyashita H, Troncoso P, Babaian RJ. BCG-induced granulomatous prostatitis: a comparative ultrasound and pathologic study. Urology. 1992; 39:364–367.

5. Naik KS, Carey BM. The transrectal ultrasound and MRI appearances of granulomatous prostatitis and its differentiation from carcinoma. Clin Radiol. 1999; 54:173–175.

6. Gevenois PA, Stallenberg B, Sintzoff SA, Salmon I, Van Rogemorter G, Struyven J. Granulomatous prostatitis: a pitfall in MR imaging of prostatic carcinoma. Eur Radiol. 1992; 2:365–367.

7. Takeuchi M, Suzuki T, Sasaki S, Ito M, Hamamoto S, Kawai N, et al. Clinicopathologic significance of high signal intensity on diffusion-weighted MR imaging in the ureter, urethra, prostate and bone of patients with bladder cancer. Acad Radiol. 2012; 19:827–833.

8. Ma W, Kang SK, Hricak H, Gerst SR, Zhang J. Imaging appearance of granulomatous disease after intravesical Bacille Calmette-Guerin (BCG) treatment of bladder carcinoma. AJR Am J Roentgenol. 2009; 192:1494–1500.

9. Suzuki T, Takeuchi M, Naiki T, Kawai N, Kohri K, Hara M, et al. MRI findings of granulomatous prostatitis developing after intravesical Bacillus Calmette-Guérin therapy. Clin Radiol. 2013; 68:595–599.

10. Oppenheimer JR, Kahane H, Epstein JI. Granulomatous prostatitis on needle biopsy. Arch Pathol Lab Med. 1997; 121:724–729.

11. Bour L, Schull A, Delongchamps NB, Beuvon F, Muradyan N, Legmann P, et al. Multiparametric MRI features of granulomatous prostatitis and tubercular prostate abscess. Diagn Interv Imaging. 2013; 94:84–90.

12. Engin G, Acunas¸ B, Acunas¸ G, Tunaci M. Imaging of extrapulmonary tuberculosis. Radiographics. 2000; 20:471–488.

13. Fan ZM, Zeng QY, Huo JW, Bai L, Liu ZS, Luo LF, et al. Macronodular multi-organs tuberculoma: CT and MR appearances. J Gastroenterol. 1998; 33:285–288.

14. Kawamori Y, Matsui O, Kitagawa K, Kadoya M, Takashima T, Yamahana T. Macronodular tuberculoma of the liver: CT and MR findings. AJR Am J Roentgenol. 1992; 158:311–313.

15. Padhani AR, Harvey CJ, Cosgrove DO. Angiogenesis imaging in the management of prostate cancer. Nat Clin Pract Urol. 2005; 2:596–607.

16. Bonekamp D, Jacobs MA, El-Khouli R, Stoianovici D, Macura KJ. Advancements in MR imaging of the prostate: from diagnosis to interventions. Radiographics. 2011; 31:677–703.