Diagnostic ultrasound ( PDFDrive )

388 PART II Abdominal and Pelvic Sonography
A
B
C
D
FIG. 10.7 Normal Anatomic Variants. (A) Axial view with benign glandular ectasia (arrows) visible as a peripheral hypoechoic area containing
multiple radially oriented tubes. This hypoechoic appearance should not be mistaken for cancer. (B) Parasagittal view of benign ectatic glands
(arrows). (C) Axial view shows extensive echogenic material, both calciications and corpora amylacea (arrows), along the surgical capsule and
peripheral zone. This has no clinical signiicance and usually is not palpable. It hinders ultrasonic visibility. (D) Doppler examination of same patient
shows the extensive Doppler noise artifact caused by the calciications. Virtually all the visible color is artifactual.
elevation) or there is need for precise gland volume determination
to plan surgical or medical treatment. 19
he appearance of BPH is heterogeneous and depends on
underlying histopathologic changes. his heterogeneity hinders
cancer detection for both TRUS and mpMRI. Typically there is
enlargement of the inner gland (transition zone) with hypoechoic,
isoechoic, or hyperechoic nodules. 31 he speciic echo pattern
depends on the admixture of glandular, stromal, and muscular
elements and nodules, which may be ibroblastic, ibromuscular,
muscular, adenomatous, or ibroadenomatous. Hyperplasia of
the periurethral glandular elements results in “median lobe”
enlargement manifesting as a bulge into the urinary bladder (see
Fig. 10.4E). Calciications and degenerative or retention cysts
are common. 31 Benign BPH nodules tend to have distinct margins,
whereas transition zone cancer usually manifests as a difuse,
poorly marginated, usually hypoechoic nodule that may cause
an asymmetrical bulge of the adjacent anterior contour similar
to indings on mpMRI. 32
Because of the distortion of the gland in patients with BPH,
some hyperplastic nodules may bulge into the peripheral zone
when they actually originate in the transition zone. Hypoechoic,
well-circumscribed transition zone nodules are virtually always
benign. 33 Although BPH nodules are generally conined to the
transition zone, on occasion they can form entirely within the
peripheral zone, appearing as an isoechoic nodule with a wellcircumscribed
halo and oten containing a small degenerative
cyst and frequently create a prominent bulge at the capsule. hey
are similar in appearance to BPH nodules seen in the transition
zone on TRUS and mpMRI (see Fig. 10.4G). Because these benign,
peripheral zone nodules are palpable as a irm or hard, cancer-like
nodule, they should undergo biopsy to conirm their benign
nature and obviate continuing concern. 34,35
Ater exclusion of other systemic causes of the symptoms,
such as neurologic disease, diabetes, and local urinary conditions,
treatment focuses on the prostate. Transurethral resection of
the prostate (TURP) is considered the standard of care for many
patients, but other treatments can include watchful waiting,
medical therapy, minimally invasive therapies, open surgery, and
laser therapy. 19,36
TURP initially leaves a large basal surgical defect that
rapidly contracts as the gland collapses into the defect, oten
surprising unwary urologists who may think they have removed
considerably more tissue than the visible defect suggests
(see Fig. 10.4F).