Presentation
Elevated prostate-specific antigen(PSA): 7,7 ng/mL. Free PSA 11%.
Patient Data
Findings:
Quality: increased noise, some geometric distortion on DWI, does not compromise diagnostic confidence
Prostate size: 44 x 36 x 49 mm (CC x AP x ML) ≈40 mL, PSA density ~0.19 ng/mL2
Hemorrhage: none
Peripheral zone (PZ): bilateral heterogeneous signal alteration in T2w imaging, focal finding in a left posterior basal location
focal lesion #1 (PZpl):
- location: left basal posterolateral peripheral zone (PZpl)
- lesion size: ~14 mm
- T2W: homogeneous, hypointense focus
- DWI: markedly hyperintense on DWI (b1400) and markedly hypointense
- DCE: focal early enhancement - positive
Transition zone (TZ): moderate heterogeneity, some BPH nodules
Prostate margin: capsular contact, no bulge or breach
Overall PI-RADS category: 4/5
Neurovascular bundles: probably not involved
Seminal vesicles: contracted, not involved, but close proximity of the lesion to the proximal part of the left seminal vesicle
Lymph nodes: multiple small oval iliac lymph nodes (up to 6 mm size, fatty hilum, smooth margins)
Pelvic bones: no osseous metastases, a right-sided hip endoprosthesis
Other pelvic organs: normal
Impression:
A highly suspicious lesion in the left basal peripheral zone(PZpl) - PI-RADS 4.
A prostate biopsy was recommended.
Key findings:
The suspect lesion is depicted.
The axial images are all in the same plane, which is illustrated on the sagittal image (blue dotted line). The focal lesion can be seen in the b1400 and corresponding ADC images and can be also seen in sagittal and coronal T2w images, but it is rather difficult to see the focus on the axial T2w images.
MR in-bore biopsy:
After patient preparation and positioning as well as the acquisition of planning sequences, the suspicious lesion in the left basal peripheral zone (PZpl) is re-identified on the images, marked and locked with the navigation software.
Two biopsy cores are obtained from the lesion with a 150cm 18G biopsy needle, registered and sent to pathology.
Case Discussion
This case illustrates a PI-RADS 4 lesion of the left basal posterolateral peripheral zone (PZpl) in a patient with a right hip endoprosthesis. mpMRI and MR in-bore biopsy were done at 1.5 Tesla.
Histology of the MR in-bore biopsy revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason Score 4+3=7b, G3, high-grade, in one core and 3+4=7a in the other core).
The patient is scheduled for radiation therapy.
Of note is that this prostate cancer is located in the left base in close proximity to the proximal part of the left seminal vesicle.