Prostate adenocarcinoma: apical nodule on MRI (PI-RADS 3)

Case contributed by Dr Matthew Bastian-Jordan


Screening MRI for raised PSA.

Patient Data

Age: 55 years
Gender: Male

mp MRI of the prostate

Multiplanar MRI demonstrates an ill-defined transition zone anterior apical nodule that has restricted diffusion and early avid enhancement.

When reporting a lesion under PI-RADS v2, there are different dominant sequences for the peripheral and transition zones.

In the transition zone (TZ) T2W is dominant. In this case the T2W grading is given as a 3 (please see the guidelines for the grading).

The overall grading can stay as a 3 or be pushed to a 4 if the DWI grading is considered a 5 (in this case the DWI grading is only a 4). There is no role for DCE in grading TZ lesions.

Overall PI-RADS grading of the TZ lesion is a 3.

PI-RADS grading T2 = 3, DWI = 4 and DCE +ve.

Overall TZ grading: PI-RADS = 3. 

PSMA PET imaging demonstrates tracer uptake corresponding to the MRI findings.

Initial cognitive TRUS biopsy was negative.

MRI guided biopsy using a Dynatrim system then performed.


There is prostatic adenocarcinoma of acinar/usual type, ISUP grade group 3; Gleason score 4 + 3 = 7, involving four of the cores, amounting to approximately 25% if the prostatic tissue in section. No perineural invasion or extraprostatic extension is identified.

ISUP prostatic adenocarcinoma grade groups

Group 1: Gleason score 6 or less; group 2: 3+4=7; group 3: 4+3=7; group 4: score 8; group 5: score 9 or 10.

Reference: Epstein et al. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System AM J Surg Path 2016 Feb;40(2):244-52

Case Discussion

The MRI guided biopsy was positive for adenocarcinoma as per the attached pathology report.

This case highlights the added utility of PSMA PET and MRI in bore targeted biopsy in the work up of a patient suspected to have prostate cancer.

It also illustrates the use of PI-RADS v2 in grading lesions and the introduction of a dominant sequence in the transition and peripheral zones, a change from version 1.

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Case information

rID: 46415
Published: 6th Jul 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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