Prostate adenocarcinoma: apical nodule on MRI (PIRADS 3)

Case contributed by Dr Matthew Bastian-Jordan

Presentation

Screening MRI for raised PSA.

Patient Data

Age: 55
Gender: Male
MRI

mp MRI of the prostate

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

When reporting a lesion under PIRADs V2, there are dominant sequences in the peripheral and transitional zones.

In the transitional zone (TZ) T2 is dominant. In this case the T2 grading is given as a 3 (please see the ACR 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 lesion.

Overall PIRADS grading of the TZ lesion is a 3

PIRADS grading T2 = 3, DWI = 4 and DCE +ve.

Overall TZ grading: PIRADS = 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.

Histopathology:

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 PIRADS V2 in grading lesions and the introduction of a dominant sequence in the transitional and peripheral zones, a change from version 1.

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Case information

rID: 46415
Case created: 4th Jul 2016
Last edited: 6th Jul 2016
Inclusion in quiz mode: Included

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