Prostate cancer

Case contributed by Dr Joachim Feger

Presentation

Persistently rising prostate-specific antigen (PSA).

Patient Data

Age: 70 years
Gender: Male
MRI

Multi-parametric magnetic resonance imaging (mpMRI)

Findings:

Quality:  mild geometric distortion on DWI, does not compromise diagnostic confidence

Prostate size: 51 x 44 x 52 mm (CC x AP x ML) ≈ 61 mL.

Hemorrhage:  none

Peripheral zone (PZ):  uniform hyperintense signal with one focal finding as below:

Focal lesion #1:

  • Location:  right mid gland/apical anterior peripheral zone (RA-PZa) / right anterior fibromuscular stroma (AFMS) , visible on axial images (ima 11-14), sagittal images (ima 17)
  • Lesion size:  17 x 9 x 13 mm
  • T2w:  circumscribed, homogenous moderate hypointense  focus - category 5/5
  • DWI:  markedly hyperintense on DWI (b1000 and b1400) and markedly hypointense on ADC focus - category 5/5
  • DCE:  focal early enhancement - positive

Transition zone (TZ):  moderate heterogeneity, multiple BPH nodules with a focal finding as below:

Focal lesion #2:

  • Location:  mid basal anterior fibromuscular stroma (AFMS), visible on axial images (ima 17-18), sagittal images (ima 13-15)
  • Lesion size:  13 x 8 x 16 mm
  • T2w:  circumscribed, homogenous moderate hypointense  focus - category 5/5
  • DWI:  markedly hyperintense on DWI (b1000 and b1400) and markedly hypointense on ADC focus - category 5/5
  • DCE:  focal early enhancement - positive

Prostate margin:  lesion #1 with broad capsular contact (≈ 16 mm)

Lesion overall PI-RADS category:  5

Neurovascular bundles:  not involved

Seminal vesicles:  not involved

Lymph nodes:  no enlarged or suspicious lymph nodes seen

Pelvic bones:  typical “herniation pit” at the anterior aspect of the superolateral femoral head-neck junction, subchondral cyst of the symphysis pubis, no signs of bony metastasis

 

Impression:

Very highly suspicious lesion of the right apical, anterior peripheral zone (PZa) with broad capsular contact and further lesion of the mid basal anterior fibromuscular stroma (AFMS) - PI-RADS 5.

Prostate biopsy was recommended.

Annotated image

Key findings

Key images:

Focal lesion #1 (red arrows):

  • circumscribed, homogenous moderate hypointense focus, markedly hyperintense in high b-value (b1400) and markedly hypointense in ADC (red arrows) with early enhancement on DCE (not shown),
  • located in the right mid gland/apical anterior peripheral zone / right anterior fibromuscular stroma (AFMS)

Focal lesion #2 (blue arrowheads):

  • circumscribed, homogenous moderate hypointense focus, markedly hyperintense in high b-value (b1400) and markedly hypointense in ADC (blue  arrowheads) with early enhancement on DCE,
  • located in the middle (bilateral) of the basal anterior fibromuscular stroma (AFMS)

Case Discussion

This case demonstrates a PI-RADS 5 lesion of the right apical anterior peripheral zone (PZa) and a further PI-RADS 5 lesion of the basal anterior fibromuscular stroma (AFMS).

Histology of the MR in-bore revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason score 4+3=7b, G2b, high grade) within the two cores.

After consultation with his urologist patient is receiving radiation therapy.

PlayAdd to Share

Case information

rID: 73022
Published: 6th Jan 2020
Last edited: 6th Jan 2021
Inclusion in quiz mode: Included