Prostate cancer (1.5 T MRI)

Case contributed by Dr Joachim Feger

Presentation

Elevated prostate-specific antigen(PSA): 7,7 ng/mL. Free PSA 11%.

Patient Data

Age: 75 years
Gender: Male
MRI

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 left posterior  basal as below:

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

Lesion 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.

Prostate biopsy was recommended.

Annotated image

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 clearly 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.

MRI

MR in-bore biopsy

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 (LB-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 (LB-PZpl) in a patient with a right hip endoprosthesis. mpMRI and MR in-bore biopsy were done in 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 the prostate cancer is located in the left base in close proximity to the proximal part of the left seminal vesicle.

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Case information

rID: 74006
Published: 3rd Mar 2020
Last edited: 4th May 2020
Inclusion in quiz mode: Included