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Prostate cancer

Case contributed by Dr Joachim Feger

Presentation

Elevated prostate-specific antigen (PSA): 5.8 ng/mL.

Patient Data

Age: 65 years
Gender: Male
MRI

mpMRI

Findings:

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

Prostate size: 42 x 40 x 40 mm (CC x AP x ML) ≈ 33 mL, PSA density ≈ 0.17 ng/mL2.

Hemorrhage:  none

Peripheral zone (PZ):  bilateral linear/wedge-shaped hypointensities, focal finding in the left posterior mid gland and basal zones as below:

Transition zone (TZ):  moderate heterogeneity, some BPH nodules in the apical zone, focal finding in the left posterior mid gland and basal zones as below:

Focal lesion #1 (PZpm/pl and TZp):

Location: left mid gland and basal posterior peripheral zone (PZpm/pl) and left transition zone (TZp) 

Lesion size:  ≈ 20 x 16 mm

T2w: heterogeneous, low signal in the posteromedial peripheral zone (PZpm) and homogeneous, moderately hypointense signal in the posterior transition zone (TZp) with indistinct/obscured prostate pseudocapsule –  “erased charcoal sign” – category 5/5

DWI: focal slightly to markedly hyperintense on DWI (b1000) and markedly hypointense on ADC in the posterior transition zone (TZp) and in the posteromedial part of the peripheral zone (PZpm) - category 3/5 and 5/5, respectively

DCE: focal early enhancement - positive

Prostate margin:  capsular contact, no bulge or breach

Lesion overall PI-RADS category:  5

Neurovascular bundles:  probably not involved

Seminal vesicles:  contracted, not involved

Lymph nodes:  multiple small oval iliac lymph nodes (up to 6 mm size, fatty hilum, smooth margins)

Pelvic bones: no osseous metastases

Other pelvic organs: normal

 

Impression:

Very highly suspicious lesion in the left peripheral zone (PZpm/pl) and left posterior transition zone (TZp) - PI-RADS 5.

Prostate biopsy was recommended.

MRI

MR in-bore biopsy

After patient preparation and positioning as well as the acquisition of planning sequences, the suspicious lesion in the left mid gland and basal, posterior peripheral and transition zone is re-identified on the images, marked and locked with the navigation software.

Two biopsy cores are obtained from the lesion with an 150cm 18G biopsy needle, registered and sent to pathology.

Case Discussion

This case demonstrates a PI-RADS 5 lesion of the posterior transition zone and the posteromedial and posterolateral peripheral zone. The case also depicts the “erased charcoal sign”, which refers to an appearance of a homogeneously T2 low-signal lesion in the transition zone of the prostate with indistinct margins. In this case, it is the smudged appearing border between transition and peripheral zones, which is also referred to as “pseudocapsule” or “surgical capsule”.

Histology of the MR-in bore biopsy revealed an infiltrate of an adenocarcinoma (modified Gleason score 4+5=9, high grade) within both cores.

The patient underwent radical retropubic prostatovesiculectomy with pelvic lymphadenectomy.

Final histology of the prostatovesiculectomy preparation revealed poorly differentiated acinar adenocarcinoma in both lobes  (≈10% right lobe, ≈30% left lobe) with perineural tumor growth.

Gleason score 4+5=9, ISUP grade 5.

Resection margins and seminal vesicles were free from tumor cells.

Tumorclassification: pT2c, pN0, R0.

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Case information

rID: 72858
Published: 19th Dec 2019
Last edited: 12th Mar 2020
Inclusion in quiz mode: Included

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