Prostate cancer - extraprostatic extension
Updates to Case Attributes
This case shows a typical PI-RADS 5 lesion of the right posterolateral peripheral zone (PZpl), a smaller PI-RADS 4 lesion further basal as well as a PI-RADS 3 finding in the left transition zone.
The case also demonstrates, target planning and documentation while doing aan MR in-bore biopsy with two different targets.
Histology of the MR in-bore biopsy of the right posterolateral peripheral zone revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason Score 4+5=9, G2b, high grade) within the two cores. The core taken from the left transitional zone turned out to be chronic prostatitis.
The patient underwent robot-assisted, laparoscopic, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy about 7 months after mpMRI.
Final histology of the prostatovesiculectomy preparation revealed poorly differentiated acinar adenocarcinoma in both lobes with 95% of the tumour located on the right side. There was right sided-sided extraprostatic extension, nonfocal infiltration of the periprostatic fatty tissue and perineural invasion.
Grading G3, Gleason score 5+3=8, WHO grade 4.
Seminal vesicles were free of tumour cells.
One of seven lymph nodes of the right pelvic nodes was positive for tumour cells.
TumorTumour classification: pT3a pN1(1/16) M0 R0.
The patient also has been receiving adjuvant intensity modulated-modulated radiotherapy and androgen deprivation therapy (ADT).
-<p>This case shows a typical <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 5</a> lesion of the right posterolateral peripheral zone (PZpl), a smaller <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 4</a> lesion further basal as well as a <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 3</a> finding in the left transition zone.</p><p>The case also demonstrates, target planning and documentation while doing a <a href="/articles/mri-targeted-prostate-biopsy-1">MR in-bore biopsy </a>with two different targets.</p><p>Histology of the MR in-bore biopsy of the right posterolateral peripheral zone revealed a continuous infiltrate of an <a href="/articles/prostatic-carcinoma-1">acinar adenocarcinoma</a> (modified <a href="/articles/gleason-score-1">Gleason Score</a> 4+5=9, G2b, high grade) within the two cores. The core taken from the left transitional zone turned out to be chronic prostatitis.</p><p>The patient underwent robot-assisted, laparoscopic, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy about 7 months after mpMRI.</p><p>Final histology of the prostatovesiculectomy preparation revealed poorly differentiated <a href="/articles/prostatic-carcinoma-1">acinar adenocarcinoma</a> in both lobes with 95% of the tumour located on the right side. There was right sided <a href="/articles/extraprostatic-extension-of-prostate-cancer">extraprostatic extension</a>, nonfocal infiltration of the periprostatic fatty tissue and perineural invasion.</p><p>Grading G3, <a href="/articles/gleason-score-1">Gleason score</a> 5+3=8, WHO grade 4.</p><p>Seminal vesicles were free of tumour cells.</p><p>One of seven lymph nodes of the right pelvic nodes was positive for tumour cells.</p><p>Tumor classification: <a href="/articles/prostate-cancer-staging-1">pT3a pN1(1/16) M0 R0</a>.</p><p>The patient also has been receiving adjuvant intensity modulated radiotherapy and androgen deprivation therapy (ADT).</p>- +<p>This case shows a typical <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 5</a> lesion of the right posterolateral peripheral zone (PZpl), a smaller <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 4</a> lesion further basal as well as a <a href="/articles/prostate-imaging-reporting-and-data-system-pi-rads-1">PI-RADS 3</a> finding in the left transition zone.</p><p>The case also demonstrates, target planning and documentation while doing an <a href="/articles/mri-targeted-prostate-biopsy-1">MR in-bore biopsy </a>with two different targets.</p><p>Histology of the MR in-bore biopsy of the right posterolateral peripheral zone revealed a continuous infiltrate of an <a href="/articles/prostatic-carcinoma-1">acinar adenocarcinoma</a> (modified <a href="/articles/gleason-score-1">Gleason Score</a> 4+5=9, G2b, high grade) within the two cores. The core taken from the left transitional zone turned out to be chronic prostatitis.</p><p>The patient underwent robot-assisted, laparoscopic, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy about 7 months after mpMRI.</p><p>Final histology of the prostatovesiculectomy preparation revealed poorly differentiated <a href="/articles/prostatic-carcinoma-1">acinar adenocarcinoma</a> in both lobes with 95% of the tumour located on the right side. There was right-sided <a href="/articles/extraprostatic-extension-of-prostate-cancer">extraprostatic extension</a>, nonfocal infiltration of the periprostatic fatty tissue and perineural invasion.</p><p>Grading G3, <a href="/articles/gleason-score-1">Gleason score</a> 5+3=8, WHO grade 4.</p><p>Seminal vesicles were free of tumour cells.</p><p>One of seven lymph nodes of the right pelvic nodes was positive for tumour cells.</p><p>Tumour classification: <a href="/articles/prostate-cancer-staging-1">pT3a pN1(1/16) M0 R0</a>.</p><p>The patient also has been receiving adjuvant intensity-modulated radiotherapy and androgen deprivation therapy (ADT).</p>
Updates to Study Attributes
Findings:
Quality: mild geometric distortion on DWI, does not compromise diagnostic confidence
Prostate size: 50 x 34 x 60 mm (CC x AP x ML) ≈ 53 mL, PSA density ≈ 0.17 ng/mL2
Haemorrhage: none
Peripheral zone (PZ): uniform hyperintenshyperintense signal with two focal findings as below
Focal lesion #1:
- Location: right apical/midglandular posterolateral peripheral zone (RAM-PZpl), visible on axial images (ima 10-12), sagittal images (ima 20)
- Lesion size: 18 x 10 x 17 mm
- T2w: circumscribed, homogenous moderate hypointense focus - category 5/5
- DWI: markedly hyperintense on DWI (b1000) and markedly hypointense on ADC focus - category 5/5
- DCE: focal early enhancement - positive
Focal lesion #2:
- Location: right basal posterolateral peripheral zone (RB-PZpl), on axial images (ima 15), sagittal images (ima 20)
- Lesion size: 8 x 7 x 8 mm
- T2w: circumscribed, homogenous moderate hypointense focus - category 4/5
- DWI: markedly hyperintense on DWI (b1000) and markedly hypointense on ADC focus - category 4/5
- DCE: focal early enhancement - positive
Transition zone (TZ): moderate heterogeneity, multiple BPH nodules and a focal finding as below:
Focal lesion #3:
-
Location: left
midglandmid gland anterior transition zone (LM-TZa), on axial images (ima 11-13) -
T2w:
heterogenousheterogeneous low signal intensity with obscured margins - category 3/5 - DWI: isointense on DWI (b1000) and markedly hypointense on ADC - category 3/5
- DCE: focal early enhancement - positive
Prostate margin: lesion #1 withbroad capsular contact (≈ 17 mm) along with some irregularity, lesion #2 also with capsular contact
Lesion overall PI-RADS category: 5
Neurovascular bundles: adjacent to lesion #1 and lesion #2
Seminal vesicles: not involved
Lymph nodes: multiple small oval iliac lymph nodes (up to 8 mm size, fatty hilum, smooth margins)
Pelvic bones: severea severe case of right hip osteoarthritis, no signs of bony metastasis
Impression:
Very highly and highly suspicious lesions of the right apical/midgland/mid gland and basal, posterolateral peripheral zones (PZpl) with capsular contact - PI-RADS 5.
FurtherA further questionable finding of the left transition zone - PI-RADS 3.
MRI putative stage: cT3aNxMx.
Prostate biopsy was recommended.
Updates to Study Attributes
Key images:
Focal lesion #1 (red arrows) :
large (≥ 15mm) circumscribed, homogenous moderate hypointensefocus, markedly hyperintense in DWI and markedly hypointense in ADC (red arrows) with early enhancement on DCE
located in the right apical/midglandular posterolateral peripheral zone (RAM-PZpl)
PI-RADS category 5/5
Focal lesion #2 (blue arrowheads) :
small (<15mm) circumscribed, homogenous moderate hypointensefocus, markedly hyperintense in DWI and markedly hypointense in ADC (bluearrowheads) with early enhancement on DCE (not shown)
located in the right basal posterolateral peripheral zone (RB-PZpl)
PI-RADS category 4/5
Focal lesion #3 (green arrowheads) :
low signal intensity with obscured margins,isointense on DWI and markedly hypointense on ADC (green arrowheads)
located in the left basal/midglandular transition zone
PI-RADS category 3/5
Updates to Study Attributes
After patient preparation and positioning andand acquisition of planning sequences, the suspicious lesion in the right apical/midglandular posterolateral zone (RM-PZpl), as well as the questionable finding in the left midglandmid gland anterior transition zone (LM-TZa), are re-identified on the images, marked and locked with the navigation software.
Two biopsy cores were obtained from the lesion in the in the right posterolateral zone (RM-PZpl) and one biopsy core from the lesion in the left anterioranterior transition zone (LM-TZa), in both cases with a 150cm 18G biopsy needle.
The images also nicely depict some challenges involved with the MR in-bore biopsy procedure. In this one can see a significant displacement of the prostate, while directing the needle guide. This is probably the result of the needle guide being introduced to deep into the rectum.