Prostate cancer - extraprostatic extension

Case contributed by Joachim Feger , 20 Dec 2019
Diagnosis certain
Changed by Joachim Feger, 6 Feb 2020

Updates to Case Attributes

Presentation was changed:
Elevated prostate specific-specific antigen (PSA): 9.1 ng/mL. Free PSA: 11%.
Body was changed:

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 was changed:

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

Findings was changed:

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

Findings was changed:

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.

Updates to Quizquestion Attributes

Answer was changed:
Yes, there is a broadcapsular contact (≥15mm) of the right posterolateral border. So there is a fair chance of extraprostatic extension.

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