Prostate cancer - extraprostatic extension
Updates to Case Attributes
This case displays the “erased charcoal sign” in a PI-RADS 5 lesion of the left anterior transition zone (TZa) and anterior fibromuscular stroma (AFS) with extraprostatic extension.
Histology of an MR in-bore biopsy revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason score 4+5=9, G2b, high grade) within both cores.
The patient underwent robot-assisted, laparoscopic, bilateral intrafascial, nerve-conserving, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy.
Final histology of the prostatovesiculectomy preparation revealed poorly differentiated acinar adenocarcinoma in both lobes accentuated on the left side with ~40% of prostate volume and with complete capsular penetration and left-sided infiltration of the periprostatic fatty tissue.
Grading G3, Gleason score 5+4=9, WHO grade 5.
Seminal vesicles were free of tumour cells. Interestingly all resected lymph nodes were free of tumour cells.
Tumour classification: pT3a N0 M0 R1.
The patient also received adjuvant intensity-modulated radiotherapy.
-<p>This case displays the “<a href="/articles/erased-charcoal-sign-prostate-cancer">erased charcoal sign</a>” in a PI-RADS 5 lesion of the left anterior transition zone (TZa) and anterior fibromuscular stroma (AFS) with <a href="/articles/extraprostatic-extension-of-prostate-cancer">extraprostatic extension</a>.</p><p>Histology of an MR in-bore biopsy 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 both cores.</p><p>The patient underwent robot-assisted, laparoscopic, bilateral intrafascial, nerve-conserving, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy.</p><p>Final histology of the prostatovesiculectomy preparation revealed poorly differentiated <a href="/articles/prostatic-carcinoma-1">acinar adenocarcinoma</a> in both lobes accentuated on the left side with ~40% of prostate volume and with complete capsular penetration and left-sided infiltration of the periprostatic fatty tissue.</p><p>Grading G3, <a href="/articles/gleason-score-1">Gleason score</a> 5+4=9, WHO grade 5.</p><p>Seminal vesicles were free of tumour cells. Interestingly all resected lymph nodes were free of tumour cells.</p><p><a title="Prostate cancer (staging)" href="/articles/prostate-cancer-staging-1">Tumour classification</a>: pT3a N0 M0 R1.</p><p>The patient also received adjuvant intensity-modulated radiotherapy.</p>- +<p>This case displays the “<a href="/articles/erased-charcoal-sign-prostate-cancer">erased charcoal sign</a>” in a PI-RADS 5 lesion of the left anterior transition zone (TZa) and anterior fibromuscular stroma (AFS) with <a href="/articles/extraprostatic-extension-of-prostate-cancer">extraprostatic extension</a>.</p><p>Histology of an <a title="MRI targeted prostate biopsy" href="/articles/mri-targeted-prostate-biopsy-1">MR in-bore biopsy</a> revealed a continuous infiltrate of an <a href="/articles/prostate-cancer-3">acinar adenocarcinoma </a>(modified <a href="/articles/gleason-score-1">Gleason score</a> 4+5=9, G2b, high grade) within both cores.</p><p>The patient underwent robot-assisted, laparoscopic, bilateral intrafascial, nerve-conserving, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy.</p><p>Final histology of the prostatovesiculectomy preparation revealed poorly differentiated acinar adenocarcinoma in both lobes accentuated on the left side with ~40% of prostate volume and with complete capsular penetration and left-sided infiltration of the periprostatic fatty tissue.</p><p>Grading G3, Gleason score 5+4=9, WHO grade 5.</p><p>Seminal vesicles were free of tumour cells. Interestingly all resected lymph nodes were free of tumour cells.</p><p><a href="/articles/prostate-cancer-staging-1">Tumour classification</a>: pT3a N0 M0 R1.</p><p>The patient also received adjuvant intensity-modulated radiotherapy.</p>
References changed:
- 1. Turkbey B, Rosenkrantz A, Haider M et al. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. Eur Urol. 2019;76(3):340-51. <a href="https://doi.org/10.1016/j.eururo.2019.02.033">doi:10.1016/j.eururo.2019.02.033</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30898406">Pubmed</a>
- 3. Mehralivand S, Shih J, Harmon S et al. A Grading System for the Assessment of Risk of Extraprostatic Extension of Prostate Cancer at Multiparametric MRI. Radiology. 2019;290(3):709-19. <a href="https://doi.org/10.1148/radiol.2018181278">doi:10.1148/radiol.2018181278</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30667329">Pubmed</a>
- 4. Thoeny H, Barbieri S, Froehlich J, Turkbey B, Choyke P. Functional and Targeted Lymph Node Imaging in Prostate Cancer: Current Status and Future Challenges. Radiology. 2017;285(3):728-43. <a href="https://doi.org/10.1148/radiol.2017161517">doi:10.1148/radiol.2017161517</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29155624">Pubmed</a>
- 5. Blarer J, Padevit C, Horton K, Pfofe D, John H, Horstmann M. Pre-Prostatic Tissue Removed in Robotic Assisted Lymph Node Dissection for Prostate Cancer Contains Lymph Nodes. Urol Ann. 2013;5(4):259-63. <a href="https://doi.org/10.4103/0974-7796.120301">doi:10.4103/0974-7796.120301</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24311906">Pubmed</a>
- 1. Turkbey B, Rosenkrantz AB, Haider MA, Padhani AR, Villeirs G, Macura KJ, Tempany CM, Choyke PL, Cornud F, Margolis DJ, Thoeny HC, Verma S, Barentsz J, Weinreb JC. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. (2019) European urology. 76 (3): 340-351. <a href="https://doi.org/10.1016/j.eururo.2019.02.033">doi:10.1016/j.eururo.2019.02.033</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30898406">Pubmed</a> <span class="ref_v4"></span>
- 3. Sherif Mehralivand, Joanna H. Shih, Stephanie Harmon, Clayton Smith, Jonathan Bloom, Marcin Czarniecki, Samuel Gold, Graham Hale, Kareem Rayn, Maria J. Merino, Bradford J. Wood, Peter A. Pinto, Peter L. Choyke, Baris Turkbey. A Grading System for the Assessment of Risk of Extraprostatic Extension of Prostate Cancer at Multiparametric MRI. (2019) Radiology. 290 (3): 709-719. <a href="https://doi.org/10.1148/radiol.2018181278">doi:10.1148/radiol.2018181278</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30667329">Pubmed</a> <span class="ref_v4"></span>
- 4. Harriet C. Thoeny, Sebastiano Barbieri, Johannes M. Froehlich, Baris Turkbey, Peter L. Choyke. Functional and Targeted Lymph Node Imaging in Prostate Cancer: Current Status and Future Challenges. (2017) Radiology. 285 (3): 728-743. <a href="https://doi.org/10.1148/radiol.2017161517">doi:10.1148/radiol.2017161517</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29155624">Pubmed</a> <span class="ref_v4"></span>
- 5. J Blarer, C Padevit, K Horton, D Pfofe, H John, M Horstmann. Pre-prostatic tissue removed in robotic assisted lymph node dissection for prostate cancer contains lymph nodes. (2013) Urology Annals. 5 (4): 259. <a href="https://doi.org/10.4103/0974-7796.120301">doi:10.4103/0974-7796.120301</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24311906">Pubmed</a> <span class="ref_v4"></span>
Updates to Link Attributes
Updates to Primarylink Attributes
Updates to Study Attributes
Findings:
Quality: mildmild geometric distortion on DWI, does not compromise diagnostic confidence
Prostate size: 40 x 32 x 41 mm (CC x AP x ML) ≈ 27≈27 mL, PSA density ≈ 0 ~0.42 ng/mL2.
Haemorrhage: nonenone
Peripheral zone (PZ): heterogeneouslyheterogeneously slightly, decreased signal, linear/wedge-shaped hypointensities
Transition zone (TZ): moderate moderate heterogeneity, focal finding as below:
Focal lesion #1:
Location leftleft mid gland anterior transition zone from (LM-TZa(TZa) extending to the right and from apical to basal.
Lesion 2121 x 13 x16 mm
T2w: circumscribed homogeneous, hypointense: “erased charcoal sign”, with capsular contact and bulge anteriorly - category 5/5
DWI: focal slightly hyperintense on DWI (b1000) and markedly hypointense on ADC - category 3/5
DCE: focal early enhancement - positive
Prostate margin: capsular contact, bulge and breach of the left anterior margin
Lesion overallOverall PI-RADS category: 55
Seminal vesicles: notnot involved
Lymph nodes: enlarged enlarged lymph node adjacent to the left internal iliac vessels (≈11mm~11 mm), the round suspicious lesion (≈6mm~6 mm) in the preprostatic fat tissue
Pelvic bones: no osseous metastases
Other pelvic organs: right bladder diverticulum
Impression:
VeryA very highly suspicious lesion in the left anterior transition zone (TZa) and anterior fibromuscular stroma (AFS) with extraprostatic extension.
Highly suspicious lymph nodes in the left iliac fossa and in the preprostatic fat tissue.
MRI putative stage cT3a - PI-RADS 5
ProstateA prostate biopsy was recommended.