Presentation
Rise of prostate-specific antigen (PSA) from 7.2 ng/mL to 7.8 ng/mL within 6 months. Free PSA: 7%. Previous negative biopsy.
Patient Data
Quality: mild to moderate geometric distortion on DWI, does not compromise diagnostic confidence
Prostate size: 38 x 32 x 50 mm (CC x AP x M) ≈32 mL, PSA density ~0.24 ng/mL2
Hemorrhage: none
Peripheral zone (PZ): uniform hyperintense signal with one focal finding as below:
Focal lesion #1:
- location: right basal posterolateral peripheral zone (PZpl), visible on axial images (ima 10-12), sagittal images (ima 14-19)
- lesion size: 13 x 15 x 25 mm
- T2w: non-circumscribed, homogenous mild to moderate hypointense focus - category 3/5
- DWI: markedly hyperintense on DWI (b1000) and markedly hypointense on ADC focus - category 5/5
- DCE: focal early enhancement - positive
Transition zone (TZ): moderate heterogeneity, multiple BPH nodules
Prostate margin: lesion #1 with broad capsular contact (~25 mm)
Overall PI-RADS category: 5
Neurovascular bundles: directly adjacent to lesion #1
Seminal vesicles: asymmetric hypointense signal intensity around the right ejaculatory duct and extending from the base of the prostate into and around the right seminal vesicle (ima 17)
Lymph nodes: no enlarged or suspicious lymph nodes
Pelvic bones: no signs of bony metastasis
Impression:
Highly suspicious lesion of the right basal, posterolateral peripheral zone (PZpl) with probable extraprostatic extension and possible seminal invasion - PI-RADS 5.
A prostate biopsy was recommended.
MR in-bore biopsy:
After patient preparation and positioning and acquisition of planning sequences, the suspicious lesion in the right basal posterolateral zone (PZpl) is re-identified on the images, marked and locked with the navigation software.
Two biopsy cores were obtained from the lesion with a 150 cm 18G biopsy needle, documented and sent to pathology.
Case Discussion
This case shows a PI-RADS 5 lesion of the right basal posterolateral peripheral zone (PZpl).
An extraprostatic extension can be presumed due to the broad capsular contact.
Histology of the MR in-bore revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason score 4+5=9, G2b, high grade) within the two cores.
So far the patient underwent robot-assisted, laparoscopic, radical prostatovesiculectomy with bilateral pelvic lymphadenectomy about 4 months after the prostate MRI.
Final histology of the prostatovesiculectomy preparation revealed poorly differentiated acinar adenocarcinoma with infiltration of the periprostatic fatty tissue and perineural invasion.
There was also infiltration of the seminal vesicles on histology.
Gleason Score 4+5=9, ISUP grade 5.
Tumor classification: pT3b N0 M0 R0.
This case also shows some challenges of multiparametric MRI of the prostate: on first look, both seminal vesicles appear rather inconspicuous and this was also initially reported this way.
What should attract attention, however, is that the tumor is located far up in the base of the prostate with broad contact to the capsule and thus close proximity to the right seminal vesicle.
As mentioned, the patient was R0 resected so far, because of the Gleason 9 and pT3b situation adjuvant radiation therapy has been recommended.
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