Presentation
Continuously rising prostate-specific antigen (PSA) level.
Patient Data
Findings:
Quality: mild geometric distortion on DWI, does not compromise diagnostic confidence
Prostate size: 47 x 32 x 70 mm (CC x AP x ML) ≈56 mL.
Hemorrhage: none
Peripheral zone (PZ): slightly heterogeneous high signal, faint linear/wedge-shaped hypointensities
Transition zone (TZ): moderate heterogeneity, some BPH nodules, focal finding as below:
Focal lesion #1:
- location: right apical and mid gland anterior transition zone (TZa) extending to the left
- lesion size: 21 x 22 x16 mm
- T2w: circumscribed homogeneous, hypointense, with a small area of capsular contact - 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: a small area of capsular contact
Overall PI-RADS category: 5
Neurovascular bundles: not involved
Seminal vesicles: not involved
Lymph nodes: multiple small oval iliac lymph nodes (up to 5 mm size, fatty hilum, smooth margins)
Pelvic bones: no osseous metastases
Other pelvic organs: normal
Impression:
A highly suspicious lesion in the right anterior transition zone (TZa) - PI-RADS 5.
A prostate biopsy was recommended.
MR in-bore biopsy:
After patient preparation and positioning as well as the acquisition of planning sequences, the suspicious lesion in the right midglandular and apical, anterior transition zone (TZa) is re-identified on the images, marked and locked with the navigation software.
Two biopsy cores are obtained from the lesion with a 150cm 18G biopsy needle, registered and sent to pathology.
Case Discussion
This case demonstrates a PI-RADS 5 lesion of the anterior transition zone.
Histology of the biopsy revealed a continuous infiltrate of an acinar adenocarcinoma (modified Gleason score 3+4=7a within one core and 4+5=9 within the other core.
The patient underwent radical retroperitoneal prostatectomy with pelvic lymphadenectomy.
Final histology of the prostatectomy preparation revealed adenocarcinoma in both lobes (≈14%): Gleason score 4+5=9, WHO grade 5.
Resection margins were free from tumor cells.
Tumorclassification: pT2c, pN0, R0.