Prostate cancer - tumor recurrence

Case contributed by Joachim Feger

Presentation

Known prostate cancer, status post prostatectomy now biochemical recurrence (BCR).

Patient Data

Age: 70 years
Gender: Male

bpMRI

mri

Findings:

Status post-prostatectomy with a prostatectomy fossa.

  • T2 inhomogeneously hyperintense nodular mass, markedly hyperintense on b1400 and markedly hypointense in ADC map around the prostatectomy margins of the vesicourethral anastomosis, especially on the right and less on the left posterolateral margin, also on the anterior inferior margin
  • further suspicious nodular in T2 hyperintense finding in the bladder neck

Seminal vesicles:  retained right seminal vesicle with no obvious tumor growth

Lymph nodes:  three suspicious lymph nodes in the perirectal, presacral fatty tissue (up to 8mm size)

Impression:

Status post radical prostatectomy.

Local tumor recurrence at the vesicourethral anastomosis and bladder neck.

Pelvic lymph node metastases in the presacral perirectal fatty tissue.

Annotated image

Key findings:

  • nodular mass around prostatectomy margins of the vesicourethral anastomosis especially on the right and left posterolateral margin (red arrows), but also on the anterior inferior margin (red arrowhead) with correspondent diffusion restriction (blue arrows, blue arrowhead)
  • suspicious nodular finding in the bladder neck (orange arrowhead)

PSMA SPECT/CT

Nuclear medicine

Findings:

  • subdiaphragmatic focus of increased uptake in the left lobe of the liver

  • increased uptake in a para-aortic lymph node

  • high-intensity uptake in a left iliacal lymph node

  • low to moderate uptake in presacral lymph nodes

  • uptake in the prostatectomy fossa

  • increased uptake  in the left proximal femur

Impression:

Metastases in the left iliac and para-aortic lymph nodes.

Bone metastasis in the left proximal femur.

Liver metastasis in the left lobe in a subdiaphragmatic position.

Case Discussion

This case shows local tumor-recurrence of prostate cancer near the vesicourethral anastomosis and in the bladder neck in a patient who had a previous radical prostatectomy.

MRI was done for local re-staging. It also depicts three small presacral lymph nodes.

PSMA SPECT/CT showed liver metastasis in the left lobe, left para-aortic and common iliac lymph node metastasis and bone metastasis in the left proximal femur.

The patient receives systemic therapy.

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