Prostate cancer with extraprostatic extension

Case contributed by Dr Joachim Feger

Presentation

Rising prostate-specific antigen (PSA): 11.2 ng/mL.

Patient Data

Age: 50 years
Gender: Male

Findings:

Quality:  mild geometric distortion on DWI, does not compromise diagnostic confidence

Prostate size:    40 x 32 x 41 mm (CC x AP x ML) ≈ 27 mL, PSA density ≈ 0.42 ng/mL2.

Hemorrhage:  none

Peripheral zone (PZ):  heterogeneously slightly, decreased signal, linear/wedge-shaped hypointensities

Transition zone (TZ):  moderate heterogeneity, focal finding as below:

Focal lesion #1:

Location:  left mid gland anterior transition zone from (LM-TZa) extending to the right and from apical to basal.

Lesion size:  21 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 overall PI-RADS category:  5

Seminal vesicles:  not involved

Lymph nodes:  enlarged lymph node adjacent to the left internal iliac vessels (≈11mm),  round suspicious lesion (≈6mm) in the preprostatic fat tissue

Pelvic bones: no osseous metastases

Other pelvic organs: right bladder diverticulum

 

Impression:

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

Prostate biopsy was recommended.

Case Discussion

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 tumor cells. Interestingly all resected lymph nodes were free of tumor cells.

Tumor classification: pT3a N0 M0 R1.

The patient also received adjuvant intensity-modulated radiotherapy.

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Case information

rID: 72861
Published: 20th Dec 2019
Last edited: 26th Feb 2020
Inclusion in quiz mode: Included

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