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Prostate Cancer

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History

64-year-old male with biopsy proven prostate adenocarcinoma on the right.

Age

60-69

Sex

Male

Path Proven

Yes
Irregular loss of peripheral bright T2 in prostateSeminal vesicle involvementRight lateral base of Prostate showing contrast enhancement and does not wash out.showing diffusion restriction corresponding to the area of involvement seen on other imagesT1 brightness on left base of prostate representing hemorrhage.T1 brightness on left base of prostate representing hemorrhage.T1 brightness on left base of prostate representing hemorrhage.T1 brightness on left base of prostate representing hemorrhage.T1 brightness on left base of prostate representing hemorrhage.T1 brightness on left base of prostate representing hemorrhage.

Findings

The prostate gland is enlarged. The central gland is enlarged, and has a lobulated contour with associated cystic change compatible with benign prostatic hypertrophy. On the diffusion weighted images, there is an irregularly shaped area of diffusion restriction involving the right lateral base. It also involves both the peripheral zone and transitional zone. This area roughly corresponds to a region of marked T2 hypointensity on the T2 weighted images, although its margins are poorly defined on the T2 images given that the majority of the peripheral zone is abnormally T2 hypointense. The precontrast T1-weighted images show a crescentic area of intrinsically high T1 signal involving the majority of the left peripheral zone. This finding is most consistent with post biopsy hemorrhage. The dynamic contrast enhanced images demonstrate an area of avid, early arterial enhancement with washout involving the right lateral peripheral zone and transition zone at the base. This region conforms nearly exactly to the area of diffusion restriction described before. There is also avid early arterial enhancement involving the base of the right seminal vesicle and the borders of the prostate along the right posterior margin near the base are ill-defined, concerning for extracapsular extension

Differential Diagnosis

1. Benign Prostatic Hypertrophy (BPH) 2. Bladder Carcinoma

Diagnosis

Biopsy proven Prostate Adenocarcinoma

Discussion

Prostate cancer mostly occurs in the peripheral zone of prostate. It is mostly asymptomatic with abnormal digital rectal exam but can present with symptoms similar to BPH like hesitancy, urgency, increased frequency; there can be bone pain due to osteoblastic metastases to vertebrae. It can result into bladder outlet obstruction, obstructive uropathy, uremia and pathological fractures. There can be elevated PSA but it not specific for prostate cancer; PSA velocity is a more specific test.  It appears as diffuse low signal intensity on T1 weighted images and low signal on T2 weighted images in the peripheral zone.  Moreover there is restricted diffusion in diffusion-weighted images. If there is a hemorrhage because of a recent biopsy, it would appear with increased signal on T1 pre-contrast images. Obliteration of rectoprostatic angle suggest extracapsular extension.

Staging

A and T1: Clinically localized (tumor not palpable on digital rectal exam)

B and T2: Confined to prostate

B1 and T2a: Tumor involves < 1/2 of 1 lobe

B2 and T2b: Tumor involves > 1/2 of 1 lobe

B2 and T2c: Tumor involves both lobes

C and T3: Locally invasive beyond prostatic capsule

C1 and T3a: Unilateral or bilateral extracapsular extension

C1 and T3b: Seminal vesicle invasion

C2: Extracapsular extension producing bladder outlet or ureteral obstruction

T4: Invades adjacent tissuesBladder, rectum, levator ani, pelvic sidewall

D and N/M: Lymph node and distant metastases to bones, lung, liver, and brain

 

Teaching Point

Low signal intensity on T2 weighted images in the peripheral zone of prostate is highly suggestive of prostate carcinoma.

Authors & Contributors

Umar Tariq

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Case | by Dr. Radut