Case Of the Week (COW) 09 Mar 2014
Answer:
Carcinoma Prostate with left Extraglandular Invasion and Regional (Left Iliac) lymphadenopathy.
Findings:
Large T2 hypointense mass is visualized in the peripheral gland, involving the base , mid gland and apex of the prostate gland on the left side. It extends upto 6mm of Bladder neck on left side. These regions show restricted diffusion with low ADC values. There is an irregular capsular bulge with extraglandular invasion and neurovascular bundle involvement on the left side. The left seminal vesicles are also seen to partially infiltrated. Multiple left iliac lymphadenopathy with restricted diffusion, reflecting neoplastic infiltration, largest measuring 12mm is noted. Foci of hemorrhage noted in the right mid body. There is Prostatomegaly with indentation of posterior Bladder wall. The above Features were consistent with Carcinoma Prostate with left Extraglandular Invasion and Regional (Left Iliac) lymphadenopathy. No evidence of ascites or significant retroperitoneal lymphadenopathy.
Discussion:
This gentleman had Elevated PSA (53.30 ng/ml) levels. A Transrectal biopsy of mass with HPE revealed an Infiltrating Adenocarcinoma of Prostate (Gleason Score – 7 / 10). Tumor in Prostate is identified by the presence of low signal intensity in high signal peripheral zone . Tumor appears as areas of restricted diffusion with low ADC values in Diffusion weighted Imaging. In 3D Multivoxel MR Spectroscopy , the tumor foci show increased choline and creatine to citrate ratio of >1.5. Identifying extracapsular invasion is important for staging . The key features to identify these are : Capsular deformation Mass > 12mm in contact with the capsule Secondary signs associated with extracapsular disease are Asymmetric capsular bulging, obliteration of the rectoprostatic angle, and involvement of the neurovascular bundle. Visualizing the direct extensionof tumor into the fat -clearest sign. Nodal metastasis commonly occurs to iliac and obturator nodes. It is identified by their size criteria -- Oval >10mm;Round Short Axis>8mm and with restricted diffusion.
REF : MR IMAGING AND MR SPECTROSCOPY IN PROSTATE CANCER MANAGEMENT -KATZ et al RCNA (2006) -723-734
Contributed By:
Dr. Babu Peter MD, DNB
Associate Professor, Barnard Institute of Radiology
Senior Consultant Radiologist, Aarthi Scans, Chennai
Answer:
Carcinoma Prostate with left Extraglandular Invasion and Regional (Left Iliac) lymphadenopathy.
Findings:
Large T2 hypointense mass is visualized in the peripheral gland, involving the base , mid gland and apex of the prostate gland on the left side. It extends upto 6mm of Bladder neck on left side. These regions show restricted diffusion with low ADC values. There is an irregular capsular bulge with extraglandular invasion and neurovascular bundle involvement on the left side. The left seminal vesicles are also seen to partially infiltrated. Multiple left iliac lymphadenopathy with restricted diffusion, reflecting neoplastic infiltration, largest measuring 12mm is noted. Foci of hemorrhage noted in the right mid body. There is Prostatomegaly with indentation of posterior Bladder wall. The above Features were consistent with Carcinoma Prostate with left Extraglandular Invasion and Regional (Left Iliac) lymphadenopathy. No evidence of ascites or significant retroperitoneal lymphadenopathy.
Discussion:
This gentleman had Elevated PSA (53.30 ng/ml) levels. A Transrectal biopsy of mass with HPE revealed an Infiltrating Adenocarcinoma of Prostate (Gleason Score – 7 / 10). Tumor in Prostate is identified by the presence of low signal intensity in high signal peripheral zone . Tumor appears as areas of restricted diffusion with low ADC values in Diffusion weighted Imaging. In 3D Multivoxel MR Spectroscopy , the tumor foci show increased choline and creatine to citrate ratio of >1.5. Identifying extracapsular invasion is important for staging . The key features to identify these are : Capsular deformation Mass > 12mm in contact with the capsule Secondary signs associated with extracapsular disease are Asymmetric capsular bulging, obliteration of the rectoprostatic angle, and involvement of the neurovascular bundle. Visualizing the direct extensionof tumor into the fat -clearest sign. Nodal metastasis commonly occurs to iliac and obturator nodes. It is identified by their size criteria -- Oval >10mm;Round Short Axis>8mm and with restricted diffusion.
REF : MR IMAGING AND MR SPECTROSCOPY IN PROSTATE CANCER MANAGEMENT -KATZ et al RCNA (2006) -723-734
Contributed By:
Dr. Babu Peter MD, DNB
Associate Professor, Barnard Institute of Radiology
Senior Consultant Radiologist, Aarthi Scans, Chennai