IMRT recurrent w psa rising, false negative scans but the MRI

Hey, I am under investigation for radioi recurrent pc after IMRT.

The latest MRI results came in and I think I have to do the MRI

fusion type biopsy.

thanks.

-k

PSA -
11/16/10 to 09/20/13      8.2 to 0.2  (2012 Focused IMRT 75g)
09/20/13 to 10/05/16      0.2 to 2.8
10/05/16 to 10/27/17      2.8 to 5.7

(Now 66) 65 year old man with is a history of prostate cancer, Gleason 7,low volume,

with presenting (before IMRT) PSA 7.3, who completed a course of definitive
external beam radiotherapy on August 8, 2012. He has since developed a
biochemical recurrence, with a very slowly rising PSA from 0.3 in 2014 to 1.0
in 2015 to 2.1 in May of 2016 to 2.4 in July of 2016. This is consistent with
recurrent prostate cancer.)

11/22/17 MRI

TECHNIQUE: MRI of the prostate gland was obtained at 3T without
an endorectal coil before and after intravenous administration of
8 mL Gadavist.
 
COMPARISON: MR images from MRI guided prostate biopsy on November
23, 2016.
 
FINDINGS:
PROSTATE GLAND SIZE: 3.7 x 4.8 x 4.5 cm, volume 42 mL. Fiducial
markers in the prostate gland.
 
FOCAL LESION(S):
There is a 1.1 x 0.6 cm focal lesion in the peripheral zone,
located in right mid prostate gland, posterolateral region
(400:11). The lesion is diffusion restricting, dynamic contrast
enhancement is positive, and is hypointense on T2WI. Contiguous
with this lesion, there is a 1.3 x 1.1 cm focal lesion in the
transitional zone, located in right mid prostate gland,
posterolateral region (3:15). The lesion is hypointense on T2WI,
diffusion restricting, and dynamic contrast enhancement is
positive.
 
There is extraprostatic extension at the right mid prostate gland
posterolateral region (3:14 , 11:113).
 
There is a focus of enhancement and restricted diffusion at the
medial aspect of right seminal vesicle (11:100 and 400:4), could
reflect a small lymph node.
 
TRANSITIONAL ZONE: Changes of glandular and stromal hyperplasia
(BPH)
 
PERIPHERAL ZONE: Diffuse low T2 signal
 
EXTRA-PROSTATIC EXTENSION: Present.
 
NEUROVASCULAR BUNDLE: Normal
 
SEMINAL VESICLES: Normal
 
URINARY BLADDER: Underdistended
 
PELVIC LYMPH NODES: No enlarged pelvic lymph nodes.
 
BONES: The visualized pelvic bones are unremarkable.
 
OTHER: Left varicocele.
 
IMPRESSION:
PI-RADS 5 focal lesion involving the peripheral and transitional
zone, right mid prostate gland, posterolateral region,
approximately 2.0 x 1.0 cm in extent with extraprostatic
extension in the posterolateral region.
 
Focus of enhancement and restricted diffusion at the medial
aspect of right seminal vesicle could reflect a small lymph node.
 
 
 
NOTE:
PI-RADS (Prostate Imaging Reporting and Data System) assessment
uses a 5 point scale based on the likelihood (probability) that a
combination of multi-parametric MRI findings on T2W, DWI, and DCE
correlates with the presence of a clinically significant cancer
for each lesion in the prostate gland. A clinically significant
cancer is defined on pathology/histology as Gleason score > or
equal to 7 (including 3+4 or 4+3 and/or volume > 0.5cc), and/or
extra-prostatic extension (EPE).


Nov. 2016 - MRI biopsy

INDICATION: 65 year old man with is a history of prostate cancer, Gleason 7,
low volume, withpresenting PSA 7.3, who completed a course of definitive
external beam radiotherapy on August 8, 2012. He has since developed a
biochemical recurrence, with a very slowly rising PSA from 0.3 in 2014 to 1.0
in 2015 to 2.1 in May of 2016 to 2.4 in July of 2016. This is consistent with
recurrent prostate cancer. He recently underwent an MRI on August 6, 2016,
and this demonstrated a right anterior apical prostate nodule suggestive of
recurrent prostatecancer.

 MRI-guided transrectal prostate biopsy.
 Once the biopsy approach was determined, the biopsy device
was placed in the proper position under MR guidance, using oblique T2 weighted images parallel to the plane of the needle.
The specimens were obtained from the transition zone of the right anterior
apex. Three 18-G core samples were obtained.

PATHOLOGIC DIAGNOSIS:

Prostate, core biopsies, three:
1A)  Right apex medial I:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

2A)  Right apex lateral II:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

3A)  Right apex anterior:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

-------------------------------

Aug 2016 MRI w Coil

TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 3.0 T
magnet.
This study was performed with endorectal coil for high resolution detail.
1 mg of intramuscular glucagon was administered to reduce artifact related to
bowel motion.
Intravenous contrast: 8 mL Gadavist.

COMPARISON: Prostate MRI from 5 February 2012

FINDINGS:

The prostate gland measures 2.8 x 5.5 x 4.7 cm (AP x SI x TV), yielding a
calculated volume of 38 cc. There are 4 foci of susceptibility corresponding
to the fiducial markers placed for external beam radiation. The prostate
gland has decreased in size compared to the prior MRI from February 2012,
likely relating to treatment response.

Within the right anterior gland, at the apex, there is a T2 hypointense nodule
(05:27) which is ill-defined, more conspicuous on the ADC map (602:9), were it
measures 1.7 x 1.2 cm. If measured in a similar fashion on the current and
prior examinations on contrast-enhanced images, the greatest dimension on the
current study is approximately 1.0 x 1.3 cm on axial images (series 8, image
221); compared to 1.2 x 1,7 cm on the prior examination (series 7, image 168
from February 2012). Compared to the prior MRI, the lesion is further towards
the apex, possibly secondary to global prostatic atrophy related to radiation
treatment. No other suspicious lesions are appreciated.

The neurovascular bundles appear free of tumor. The seminal vesicles appear
normal in signal intensity and morphology. There is no significant adenopathy
and the visualized osseous structures appear grossly unremarkable.

IMPRESSION:

1. Right anterior apical prostate nodule still shows abnormal kinetics and
restricted diffusion, but is slightly smaller and more towards the apex
compared to February 2012.
2. No lymphadenopathy or evidence of extracapsular extension.

-------------------------------

11/11/16 BONE SCAN

TECHNIQUE: ISOTOPE DATA: (11/11/16) 26.6 mCi Tc-99m MDP.

Anterior and posterior whole-body images were obtained approximately 3 hours
following intravenous injection of the radiopharmaceutical.

FINDINGS: The images do not show any foci of increased tracer uptake suspicious
for metastatic disease.

The above described findings are consistent with normal physiologic uptake.

The kidneys and urinary bladder are visualized, the normal route of tracer
excretion.

IMPRESSION: No evidence of osseous metastatic disease.

---------------------------------------

First MRI in comparison -

Feb 2012 MRI w Coil

TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained before,
during, and immediately after the intravenous injection of 8 mL of Gadovist
contrast, 1 mg of intramuscular glucagon and 200 mg of lidocaine were
administered. An endorectal coil was also placed.

3D series were sent to an independent workstation for computerized assessment
of the contrast dynamics.

FINDINGS:
The prostate gland measures 4.7 x 3.5 x 5.0 cm (CC x AP x TV), yielding a
calculated volume of 43 cc. The central gland is enlarged and shows a
heterogeneous swirled and whorled appearance with well-defined nodules
indicative of benign prostatic hyperplasia.

A focal area of low signal on T2-weighted images relative to normal prostate
is noted in the apex of the right central gland measuring 1.9 x 1.3 x 1.4 cm
(CC x TV x AP). In the axial images it extends to the midline (5:25 and
301:48), although the area of abnormality is confined to the right gland.
This area enhances avidly and washes out on delayed images. This area shows
mild restricted diffusion. This is concerning for central gland prostate
cancer that is both posterior and anterior to the urethra. This area is at
the most inferior aspect of the apex and bulges approximately 2 mm inferior to
the adjacent left glandular apex (4:16) but remains well circumscribed and
there is not definite extension outside the gland. There is a large area of
involvement along the periphery anteriorly and laterally at the left apex of
the central gland with slight bulging anteriorly as well.

There is no evidence for tumor in the right peripheral zone. The left
peripheral zone has mildly decreased signal intensity on T2-weighted images
and increased signal intensity on T1-weighted images in the left apex and mid
gland with a geographic non-mass-like configuration and no corresponding
abnormal enhancement. Sensitivity for tumor is decreased here though none is
seen.

The neurovascular bundle is free of tumor. The seminal vesicles are normal in
signal intensity and morphology. There is no significant adenopathy and the
visualized osseous structures are normal. No clear diffusion-weighted
abnormalities are noted.

IMPRESSION:
1.9 cm abnormality in the right apex central gland highly suspicious for
prostate cancer with 2 mm of smooth inferior bulging in the deep apex relative
to the left glandular apex, but not definite evidence of extracapsular
extension. No definite peripheral gland tumor.

PSA -
11/16/10 to 09/20/13      8.2 to 0.2  (2012 Focused IMRT 75g)
09/20/13 to 10/05/16      0.2 to 2.8
10/05/16 to 10/27/17      2.8 to 5.7

-k