Abstract: 63-year-old male patient was referred by his urologist for
multiparametric magnetic resonance imaging (MRI) of the prostate
gland,following previous negative prostate biopsy. The patient’s
prostate-specific antigen (PSA) levels remained elevated, most recently
10.8 ng/ml, despite Avodart. Additionally, this patient had undergone
While multiparametric prostate MRI is not currently
used as a first-line tool for diagnosing prostate cancer, it has proven
very helpful for directing targeted biopsies, particularly in select men
like our patient with persistent, elevated PSA levels, and a previous
negative transrectal ultrasound-guided biopsy.1 Yacoub et al
concluded that the information gleaned from prostate MRI for direct
targeting of lesions for biopsy may help increase diagnostic yield,
improve accuracy of identification and characterization of prostate
cancers, and assist in patient selection for specific therapies.2
Final pathology report: Prostate, right peripheral zone base, MRI-guided needle biopsy showed diagnosis (Figure 7).
- Adenocarcinoma, Gleason Grade 4 + Gleason Grade 3 = 7
- Total surface area involved: 50%
- Number of needle biopsy cores involved: 4 of 4
- Perineural invasion: present
Multiparametric MR imaging was performed to acquire high-resolution
images through the prostate gland and seminal vesicles. A suspicious
region measuring 1.2 × 0.8 cm was identified in the right midland/base
(Figure 1), abutting the central zone right of midline, coursing along
and invading the right ejaculatory duct. It demonstrated restricted
diffusion (Figure 2) and was concordant on multiple sequences,making it
amenable to MRI-guided biopsy.
Following anorectal resection, CT-guided transgluteal prostate biopsy is often considered because it is both safe and effective;3
however, our institution has a transrectal MRI guidance system (Figure
3) with a very small needle guide that could be easily accommodated by
the neoanus (Figure 4).
The patient returned approximately 2 weeks
later for MRI-guided biopsy. He underwent oral antibiotic prophylaxis
and Betadine was applied to the neoanus prior to insertion of the needle
guide. Viscous lidocaine was used as both a topical anesthetic and
lubricant for insertion. Once in place the needle guide was imaged with a
T2-weighted calibration scan in the sagittal plane and the target was
relocalized.Planning software was used to calculate the delta between
the tip of the needle guide and the lesion. Angulation and insertion
adjustments were made in the A/P, L/R and H/F directions (Figure 5). The
suspicious region was relocalized and targeted from a T2-weighted axial
image (Figure 6).
Four core biopsy samples were taken using an
18-g, 175-mm, fully automatic, MRI-compatible gun. The specimens were
placed informalin and sent for histological evaluation. The patient
tolerated the procedure well, and after brief observation and
demonstrated ability to void, was discharged to home.
MRI of the prostate has earned its place in the diagnostic armamentarium
for prostate cancer detection. Recent literature and experience have
proven its value for cancer diagnosis, grading and staging when used to
target specific areas of the prostate gland for biopsy.2 In
the unusual clinical scenario of the patient presenting
post-abdomino-perineal resection (APR), MRI-guidance may be used when
insertion depth is adequate, providing more control and less radiation
than transgluteal computed tomography (CT) guided prostate biopsy.
Multiparametric MRI and MRI-guided biopsy are helpful to target specific
areas of the prostate gland for biopsy, even in patients who have
- Sciarra A, Panebianco V, Cattarino S, et al.
Multiparametric magnetic resonance imaging of the prostate can improve
the predictive value of the urinary prostate cancer antigen 3 test in
patients with elevated prostate-specific antigen levels and a previous
negative biopsy. BJU Int. 2012;110:1661-1665.
- Yacoub JH, Verma S, Moulton JS, et al. Imaging-guided prostate biopsy: Conventional and emerging techniques. RadioGraphics. 2012;32:819-837.
- Cantwell CP, Hahn PF, Gervais DA, et al. Prostate biopsy after ano-rectal resection: Value of CT-guided trans-gluteal biopsy. Eur Radiol. 2008; 18:738-742.