April 15, 2018, Dr Chee L Khoo
Last fortnight we review the PI-RADS score in relation to prostate MRI and i thought we might go through a real case study and how it relates to general practice. Otherwise well 42 year old gentleman with no family history of prostate cancer or any other hormone related cancers presented for general check-up in 2011 in addition to the usual coughs and colds. We discuss prostate cancer screening many years ago and we have been checking his PSA every 12-18 months since. He has no prostatic symptoms. These have been his PSA readings over the years.
|Reference range||<3.0 mcg/L||<3.0mcg/L||<3.5 mcg/L||<3.5 mcg/L|
As there was a rising trend, we decided to monitor a little closer. He wasn’t always on time with his consultation.
|Year||March 2016||Sept 2016||May 2017||Dec 2017|
|Reference range||<3.5 mcg/L||<3.5mcg/L||<3.5 mcg/L||<3.5 mcg/L|
It was about the time when the PROMIS study results were published. This provided guidelines for investigations and management. He was referred to Spectrum Radiology for a Prostate MRI in January 2018. This was report from Spectrum:
The peripheral zone demonstrates diffuse heterogeneous mildly low T2 signal intensity with associated mildly restricted diffusion and mild non-focal enhancement. The appearance is likely related to inflammation. Detail is obscured which makes assessment difficult. A small focus of moderately restricted diffusion in the left posterior peripheral zone at the apical
level without corresponding circumscribed signal abnormality or differential enhancement is indeterminate.
The appearance is consistent with PI-RADS 3: The presence of clinically significant disease is equivocal. If clinically warranted, a followup MRI in 6-12 months may be of value to exclude any underlying foci of prostate carcinoma. Urology review should be considered.
He was duly referred to a local urologist and underwent a trans-perineal biopsy which revealed multiple areas of prostate in situ neoplasia (PIN) and three biopsies positive for prostate adenocarcinoma. The lesion on MRI was target.
He is now pondering treatment options including watchful wait.