PMC8516009_01
(a, b) Transverse and Coronal PSMA-PET/CT images. A small prostate after TURP is seen with tracer capture (thin arrows) in the left prostate lodge, suspected for locoregional recurrence; (c, d) Transverse and Coronal T2 weighted MR images. These images demonstrate a small gland of only 8.5 cc secondary to TURP and show a diffuse T2 hypointensity of the peripheral zone. On the left, there is a diffuse, more pronounced thickening of the peripheral zone with mainly subcapsular disruption of the internal architecture in the centre, extending from the apex to the posterolateral base of the prostate (arrowheads); (e) Diffusion Weighted Imaging of the prostate. A high signal intensity is seen, indicating restricted diffusion in the left peripheral zone (thick arrow); (f) ADC map of the prostate. ADC values of 660-710 confirm an unequivocal restricted diffusion in the left peripheral zone (thick arrow), suggesting high-grade malignancy.
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Tomography/CT (PSMA-PET/CT) showed suspect local tracer capture (Figure 1a and 1b). Multiparametric MRI demonstrated a small gland of only 8.5 cc secondary to TURP and showed a diffuse T2 hypointensity of the peripheral zone, with a more pronounced thickening and mainly subcapsular disruption of the internal architecture on the left (Figure 1c and 1d). The perfusion study showed hypervascular contrast enhancement and the entire zone showed an unequivocal restricted diffusion suggesting high-grade malignancy (Figure 1e and 1f). The periphery was scored according to the Prostate Imaging-Reporting and Data System v2: PI-RADS 5.
Sagittal MRI (left) and transperineal US fusion (right) as seen on the ultrasound system monitor during biopsy. The biopsy needle (arrows) enters the ROI (circle) during sampling of the PI-RADS 5 lesion in the small prostate after TURP. Despite the inferior quality of transperineal US compared to transrectal ultrasound when imaging the prostate, software fusion allows accurate sampling. In the right lower corner, drawing of transperineal prostate biopsy. The convex US probe is placed sagitally on the patient's perineum, introducing the biopsy needle anteriorly of the probe. Adapted with permission from Shinohara et al... A = Anterior; P = Posterior; F = Feet; H = Head.
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Next, the ultrasound probe was placed sagittally on the perineum and some further minor adjustments were made to optimise the image overlay and thus the MRI-US correlation (Figure 2).