Persistent elevation of PSA (12 ng/ml). Initial routine TRUS biopsy was negative. Follow-up saturation TRUS biopsy (24 cores) was also negative. MRI for "clearance" of malignancy.
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Typical features of prostate cancer on MRI = T2 hypointense lesion with restricted diffusion, low ADC and increased K trans i.e. microvascular permeability.
This cancer is in a location that is notoriously difficult to diagnose on transrectal biopsy i.e. at the apex of the gland anteriorly, abutting the urethra. Most TRUS biopsies target the peripheral zone (site of most cancers) and the central zone in the midportion of the gland. This patient had a positive histological diagnosis following a third "guided" or "templated" transperineal ultrasound-guided biopsy targeting the periurethral tissue of the gland (with a urinary catheter in situ). This is the same technique used by radiation oncologists for brachytherapy of prostate cancer.