Figure 7.

MRI-guided biopsy after focal therapy in 65-year-old man who was diagnosed with Gleason score 3+3 prostate cancer in several left-sided cores 7 years previously, after a screening PSA was found to be elevated at 4.9 ng/mL. The patient underwent high intensity focused ultrasound outside of the United States. Post-procedural nadir PSA was 0.3 ng/mL, but recently rise to 2.7 ng/mL, despite repeat treatment with high intensity focused ultrasound 1 year before. (A) Axial T2-weighted MR image shows a concerning ellipsoid focus (arrow) of reduced T2 signal in the left peripheral zone. Extensive fibrotic signal in the posterior portion of the prostate is likely post-treatment in nature; (B) axial T1-weighted MR image obtained early after the administration of intravenous gadolinium demonstrates prominent corresponding focal enhancement (arrow), also concerning for tumor (diffusion imaging in this case was non-contributory due to degradation from bilateral total hip replacements); (C) axial oblique T2-weighted MR image obtained in the plane of the needle sleeve after needle deployment during direct MRI-guided biopsy shows the needle (arrow) traversing the target. Pathology showed Gleason score 3+4 cancer in 15% of the tissue obtained. Patient was subsequently treated by external beam radiotherapy.