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. 2021 Apr 1;22(7):1087–1099. doi: 10.3348/kjr.2020.1224

Fig. 5. A 77-year-old male presented with an elevated serum PSA of 11 ng/mL.

Fig. 5

Initial systematic transrectal ultrasound biopsy was negative for cancer. mpMRI was performed.

A. T2-weighted imaging shows a small lesion in the peripheral zone at the left midgland (arrow). B. ADC map shows focal marked hypointensity (arrow). C. DWI shows focal marked hyperintensity (arrow). The lesion was graded as Prostate Imaging-Reporting and Data System 4. MRI-ultrasound fusion targeted biopsy, however, showed a Gleason 3 + 3 cancer. A decision was made for the patient to undergo AS. Serial PSA levels over 1 year showed an increase to 18.1 ng/mL. Repeat mpMRI was performed before the confirmatory biopsy at 1 year. D. T2-weighted imaging shows a relatively stable size of the hypointense lesion in the peripheral zone at the left midgland (arrow). E, F. ADC map and DWI show marked restricted diffusion and similar findings as before (arrows). Although the imaging findings were deemed stable (Prostate Cancer Radiological Estimation of Change in Sequential Evaluation score 3), there was a high clinical suspicion for disease progression based on the PSA kinetics. Both systematic and targeted biopsy were repeated. MRI-ultrasound fusion targeted biopsy showed a Gleason 4 + 4 cancer. The patient was taken off AS. ADC = apparent diffusion coefficient, AS = active surveillance, DWI = diffusion-weighted imaging, mpMRI = multiparametric MRI, PSA = prostate-specific antigen