History: 71 yo male post radical prostatectomy 4 years ago for Gleason 4+5 prostate cancer Pre-op staging CT and MDP bone scan were negative for metastatic disease Pathology: Gleason 4+5, with bilateral SV involvement and 1/3 R pelvic nodes positive. Patient was started on early hormone therapy and PSA remained < 0.4 during post operative follow up period. LHRH agonist therapy discontinued due to side effects Now with serially rising PSA, up to 4.4 Pelvic/Prostate MRI, CT C/A/P and MDP bone scan were ordered to assess for recurrence/metastases Case courtesy of: Amirkasra Mojtahed, MD and Steven C. Eberhardt, MD Department of Radiology, University of New Mexico Hospital, Albuquerque, NM

A B Initial MDP bone scan (A) demonstrates marked radiopharmaceutical uptake within the right acetabulum anteriorly, which correlates with sclerotic lesion on CT (B) performed 2 weeks later. Case courtesy of: Amirkasra Mojthed, MD, Steven C. Eberhardt MD, UNM Radiology

MRI Pelvis/Prostate (3T, no ER coil) performed 2 days after CT: B B C MRI Pelvis/Prostate (3T, no ER coil) performed 2 days after CT: Axial (A) and coronal (B) T2WI of the prostatectomy bed show no local recurrence. Large FOV axial T1WI (C) demonstrates a hypointense lesion within the anterior right acetabulum/pubic root, correlating with lesion on preceding CT and bone scan. Case courtesy of: Amirkasra Mojthed, MD, Steven C. Eberhardt MD, UNM Radiology

Teaching point In cases of biochemical failure following RRP, bone scan, CT and MRI can be useful in finding a cause for the rising PSA. Large field of view sequences on MRI can be helpful in assessing for regional osseous metastases or adenopathy, in addition to small field of view sequences for recurrence in the operative bed. CT and MDP bone scan can be used to provide a more broad survey Case courtesy of: Amirkasra Mojthed, MD, Steven C. Eberhardt MD, UNM Radiology

Useful references May EJ, Viers LD et al.  Prostate cancer post-treatment follow-up and recurrence evaluation.  Abdominal Radiology, May 2016, Volume 41, Issue 5, pp 862-876 Sella, Tamar, et al. "Suspected Local Recurrence after Radical Prostatectomy: Endorectal Coil MR Imaging 1."Radiology 231.2 (2004): 379-385. Casciani, Emanuele, et al. "Endorectal and dynamic contrast-enhanced MRI for detection of local recurrence after radical prostatectomy." American Journal of Roentgenology 190.5 (2008): 1187-1192.