0:00

This is a 73-year-old with a PSA of 8.

0:05

We have our axial T2, our axial diffusion images,

0:10

uh, ADC map windowed at 1400x1400, an interpolated

0:15

B equals 1600 diffusion image, and an arterial

0:20

phase from the dynamic post-contrast series.

0:24

And we start in the peripheral zone, and almost all

0:28

of the peripheral zone is high signal on the ADC map.

0:32

Which is normal.

0:33

These low areas here are actually going

0:35

to correspond to things in the transition

0:37

zone, so we'll get to that in a bit.

0:40

Um, that looks good.

0:42

Now anteriorly, there's some low

0:44

signal and some diffusion restriction.

0:47

And what's important not to, uh, make a

0:49

mistake on this case is that this, even

0:51

though it's anterior, is not anterior stroma.

0:53

In most prostate glands, there is

0:56

peripheral zone tissue anteriorly in

0:58

the mid and apical part of the gland.

1:00

So here is normal.

1:02

Peripheral zone tissue on the right,

1:04

anterior to the transition zone.

1:06

This is abnormal.

1:07

So this is not anterior stroma.

1:09

This is abnormal peripheral zone tissue.

1:11

So low signal on the ADC map.

1:13

ADC value measures, why is it saying zero?

1:16

Let's try that again.

1:19

Uh, the ADC map measures 811.

1:27

So well below that 1,000 threshold, obviously

1:31

focally bright on the high B-value image, and there is

1:35

focal early enhancement on the post-contrast series.

1:39

So since this is greater than 1.5 centimeters in diameter, this is a

1:41

PIRADS 5 lesion with the diffusion

1:42

characteristics leading the scoring.

1:46

It also scores a 5 on the T2 and

1:51

it scores a positive on the DCE.

1:54

So this was biopsied and came back

1:56

with Gleason 4 plus 3 disease.

1:59

The remainder of the peripheral

2:00

zone, no other lesions were seen.

2:02

In the transition zone, you have this heterogeneous

2:05

appearance, which is very typical for hypertrophy.

2:09

Now this here is thickened anterior stroma.

2:13

It's located on the margin of the

2:15

transition zone and the edge of the gland.

2:17

There's no peripheral zone tissue here, right?

2:20

It goes along the contours.

2:21

It has mildly restricted diffusion.

2:24

It's not terribly bright on the high B-value

2:26

image and doesn't show any contrast enhancement.

2:29

And if I had the delayed image of this

2:32

dynamic series, I could show you it also

2:33

doesn't show any contrast enhancement.

2:36

So this case is a very nice example of an abnormal

2:42

anterior peripheral zone tissue, and it's important

2:44

not to confuse this area with the anterior stroma.

2:47

For completeness' sake, we need to look at the

2:49

seminal vesicles, which I've kind of zoomed

2:51

off the image here, but these guys look normal.

2:55

There's no abnormal tissue in the region of

2:57

the neurovascular bundles, and there's no

2:59

abnormal tissue growing back to the rectum.

3:00

We wouldn't, honestly, we would not

3:03

expect that, sorry, expect that.

3:05

Like if it's an anterior tumor.

3:07

If you look at the sagittal images, which

3:09

I'll blow up here, then this tumor does

3:12

look like it bulges the anterior capsule.

3:15

So we know that when tumors have a long

3:17

amount of contact along the capsule and

3:19

cause a smooth bulge, the risk of microscopic

3:22

extracapsular extension is increased.

3:24

But we're looking for macroscopic

3:26

extracapsular extension on the MRI

3:28

findings, and there's none in this case.

3:31

This is an anterior peripheral zone tumor.