0:00

This is a case with a 55-year-old with a PSA elevated to 5.5

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3 00:00:05,740 --> 00:00:09,210 We have our axial T2 ADC map, high B-value,

0:09

and arterial phase post-contrast imaging.

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And we'll start in the peripheral zone, so little

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heterogeneous appearance, no focal areas of diffusion

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restriction coming down, down, down, down, down, down.

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Now here's a focal black hole in

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the peripheral zone on the ADC map.

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ADC value measures.

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750, which is below my 1000 threshold.

0:35

It's bright on the high B-value image.

0:39

So we're looking at a PI-RADS 4 or 5 lesion.

0:42

I've mentioned in the past it's very unusual to

0:44

have a diffusion-restricting lesion that doesn't

0:47

have a correlate on T2, although it does happen

0:49

sometimes, so you trust your diffusion images.

0:51

Here on the T2, a very poorly defined area

0:54

of decreased T2 signal, but sometimes the apex is

0:57

better viewed on the coronal or sagittal images.

1:00

If you look in this area on the sagittal image,

1:02

there is a moderately well-defined area of

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decreased T2 signal compared to the right side,

1:08

where it's nice and bright, back to the left side.

1:11

There's your lesion right there.

1:13

So, I believe this measured less than 1.

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5 centimeters.

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It's going to be a PI-RADS 4 lesion.

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There's no obvious extracapsular

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disease, so it stays PI-RADS 4.

1:23

The enhancement is equivocal.

1:24

It doesn't make a difference to the scoring.

1:26

This was biopsied.

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And came back as Gleason 4 plus 3 disease.

1:33

Looking in the remainder of the peripheral zone,

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have a little bit of decreased T2 signal here.

1:41

The ADC values measure above 1300.

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There's nothing present on the, on the high B

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value image, and there's no enhancement here.

1:53

Excuse me.

1:57

At the time we read this study initially, this was

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before PI-RADS came out, the T2 images had a very,

2:03

very high, um, uh, weighting in our decision-making.

2:06

So this actually was biopsied, and

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this came back as benign tissue.

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So I'm happy now.

2:12

Saying that, I would have called it a PI-RADS II lesion.

2:14

Uh, we can look at the posterior portion of the

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peripheral zone, and we see this sort of midline

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symmetric area of decreased T2 signal, and it has a

2:23

little bit of associated diffusion restriction, and

2:25

kind of equivocal brightness on the high B value.

2:29

This is a typical location of the ejaculatory ducts.

2:32

And they'll typically have this appearance, and unless I see

2:35

either some asymmetry, or some bulging, or really markedly

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restricted diffusion, and it's really bright on the high B

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value image, I'm happy calling those the ejaculatory ducts.

2:46

And if you scroll up, you can see they're contiguous

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with the region of the central zone and the seminal

2:50

vesicles that come down here, here, here, to

2:53

your ejaculatory ducts, and they'll eventually,

2:59

Transition zone has kind of the normal

3:01

heterogeneous and nodular appearance of hypertrophy.

3:04

Here's another example of nice thickened anterior stroma.

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Goes across the midline, has this crescent shape.

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It's going to have diffusion restriction.

3:13

Not very bright on the high B-value images.

3:16

And again, no enhancement at

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all on the post-contrast images.