0:01

This is a case of a 75-year-old with a

0:03

PSA rising to 9 and urinary symptoms.

0:07

So again, our axial T2 images, our

0:11

axial ADC map, blended at 1400 by 1400.

0:15

Our high B value, again, an interpolated B equals 1600.

0:19

And a post-contrast, and in this case, it's not an arterial

0:22

phase, it's a delayed phase, so it's not going to be

0:24

useful for scoring anything based on dynamic enhancement.

0:28

So again, we'll start in the peripheral zone,

0:30

and this peripheral zone is dark everywhere.

0:34

It's really heterogeneous.

0:36

Uh, it's not a normal bright area.

0:38

Uh, peripheral zone on T2.

0:40

On the ADC map, it's also heterogeneous,

0:43

but there's no black hole jumping out

0:45

at me until you come down to the apex.

0:47

And then down here at the right apex, both on the right

0:51

side and the posterior midline, there's this big black hole.

0:54

The ADC value is 850, 860.

0:58

It's definitely bright on the high B value images.

1:02

It measures two centimeters in diameter.

1:05

So based on the ADC, sorry, based on the diffusion

1:08

criteria, this is a PI-RADS 5 lesion, greater than 1.

1:11

5 centimeters, low signal on the ADC

1:14

map, high signal on the high B value.

1:17

The fact that its ADC value is

1:18

below my threshold for 1000, great.

1:20

Enhances in the delayed phase, doesn't help at all.

1:24

And on the T2, it's just an amorphous

1:26

kind of area of low T2 signal.

1:29

Like, it doesn't look like you can pluck it off the

1:31

prostate, but also there's no normal prostate around it.

1:34

So that comparison may not work.

1:36

How it scores on T2 doesn't matter.

1:38

It's PI-RADS 5 on diffusion.

1:40

It's in the peripheral zone.

1:41

It's a PI-RADS 5 lesion.

1:43

If you look at the margin, it looks like it infiltrates

1:46

outside the normal margin of the prostate.

1:48

It's not smooth, it's irregular, it's lumpy-bumpy.

1:51

There's, you know, up to five

1:52

millimeters of extracapsular extension.

1:57

Now, in the report, you're going to say PI-RADS 5

2:00

lesion, but when it looks like this, I say PI-RADS 5

2:04

tumor because it's a tumor and I want to be definite.

2:08

Um, this is biopsy.

2:09

It was at least in three plus four disease.

2:12

Um, so at least it correlates the fact

2:14

that it's out of the gland isn't great.

2:16

We talk a lot about the rectoprostatic angles and

2:19

that's an old term when prostate MRI first came out and

2:23

really, you know, when they're obliterated, it means the

2:25

process come all the way down here and it's, you know,

2:27

it's, it's, it's invading or it's touching the rectum.

2:30

In this case, I would say the angle on

2:32

the right is a little obliterated, right?

2:34

It's not.

2:35

Look and compare this side.

2:36

Look how, how far the prostate goes, between the

2:38

rectal wall goes before it gets to the prostate.

2:40

And here it hits the prostate much earlier.

2:42

It doesn't mean the rectum is involved.

2:45

It's just something you used to look at to remind

2:48

yourself to look at that area And if that angle is

2:50

asymmetric on one side It very strongly suggests

2:53

that there's extracapsular extension on that side.

2:56

A lot of people don't use that anymore Even though I'm not

2:59

old, I'm old school and I still make sure I look at that But

3:02

just because I say the rectoprostatic angle is a bit of

3:05

face doesn't mean there's rectal invasion I wouldn't say

3:07

there's rectal wall invasion here, but there is some extracapsular

3:10

spread There's no other area in the peripheral zone

3:14

that had no focal diffuse diffusion restriction like that.

3:18

We look at the transition zone.

3:20

It's enlarged, it's heterogeneous, it doesn't have

3:23

a focal mass within it or anything that meets the

3:27

T2, the T2 criteria for a PI-RADS 3 or 4 lesion.

3:30

Again, you have this anterior stroma here, which

3:34

is Uh, sort of this thickened low T2 signal rind.

3:38

In this case, it's not diffusion

3:39

restricting, but look, it's not enhancing.

3:41

This is a delayed image.

3:42

So again, another example of

3:44

thickened anterior stroma up here.

3:47

But the key on this point is you have a big infiltrative

3:50

peripheral zone tumor, uh, with extracapsular extension.