0:00

This is a 70-year-old with a PSA of 7, and as we

0:05

look at the pictures, they're not very pretty.

0:08

There's a lot of air in the rectum, which causes

0:10

a lot of motion on the post-contrast series.

0:13

There's a lot of warping of the prostate due

0:16

to susceptibility artifact from that air.

0:18

I mean, the shape of the prostate on the ADC map

0:21

in the high B-value image does not look like the

0:24

shape of the prostate on the T2-weighted images.

0:27

In addition, these images are very noisy,

0:30

very grainy, and the quality is low.

0:32

The T2 images aren't terrible,

0:34

but they are a little bit blurry.

0:36

Um, and that's probably due to a little

0:37

bit of motion because of the air.

0:39

So, we'll read the case the best we can.

0:43

We'll start, um, at the base, sorry, at the

0:45

apex of the gland on the T2-weighted images.

0:48

And there is a focal area of low T2 signal.

0:51

You can almost pluck it off.

0:53

Um, that's the PI-RADS 4 appearance.

0:55

There is corresponding diffusion

0:57

restriction, which is dark on the ADC map.

1:00

The ADC value is well less than, um, 1,000 on this case.

1:04

And it's bright on the interpolated

1:06

high B-value, uh, measures less than 1.

1:08

5 centimeters.

1:10

There's no extracapsular extent.

1:11

Can't really tell if it's enhancing or not.

1:14

So this is going to be a PI-RADS 4 finding.

1:17

And this was biopsied and there was Gleason

1:20

5 plus 4 disease in it, so that's good.

1:23

We'll continue our way, um, up the gland.

1:26

And still have a kind of heterogeneous

1:28

appearance here on the right.

1:29

The left side looks fine.

1:31

And as we get more towards the base, there's another

1:33

low T2 signal nodule in the peripheral zone that

1:37

looks like you could pluck it right off the page.

1:39

Um, I think it measures about 1.5 centimeters, that's a PI-RADS 5 appearance.

1:44

And then there is some correlative diffusion

1:47

restriction on the ADC map with ADC values less than a thousand.

1:50

And there's no correlation on the high B value.

1:53

So this wasn't reported when the scan was initially

1:56

read, now probably, I don't know, 10 years ago.

1:59

And it also wasn't even included in the write-up when

2:01

I made this fellowship a couple of years ago, so it's

2:04

kind of missed twice, which is a bit concerning to me.

2:07

Um, so, going by strict PI-RADS, alright,

2:12

it's focal low signal on the ADC map,

2:15

no correlate on the high B-value image.

2:18

That gives it a PI-RADS score of 3.

2:20

If you think it's enhancing, which maybe

2:22

it is, that bumps it up to a score of 4.

2:25

Right?

2:25

And because of its size, though, it's gonna be PI-RADS 5.

2:32

I never quite know how to explain when something

2:34

looks like an absolute black hole on the ADC map,

2:37

and you don't see it at all on the high B-value.

2:39

Because the high B-value images are made by

2:42

taking the ADC value and then interpolating.

2:45

Uh, uh, what the signal would be if the B-value were higher.

2:48

So like these two images are, are kind of the same thing.

2:53

The fact that this is a really poor quality study makes me

2:56

a little more likely to say there's some type of artifact

2:58

going on, but I don't have a good explanation for it.

3:01

Um, if I were reading this study today, I would have called

3:04

this a PI-RADS 5 lesion and it would have been biopsied.

3:06

If you go a little more cephalad, we see that there's

3:10

also some low signal in these regions, and on the right,

3:13

it almost blends in with the second lesion, but not quite.

3:17

There's also low ADC signal associated with these areas, and

3:21

there's no high signal in those regions on the high B-value.

3:24

I think that this tissue here, and this tissue here, if

3:28

you, if you scroll and trace where they go,

3:31

they all come back to the base of the seminal vesicles.

3:34

This is normal central zone tissue, which can be

3:37

low signal on T2 and have diffusion restriction, and

3:40

it's adjacent to this abnormal region right here.