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This is a case of a 70-year-old with a PSA of 44, a rock

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hard prostate on physical exam, and urinary retention.

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For images, we have axial T2, axial ADC map,

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a B equals 1600 interpolated diffusion-weighted image,

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and arterial phase post-contrast subtraction images.

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The thing you notice about this

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prostate is there is no zonal anatomy.

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The entire prostate is kind of this,

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this gray, low-signal appearance.

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This is sometimes what they call the quote,

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smudged charcoal, unquote, appearance of

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what a transition zone tumor can look like.

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And they say smudged because it's low signal, but

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there are no margins, all the different things. Uh, pieces

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of zonal anatomy are, are sort of blurred together.

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The entire gland has a black hole on

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the ADC map, windowed at 1400x1400.

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The entire gland is bright on the high B

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value image, and nearly the entire gland

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enhances very early in the arterial phase.

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You can see the arteries are

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enhanced, but there are no veins.

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This was biopsied.

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This was diffuse Gleason 5 plus 4

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disease, so very, very high-grade disease.

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So things to look at when the entire prostate

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is involved is, uh, And the PSA is 44.

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It's obviously extracapsular disease.

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On this image alone, you can see a lytic lesion in the bone.

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So there's a round arrow marrow replacement

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signal here in the anterior right pubis.

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And the bones are usually the last thing that I

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look at, but it just happens to be on this image.

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As we scroll, uh, superiorly, we notice that there's

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a lot of very low signal within the, uh, base of

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the vas deferens, and kind of the angle between

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the vas deferens and the prostate is obliterated.

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In some prior cases, I did show

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some low signal vas deferens.

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Um, those areas were lower signal than this, and more well

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defined, and you could still actually make out the anatomy.

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So, this is going to be seminal vesicle invasion.

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What other signs on this point to that,

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as opposed to being normal?

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One is, there's diffuse diffusion restriction in these

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soft tissues, and in the other case, with very low

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signal vas deferens, they did not restrict diffusion.

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If we look at the delayed post-contrast

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images, this region's enhancing.

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So normally, the vas deferens don't enhance, but in

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this case, This area shows brisk contrast enhancement.

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So vas deferens invasion, seminal vesicle invasion.

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If you look at the region of the neurovascular

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bundles, there is abnormal soft tissue on both sides.

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So there's direct extent into the

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region of the neurovascular bundles.

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And if we scroll more superiorly, there's actually

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a large, irregular, uh, and pathologic lymph nodes.

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This is along the pelvic sidewall.

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It's not, um, a periprostatic lymph node.

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It's not in the mesoerectal fat.

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It's actually lateral to the, uh, these

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structures and it's along the pelvic sidewall.

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So this is diffuse high-grade neoplasm with

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seminal vesicle invasion, invasion to the region

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of the neurovascular bundles, local regional

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lymphadenopathy, and bony metastatic disease.