0:01

So this is a case of a 73-year-old

0:03

with a PSA of 12 in a nodular gland.

0:05

So, an older patient with a high PSA, an abnormal

0:09

rectal exam, so very high pre-test probability

0:12

that there's a significant prostate cancer.

0:15

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

0:19

axial high B value image, it's interpolated with

0:22

B equals 1600, and I don't have an arterial phase

0:26

dynamic image, so instead I've thrown up a coronal T2.

0:30

And the first thing I think when I look at these

0:32

diffusion images are They're very noisy, or sorry, the

0:36

ADC map, they're very noisy and they're very warped.

0:39

I know it's going to be a difficult exam to read.

0:41

So in these cases, I definitely always

0:43

start by looking at the T2 images.

0:46

It's uncommon to have a peripheral

0:48

zone cancer that's not dark on T2.

0:50

There, it does happen, and that's why we rely heavily on

0:53

the diffusion images, both for its specificity and because,

0:57

uh, and it's increased sensitivity compared to the T2.

1:00

But if the diffusion Or ADC images look terrible,

1:04

I'm definitely going to start with the T2 images

1:06

to see if I find a focal low signal nodule.

1:09

And then I'll look at the ADC map to see if it's low signal.

1:14

So we start at the top, we have some transition zone.

1:18

And here's our central zone right

1:20

here, coming in through here and here.

1:23

What can you come down?

1:24

So, little bit heterogeneous.

1:27

A predominantly high signal on this image.

1:29

We do have some two focal, small, 5mm nodules that

1:33

would be concerning, and the ADC map is not of good

1:36

enough quality, uh, to say if they restrict diffusion.

1:40

Come down some more, and we see some more well-defined

1:42

areas of low T2 signal that would be concerning,

1:45

and again, the ADC map is simply not good enough.

1:48

Come down more.

1:49

Now we're getting into what looks like a really well-defined,

1:52

almost 2cm, area of decreased T2 signal.

1:56

On the ADC map, there's maybe some low signal here.

2:00

It's very, very warped.

2:03

But on the high B value, there's

2:04

obviously something right here.

2:06

And if you look on the coronal image,

2:09

we can see this large 2-centimeter here.

2:12

Lesion in the right peripheral zone and we can also

2:14

see that it's bulging outside the gland right here. So

2:18

this is going to be a PI-RADS 5 lesion. I'm happy that

2:22

it meets the criteria both on diffusion and on T2.

2:27

We don't need the post-contrast images. This was

2:30

biopsied and was Gleason 4 plus 4 disease. So the

2:33

question is, what do you say about these areas?

2:37

In this case, where I know there's a large cancer with

2:40

extracapsular disease, I'm probably going to call these PI

2:43

RADS 4 lesions and just say that the diffusion images are

2:46

not good enough to be used in the ranking system.

2:52

Now, the question is, do these need to be, uh,

2:54

biopsied with, excuse me, with the targeted biopsy?

2:58

The answer is probably not, because we have

3:00

a big lesion. We see extracapsular spread.

3:03

If we scroll slightly more inferiorly,

3:05

there's a perirectal lymph node.

3:07

So this is a PI-RADS 5.

3:09

You know, I'm not going to say

3:10

highly suspicious for neoplasm.

3:12

I'm just going to call it a PI-RADS 5 neoplasm with direct

3:15

extracapsular extension, and perirectal lymphadenopathy.

3:19

Um, so in this case, even though the diffusion images

3:23

were pretty bad, fortunately for the radiologist,

3:26

unfortunately for the patient, there's sufficient

3:28

disease and big enough disease that we can get

3:31

away with giving a proper and accurate report,

3:33

even though the exam did not come out so nicely.