0:00

Seventy-year-old with a PSA of 6,

0:03

a nodular gland, and no urinary symptoms.

0:06

We have our axial T2-weighted images, our ADC map

0:09

windowed at 1400x1400, a high B-value, diffusion

0:14

weighted image. This is an interpolated B equals

0:16

1,600 image, and an arterial phase post-contrast.

0:21

I believe this was done, uh, without contrast,

0:24

sorry, without fat suppression by mistake.

0:27

I don't know what the reason for that was.

0:29

So again, so we start in the, uh, peripheral zone.

0:32

And the peripheral zone is looking

0:33

relatively high signal on the ADC map.

0:36

Relatively high signal on the ADC map.

0:38

And here we come down.

0:40

Sorry, up.

0:42

We'll go down.

0:44

And there's a big black hole here on the ADC map.

0:47

Uh, in the left posterior-lateral peripheral zone.

0:50

The ADC value here is very, very low.

0:53

It is 540.

0:56

Uh, so that is, uh, well below the threshold

0:58

of a thousand that I like to use.

1:01

There's a corresponding very well-defined

1:03

low T2 signal nodule on the T2 images.

1:07

It looks like you could almost

1:07

pluck it right out of the image.

1:10

There's corresponding, uh, signal on the high B-value image.

1:14

So I believe this measured about 1.5 centimeters.

1:16

So this gets a PI-RADS score of 5 for the diffusion.

1:21

It gets a PI-RADS score of 5 on the T2, and

1:25

it also gets a plus for the dynamic curve.

1:27

Post-contrast enhancement, because look

1:29

there's focal arterial enhancement right here.

1:31

This is a PI-RADS 5 lesion.

1:33

This was biopsied and was Gleason, uh,

1:36

either 4 plus 3 or 3 plus 4 disease.

1:39

I can't exactly remember.

1:40

Uh, Gleason 3 plus 4 and 4 plus 4 disease.

1:46

There's no other areas of

1:47

diffusion restriction sitting here

1:49

in the, uh, peripheral zone.

1:51

So no other lesions in the peripheral zone.

1:53

So now look at the transition zone.

1:54

It's not terribly enlarged, has this normal

1:57

heterogeneous nodular appearance of the transition zone.

2:01

Now anteriorly, there's this thickened low signal,

2:04

right, and it kind of invaginates into the midline

2:07

between the two lobes and the nodules right here.

2:10

And it's very low signal, and it's crescentric,

2:13

and it has very mild diffusion restriction,

2:16

and it's not terribly bright on the B equals

2:18

1600 images, and there is no enhancement.

2:20

So I'm happy calling this anterior stroma.

2:24

Remainder of the transition zone looks normal.

2:26

The region of the central gland, which

2:28

is kind of right in here, looks normal.

2:31

Uh, the cellular vesicles look okay.

2:35

There's no abnormal soft tissue sitting here

2:37

where the, uh, the nerve vascular bundles going?

2:40

The interface with the rectum is fine.

2:42

Is there extra capsular extension from this lesion?

2:44

Uh, you could argue maybe there's a couple

2:47

millimeters, or you could say there's no definite.

2:49

I think it could go either way in this case.

2:52

Um, there were in this case, on the systematic biopsies

2:57

that accompanied the targeted biopsy, there was

3:00

some Gleason 4 plus 3 disease seen laterally on the

3:04

right, and even in retrospect, you know, I don't see

3:07

anything I would call a PI-RADS 4 or PI-RADS 5 lesion.

3:11

This diffusion restriction is only very mild.

3:14

There's really no focal correlate

3:17

on the high B-value image, and there's no early enhancement.

3:19

So even if you were going to call this a 3 for

3:21

diffusion, it would not get bumped up to a 4.

3:24

Um, so the fact is that, you know, there are some

3:30

small cancers that are not going to show up on

3:32

the MRI, and we hope that most of them occur in

3:35

patients who have other cancers that did show

3:38

up on the MRI, but, but no test is perfect.

3:40

But even in retrospect, I don't see anything on the

3:43

right that I would have called a suspicious lesion.