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A case of a 50-year-old with a

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PSA 4 and no urinary symptoms.

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On the images I've brought up the axial T2 images, an axial

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ADC map windowed at 1400, 1400, a high b-value image with

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a b-value of 1600, and since this case does not have post

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contrast images, I've just pulled up a coronal T2 image.

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So the first thing you notice in this case.

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Um, is that there is this large low-signal

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mass in the anterior peripheral zone.

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So in many glands there is peripheral zone

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tissue anteriorly in the mid and apical gland.

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This is going to be the transition

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zone and here's the peripheral zone.

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If you look on the diffusion images,

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so the ADC map and the high b-value.

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We have this well-defined black

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hole, so it's very dark on ADC.

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The ADC values are quite low.

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If we measure them, they're going to be in the

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600s, so it's very low, 666, not a good number.

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And it's high signal on the high b-value, and it's

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much higher signal than the remainder of the gland.

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It's the only part of the gland that really has high signal.

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These images can be difficult to window because

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Uh, they're not absolute values, and sometimes you

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can make things that are just a little bit high

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signal look very high signal by having very narrow

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windows, but in this case, there's no confusion.

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The rest of the gland is dark, and this is quite

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bright, uh, so being high signal on the high

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b-value, and very low signal on the ADC map.

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And again, my cutoff tends to be about a thousand,

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which looks like a black hole when windowed like this.

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That gives you a score of either a PI-RADS

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4 or PI-RADS 5 in the peripheral zone.

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And since the abnormality is greater than 1.

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5 centimeters, in this case, it's PI-RADS 5.

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So this is going to be a PI-RADS 5 lesion.

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The diffusion characteristics outrank

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everything else in the peripheral zone.

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Um, so, um, Although, it also gets a PI-RADS 5

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for T2 in this case, but it's not that important.

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The remainder of the peripheral zone is

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uniformly bright on the ADC map and dark on the

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high b-value image, so no other focal lesions.

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We move to the transition zone, which is small and

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has a typical appearance of the transition zone.

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The tumor is probably invading

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the transition zone posteriorly.

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We've already mentioned it in the

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peripheral zone, so we don't need to again.

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We have some central zone tissue here and

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here, which you can also see here and here.

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Posteriorly in the gland, so

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transition zone tissue go anteriorly.

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You have the tumor, um, and the

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anterior stroma looks normal.

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It's not thickened at all.

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Uh, so we have this PI-RADS 5 lesion.

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It does not look like there's macroscopic.

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Extracapsular invasion.

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There may be some microscopic invasion.

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It's difficult to tell, but we're really looking

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to document macroscopic extracapsular spread.

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We also need to look for tumor in the

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seminal vesicles, of which there's none.

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There's no abnormal soft tissue along

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the course of the neurovascular bundle.

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So here and here, we wouldn't

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expect that with an anterior tumor.

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There's no evidence of any invasion to the rectum.

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Also, it's an anterior tumor.

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We would not expect that.

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So it's a pretty straightforward case with a suspected

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high-grade PI-RADS 5 lesion in the anterior gland.

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And if we look and see what the biopsy results

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of this were, sixth core is all 3 plus 4 disease.

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So anterior significant prostate cancer.