0:00

This case does not have a history, but I'm going to

0:03

assume it's a middle-aged older man with an elevated

0:07

PSA, because that's all the cases we're showing here.

0:11

Uh, so this is actually an older case, uh, that was scanned.

0:14

Very early in our experience with, uh, with prostate MRI.

0:19

So we ended up biopsying a bunch of findings

0:21

that we wouldn't have normally biopsied,

0:23

you know, if we were reading the case today,

0:24

because we've learned a lot since that time.

0:26

So it offers some nice correlation on some, on some

0:29

Benign findings that can look worrisome on the MR.

0:33

So it will take the opportunity with this case

0:35

To just go through the thought process of certain

0:37

Lesions and then describe how we handle them now.

0:40

So we've got the axial T2, the axial ADC

0:43

Map, and it's windowed at 1400x1400.

0:46

An interpolated B equals 1600 image.

0:49

And this is a post-contrast image from the

0:51

Dynamics series, but it turns out it's not.

0:53

It's not an arterial phase, it's more of a delayed phase,

0:56

So we, we will not be able to use it all that heavily.

0:59

Um, that's just what happens when you reach

1:00

Into the archives, sometimes you grab, uh, stuff

1:03

That, you look for things that you didn't save

1:05

At the time that you, cause you, you messed up.

1:08

Anyway, um, in the write-up, the first lesion

1:12

Described, and again, I'm gonna go out of order

1:14

So there's parallels with, with the write-up.

1:16

Um, we're looking at the transition zone in

1:18

This case, and we're looking at this right here.

1:27

here's a well-defined, well-circumscribed, so

1:32

circumscribed in the PI-RADS lexicon means it has

1:35

very well-defined borders all the way around.

1:38

Encapsulated means it has an actual dark border,

1:41

rim around it that's separate from the lesion.

1:44

If it's circumscribed, this means well-defined margins.

1:46

So it's well-circumscribed.

1:47

It's T2 dark, okay?

1:49

It's not lenticular-shaped.

1:51

It's not between nodules.

1:53

It actually looks like it's inside of a nodule.

1:56

So based on the characterization,

2:00

this would be a PI-RADS 2.

2:02

The problem is it markedly restricts diffusion.

2:06

If I put an ROI on the ADC map, I'm

2:10

going to get an ADC value in the 600s.

2:13

It's also focally bright on the high B-value image.

2:19

So, if we go to our graph here, it's got a score of 2.

2:25

For T2, it's got a score of 4 for DWI,

2:31

and that makes it a PI-RADS 3 lesion.

2:33

And at that time, we were biopsying, um, all of those,

2:37

and this was biopsied, and it came back as normal tissue.

2:40

Uh, this is kind of the typical

2:42

appearance of a quote, atypical nodule.

2:44

Um, and they're all over the place

2:46

in a lot of transition zones.

2:48

And, I've kind of stopped calling these biopsies,

2:52

biopsyable lesions, mostly because I, the purpose of doing

2:57

the MR is to stop doing biopsy in men who don't need

3:01

biopsies, and these are just way, way, way too common, and it

3:04

almost negates, in my mind, the purpose of doing the MRI.

3:08

Again, what makes me not worry about this being neoplasm

3:12

In a non-pyretic term is that it's inside of a nodule.

3:16

You typically don't get cancers inside nodules.

3:19

They grow between the nodules.

3:20

They push them out of the way.

3:22

There will always be some exceptions,

3:23

but in general, uh, that's, that's true.

3:26

So this is probably what an atypical nodule looks

3:28

Like or some low signal inside of another nodule.

3:30

So that's the first lesion discussed.

3:33

And they're right up.

3:34

The second one is right here,

3:35

Which is in the peripheral zone.

3:37

I'll scroll up and down just a little bit,

3:39

Just to convince you it is the peripheral zone.

3:41

So right here, and we'll find it again on the ADC map.

3:46

So we have a well-defined low T2

3:49

Signal nodule in the peripheral zone.

3:52

Measures less than a centimeter.

3:55

It has corresponding ADC abnormality, right?

3:58

It's focal, it's well-defined, it

4:01

Stands out from the background.

4:03

The ADC value itself is 1183, or almost

4:10

1200, so well above that 1000 cutoff.

4:13

Remember, I set my 1000 cutoff above the recommended

4:16

900 cutoff, so it's well above the cutoff for

4:19

Being like severe, markedly restricted diffusion.

4:23

Um, and it's not bright on the high B value.

4:30

Diffusion in the peripheral zone, right?

4:33

Because it's focal, different from the background,

4:36

But it's not low enough to make a 4 or a 5, right?

4:40

So this is PI-RADS 3.

4:41

If it enhanced in the arterial phase, okay, the PI-RADS 3,

4:47

With enhancement, excuse me, would become a four, right?

4:52

So, if it enhanced the neurotriophage,

4:54

Call it a four, otherwise a three.

4:56

This was biopsied, and it was normal tissue.

5:00

The third lesion, discussed in the write-up,

5:02

Is this one right here in the peripheral zone.

5:06

And to me, this looks like a

5:07

Poorly defined wedge-shaped area

5:10

Of decreased T2 signal.

5:12

And that's the PI-RADS 2 for T2.

5:14

But as we know, it's the diffusion that

5:16

Really counts in the peripheral zone.

5:18

And it markedly restricts diffusion, right?

5:20

So this has an ADC value of 746.

5:25

It's dark on the ADC map.

5:27

And it's actually, I'm gonna find it again, right here.

5:31

It's actually bright.

5:34

Uh, on the high B value.

5:35

So even though it's wedge-shaped, the very

5:37

Low ADC values make this a PI-RADS IV lesion.

5:41

And this is one of the lesions I would

5:43

Hesitate to call a PI-RADS IV lesion.

5:45

Currently, because in my mind, I'm saying wedge-shaped, ill

5:49

Defined on T2, it's gonna be benign, but the ADC is so low,

5:54

You gotta call it a 4, and I was thinking, it's just gonna

5:57

Bring the stats down, and the person doesn't need a biopsy.

6:00

This was biopsied, and uh, most of the cores were negative.

6:04

There was one core with 1 mm of 3 plus 3 disease, I believe

6:09

That's right, um, inside of this Inside of this core.

6:15

Yep.

6:15

So a very small amount of 3 plus 3 disease So either, you

6:21

Know, the biopsy happened to be near an area of low-grade

6:24

Disease or this represents low-grade disease Or the whole

6:29

Thing is low-grade disease and all the other biopsies

6:31

Missed it in that one core You know nicked an edge of it.

6:35

That's almost possible So this is one of those things

6:38

That you are actually going to call a PI-RADS 4 lesion.