0:00

This is a case of a 67-year-old whose PSA has risen to 8.

0:06

As for the images, we have our axial T2, our ADC map,

0:09

wintered at 1400 1400, our high B-value image, 1600,

0:13

it's interpolated, and an arterial phase post-contrast

0:16

sequence, and I know I, I had a finding on the screen

0:20

when you open it up, but let's go the way I normally go.

0:22

So we'll start in the peripheral zone.

0:25

So peripheral zone is looking mostly T2 bright on the...

0:29

and on the ADC map, bright, bright, bright, bright

0:34

bright. As we go down, bright, bright, bright, bright,

0:37

a little asymmetric here, some streaky stuff there.

0:41

Um, this is not going to black hole.

0:43

It's not going to be less than a thousand ADC.

0:45

Map so streaky, streaky on the T2 and ADC is,

0:50

uh, PIRATES 2, which doesn't even get mentioned.

0:54

Let me come down.

0:55

So one area that drew my attention is right here.

0:59

And this is either going to be a little bit

1:01

of low T2 signal in the peripheral zone.

1:04

It's also in the location, if we come up to the top.

1:08

Seminal vesicles come in of the central zone.

1:13

The ADC map is minimally asymmetric.

1:17

The ADC values here are 1,300, they're 1,300 here.

1:20

Uh, not bright on the high B-value image.

1:24

It's really not dark enough for me to worry about.

1:26

This has some focal diffusion restriction

1:29

different from the other side.

1:31

And if we look on the coronal images, In this

1:37

area right here, I think we're seeing a little

1:39

bit of asymmetrically enlarged, um, central zone

1:43

tissue, either that or the gland's a little askew.

1:46

It's not, you know, if you look,

1:47

it's not completely vertical here.

1:50

It's rotated off to the side a little bit,

1:52

rotated clockwise a little bit, sorry.

1:54

So I think this is just asymmetric peripheral zone

1:56

tissue, so I'm not going to mention that or go after that.

2:00

So that's the peripheral zone.

2:02

We look in the transition zone, and

2:04

for the most part, it has this normal

2:07

heterogeneous nodular appearance.

2:10

As we come towards the base, however,

2:13

we see this lenticular shape.

2:15

So it's not a crescent anymore.

2:17

It doesn't look like, uh, low T2

2:19

signal that's squished between nodules.

2:22

It actually looks like it's causing

2:24

some mass effect on the nodules.

2:26

Uh, that's lenticular shaped.

2:28

It's low T2 signal.

2:30

It's in the transition zone.

2:32

It's greater than 1.5 centimeters in diameter.

2:36

That's PI-RADS 5 based on the T2 characteristics.

2:40

The fact that it has a very low signal on the ADC map.

2:44

The ADC value measured 600, and it's very bright.

2:48

On the high B-value images, you know, that scores

2:51

PI-RADS 5 on the, uh, diffusion scale as well.

2:55

But, you know, we go by T2, but it's nice

2:57

when the diffusion kind of correlates that.

3:00

We can come and look at the post-contrast images.

3:02

Nope, that's not the post-contrast images.

3:06

Here we go.

3:07

And there is focal early enhancement in

3:09

the arterial phase of the dynamic series.

3:12

Uh, so this is what an anterior

3:13

transition zone lesion looks like, right?

3:16

It's not anterior stroma, because anterior

3:19

stroma A doesn't enhance like this.

3:22

Two, anterior stroma is usually darker than this

3:25

on T2 and doesn't restrict diffusion as much.

3:28

It's not symmetric.

3:29

It's not, uh, invaginating between nodules.

3:32

It's pushing everything out of the way.

3:35

This is the normal appearance of the

3:37

stroma between the nodules as we go.

3:39

A bit more inferiorly in the gland up high.

3:42

That looks different.

3:43

Inferiorly, you could argue is some of

3:45

this tumor in the anterior peripheral zone.

3:48

Yes, it absolutely is here.

3:50

So peripheral zone on the left.

3:51

Here's peripheral zone on the right.

3:52

Here is the anterior margin, the transition zone, and this.

3:55

Is abnormal peripheral zone tissue with the low ADC map,

3:59

the high signal on the high B value, and the enhancement.

4:03

So whether or not you place this in the anterior

4:05

peripheral zone inferiorly or in the anterior

4:08

transition zone superiorly, it both has characteristics.

4:11

Of Pyrad's 5 lesion, that based on the size.

4:15

Now this has sort of a broad-based bulge of the capsule.

4:18

We know that increases the chances of microscopic.

4:21

Extracapsular spread, but on the MR, we're.

4:23

Looking for macroscopic extracapsular spread.

4:26

So here's a nice example of an anterior.

4:29

Tumor in the transition zone.

4:31

So we've looked at the peripheral zone, the.

4:32

Transition zone, the stroma, the central zone.

4:35

We have to continue our evaluation.

4:38

Sorry, I keep going the wrong way.

4:39

But look in the seminal vesicles.

4:40

There's no evidence of abnormal.

4:41

Soft tissue in the seminal vesicles.

4:43

The area where the neurovascular bundles run is messy.

4:46

But symmetric, and there's no, you know, soft tissue.

4:49

Obliterating the fat or the little black dots that.

4:52

Are the nerves, the arteries, and the blood vessels.

4:55

Uh, venous structures, and also inferiorly there's.

4:58

No evidence of anything growing into the rectum.

5:02

Again, you wouldn't expect that, it's an anterior tumor,

5:05

but gotta keep reminding myself to look on every single case.