0:01

I'd like to give you a couple of

0:01

position statements, one of which

0:04

focuses on dynamic contrast-enhanced MRI.

0:08

I've already alluded to two

0:10

other important positions.

0:11

One, you do not need 3 Tesla imaging to do high

0:14

quality MRI of the prostate, including DCE MRI.

0:20

Number two, you do not need an endorectal

0:22

coil to do high-quality staging

0:27

diagnostic MRI of the prostate gland.

0:30

And in fact, The coil can even push the

0:32

prostate forward and obscure capsular invasion.

0:36

So in some ways, it's disadvantageous.

0:39

And I have had that happen on an endorectal study.

0:42

But finally, with dynamic contrast-

0:45

enhanced MRI, you're probably wondering

0:48

from prior vignettes, when should you

0:50

use it and when can you not use it?

0:54

The scenario where you don't need to use it is an

0:58

individual who is having a screening evaluation

1:02

with a PSA level that is less than 10,

1:07

a digital rectal examination where the prostate

1:10

may be a little big, but no focal nodules are

1:13

identified, and there is no family history of

1:16

genetic cancers like prostate, colon, breast,

1:22

and pancreas, which are interrelated.

1:25

Uh, genetically.

1:26

If the patient has already had a prior biopsy,

1:30

they have to meet tier one criteria, which

1:33

is defined in another vignette, to avoid using

1:36

DCE MRI, or they meet the Epstein inclusion

1:41

criteria, which again is in a separate vignette.

1:45

So in the virgin prostate or in

1:48

the biopsy prostate, those are the

1:50

criteria where you don't need DCE MRI.

1:54

How about a scenario where you need DCE MRI?

1:56

Okay.

1:57

Let's say you've got somebody with a PSA

2:01

of 40, and maybe they had an ultrasound that was

2:04

inconclusive or they thought they saw something.

2:07

You're gonna perform DCE MRI to make sure

2:11

you don't have an uber-aggressive small lesion.

2:15

You might also use it to stage and

2:18

to characterize a larger lesion.

2:20

Let's take a look.

2:21

Here's a gentleman.

2:22

Asymptomatic, comes home, you know,

2:25

he pees once or twice a night.

2:27

So he gets up in the middle of the night,

2:28

no other symptoms, on vacation, opens his

2:31

mailbox, rips open his laboratory exam,

2:34

and sees that his screening PSA for the

2:36

year is over 40 nanograms per deciliter.

2:41

That person is having T2, diffusion, an ADC map.

2:48

And DCE MRI.

2:50

Here is the T2, showing a charcoal-like

2:53

smear of the entire right side of the gland.

2:57

Here is the DCE MRI, and on the very first

3:01

7 to 12-second image of the dynamic, Boom!

3:05

An explosion.

3:07

The contrast shows up immediately.

3:09

And it progressively washes out as

3:11

we get deeper into the time-activity

3:14

curve, where it becomes less conspicuous

3:17

compared to the rest of the gland.

3:19

High-velocity wash in.

3:21

High-velocity washout.

3:23

This is an aggressive tumor corroborated by DCE.