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Okay, we've got a difficult case,

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a problem-solving case in a 76-year-old man.

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He's got an elevated PSA of 12.28 on 2/23/18.

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However, his PSA on 3/22/12, which was

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almost six years earlier, was 5.28.

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So the PSA is rising.

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His PSA density was 0.173 nanograms per ml per CC.

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So typically, the cutoff value for

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PSA density for increased risk is 0.2.

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0:46

making process when we do clinical radiographic

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correlation and expand our scoring method

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to the Likert scoring method, which is used

0:59

by more advanced practitioners integrating

1:02

the clinical with the radiographic.

1:05

So let's take a look at this case.

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We start out, maybe not with the optimal image

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that I want to show you, but there is an area

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of mass effect that straddles the surgical

1:17

capsule, which is a pseudocapsule, between the

1:21

TZ and the PZ, the PZ being a little bit whiter.

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Now one caveat that's been brought to

1:28

my attention, and it's true, TZ cancers

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almost never develop posteriorly.

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They're usually in the

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anterior portion of the gland.

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And they usually like to butt up against the AS.

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And in my experience, they also like to cross the

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midline in this area, the so-called gray zone.

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So these are usually larger cancers,

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and they often do diffusion restrict.

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So this cancer's a little further back.

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So one question you have to ask yourself is, is

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this a cancer being extruded from the TZP, or is

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it a cancer that is in the PZ that's invading?

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Now we've got some strong evidence that

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all is not well in the state of prostate.

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On the right, we've got diffusion

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restriction that's exaggerated.

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We've got very dark signal on the ADC map.

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Pay no attention to this linear area

2:33

of abnormality in the left PZP and PZM,

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because we're going to tackle it separately.

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Let's stay with this lesion

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and let's roll and scroll.

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And here we've got more typical PZ signal.

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Nice and bright.

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Separated from the TZ by

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the false surgical capsule.

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Not to be confused with the anatomic capsule.

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But we also have a well

3:03

defined encapsulated nodule.

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That's good.

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So we don't want to see this phenomenon of

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Intermediate signal intensity with smearing,

3:15

with an ill-defined crescentaric character to it.

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And we don't, at this level.

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Now let's go back to our other lesion.

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Our other lesion, we don't have

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that encapsulated look anymore.

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So even if it was in the TZ, we still

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have to be nervous because of its shape.

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And its diffusion characteristics.

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We'll get to the DCE, Dynamic

3:41

Contrast-Enhanced MRI, in a moment.

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Let's keep scrolling though.

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As we get down lower, here's a pretty

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white, arcuate, clean, peripheral

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zone, down low, closer to the apex.

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But on the other side, there's no doubt

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anymore that our lesion, which has mass

4:05

effect, which has a lot of capsular contact,

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worrisome for capsular invasion, is in the PZ.

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We go over to our diffusion high B value

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image, and it is as white as a ghost.

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It's easy.

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And we go over to the ADC map, and it is black.

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Now we go over to the contrast-enhanced image.

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And even though it's not overwhelmingly

4:37

hypervascular, it does correspond

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in shape to this lesion over here.

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And on the next cut, the shape,

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I think, is even a little better.

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And it looks a little different

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than anything else on the image.

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I'm going to window it rather tightly for you.

4:56

You absolutely have to call this a

4:58

PIRADS 5 in the right anterior PZ.

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Because of its shape, its size, greater than 1.

5:07

5 and its diffusion characteristics.

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You can even forget about the

5:12

DCAMRI, which is positive.

5:16

Now we also have some linear foci

5:19

in the back and the PZ on the right,

5:22

which do not diffusion restrict.

5:25

So we would write these off as areas

5:27

of linear scar, so-called PIRADS 2.

5:32

Now we've got another lesion

5:33

that's a little bit more difficult.

5:35

It's kind of a tweener.

5:37

It's rather linear, but not as linear as the one

5:42

on the right in the left posterior PZM or PZP.

5:49

It does have diffusion restriction,

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but not as powerful or as intense

5:55

as the one seen on this side.

5:57

It does have some hypodensity

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or intensity on the ADC map.

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It does have a little bit of hypervascularity.

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It does not have the size

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criteria for a PIRADS 5.

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So, this one, you could go with

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a PIRADS 3 or a PIRADS 4.

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You could kind of straddle

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the fence and make a decision.

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So how are you going to make your decision?

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Well, first of all, does it really matter?

6:29

You're already going in after this

6:31

lesion, so don't fret over it.

6:34

You're going to take a sample of that anyway.

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Just direct the clinician to that location.

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You could use your PSA density, which is under 0.2,

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to downgrade it into the PIRADS 3 category.

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Or you could say, you know what, I've already

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got a cancer, it's a big cancer, it looks

6:57

like a potentially aggressive cancer, the PSA

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density is below 2, but not that much below 2.

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It's 0.

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17, the patient's age, the rise in the PSA,

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and all of those things coming together, I

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think I'll err on the side of probable cancer,

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And I would go with a Likert classification,

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in which I integrate all of the factors,

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in this case, to push it up a little bit.

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But once again, I remind you, it doesn't

7:29

really matter, because you're going

7:31

in and you're biopsying it anyway.

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Now, a couple of other caveats.

7:38

We've already said that TZ cancers, and

7:40

this is not a TZ cancer, it's a PZ cancer.

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But initially it looked like a TZ cancer,

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but most TZ cancers are in the front.

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Another helpful characteristic that we already

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pointed out was the phenomenon of encapsulation.

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A third phenomenon in the TZ that'll help

8:00

you, especially when you have these extruded

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areas of TZ that push into the PZ that

8:07

look a little scary, is when you see nice,

8:10

bright, white, hyperplastic acini, like this.

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This implies differentiation.

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You know, you're making secretory material.

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So when you see these microcysts

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associated with your mass or your nodule,

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that is a potential sign of benignity.

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So I think we'll, we'll stop

8:33

right there on this case.

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We've got an anterior rightward, an

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anterior right PZ, Pirates 5, Likert 5.

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In other words, this is

8:45

cancer till proven otherwise.

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with a large area of capsular contact,

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suspicious for capsular microinvasion.

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We've got a non-contentious linear lesion,

8:58

probably remote scarring from prostatitis, with

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no diffusion restriction, and no abnormality

9:06

on the ADC map, and no hypervascularity.

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And we've got a tweener lesion, in the left

9:12

PZP PZM, that has some Diffusion restriction,

9:18

and some signal alteration on the ADC map,

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and some vascularity, and we've given you

9:24

some criteria to decide whether you're

9:26

going to go PIRADS 3 or PIRADS 4, or you're

9:30

going to use the clinical radiographic