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Case Review: Charcoal Sign in the Transition Zone

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Let's have a look at this 71-year-old with

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prostate cancer diagnosed one year ago.

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And the PSA level is at

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4.03 nanograms per mL.

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So not a very high PSA.

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Maybe we're dealing with a, a lower grade

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cancer or not a very aggressive cancer.

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But this case is illustrating two major points.

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The Charcot side in the transition

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zone, or central region of the prostate.

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And, and here we are with our,

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our Charcot smearing the gland.

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I'm gonna scroll it for you in a second.

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But there's the smear right there, just

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like you'd smear cream cheese on a bagel.

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Let's scroll, and there's a lot

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of smearing going on in here.

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We threw a lot of cream cheese on our bagel.

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Alright, we're going up, we're going down.

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Now we're starting to get out of it.

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Things are looking a little more

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heterogeneous, like they should.

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In the central region of the prostate.

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Now we're down by the apex.

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Now we see the anterior fibromuscular stroma.

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Let's go back up again.

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Smearing right there.

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So we've wiped out the architecture.

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The nodular heterogeneity of the

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transitional zone of the prostate.

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This is a fat suppression 3D image.

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Doesn't add a tremendous amount.

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Although it does show you that the

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lesion is approaching the midline.

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And perhaps anteriorly crossing the midline.

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The midline.

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Now, it's common for BPH patients to have

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hypervascularity in the middle of the gland,

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but that hypervascularity usually does this.

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It comes in pretty strong,

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but not all that strong.

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And then it continues to go up and up and up.

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And usually in the form of innumerable

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nodules, often not one big dominant nodule.

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And if there's a big dominant nodule,

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it's often pretty round, or it

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may be oval, but it usually isn't.

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Lentiform like this.

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Look how lentiform our lesion is.

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If I trace it out, pretty lentiform, isn't it?

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So now, let's go to our DCMRI.

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Even though any DCMRI, you know, can be

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complementary or non-complementary, in other

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words, it's not a major criteria at all, and for

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screening, a lot of people don't use it at all,

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or for surveillance, people don't use it at all,

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in situations like this, it can be comforting.

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So let's go to the mask, and what

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we don't want to see is immediate,

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large, intense, lentiform enhancement.

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And do we?

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Let's go right to the first 10

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seconds after our dynamic, bang!

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That's the only thing that shows up in the image.

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We've got a problem.

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Now let's see what it does as we

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continue into our 20-second, and our

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30-second, and our 40, and our 50.

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The rest of the gland is catching up to it.

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Our tumor is washing out, so its

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curve looks something like this.

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Even though it's in the central zone, where

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we get a lot of curves that go up, this one is

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going up really quickly and then coming down.

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A washout-type curve.

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So here the DCE MRI helped us corroborating

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the diagnosis of our Charcot sign.

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And yet, our diffusion image, which I'll pull

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down right now, wasn't all that impressive.

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There's our lentiform lesion right there.

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And let's pull down our ADC map.

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Remembering that in the central

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region of the prostate gland in

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the TZ, the diffusion restriction

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characteristics are not a major criteria.

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It's the morphology, the blackness,

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the homogeneity, the smearing, the

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boundary crossing that you use in the

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central region of the prostate gland.

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And this case, illustrating

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the Charcot sign of the TZ.

Report

Editorial Note

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

John F. Feller, MD

Chief Medical Officer, HALO Diagnostics. Medical Director & Founder, Desert Medical Imaging. Chief of Radiology, American Medical Center, Shanghai, China.

HALO Diagnostics

Tags

Prostate/seminal vesicles

Neoplastic

MRI

Genitourinary (GU)

Body

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