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Case Review: Interesting PI-RADS 4 Case

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Okay, here's an interesting case

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of an 83-year-old with a PSA of 7.8,

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13 days before this study.

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But the PSA density, which is the PSA

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divided by the gland volume, is 0.21 nanograms

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per mL per cc.

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So, the PSA density is slightly above the Rubicon,

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in other words, it's higher than the point

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0.2 cutoff that makes you more suspicious

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and gives you greater likelihood of

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having a cancer inside the gland.

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So, in certain circumstances, we may

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use that to push us one way or another.

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Just like we might use a series of negative

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biopsies to push us one way or another.

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Or a very stable PSA over

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a long period of time, etc.

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So we have in the upper left-hand

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corner an axial T2, 2D

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fast spin-echo, patient's been properly prepped,

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there's only fluid and feces, no air to destroy

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our diffusion image, which happens a lot; want

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to make sure the air is out of the rectum.

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We have a diffusion-weighted high B-value

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image on the right, upper right, the

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ADC map on the lower left, and our DCE,

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dynamic contrast-enhanced, gadolinium

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augmented MR in the lower right-hand corner.

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So let's start out

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with the T2.

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You know, I find it easiest to look

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at the ADC map first because kind of

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that's where the hot spots are.

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It's kind of like looking at the STIR (Short Tau Inversion Recovery)

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image in, in musculoskeletal MRI (Magnetic Resonance Imaging).

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You know, it's a little easier to

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see white on dark than it is to

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see dark on dark or dark on white.

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So right away we see this dot in

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the, on the left side of the gland.

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And it's down low near the apex in the

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peripheral zone, and it corresponds not just to

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a lesion but to a lesion that's. Now, we like

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to see a nodule, but even worse, a nodule with

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speculation, kind of like a breast cancer.

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That's even worse.

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And this thing has some

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speculation associated with it.

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It's not very big, but it's, it's darn bright.

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Look at it on the ADC map.

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It's darn dark.

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I'm going to blow it up even a little bigger.

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Look how black it is.

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So it's telling you there's really profound

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diffusion restriction of this lesion.

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It's less than 15 millimeters, so it

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meets PI-RADS criteria for a PI-RADS 4.

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Now we're not done yet.

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Let's go down all the way to the

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urethra, and now let's work our way back

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approximately, and we run into something else.

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Now maybe these are connected, maybe not.

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You know, here's a lesion,

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That's still part of the lesion.

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Maybe that's connected, but

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let's assume it's not connected.

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This lesion is abutting the anatomic capsule.

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It's definitely asymmetric from the other side,

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and it has a faced the surgical pseudo-capsule.

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Now, I've said in the past, in other vignettes

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that you can get extrusion of TZ material

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out, so that extrusion is almost always in

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the form of an encapsulated gray nodule.

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In other words, it's well-circumscribed or.

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It's extruded in the form, we'll use blue

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for water, in the form of a very white

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nodule and sometimes multiple white nodules.

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So they're round, they're homogeneous, they

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may be multiple, but that isn't the case here.

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This one's more of a wax on, wax off.

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It's ill-defined, it doesn't have edges to it.

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Let's go over to the diffusion image.

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It diffusion restricts, but not

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as much as our other lesion.

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There's less diffusion restriction.

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There is less low signal

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intensity on the parametric map.

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So, this one, you might downgrade a little bit.

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You might, if it had been sitting there all

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by itself, you might call it a PI-RADS 3.

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So, what's a mother to do?

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You might look at your DCE MRI (Dynamic contrast-enhanced magnetic resonance imaging).

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Let's do that.

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Let's go to the original lesion that

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we were confident was a PI-RADS 4.

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Lots of diffusion restriction.

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Lots of low signal on the parametric map.

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Hypervascular.

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Now let's go to our other lesion.

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The one that's closer to the mid gland.

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It's hypervascular.

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In fact, it's even more hypervascular,

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although slightly so, than the lesion

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that diffusion restricts more avidly.

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So, this one is in the mid gland, PZP.

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If you gave it a PI-RADS 3 because of its weak

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diffusivity or diffusion characteristics, then

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you might give it a 3 plus 1 because of the

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hypervascularity making it another PI-RADS 4.

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So this is an example of a pure lower down in the

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apex PI-RADS 4, and up in the mid gland, more in

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the back, a PI-RADS 4 because we have a PI-RADS

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3 by strict criteria and then adding as a bumper

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for The DCE MRI is a 1, so 3 plus 1 equals 4.

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Remember though, when you are looking at these two

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types of lesions, the true PI-RADS 4s tend to have

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a higher Gleason value than the 3 plus 1 equals 4.

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And we'll stop right there.

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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