0:02

0:02

At 1.5 Tesla, we do not have balloon

0:04

inflation of the rectum.

0:06

Therefore, we don't have compression of

0:09

the peripheral zone of the prostate gland.

0:11

And now, with a one millimeter

0:13

cut, let's make it even bigger.

0:16

We can see a round but slightly

0:20

irregular mass near the midline.

0:22

Let's scroll it, and it is

0:24

invading the capsule, isn't it?

0:27

There's the T2 2D image at three

0:31

millimeter slice thickness.

0:34

The 3D T2 at one millimeter slice thickness.

0:39

And here is the diffusion image demonstrating

0:42

diffusion restriction of that nodule,

0:45

which was somewhat hidden by the balloon

0:49

inflation at 3 Tesla and the associated

0:53

artifacts from periodic and aperiodic motion.

0:57

Let's look at this portion of the gland.

0:59

There is some diffusion restriction present.

1:03

The left gland is a little more swollen and

1:06

bigger than the right gland, at the mid level.

1:09

And there is diffusion restriction, but

1:11

again, that's a minor criteria in the

1:14

central region of the prostate, or TZ.

1:18

Now remember, nodularity is a

1:21

good thing in the central region.

1:23

Let's go down to the apex

1:24

of the gland, down lower.

1:25

There's some nodularity, but there's

1:27

also some diffusion restriction.

1:29

So this one's more well-circumscribed.

1:32

But nodularity is not a good

1:34

thing in the peripheral zone.

1:36

So, nodularity Pz, danger.

1:39

Nodularity Tz, not danger.

1:42

Let's take a look at these areas

1:44

in the sagittal projection.

1:47

Let's go to our nodule down low.

1:50

Here it is.

1:52

And there it is in the sagittal projection.

1:54

Better seen without balloon inflation.

1:57

We don't have all the motion

1:58

artifacts that we described at 3T.

2:01

We don't have the susceptibility

2:02

artifacts that we saw at 3T.

2:06

Here is the mid and upper portion, or

2:08

base of the gland, where there was some

2:10

mass effect and diffusion restriction.

2:13

And what about our lesion posteriorly?

2:16

That one's right there.

2:17

It's a little harder to see sagittally, but

2:19

it's clear as day in the axial projection.

2:23

Let's look at the coronal, just for giggles.

2:26

The coronal projection, mass effect

2:28

in the left gland, ill-defined.

2:31

And the apical nodule area, let's go down there,

2:35

down to the nodule, down low, there it is.

2:39

And pretty hard to see in the coronal, admittedly.

2:42

Let's look at the ADC map.

2:44

I think mapping with the axial

2:46

is probably our easiest bet.

2:49

Let's go to our lower lesion here.

2:53

There is diffusion restriction, not that

2:55

helpful, but a supplementary finding.

2:59

Let's go to the larger area of mass effect here.

3:03

Some diffusion restriction, but ill-defined.

3:06

And then finally, the key lesion

3:08

back here, clearly well-defined.

3:12

So at the very least, we've got a PIRADS 4

3:16

in the PZ, in the middle, PZM, corresponding

3:22

to a focal nodular area of well-defined

3:25

diffusion restriction that shows up bright on

3:29

the diffusion image and dark on the ADC map.

3:32

These other areas are suspicious.

3:35

I would personally read them as PIRADS 3s.

3:40

One was read as a three

3:41

and one was read as a four.

3:44

And at surgery, we have the patient's report.

3:47

We actually have the biopsy report,

3:49

but not the surgical report.

3:50

7 of 17 cores positive.

3:53

Gleason 7, 8, and 9.

3:56

All of them.

3:58

The left gland was affected

3:59

in all three of those areas.

4:02

The lower-lying nodule near the apex.

4:05

The more ill-defined mass effect in

4:07

the middle and base of the gland.

4:09

And this lesion in the midline

4:12

entering the capsule was a Gleason 9.

4:17

So this is an example of 3 Tesla up against

4:22

1.5 Tesla.

4:23

In this example,

4:24

the 1.5 Tesla wins for the 3 reasons we mentioned.

4:29

No inflation, very convenient for the patient,

4:32

don't have to put anything in the rectum.

4:34

No compression of the prostate gland.

4:37

Motion artifacts are less.

4:39

Susceptibility artifacts are less.

4:42

The case is proven.

4:43

The patient underwent radical prostatectomy

4:46

with sparing of the right neurovascular bundle.

4:49

The left neurovascular bundle was taken down.

4:53

The patient has scant microscopic

4:55

midline capsular invasion.

4:58

The case is proven.