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Case Review: PI-RADS 4, Stage IIB

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0:00

Okay, let's take a PI-RADS 4.

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This is an 82-year-old with a PSA of 4.63.

0:07

The gland volume calculated

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using the bullet formula, 36.5 cc's, which is above, uh,

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the normal, which is 25 cc's.

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Remember, the bullet is length times width

0:19

times height times 5 pi divided by 24.

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Then you can take that number and

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you can divide it into the PSA to

0:27

get the tumor density, which was 1.27 in this patient.

0:31

The patient has had a TURP, a Transurethral

0:34

Prostatectomy, to open him up.

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Look at the two sides in the axial projection.

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Let's scroll to the base, up by the seminal

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vesicles, down more towards the apex, mid to

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apical region on the right, looks different than

0:47

the left, grayer, fatter, more bulgy looking.

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There's your TURP defect.

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There's a nodule in the TURP defect.

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Is this real?

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Well, the ADC map says it's real.

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The ADC map shows diffusion restriction.

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With a pretty sharp edge

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along the anterior margin.

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In the peripheral zone, the PZ

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lateral, posterolateral, PZL, and

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PZP, posterior portion of the gland.

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Let's turn our attention to

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the diffusion-weighted imaging.

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Let's start out with the B value of zero, which

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is basically a T2 echoplanar VASPIN echo image.

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Then let's go on to a B value of 50.

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Is there anything getting brighter?

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Not yet.

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Let's try a B value of 150.

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Anything getting brighter?

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Not yet.

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Let's go to a B value of 990.

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Anything getting, getting brighter?

1:44

There sure is.

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Let's go to a B value of 16 or 1500.

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Is anything getting brighter on the right?

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This is 1500.

1:53

Sure is.

1:55

So our major criteria of tumor diffusion

1:58

restriction, getting brighter, getting

2:01

substantially brighter, with a defined area of

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low signal on the ADC map corresponding to an

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anatomic abnormality on the T2-weighted image in

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the PZ, the PZL, and PZP to be specific, are met.

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Let's take a look at our DCE MRI to see if our

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lesion has the typical characteristics of an

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aggressive tumor, namely early hypervascularity.

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So here we are at the mask, and here we

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are at the 10-second interval, immediately

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upon arrival, and indeed, immediately upon

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arrival, this area, and this area right

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here, correspond to this hypervascularity

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in the right portion of the gland.

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More than 50 percent of the volume

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of the gland is involved on the right

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side, so this would correlate with a T.

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Now let's take a quick look at the

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coronal, which has something to add.

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It gives us an idea of the cranial caudate height.

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So how apical is it?

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Not all the way at the apex.

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It's a little above the apex.

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More apical to mid and mid.

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So this is all a portion of the tumor.

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Compare it with the other side.

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So you have to use all projections.

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Right side, bulgy, gray.

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Left side, wispy and white.

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The architecture is preserved.

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We see lines between glands.

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We see lines between zones.

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All that is wiped away, almost like a charcoal

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eraser has taken to the right side of the gland.

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This is an example of a

3:45

PI-RADS 4 with a T stage 2B.

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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