0:00

Okay, this is a 71-year-old imaged

0:02

at 3 Tesla with a body array coil.

0:06

Let's scroll the axial.

0:07

There's an obvious mass in the left PZL, PZP,

0:11

and PZM, lateral, posterior,

0:14

and medial, with transcapsular extension

0:16

invading the left neurovascular bundle

0:18

on the axial T2 FASP and echo image.

0:21

I'm going to give you some ancillary

0:24

findings, which you'll see in the report.

0:26

If you choose to click on it, the patient

0:28

said bilateral inguinal hernia repairs.

0:31

There's actually a screw in the left hip,

0:33

which you'll see when you review, uh,

0:35

the images as we scroll through them.

0:37

I'm not really concerned with it.

0:38

It's on the film edge.

0:40

But I won't completely give you or pass off

0:42

these inguinal nodes because of their plumpness.

0:45

The fact that they don't have any fat in them.

0:48

There's certainly one on the right and

0:49

there's one on the film edge on the left.

0:52

So that's an issue that might have to

0:54

be revisited, uh, should we have time.

0:58

So now as we continue to scroll, um,

1:02

I'm going to focus on three things.

1:05

I'm gonna, I'm gonna focus on

1:06

the T staging of this case.

1:09

I'm gonna focus on D C M R I, D C E M R

1:13

I, Dynamic Contrast Enhanced MRI when it's

1:16

useful, which is usually with small areas of

1:20

micro-invasion, very small tumors, and also

1:25

in determining whether a tumor is highly

1:29

aggressive or not based on its curve analysis.

1:33

And then finally, I'm gonna

1:34

take you through a checklist

1:36

of things that have to be evaluated when you

1:39

have a tumor that appears to extend outside

1:42

of the prostate gland and is aggressive.

1:45

And I'll probably give you a little kicker at

1:47

the end, that I'm going to show you a PI-RADS 3

1:50

lesion as part of this nasty PI-RADS 5 lesion.

1:55

So, the third point, the checklist.

1:58

We've already seen that this tumor

1:59

is extending out of the capsule.

2:03

So what else do we want to know?

2:04

Is it invading the rectum?

2:06

Answer:

2:08

No.

2:08

Close to it though.

2:10

Is it invading the bladder neck?

2:12

I think perhaps a sagittal

2:14

would be better to assess that.

2:16

And it's protruding up into

2:18

the base of the bladder.

2:20

But it doesn't appear to invade the bladder.

2:23

But you have to at least alert the physician

2:25

that that potential might be present.

2:28

So I'd say the jury's still

2:30

out on bladder neck invasion.

2:33

What about the preprostatic

2:35

space of the retzius and the apex?

2:37

Not involved.

2:39

How about the skeleton?

2:41

Well, let's go over to our contrast-enhanced

2:43

MRI, which is kind of like a bone scan.

2:46

And we see that the left ischium is lighting up.

2:50

It's enhancing.

2:51

So we have, basically, a complementary

2:54

free bone scan from our dynamic contrast-

2:58

enhanced and delayed contrast MRI.

3:00

So the bones are positive.

3:04

What about adenopathy?

3:06

Let's go back to our axial projection.

3:08

Gonna slide back over here.

3:12

And check out the regional lymph nodes.

3:16

So we already said we thought there

3:17

was a suspicious lymph node in the right

3:20

inguinal and probably left inguinal region.

3:22

There's another very plump lymph node in the back.

3:25

Okay.

3:26

Posteriorly, and then in the coronal

3:29

projection, this is a fat-suppressed

3:32

coronal projection right there.

3:34

That is not a vessel.

3:35

There's a vessel next to it.

3:36

There are paired large lymph nodes in the

3:40

iliac chain, the lower one approaching

3:42

the obturator chain on the left.

3:45

And on our fat-suppressed image

3:46

there again is our bony metastasis.

3:49

And then finally the last portion of our checklist

3:52

is the seminal vesicle, which the reader not

3:55

inappropriately said she thought was normal.

3:59

So there is tumor right next to the base of the

4:01

seminal vesicle, but is there microinvasion?

4:04

I think that's really hard to tell

4:07

without some additional sequences.

4:10

Let's look at this coronal

4:12

heavily fat-suppressed image.

4:14

Let's look at our tumor.

4:16

Here's our tumor, and here's

4:18

the base of the seminal vesicle.

4:20

Now this, this side's a little

4:21

more smudgy than that side.

4:24

Is that enough to say that there's

4:26

seminal vesicle microinvasion?

4:28

Well, maybe not.

4:30

But how about our DCE MRI?

4:33

Let's take a look at it on the right.

4:35

This is one of our delayed

4:36

images from the DCE MRI.

4:39

And look at the base of the left seminal vesicle.

4:41

Let's go to the seminal vesicle right there.

4:43

There's the base.

4:44

And I think you'd all agree that that

4:46

is busier and brighter on the left side.

4:49

And it is on the right side.

4:51

Let's go to something more dynamic.

4:55

Let's go right to the seminal vesicle again.

4:57

The tumor's gonna be obvious.

4:59

There's the obvious hypervascular tumor.

5:01

Go right to the base of the

5:02

seminal vesicle, right there.

5:04

Oh yeah.

5:06

No question about it.

5:07

At the base of the seminal vesicle,

5:10

let's go right to the base.

5:13

Oh, right there.

5:14

Right at the base of the seminal

5:15

vesicle, there's tumor microinvasion.

5:18

And that whole side demonstrates

5:20

some amorphous enhancement.

5:22

So the dynamic DCE MRI showed us micro

5:28

invasion at the base of the seminal vesicle.

5:30

So we've got bone, we've got seminal vesicle,

5:33

we've got lymphadenopathy, and we've got

5:35

transcapsular extension with invasion of the

5:38

neurovascular bundle as part of our checklist.

5:44

Now, let's talk about DCEMRI for a minute.

5:47

It is a supplementary tool.

5:49

We're moving away from it for

5:51

screening and surveillance.

5:53

It's time-consuming.

5:54

It's somewhat expensive.

5:56

It's expensive.

5:56

And it doesn't add a lot in the general

5:58

surveillance and detection of cancer.

6:01

Perhaps with two to three-millimeter

6:03

cancers, it adds a little value.

6:06

But other than that, its role is in

6:09

aggressiveness and microinvasion.

6:11

But when can you get false negatives with DCEMRI?

6:14

In a lot of the same circumstances,

6:16

you get them with diffusion imaging.

6:18

For instance, let's pull down

6:20

the diffusion image in this case.

6:23

Let's pull this one down.

6:25

It's bright, but it's not as bright as you

6:27

would expect it to be for this aggressive.

6:28

Thank you.

6:29

Hypervascular transcapsular tumor.

6:32

So what can cause that?

6:34

Well, if a tumor was lower grade, it

6:37

wouldn't be as diffusion-restricted.

6:39

But if the patient has had antiandrogen therapy,

6:43

an androgen blocker, as this patient has, then

6:47

that would diminish not only the diffusion,

6:50

but also the DCEMRI even more prominently.

6:53

Radiation is a common cause

6:56

of altering the diffusion characteristics

6:59

and DCEMRI properties of a tumor.

7:03

Biopsy can change it.

7:05

And then, there are certain technical factors

7:08

that can alter the characteristics of DCEMRI

7:12

and diffusion imaging, including a balloon,

7:16

by compressing the tissue, air in the rectum,

7:20

near-field artifacts, and even pulsation

7:23

can contribute to alteration, technical

7:25

alterations, in those characteristics.

7:30

Now, let's T stage it.

7:32

So we said we were going to do the list.

7:33

We did the list.

7:35

We said we were going to talk about DCEMRI

7:37

and what can limit it and where it's valuable.

7:39

We've done that.

7:40

Let's T stage it.

7:42

This T stage, as you might have seen in the title,

7:46

is an N3, uh, it's a T3A, sorry, a T3A N1 M1B.

7:53

So what does N1?

7:57

N1 means there is regional lymphadenopathy.

7:59

We've already pointed that out.

8:01

At least one large cluster of nodes

8:04

in the external and obturator chain.

8:07

What about the M1?

8:10

Well, this is an M1B, B for bone,

8:14

because there's bony metastases.

8:17

There are no distant metastases, non-bony,

8:21

which would take us into the M1C category.

8:26

And there is transcapsular extension,

8:29

so that takes us into the T3 category.

8:32

So this is a T3A, N1, M1B lesion.

8:38

Now we said as a kicker, we would

8:42

show you a PI RADS 3 lesion.

8:45

This clearly is not one.

8:46

This is a PI RADS 5 with transcapsular extension.

8:49

But right there, look at your peripheral zone.

8:53

Your peripheral zone should be bright.

8:56

It shouldn't have this sort of charcoal,

8:58

ill defined like area of signal alteration.

9:03

I think it's a good time to

9:04

look at the, the DCE MRI.

9:07

Let's go right to the first image.

9:09

And there really isn't much vascularity there.

9:11

Is it diffusion restricted?

9:14

Let's check that out.

9:15

It is a little diffusion restricted.

9:17

So there's some minor diffusion restriction.

9:19

The lesion is non mass like.

9:22

It's ill defined.

9:24

It has no, no borders to it.

9:27

It's bulging very little,

9:29

maybe a tiny bit laterally.

9:31

So it's kind of a tweener lesion.

9:34

So, in the peripheral zone, a score of 3

9:38

would be given to a peripheral lesion that

9:42

is heterogeneous or non-circumscribed.

9:45

It can be a little bit round.

9:47

The hypointensity isn't tremendous.

9:51

It's moderate, and it doesn't really fit into a 2.

9:54

A 4 or a 5.

9:57

And in this case, the diffusion

9:59

restriction was very modest.

10:01

Let's look at the ADC map

10:02

and see what that looks like.

10:04

The ADC map changes were also very modest.

10:08

So again, a tweener type lesion on a

10:10

right in the middle doesn't meet great

10:12

criteria for a 4 or a 5, doesn't meet

10:15

great criteria for a 2, it's obviously not

10:17

a 1 because a 1 would be totally normal.

10:20

So we would PI-RADS 3 that lesion, and we

10:22

would direct the biopsy, the second biopsy,

10:25

to that locus if it was clinically appropriate.

10:28

So that concludes this case.

10:30

We talked about T staging, we talked

10:33

about the value and the limitations of

10:36

DCEMRI, and we went through our checklist.

10:40

Of key areas to evaluate in a case like

10:44

this that's more aggressive, that's more

10:46

extensive, and we gave you a little kicker,

10:48

showing you a second lesion in the right

10:51

PZL at about the mid-level of the prostate,

10:54

mid-gland, that corresponds to a PI-RADS 3.