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Case Review: When not to use the Leikert Grading System

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I've got a 78-year-old man with an

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elevated PSA that has remained stable at

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around 11, 11 and a half for 6 months.

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He had a negative guided biopsy in June of

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2014 using ultrasound and now undergoes MRI.

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His PSA density is 0.10 nanograms per mL per cc.

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So, a pretty low PSA density.

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So a lot of the signs point to benignity

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or something that is non-aggressive.

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So okay, that's fair.

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We're going to integrate all that information

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into our compendium of visual knowledge.

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And I'm going to scroll around here a little bit.

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And there is a beautiful demarcation

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between the peripheral zone and the central

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zone with the false surgical capsule.

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There are some scant areas of linearity.

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You're going to see that a lot.

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Some of these are septa, sometimes

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they represent prostatitis.

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And remember, prostatitis can give you

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hypervascularity, usually with a wash

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in, but occasionally with a washout.

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But prostatitis does not diffusion restrict.

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In fact, it does the opposite.

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So the diffusion image is extremely helpful in the

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peripheral zone when you're worried about these areas

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of wedge-shaped, non-mass-like, peripheral low signals.

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Another teaching point.

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There's quite a bit of heterogeneity

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in the transitional zone.

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This is the diffusion image, B-value 1600.

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A little bit of diffusion restriction here and there,

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and some crescentric ill-defined low signal on

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the T2-weighted image with absolutely no diffusion

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restriction correlate, and the ADC map was negative.

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Beware of overcalling TZ tumors

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unless they're very far in the front.

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And they diffusion-restrict,

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and they have size to them.

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Teasy abnormalities are all over the place.

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They tend to be benign or low grade, and you

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should always look for an excuse not to call them.

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So everything is just hunky-dory here, right?

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All the signs point to non-

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aggressive lesions in the prostate.

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Well, let's keep going, shall we?

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Let's go up high to the seminal vesicles.

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We're oriented.

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Now let's go down low.

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Let's go.

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And as we go down low, oh my goodness, we see a

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mass that is quite different than any other mass.

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In fact, that mass may even

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extend in front of the urethra.

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It's certainly behind the urethra, and it

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demonstrates focal diffusion restriction.

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Not only is it focal, it's pronounced.

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It's intense.

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And there's still a little bit of it over here.

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Maybe it's not as intense, but it's present.

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So we've got a periurethral tumor

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in the apex of the prostate.

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Completely unexpected, and completely counterintuitive.

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So here, you know, our Likert system of

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integration isn't all that helpful, because the

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paraclinical criteria point away from tumor, but

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the visual criteria heavily, strongly support

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the diagnosis of tumor, and we're not done yet.

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Look at our coronals.

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Here's our urethra.

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Look at that periurethral growth of our nodular grain.

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Now let's go to the ADC map.

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Let's go right down to that spot down low and see

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if it is commensurate with the diffusion restriction

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area that's bright, it should be dark, and it is.

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There's a little bit of dark signal

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in front of the urethra as well.

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So everything fits absolutely perfectly.

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So a couple points to be made here.

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First, the paraclinical is important, but it shouldn't

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completely override profound abnormalities on the MRI.

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Second, we said that TZ lesions

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have to be viewed with caution.

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Look for any excuse you possibly can not to call them.

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Another aspect of TZ lesions that I want to,

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I want to pull out here for a moment, is that

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sometimes the TZ will extrude into the PZ.

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Not in this case.

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But, you'll have nodules that are well

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circumscribed, they'll either be gray or very

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bright and they'll pop on into the peripheral zone.

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And this can be a little bit problematic,

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but they won't demonstrate the other typical

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features that support the diagnosis of cancer.

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And we already gave you another important pearl, which

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is that hypervascular lesions in the peripheral zone

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They tend not to wash out, but they can, but they do

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not diffusion restrict unless you have an abscess.

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Now abscesses do diffusion restrict,

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but you should be all over that for

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other reasons, including the clinical.

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The patient's sick, they have fever,

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the lesions are round, they have a

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capsule, and they diffusion restrict.

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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