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Mastery Series: PI-RADS 2.1 Update


MRI Mastery Series: PI-RADS 2.1 Update Pre-Course Activities
1 topic
Course Evaluation
1 topic

PI-RADS 5 with Extraprostatic Extension

4 min.
Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
CME Eligible

Hello, I'm Dr. John Feller with Halo Diagnostics. We're going to review some cases here at MRI Online. These are multiparametric MRI and prostate cases. The first patient is a 76 year old male who had a history of a negative transrectal ultrasound guided biopsy several years ago, but his PSA quickly elevated. It went from 3 to 23 in a five year period. So this multiparametric MRI of the prostate was performed.

These are the T2-weighted images. And first of all, you can see on the axial T2-weighted images that there is this area of decreased signal intensity involving the peripheral zone bilaterally. And in particular, there is extension of this tumor suspicious region through the prostate capsule into the periprosthetic fat, into the so-called rectoprostatic angle. And this is very, very suspicious of direct extraprostatic extension of prostate cancer with invasion of the neurovascular bundles.

So on the T2-weighted images, this measures over seven centimeters in maximum diameter. When we look at the diffusion-weighted imaging, we see that there is a corresponding area of very restricted diffusion, so decreased signal intensity that we see here and here involving the peripheral zone bilaterally, and when we look at the high B value images, we see that this corresponds with an area of really significantly increased signal intensity. So in the peripheral zone, we know that using PI-RADS version 2.1 that the diffusion-weighted sequence dominates and this is consistent with a PI-RADS 5 lesion given that it's larger than 1.5 CM in diameter and it's a PI-RADS 5 based on the diffusion-weighted sequence.

Now, in this patient, when we also look at the larger field of view imaging involving the remainder of the pelvis looking for so-called bones and nodes, we see the following. We see this area of significant lymph node involvement involving both common iliac lymph node chains. And when we follow this further down into the pelvis, we see there are additional enlarged nodes involving the junctional lymph nodes bilaterally and extending into the medial external iliac lymph nodes.

In addition, when we look carefully at the sacrum on the left and the large field of view images, we see this finding. This geographic area of inhomogeneous bone marrow signal alteration and enhancement that would suggest bone metastasis from prostate cancer. So in summary, this patient shows evidence of an aggressive prostate cancer, PI-RADS 5 score, with evidence of direct extraprostatic extension, neurovascular bundle invasion. In addition, we have evidence of pathologic lymph nodes and also probable bone metastasis in the left sacral ala, which would suggest a clinical TNM stage of T3A, N1 M1. An MRI targeted biopsy was performed on this about a month later, which confirmed Gleason score, adenocarcinoma Gleason score four plus five or grade group five, and this patient went on to combination therapy that included radiation therapy and hormone therapy.

LESSON 5, TOPIC 1

Mastery Series: PI-RADS 2.1 Update

Mastery Series

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Content reviewed: December 29, 2021

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