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Using Multiparametric MRI for Active Surveillance

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

This next multiparametric MRI case of the prostate shows the value of multiparametric MRI to be added to the patient who is in active surveillance for low volume, low risk prostate cancers such as Gleason 3+3 prostate cancer. This patient is a 70 year old male who was diagnosed with low risk, low volume, Gleason score 3+3 prostate cancer, also called grade group one, with transrectal ultrasound guided biopsy. This patient was being followed with active surveillance. The problem is that the transrectal ultrasound guided biopsy under Gleason scores the prostate cancer in up to 30 to 40% of cases. An MRI was obtained in this patient because the PSA was going up very rapidly and had recently reached a level of 6.0. So the clinician's concern was that the patient had higher Gleason score prostate cancer than had been previously detected with just the transrectal ultrasound guided biopsy.

So if we take a look at the Axial T2-weighted images and remembering that in the transition zone, the T2-weighted sequence is the king. You can see that there's this area of moderate homogeneous T2 shortening within the transition zone that's non-circumscribed, so it has very, very fuzzy margins. Okay. This measures over a centimeter and a half in size. If we go to the corresponding high-b value-diffusion weighted sequence, we see that this was this area of very high signal intensity, this is the b-value 1400 image. And we see that it extends into the area of the anterior fibromuscular stroma.

On the apparent diffusion coefficient images, the ADC images, we see that this corresponds with an area of significant restricted diffusion. This was well below a mean of 1000 and with ADC values as low as 600. If we look at the corresponding dynamic contrast-enhanced imaging, we see in the color overlay in the same area that there's an area of rapid washout and rapid plateau pattern of dynamic gadolinium contrast enhancement. So based on the T2 weighted sequence dominating within the transition zone, this is a PIRADS 5 lesion because it measures over 1.5 centimeters in size. We did not see any evidence of direct extra prostatic extension, seminal vesicle invasion, pelvic lymphadnopothy or osseous metastatic disease within the pelvis. So that overall this suggested a clinical TNM of T2C.

Based on the MRI findings, we did an MR targeted biopsy in-bore of this tumor suspicious region, and the biopsy came back Gleason score 3+4, or grade group 2 that's large volume. This completely alters the management of this patient. This goes from somebody that's being managed happily with active surveillance, thinking that they don't have clinically significant prostate cancer, to someone who has pattern 4 disease in their prostate cancer and needs definitive therapy. So this patient actually underwent a robotic assisted radical prostatectomy as definitive therapy and was removed from the active surveillance management that they inappropriately had been undergoing prior to their MRI.

LESSON 5, TOPIC 3

Mastery Series: PI-RADS 2.1 Update

Mastery Series

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Content reviewed: December 29, 2021

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