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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

Gleason 8 Lesion

6 min.
Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
CME Eligible
Includes DICOM files

Dr. P here with a six year old, seven months ago, negative, MRI-guided, TRUS biopsy, using ultrasound to assess the prostate negative. The PSA has continued to rise, patient now comes in for multiparametric MRI. We've got three b-values here, one b-value at 50, the other b-value at 1200, the third b-value at 1600. Reminder, I don't want to see b-values of zero, I'd rather see b-values of 50 and around 800 to make my ADC map, I only need those two. The second one was a little long for my taste, 1200 but it worked out just fine. Then the third one at 1600 stands on its own as the diffusion weighted assessment, look at what's happening.

We have a nodule anterior that becomes brighter and brighter and a second nodule, a little higher up and a little more posterior that also is becoming brighter but not as bright. A portion of that nodule is distinct and a portion of it is less distinct. That nodule is in the TZ, so that's kind of in the intermediate area. Is it a fully encapsulated nodule? No. Is it a partially encapsulated nodule or we need the T2 for that? Does it diffusion restrict? It does. Does it have some real definition? It does. Is it in the TZ? It is. Was it hypervascular? It was, so that is going to get a PI-RADS 3. On the other hand, the one anterior, it has pronounced diffusion restriction and even though it has a smooth round character to it, you cannot say that this abnormality came from the transitional zone, it's hard to tell. It also was hypervascular, it didn't have a capsule around it, it looks like it has almost an extraprostatic position to it.

So now let's drill a little deeper so we can see the origin and shape of it a little better and make an appropriate decision. So I'm going to pull down the axial T2 on the right, the axial DWI in the middle and the ADC map on the far left. So our lesion is pretty well defined against background, but it has pronounced diffusion restriction as evidenced on the ADC map and the DWI b-value 1600. In addition, look at the morphology of it, it's not very well defined in the back at all as we would prefer a TZ origin, BPH extruded nodule to have, maybe a thin stalk, maybe something that look like this, nice and graded dark with a little stock to it coming from the TZ and then perfectly round like our lesion but you could trace it back.

I don't like the fact that this lesion is gray, it has a broad base and has an ill defined posterior margin, and finally I go to my sagittal. I'm using everything I've got, dogs and cats living together, 10 days of darkness, the plague, mass hysteria, everything. Everything that's available to make a smart decision, and look at our lesion now, it's gray, round in the front but not so well defined posterior, isn't? There it is. Now I'm not going to show you the DCE-MRI which demonstrated hypervascularity early on, I don't like the morphology at all. I can't really say what zone it's coming from and it's heavily diffusion restricted. The DCE-MRI, the multiparametric portion of the MRI is positive. The ADC map confirms that it is diffusion restricts, this is getting a PI-RADS 4 or 5 depending upon its size.

And what happened? The patient had an MRI-guided biopsy. The MRI-guided biopsy showed no extra prostatic extension, a Gleason score of 8 for this lesion, a Gleason score of 7 for the lesion behind it. The patient underwent prostatectomy. Let me give you the prostatectomy report. There was a radical prostatectomy with lymph node dissection, there was a positive lymph node and there it is right there. An iliac lymph node which made this a T3 or pT3aN1 lesion. The histologic type was acinar adenocarcinoma. The Gleason score was 8 for the front lesion, 7 for the back lesion. There was as is often the case reclassification of the capsule.

Let's go back to that sagittal, it show a look like there was extra capsule extension and there was, it was proven. There was also neurovascular bundle invasion. A proven case, a tweener lesion in the transitional zone, a tough lesion far anteriorly that was not accessed from the original January biopsy seven months earlier, proven by MRI, pushing towards biopsy, biopsy confirms Gleason 8 lesion.

LESSON 3, TOPIC 1

Mastery Series: PI-RADS 2.1 Update

Mastery Series

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Content reviewed: December 29, 2021

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