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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

Caveats for Assessment: Category X- Summary

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

Dr. P here talking about some additional caveats and PI-RADS 2.1. Specifically category X. What does category X mean? Sounds like a movie. Well, if a component of the multi parametric MRI exam, the T2, the DWI or the DCE contrast, enhanced MRI is technically inadequate or it wasn't performed, it should be assigned PI-RADS assessment category X for that component. Now this occurs most commonly with DWI. Unfortunately DWI is the guts of the examination for the peripheral zone where most cancers occur. It's not as big a deal if you couldn't get an IV in and you weren't able to get the dynamic contrast enhanced portion of the study, but it's a very big deal if the DWI portion of the examination could not be performed. Let's talk about that a little further. Since DWI is often crucial for the diagnosis of clinically significant cancers in the peripheral zone, which is where most cancers occur, and inadequate or absent DWI data set should usually prompt at first pass a repeat of this component of the multi parametric MRI examination ff the cause of failure can be remedy.

Which means you've got to understand why the exam failed. Did it fail because of movement? Correctable. Did it fail because there was too much air in the rectum and the patient wasn't properly prepped? Correctable. Did it occur because the patient had metal in both hips? Maybe not correctable but maybe so. If you understand what type of metal was in there and that maybe you can use middle correction software or you can take the patient from the 3T and put them in a 1.5T where there's less artifact. Those are some potential creative solutions. DWI has other advantages besides helping you confirm the diagnosis of a PI-RADS four or five in the peripheral zone. It has a role in marrow assessment of lesions and it has a role in the detection of lymph nodes in the abdomen and pelvis.

Now, if it's not possible to repeat or so-called fix an exam by bringing the patient back. Assessment can still be accomplished with the other posting sequences that were obtained using some of the other guidelines available and your wits. For instance, you acquired the exam and you couldn't get an IV in, but you have a DWI and a T2. You can usually get a pretty accurate PI-RADS assessment of the lesion anyway and you assign category X to the DCE MRI portion of the exam. In other words, you make it known that that was a limitation.

On the other hand, what if you don't have the DWI, which is so important? Let's say you have a large lesion and the transitional zone, it is boundary crossed. It has effaced nodules, it has crossed the surgical capsule and when you inject or injected, it showed up contemporaneously, but more intense than anything else in the prostate gland. You still want to biopsy or call out that image even though you have to assign the DWI section category X. You should acknowledge that the study has a limitation, but that does not mean you cannot interpret the study and provide some useful information. Dr. P out.

LESSON 4, TOPIC 3

Mastery Series: PI-RADS 2.1 Update

Mastery Series

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Content reviewed: December 29, 2021

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