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Assessment of T2W in the Transitional Zone (TZ) Score 1

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

Dr. P here talking about T2 appearance, PI-RADS 2.0 versus PI-RADS 2.1 in the transitional zone. So we're only talking transitional zone. This is so important because the major mistakes that we have seen in prostate interpretation are over calling lesions in the transitional zone. In our experience, which exceeds now 2,000 prostate MRIs, almost all of which have included DCE MRI is that most individuals that have a biopsy over age 50 have some elements of Gleason 6, which really isn't aggressive cancer. So one of our jobs as imagers is to tailor back or tamp down unnecessary biopsies by utilizing MRI responsibly and appropriately in concert with our clinical partners, urologists. So let's look at score one. Remember, each one of these scores is talking about T2 appearance within the transitional zone. These are not PI-RADS scores. These will add up with some other scores to give you a PR-IADS designation.

So let's look at score number one, homogeneous intermediate signal intensity. This is normal. So we're going to make our prostate capsule blue. And we have a transitional zone, which we'll make gray. And we'll make it nice and homogeneous. And that would be a PIRADS, sorry, that would not be a PI-RADS, that would be a score of one. And then the peripheral zone on T2 is brighter. Let's get our white color in there. So our peripheral zone would be a little bit brighter. And this would would be a score of one for the transitional zone. Now guess what? Over age 50, nobody's transitional zone looks like that. Most of the transitional zones that you're going to see are going to have nodules inside of various shapes and sizes, some encapsulated, some not. Now let's move over to PI-RADS 2.1 modification. So you're going from 2.0 to 2.1. A score of one means that our TZ is homogeneously intermediate, which is rare, as we've already said, or a round completely encapsulated nodule.

So let me take one of these nodules and blow it up a little bit. So I'm going to blow up one of my nodules, which is located in the TZ, and I'm going to say around the periphery of that nodule, we can see an area around it that'd be thinner than this, but I'm just doing it for effect that shows that it's completely encapsulated so that there is a discreet transition between it and the surrounding background tissue of the transitional zone. So this would be still, even though we have a nodule, this would still be a score of one in the transitional zone using the PI-RAD 2.1 modification. Clearly a difference. Before, had to be uniformly one shade, gray, and now you can have a well encapsulated nodule and still give it a score of one. Let's move on now to the differences between PI-RADS 2.0 and 2.1 for a score of two. Stay tuned. Dr. P out.

LESSON 2, TOPIC 12

Mastery Series: PI-RADS 2.1 Update

Mastery Series

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Content reviewed: December 29, 2021

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