Prostate MRI Fellowship Practice Cases

Genitourinary (GU)

Prostate/seminal vesicles

Daniel Cornfeld

Stephen J Pomeranz

Gain confidence reading and reporting on Prostate MRI Cases with the Medality Fellowship Certificate Program. Practice using real-world, scrollable cases, earn CME, and receive a Fellowship Certificate™ upon completion!

Case Review

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Practice Cases

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Prostate MRI Practice Cases

A formal report is not included for this case. It is from the time before we used PIRADS but after we started performing US/MR targeted biopsies and some of the lesions we will discuss here would not be biopsied today. Four lesions were identified and targeted for biopsy.

Lesion #1 is seen in the TZ at the red arrow in Figures A-C. I would describe this as a homogeneous well circumscribed nodule (Figure A). Remember that well circumscribed means well defined with distinct non blurry margins. You could argue that this nodule is mostly encapsulated, meaning that it has a think black line around its margins. It is not lenticular. It is not located between nodules. This is T2 PIRADS score of 2. However, because it is focally, markedly, hypointense on the ADC map windowed at 1400/1400 (Figure B) and bright on the DWI with b=1600 (Figure C) it gets bumped to a PIRADS 3 lesion. The ADC value was 770. Targeted biopsy resulted in three cores of benign tissue. This is the typical appearance of an “atypical nodule.” If you look closely you can see other encapsulated nodules that are low T2 signal and restrict diffusion and some that restrict diffusion but are not T2 dark (Figures D and E).

Lesion #2 is seen in the PZ at the blue arrow in Figures A-C. It is focally discrete and different from the background, hypointense on the ADC map windowed at 1400/1400 (Figure B), and not bright on the DWI with b=1600 (Figure C). The ADC value was 1250. Based on PIRADS and a visual inspection of the ADC map this gets a score of 3 for DWI. Because ADC was > 1000 I would not score this as a 4 for DWI. This lesion is a little bit dark; it is not a “black hole.” On T2 the lesion is a circumscribed, homogenous moderately hypointense mass that looks like you could pluck it off the screen (Figure B). This is a score of 4 for T2. If this lesion enhanced early and focally it would technically get bumped to a PIRADS 4 lesion. Biopsy revealed three cores of benign prostate tissue.

Lesion #3 is seen in the PZ at the green arrow in Figures A-C. It is focally, markedly, hypointense on the ADC map windowed at 1400/1400 (Figure B) and bright on the DWI with b=1600 (Figure C). The ADC value was 870. In the PZ this makes it a PIRADS 4 lesion despite its wedge-shaped appearance with indistinct margins on the T2 images (Figure A). There was no early correlative enhancement (DCE images not provided). Three of four biopsy cores showed high grade PIN. The fourth core had 5% Gleason 3+3 tissue over a distance of only 1mm. Either this was a false positive MRI finding or the bulk of the lesion was missed on the targeted biopsy. Lesions in the PZ that are “black holes” on the ADC map are almost always well defined and mass-like on T2 but this case is an exception.

Lesion #4 is identified in the PZ by the red arrow in Figures F-H. Since it is in the peripheral zone, the diffusion images are the most important for characterization. However, this lesion is best seen on the T2 images where it is a 5mm, focally circumscribed, homogenous moderately hypointense nodule that looks like you could pluck it off the screen (Figure F). There is focally decreased signal on the ADC map windowed at 1400/1400 but I don’t think I would call it a “black hole” (Figure G). The ADC value was 1150. One could argue if it is sufficiently bright on the DWI with b=1600 (Figure H). An ADC value of 1150 is not low enough for me to score this a 4 on the DWI even if it is bright on the high b-value DWI. I give this a score of 3 for DWI. However, if this lesion enhanced early and focally it would technically get bumped to a PIRADS 4 lesion regardless of what you thought about its signal on the high b-value DWI. Biopsy revealed two cores of benign prostate tissue. I wonder if this represents a BPH nodule exophytic into the PZ. Its internal appearance is similar to the nodules in the TZ.

No neoplasm was found on systematic biopsies.

This patient has marked BPH and the prostate extends into the base of the bladder.

Case

There are multiple lesions in this case that fulfill criteria for which of the following PI-RADS scores?