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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Welcome to the Prostate MRI Fellowship Practice Cases course! In this course, you&rsquo;ll be presented with a series of worklists, comprised of 25 essential cases you must review to receive your Fellowship Certificate.

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Prostate MRI Practice Cases

This case contains additional examples of focal masses with focal enhancement but only limited diffusion restriction.

Lesion #1 measures 0.8 cm in the left posterior apical PZ. It is focally markedly hypointense on the ADC map windowed at 1400/1400 (Figure A) and hyperintense on the DWI with b=1600 (Figure B). ADC value was 550. This results in a score of 4 for DWI. The lesion is indistinct on the axial T2 images (Figure C) but appears more mass-like and distinct on the sagittal T2 images (Figure D). Remember you can use all three T2 planes. It is uncommon (but possible) for a prostate cancer to diffusion restrict but not be dark on T2. If a diffusion restricting lesion looks unimpressive on the axial T2, look at the other planes. This lesion focally enhances on the arterial phase post-contrast images (Figure E).

Note that the posterior peripheral zone on the left is distorted on the ADC map. The posterior margin of the prostate on the ADC map and high b-value DWI do not align well with the posterior margin of the prostate on the post-contrast and T2 images. This is a common problem with epi-planar diffusion imaging at 3T but there are several things that can be done to mitigate this problem. 

These include:
– The use of glucagon or buscopan to reduce rectal motion.
– Use of an enema and/or a fluid diet prior to the scan to remove air and stool from the rectum.
– Advanced DWI techniques such as multi-shot epi-planar sequences or distortion correction.
-In extreme cases of warping I have even resorted to spin-echo epi-planar images, especially on scanners with poor gradients.
Targeted biopsy resulted in three cores of Gleason 4+4 disease and one core of Gleason 3+3 disease. The high Gleason score is expected given the low ADC value.

Lesion #2 measures 0.6 cm in right para midline posterior apical PZ. It is more distinct on the T2 images than on the ADC map or high b-value DWI. It is focally hypointense on the ADC map windowed at 1400/1400 (Figure F). The ADC value was 1150. This is not dark enough to be a “black hole” and does not meet my criteria for a score of 4 on DWI. You can debate if it is bright on the DWI with b=1600 (Figure G). I do not think so. This gets a score of 3 for DWI. On T2 it is a circumscribed, homogenous moderately hypointense mass that looks like you could pluck it off the images (Figure H). This gets a score of 4 for T2. On the arterial phase post-contrast image the lesion focally enhances (Figure I), which bumps the total PIRADS score to 4.

Targeted biopsy yielded benign tissue.

Lesion #3 measures 0.4 cm in the right posterior apical peripheral zone. Like Lesion #2 it is more distinct on the T2 images than on the ADC map or high b-value DWI. It is focally hypointense on the ADC map windowed at 1400/1400 (Figure A). The ADC value was 1150. This is not dark enough to be a “black hole” and does not meet my criteria for a score of 4 on DWI. You can debate if it is bright on the DWI with b=1600 (Figure B). It is not markedly bright. This gets a score of 3 for DWI. On T2 it is a circumscribed, homogenous moderately hypointense mass that looks like you could pluck it off the images (Figure C). This gets a score of 4 for T2. On the arterial phase post-contrast image the lesion focally enhances (Figure D), which bumps the total PIRADS score to 4.
Targeted biopsy yielded benign tissue.

Before moving to the next case look at the left seminal vesicles. They are dark on T2 (Figure J) and bright on the post-contrast images (Figure K). Is this enhancing soft tissue? No, because they are also bright on the pre-contrast T1 images (Figure L) and do not restrict diffusion (Figure M). It is common for the seminal vesicles to look like this and it is important to check the pre-contrast T1 images and ADC map before deciding there is abnormally enhancing soft tissue in the seminal vesicles.

This case underscores my general approach to the PZ. I am primarily looking for black holes on the ADC map. I don’t much care what these look like on T2 or post-contrast images. Back holes should also be bright on the high b-value DWI and are going to be scored as PIRADS 4 or 5 depending on their size or the presence of extracapsular disease. Then I look for focal nodules on T2 that are focally distinct but not black holes on the ADC map (i.e. ADC > 1000). If these focally enhance then they are PIRADS 4 lesions but less likely to be neoplasm than the black holes.



Case

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