0:00

This is a 74-year-old with a PSA rising to 7.

0:04

For images, we have axial T2, axial ADC map,

0:07

windowed as a standard, a sagittal image,

0:10

uh, and a delayed post-contrast image.

0:12

I don't have a high B-value for this case.

0:15

You'll note that in the sagittal image, it's not great.

0:17

Uh, we forgot to put on a phase oversampling,

0:20

and the SAT band that's normally anterior.

0:23

Uh, it's too far posterior, so the anterior

0:24

abdominal wall is wrapped, but we can still

0:26

see the prostate, so it gets the job done.

0:29

Uh, we start in the peripheral zone, and we'll,

0:31

this time we'll start, um, in the, on the ADC

0:34

map, which is probably where you should start.

0:37

And bright, bright, bright, we'll

0:40

go back up, bright, bright, bright.

0:42

This area kind of catches my eye, some asymmetry.

0:45

It's not quite a black hole, the ADC

0:47

measured a little bit above a thousand.

0:49

But it's asymmetric, it is focal,

0:52

there is some corresponding low T2 signal.

0:56

Is it spiculated and wedge-shaped, or is

0:58

it more well-demarcated and mass-like?

1:01

You could debate.

1:03

Um, in the absence of a, um, high B-value, I can't

1:07

say if it's spiculated present on the high B-value.

1:10

But since the ADC is above 1000, probably the highest

1:13

PI-RADS score I'm going to give it based on diffusion is a 3.

1:16

So it's a 3 for diffusion, a 3 or 4 for T2.

1:20

We don't know what it is for early enhancement,

1:22

so it ends up being a PI-RADS 3 lesion.

1:25

If it's a PI-RADS 3 on diffusion and enhances

1:27

on the arterial phase, it gets bumped to a 4.

1:29

We've talked about that before.

1:31

This is a PI-RADS 3 lesion.

1:33

It was biopsied and it's normal tissue.

1:37

And you can probably talk yourself into this being a wedge-

1:39

shaped area of diffusion restriction, in which case it's

1:42

a PI-RADS 2, and you can make this wedge-shaped as well.

1:46

Uh, and then, it's a PI-RADS 2, it doesn't get biopsied.

1:50

It's not a perfect system.

1:52

So no additional areas of focal diffusion restriction.

1:55

In the peripheral zone, so that's quite good.

1:57

We look at the transition zone, and the transition zone

2:00

posteriorly looks okay, but anteriorly, there's this

2:03

thickened, cross-centric area, a very low signal, and

2:09

it's not lenticular-shaped, it's bilaterally symmetric,

2:12

it's not, you know, it's not pushing things out of the way.

2:18

Alright, this is still convex.

2:20

But it enhances.

2:22

If it enhances, it can't be normal anterior stroma.

2:25

So, this was given a PI-RADS score of 5 based

2:29

on its diameter, no greater than 2 centimeters,

2:32

and its support of poorly defined low T2 signal.

2:35

Uh, the ADC value is actually 500, which is also, you know,

2:40

pretty reassuring that we're dealing with a neoplasm here.

2:44

And at an ADC that low, you think of a high-grade neoplasm.

2:47

This came back multiple cores

2:49

of Gleason 3 plus 3 disease.

2:52

And that actually surprises me because given

2:55

the very low ADC value, I would have thought it

2:57

would have been a much more aggressive tumor.

3:01

Um, so the reason this is not anterior stroma.

3:07

is the enhancement.

3:08

Now granted, this would be pretty

3:09

thick to be anterior stroma.

3:11

And if it didn't enhance and had this appearance, I would

3:15

have a very hard time knowing what to do with this case.

3:18

And probably out of fear of missing something

3:21

aggressive, given the ADC values of 500,

3:23

I would have called it a PI-RADS 5 anyway.

3:26

And that's kind of breaking the

3:28

rules, but that's not the case.

3:30

It enhances, it's not anterior stroma.

3:32

It's a, it's a PI-RADS 5 lesion in the transition zone.