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This is a case of a 55-year-old with a PSA of 5,

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no urinary symptoms or family history,

0:07

but a palpable abnormality on the left side.

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So we have our axial T2, our ADC map, our B equals 1600

0:15

interpolated image, and an arterial phase post-contrast.

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It's done without FATSAT because there's a hip prosthesis,

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and that hip prosthesis kind of explains why there's

0:26

so much warping. Um, on the diffusion images, so again,

0:31

I see bad diffusion images, you know, this is going

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to be a hard exam to read, so when the diffusion

0:35

images look bad, I definitely always start on the T2

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images, so we'll start in the peripheral zone, at the

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base of the gland, we'll come down, and we have high

0:44

signal, high signal, High signal, maybe a little bit of

0:48

heterogeneous low signal, but nothing focal or mass-like.

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And now I come into a large, uh,

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either one, you know, it's about 1.

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5 centimeters, maybe it measured 1.

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4 centimeters, round, well-defined area on

1:00

the, And the peripheral zone, looks like

1:02

you could just pluck it right off the image.

1:04

This is going to get a PI-RADS 4 or 5 for the T2 components,

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depending on if it measures greater than or less than 1.

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5 centimeters.

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And if we look on the ADC map, which the

1:15

images don't correlate perfectly, there is a

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big black hole, which is, uh, confirmatory.

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The ADC value is 650, which is really quite low.

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This gets a PI-RADS score, again, a 4

1:28

or 5 for the diffusion, depending on

1:30

whether or not It, uh, it's bigger than 1.

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it's dark on the ADC and bright on the high

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B value, so that gets it the score of 4 or 5.

1:42

It's also enhancing in the arterial phase, so this

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is very, very highly likely to represent neoplasm.

1:49

It was biopsied, and we'll have to look and see, I

1:52

think it was a 5 plus 5 neoplasm, so a very high grade.

1:59

goes along with the very low ADC values.

2:02

So, still looking on the T2 images, we get to a region

2:06

here on the right, and, uh, this, unfortunately,

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has no good correlate on the, uh, uh, diffusion

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images, and it's either because it's not restricting

2:16

diffusion, or there's too much artifact in that area.

2:19

So, again, there are some limitations to

2:21

this system when the diffusion images don't

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work, especially in the peripheral zone.

2:25

So, you could call this a PI-RADS 2, and that's it.

2:29

Based on T two, if you think it's sort of wedge-shaped

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and wispy and ill-defined, or if you thought it had

2:35

better margins, uh, but still a little ill-defined,

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uh, or it didn't fit in any other category.

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You could call it a PI-RADS 3

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based on the T2 findings.

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Now, if you called it a PI-RADS 3 and you

2:46

thought this was a little early enhancement, that

2:48

would bump it to PI-RADS 4 and you'd biopsy it.

2:51

If you thought it was a PI-RADS 2, it

2:53

would stay at PI-RADS 2 and it would not

2:55

be a lesion you had mentioned in biopsy.

2:57

So you have a little bit of leeway here.

2:59

Now the fact that you're already going to biopsy a

3:01

lesion on the other side means you might be more likely

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to call this a PI-RADS 3 or 4 and then go after it.

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But if this was the only thing you saw, you might have a

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little conundrum and then start looking at the, at the,

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uh, PSA density and it could be a bit more complicated.

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So this area was targeted.

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And there were no, uh, all the biopsies were benign.

3:24

So one interesting thing is that the systematics

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for this case showed high-grade tumor in every

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sample taken from the left side of the gland.

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Now the tumor doesn't look like it involves the entire left

3:35

side of the gland, so that raises one or two possibilities.

3:38

Either, all right, either the biopsies on the

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left were not distributed throughout the entire

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gland, meaning The, the operator thought they had

3:47

the anterior part of the peripheral zone, but we're

3:49

still biopsying the mid or posterior part, or the

3:52

tumor extends further than you see it on the MRI.

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And I, I think it's more likely that the former is true.

3:58

Uh, the size of, of well-defined focal tumors on MR

4:01

correlates very nicely with the size on pathology sections.

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So it just goes to show that there are also

4:07

limitations to the TRUS systematic biopsy technique,

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which is why we very much favor targeted biopsies.

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Targeted or using some type of fusion technology.

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You'll note here.

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We have another example of thickened anterior

4:20

stroma It's got that characteristic shape.

4:23

We've talked about mild diffusion restriction, usually

4:26

not that bright on the high B value and non-enhancing.