BPH Pitfalls (2)
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We're talking BPH on MRI, and there are
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two teaching points to this case.
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The peripheral zone and central
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zone are very hard to discriminate.
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As the peripheral zone, let's take a look at
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the sagittal for a minute, the peripheral zone
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is heterogeneously low in signal intensity.
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So, that makes it really hard to
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identify in the axial projection.
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That being said, you might get a little scared
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by this mass that is seen in the midline.
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This is a not uncommon location to see
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epithelial and stromal hyperplasia and fibrosis.
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This dark pseudomass can be identified as nothing
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more than a benign fibrotic muscular hypertrophic
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process by its position in the midline, by its
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absence of mass effect, and then when you go from
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the B0 to the B1500 diffusion image, there is no
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diffusion restriction in the midline anywhere.
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So, this is not a cancer.
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Another lesion that might scare you a
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little bit, that has been discussed in
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another vignette, is an area of stromal
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hyperplasia and acinar glandular hypertrophy.
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It's very bright, and sometimes
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can be very pedunculated.
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It looks like it doesn't even come off the
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prostate sometimes if it's very exophytic,
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but it is coming off the prostate.
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Now when you look at your lower B value
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diffusion images, it looks scary, right?
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It looks like it's diffusion restricted,
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but the B value isn't high enough.
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You gotta have a B value of 1,200,
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1,500, 1,600, and you will see this.
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Area of proteinaceous fluid fades away,
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and it does, on the B1500 image.
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If this was a cancer, it'd be
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getting brighter, not darker.
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Furthermore, marked hyperintensity on a
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T2-weighted image is a countersign, a sign
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that goes against the diagnosis of cancer.
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For cancers are gray, or
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charcoal; they are not bright.
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So, two teaching points in this case.
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A midline area of stromal and epithelial
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hyperplasia and fibrosis that fades
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away on the high B-value image.
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And an area of stromal hypertrophy and
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glandular acinar hypertrophy that also fades
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away on the B1500 diffusion-weighted image.
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
ProScan Imaging
John F. Feller, MD
Chief Medical Officer, HALO Diagnostics. Medical Director & Founder, Desert Medical Imaging. Chief of Radiology, American Medical Center, Shanghai, China.
HALO Diagnostics
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