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Hello and welcome to Noon Conference, hosted by MRI Online

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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and previous noon conferences

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by creating a free MRI online account.

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Today we are honored to welcome Dr.

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eSSH Harrison Gani

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for a case review entitled MRI in prostate Cancer,

0:30

A case-based approach.

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Dr. Harrison Gani completed his radiology residency

0:35

and abdominal imaging subspecialty training at

0:37

Massachusetts General Hospital.

0:39

He's on the abdominal imaging staff at Massachusetts General

0:42

Hospital, where he also specializes in body MRI

0:45

and translational imaging.

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If you have any questions throughout the case review,

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please feel free to ask those using the chat.

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With that, we are ready to begin today's case review. Dr.

0:56

ti, please take it from here.

0:59

Uh, so welcome, um, all the participants online.

1:03

I, it's good afternoon here,

1:05

but I don't know which, uh, time zones you are in,

1:07

but, uh, a very good day to everybody.

1:11

Um, so

1:12

before we start looking at the cases, I just want

1:14

to take a brief moment to highlight some key points

1:18

before, uh, so that, you know, it makes your, um, readout

1:23

of the, uh, actual cases a little bit easier to interpret.

1:27

And so when we,

1:29

before you actually start looking at the MR of the prostate,

1:32

it's good to be familiar with these terms, you know,

1:34

what is a Gleason grade?

1:36

What is the patient's PSA

1:38

or prostate specific antigen level?

1:41

And then, uh, you should be able

1:42

to calculate the PSA density, which is a, a key metric

1:46

for us to, um, help us increase our confidence.

1:50

In terms of looking at the MRN making the diagnosis, uh,

1:54

we have to be quite familiar with the anatomy of the gland.

1:57

Um, you know, which, what are the different zones, uh,

2:00

what are some of the, uh, key anatomy aspects that one needs

2:03

to keep in mind when one is looking at the, um,

2:06

the MRS in terms of lesion detection.

2:09

Uh, what are the various components of the multiparametric?

2:12

Mr I know there is a, uh, big push, uh,

2:16

for not giving gadolinium

2:17

and just doing what is referred to as a bi parametric mr.

2:20

And I think if you are experienced

2:22

and are able to do that, uh,

2:24

certainly it's a desirable attribute.

2:26

But for a lot of other centers where, uh,

2:29

there is a wide range of expertise

2:30

and experience, the, the preference is still to use, uh,

2:34

gadolinium and do multiparametric.

2:36

mr. And then lastly,

2:37

I obviously are you answering the clinical question at hand,

2:40

which in most cases is detection

2:42

of clinically significant cancer so

2:44

that they can target the appropriate area,

2:46

but sometimes they also want to know information above

2:49

and beyond, which is staging of the lesion, et cetera.

2:51

So, so these are some key com components that, so, uh,

2:56

in terms of Gleason, um, score, uh, it,

3:00

it's a, uh, sort of pathology, um, derived,

3:05

um, a metric by which the pathologist looking at the, uh,

3:09

uh, slides under the microscope ascribe a score in terms of

3:14

how deviant is the, um, uh,

3:17

is the lesion from a normal appearing gland.

3:20

And it turns out that, um,

3:23

when they look at it under the microscope,

3:25

they see which is the first most common pattern,

3:28

and they give it a score from one to five,

3:30

and then they find, which is the, the second sort

3:33

of pattern, and give it a score of one to five,

3:35

and they add those two.

3:36

So the least score that somebody can get is a Gleason

3:39

of six, and those are the, the relatively indolent tumors.

3:43

And the classic adage is these patients typically die

3:46

with the cancer rather than from the cancer.

3:49

Once you start seeing, um, a grade group, uh, four,

3:54

uh, then obviously the total goes

3:56

above six and becomes seven.

3:57

So three plus four is one, you know,

4:00

seven and four plus three.

4:01

And, and this is the only time, you know, where you sort

4:04

of go against the rule of mathematics where, uh,

4:07

three plus four is where the dominant pattern is.

4:10

Three is slightly better outcome than four plus three,

4:13

where the dominant pattern is four.

4:15

And precisely for this reason, the International Society

4:18

of Neuropathologists now, uh,

4:21

have devised a new terminology, which is called,

4:24

called grade grade group.

4:25

So grade group one is at least in six grade,

4:28

group two is at least in seven, but it's three plus four.

4:30

And grade group three is at Gleason seven.

4:32

But here the dominant pattern is four plus three.

4:35

And as you can see, as you have grade group four,

4:38

which is a Gleason score of eight, four plus four, um,

4:43

uh, or, or these combinations.

4:44

And, and, and then grade group five.

4:46

So these are typ typically the higher grade, uh, cancer.

4:50

And so if you were to, uh, ask, um,

4:53

or be asked, what is the definition

4:55

of a clinically significant cancer, it's important

4:57

to understand that those are tumors

4:58

where the Gleason score is seven or above.

5:01

So the classic definition is Gleason grid score

5:04

of greater than or equal to seven,

5:05

or e sub grade of greater than

5:06

or equal to two, with a volume of more than 0.5 cc and,

5:10

and presence or absence of extra prostatic extension.

5:13

So the, the, it's important to understand, you know, the,

5:17

this definition of quote unquote clinically significant

5:20

cancer, uh, which translates to looking at the ESU grade

5:23

or the Gleason score.

5:24

So that's the first point.

5:26

The second thing is, it's also important

5:28

to know the t staging a little bit

5:30

because, um, you don't have to put this in your report,

5:33

but it's good to sort of, uh, get a sense of what it is.

5:38

And so, T one is when the tumor is not felt

5:40

by the digital rectal exam, it's present.

5:43

Uh, T two is when the tumor is present in the gland, is

5:47

and is confined to the gland, but is,

5:49

but is felt by a digital rectal exam.

5:51

And this is now broken up into three categories where

5:55

T two A is, when it is less than 50% of, of, of one side

5:59

B is when it's more than 50% of, uh,

6:01

still confined to one side.

6:04

T two C is when it's bilateral, uh, extension of the,

6:07

um, the tumor.

6:09

And then obviously when the tumor gets beyond the gland,

6:12

it goes into the capsule.

6:13

That's T three A,

6:14

and if extends into the somal vesicles, that is T three B.

6:18

And finally we have, um, T four disease that spreads

6:21

beyond the, um, uh, the gland into, you know,

6:24

adjacent organs like the bladder or goes

6:26

and involves ectomic, et cetera.

6:28

So that's sort of in a nutshell, the, the t staging now

6:31

based on the T staging

6:33

and the, uh, Gleason grade group, um, you will see in your

6:38

urologist or radiation oncologist notes this sort

6:41

of risk stratification.

6:42

And basically all it is, is

6:44

that combining the patient's PSA level, the Gleason score

6:47

and what they feel is a clinical stage

6:49

and they ascribe a risk category of low,

6:52

intermediate, high or very high.

6:54

And this is basically the risk of having distant metastasis.

6:57

So again, just, you don't have to memorize it, you just have

7:00

to be aware that these terminologies, uh, exist

7:03

for you to understand better.

7:05

What are the, um, uh, what, what,

7:07

what are the cha characteristics of the tumor that, uh,

7:10

one needs to be aware of.

7:12

Now that comes to PSA density, this is, uh, one value,

7:15

which, um, it's important.

7:17

Now, if you think about the averages of the patients

7:20

that we scan looking for prostate cancer,

7:22

these patients typically have BPH

7:24

and one of the, as the gland expands,

7:26

because there is increase in the glandular volume,

7:28

there is gonna be increased production of PSA.

7:31

So elevation of the PSA does not necessarily equal to tumor.

7:35

And that is why when you equate that

7:37

or calibrate that to the patient's gland volume,

7:40

you'll get a better sense of what the, um, uh,

7:43

the risk factor for tumor is.

7:44

So this is something that you should routinely do in your,

7:48

or put in your report if it hasn't been already done

7:51

for you, because you will know the patient's PSA value.

7:54

And so the formula is of the PSA density is the PSA value

7:58

that you have the most recent value of,

8:00

and that divided by the prosthetic volume, uh,

8:04

prosthetic volume, we can very easily calculate an mr.

8:07

It's either autos segmented in, you know,

8:09

if you have certain software

8:11

or if you don't have that, it's very easy to calculate

8:14

where you take the three maximal dimension.

8:16

So here it is the superior to inferior, anterior

8:19

to posterior, and right to left or transverse dimension,

8:23

and multiply that by 0.52.

8:25

And that gives you the prosthetic val volume.

8:28

So if you put in the PSA value in the numerator

8:30

of the prosthetic value in the denominator, looking at that,

8:34

the cutoff is 0.15.

8:36

Typically, if you have values about above 0.15,

8:39

that tells you that besides the glandular volume

8:43

contributing to PSA, there may be something else

8:45

that is probably contributing.

8:47

And so the way to use this is if you have a, uh, PA density

8:51

of more than 0.15, then you better look hard, uh,

8:55

throughout the gland to make sure

8:56

that you're not missing a tumor.

8:58

It can also help you when you have a RAD three lesion.

9:01

And if you're one of those institutions

9:03

where you don't typically biopsy those, you know, you can,

9:07

it may be one, um, indication of swaying your, um, your,

9:12

uh, biopsy colleagues to, uh, to biopsy de lesion.

9:15

So that's sort of another, uh, use, and this,

9:17

therefore, it's a very important value

9:19

to incorporate in your report.

9:21

And, and this is just to show that, you know,

9:23

using a combination of PSA density

9:25

and PY rites both, you get a higher accuracy of, uh,

9:28

detecting, uh, clinically significant cancers.

9:31

And there's ample body of literature that supports, um,

9:35

this sort of a approach where you combine the PSA density

9:38

with, uh, what you see on imaging.

9:40

So these are the various components

9:42

of the multiparametric mr.

9:43

You start with the localizer,

9:45

and then we have the tri plaine T twos.

9:46

The tri plaine T twos are primarily for anatomy delineation,

9:50

knowing the zones of the, the prostate

9:53

and lesion detection primarily in the transition zone.

9:57

We do a large field of view going all the way from aortic

9:59

bifurcation to the pubic synthesis.

10:01

And the reason for doing that is to assess her lymph nodes

10:05

and also surrounding organ

10:07

'cause they can have incidental findings and,

10:09

and looking at that.

10:11

Then we do DWI where you do a, um, uh, low B value

10:15

and intermediate B value calculate an A, D, C from that.

10:19

And the A DC basically is a slope.

10:21

Once you know the a, DC,

10:22

you can then extrapolate higher B values,

10:24

so you get a calculated B value.

10:26

At our institution, we do a b calculate B value of 2000, uh,

10:30

which typically is adequate for suppressing the entire

10:34

nor normal gland

10:35

and bringing out the tumor as you see in this case, in the,

10:38

uh, uh, in the right, uh, met posterior peripheral zone.

10:42

And then finally, um, the dynamics which are done

10:45

to complement lesion detection

10:46

primarily in the peripheral zone.

10:49

And the goal is to, uh, utilize the, um, uh,

10:53

the vascular feature of the tumor

10:54

where the tumor enhances early

10:57

and washes out relatively early.

10:59

And so you have to have sort of high temporal resolution

11:01

after you give gadolinium to look

11:03

for differential enhancement of the lesion, comparing,

11:06

comparing it to the rest of the gland.

11:08

So those are the components of the multiparametric.

11:11

Uh, Mr, uh, just a brief mention about anatomy.

11:15

And so the prostate, basically, um,

11:17

before we, uh, jump into the zones,

11:20

is divided into three distinct, uh, areas.

11:22

The part of the gland, which is, uh,

11:24

or the third of the gland that is closer to the bladder,

11:27

is referred to as the proximal, uh, third of the base.

11:30

Um, and the furthest part of the gland is referred to

11:34

as the apex, and therefore you divide the gland into third.

11:36

So we have the, the proximal third, which is the base,

11:38

the mid third, and the apical part

11:41

of the distal third of the gland.

11:43

And then after you have this sort of, uh, thirds, you kind

11:47

of look at the zones.

11:48

Now there are four distinct zones in the prostate.

11:51

The two areas that we commonly expect tumors

11:54

to arise in is the peripheral zone,

11:56

where you can see on the axial, um, diagrammatic depiction

12:00

and the satch diagrammatic depiction.

12:02

And then we have the other area

12:04

where tumors typically arise, which is the transition zone.

12:07

In addition to that, we have two other areas.

12:09

We have the anterior fibromuscular stroma,

12:12

which has no glandular element,

12:13

so tumors should not arise here.

12:16

Typically, when you have lesions

12:17

that extend into this location,

12:19

they're either coming from the transition

12:20

or they're coming from the peripheral zone.

12:23

And lastly, we have this central zone,

12:24

which is an important, uh, uh, anatomy point to keep in mind

12:29

because this can be dark on T two

12:32

and show restricted diffusion.

12:34

And it is typically

12:35

because this transition zone is enlarged in these patient,

12:39

uh, age, uh, cohorts.

12:41

The central zone is pushed superior laterally towards

12:44

the sumal vesicles.

12:45

Um, and so you need to know where it is located.

12:47

The point also is that on axial images,

12:50

it can fuse in the midline

12:52

and come down up to the level of the Vero Montana.

12:55

So this is what the anatomy, anatomy looks like on Mr.

12:59

So you can see the pedophile zone is bright on T two.

13:02

This is the sort of the transition zone, um,

13:04

which is symmetric,

13:05

and this case with the anterior fibromuscular trauma

13:08

being dark on T two.

13:10

And this is what it looks like on the, on the Sagal image.

13:14

Um, so that was about anatomy now.

13:18

And in terms of localization,

13:19

when you look at the pyres documentation, it sort

13:22

of has this very elegant segmentation into, um, you know,

13:26

multiple different areas, and they have terminologies.

13:30

Uh, again, it depends on an institutional preference.

13:33

At our place, we prefer to keep it simple.

13:35

So what we do is we first start whether it's right versus

13:38

left, then we talk about anterior versus posterior,

13:41

and the dividing line is an arbitrary line, you know,

13:44

through the center of the gland.

13:46

Then we talk about whether it's in the base, mid or apex,

13:50

and then we put it in the relevant, uh, uh,

13:54

location in terms of the, um, zonal anatomy.

13:57

So if you follow this every single time, you know,

13:59

it becomes easy to describe

14:01

and also sort of mention, so for example,

14:03

if you have something like this, you will say, this is on,

14:05

in the right posterior mid peripheral zone of the gland.

14:09

And sort of that's how you will,

14:11

if it's something on the other side,

14:13

you'll say left mid posterior, uh, uh, peripheral zone.

14:16

So you always follow the same sort of, um, uh, pattern

14:20

of localization, and that helps you in terms of

14:22

accurately localizing where the tumor is.

14:25

So this, as I said, this would be right posterior mid gland

14:28

PC lesion with no extra capsular extension.

14:30

That would be our description for, for this,

14:32

uh, specific lesion.

14:34

And then the last two slides, you know, just it's good

14:36

to have these kind of cheat sheets in your reading room.

14:38

We have one, um, you know, which kind of just helps us when,

14:43

uh, there is a confusion in terms of

14:45

what the algorithm says.

14:47

Uh, this one nicely goes

14:49

through the peripheral and the transition zone.

14:51

So having something like that is very, uh, helpful to, uh,

14:54

you know, to uh, provide, um, consistency in your read.

14:59

So that was sort of in a nutshell, just some basics.

15:01

Now we'll stop this slides and go into the cases.

15:05

So we start with our first case.

15:06

This is a, um, let just

15:10

bring up the case list.

15:13

So, yeah, so this first case is it 63-year-old gentleman.

15:17

Uh, his PSA is 7.8, and his PSA density is 0.18.

15:21

So clearly it's more than 0.15.

15:24

Uh, and you know, obviously there is, uh, the urologist

15:28

felt something on the right side,

15:29

and so they send the patient for an MR

15:31

before the patient is proceeding for a biopsy

15:34

to see if we find something

15:36

that they can target with the biopsy.

15:38

So as I mentioned, we do tri plan T two.

15:40

So we start with the localizer.

15:42

So this is the localizer and kind of just, um,

15:45

it's also a good, um, uh, check for the technologists

15:49

to know that they are covering the relevant anatomy

15:52

and there is adequate signal.

15:54

Um, you know, we don't use endorectal CO in our practice,

15:57

so we rely on the high, uh, fidelity

16:00

of the phase relu phased array coils.

16:02

And so when they look at this scout, you know

16:04

that there is good signal anterior and posteriorly,

16:07

and the channels and the coils are working well.

16:10

You'll be surprised how many times that

16:12

with these phase array coils, if one of the channels is,

16:14

you know, malfunctioning,

16:16

you may see a signal loss in certain areas

16:19

of the, um, scout.

16:20

And, and the technologies then can stop right there and,

16:23

and, and start, uh,

16:25

thinking about, you know, what's going on.

16:27

And then, as I said, we do a wide field of UT two,

16:29

and this goes all the way from the aortic bifurcation down.

16:32

So as you can see right here we are, we are coming up

16:36

to the aortic bifurcation going down, uh, up to the level

16:40

of the, uh, pubic synthesis.

16:42

And so just looking at this case, what you see is, um,

16:47

that there is a, obviously there's something arising from

16:50

the bladder in the midline in the post anti superior aspect.

16:53

But, um, let's not proceed to the, um, here's the sag,

16:58

the axi and the coronal.

17:00

Now what I usually do is I bring the tri together

17:03

and also try and bring up the T one, um, pre, um,

17:08

which right here.

17:12

So I quickly take a look at the T one pre, and,

17:14

and the goal is just to make sure

17:16

that there is no hemorrhage.

17:18

Um, if you see anything that is T one bright in the gland,

17:21

uh, obviously the pa majority of the patients that come

17:24

to us now come before biopsy.

17:26

So it's gonna be extremely uncommon

17:28

to see hemorrhage in the gland.

17:29

But there are times when, you know, there are patients

17:31

who are on anticoagulants

17:33

or, uh, you can sometimes have a little bit

17:35

of spontaneous hemorrhage.

17:36

So it's good to sort of know that

17:37

and at least be very, that those areas can have relatively,

17:41

uh, uh, low signal intensity on T two.

17:45

And so now when you look at the axial, uh, as you can see,

17:48

um, as I'm scrolling through, when you look at the, uh,

17:51

corresponding, uh, plane on the sagittal,

17:54

it is a straight axial.

17:56

Uh, and one can put pose.

17:58

The question is, uh, do we typically do a straight axial

18:01

or do we angle it to the prostate?

18:03

Uh, so just to kind of lay it out, um, if you end up, uh,

18:08

there are two things to keep in mind when you are angling,

18:11

uh, the axial to the prostate gland.

18:13

One is obviously you have to then be familiar with theat,

18:17

uh, uh, distortion if you will.

18:20

Second is if you end up doing your axial

18:22

or transverse in that, uh, oblique plane, then you also need

18:26

to make sure that your enhanced images

18:28

and your DWI are also in the same plane,

18:31

because if they're not, you know,

18:33

it'll be sometimes very difficult to precisely localize

18:35

where you're seeing and, and cross correlating.

18:39

Uh, you know, with modern day packs,

18:40

you can have the cursor core localize,

18:43

but it still makes it easier if sort of the, the planes

18:46

of all the three transfers are in the same oblique plane.

18:50

Um, the other interest in, uh, the other point

18:53

to keep in mind is, you know, you, if I ask you

18:56

what would be the oblique plane here, uh,

18:58

if one uses the analogy of say, rectal cancer, it has

19:01

to be perpendicular to the tumor.

19:03

So one starts thinking, well, we need

19:05

to be perpendicular to the gland.

19:07

The problem is when you do that,

19:08

and if I kind of just draw a line, uh, in terms of making

19:12

that, you'll see that, uh, this is perpendicular

19:15

to the gland, but this axi axial plane is going to have,

19:18

as we go down, you'll see that there'll be parts

19:21

of the peripheral zone, which are mid,

19:23

but you are anteriorly, you are seeing more of the apex.

19:26

So, uh, you have to be a little bit careful.

19:28

That's what I meant by distortion of the anatomy.

19:31

And the other, um, important thing to keep in mind is

19:35

that when you are actually doing the perpendicular plane,

19:37

you have to do it to the plane of the, um, uh,

19:41

the peripheral zone, not to the gland.

19:43

So you will kind of outline the peripheral zone

19:45

and be perpendicular to the, uh, peripheral zone,

19:48

not to the gland itself.

19:49

So that's something else to keep in mind in terms of, uh,

19:53

doing your, uh, obliquities.

19:55

So in this case, as you are scrolling through you, right

19:58

as just looking at the anatomy, this is the, uh,

20:02

the peripheral zone here is the transition zone,

20:04

the se mantle vesicles,

20:05

and this triangular area that you see.

20:07

And I'm going to bring up the, uh, let's see if I can

20:12

magnify this to show you.

20:15

Bring up the, um, uh, the coronal

20:18

and the, um, so you,

20:27

so if I can cross correlate that, you'll see

20:29

that this triangular area corresponds to this low density

20:34

or low signal intensity area at the base in the gland,

20:37

which is bilaterally symmetric,

20:38

and it's this sort of tear shaped area bilaterally,

20:41

which is symmetric and is dark.

20:43

So that is the central zone,

20:44

and you have to be familiar with this anatomy, as I said,

20:47

because, you know, these can appear dark and mimic a lesion.

20:50

Plus, if I bring up the diffusion, the high B value, DWI,

20:55

which, uh,

21:00

right here, you can see that, you know,

21:04

these areas can sometimes show bright signal on the,

21:10

on the diffusion

21:11

or dark signal on the A DC,

21:12

depending on which one are you looking at.

21:15

And so, yeah, just be wary that that's

21:16

where the central zone is.

21:18

So now as we scroll through, you see

21:20

that there is this ill-defined area in the left mid, uh,

21:23

posterior peripheral zone,

21:24

which is clearly dark on the a, DC.

21:28

And, um, as we look at the

21:32

gadolinium enhanced images, you can see that

21:37

there clearly is early enhancement in that,

21:40

um, in that lesion.

21:43

And so, um, the question now is, you know,

21:46

it's sort of localized.

21:48

Uh, margins are ill-defined,

21:50

and you, you know, its location.

21:51

You can see that it's showing all the classic features.

21:53

It has restricted diffusion.

21:55

It has, uh, T two dark signal showing early enhancement, uh,

22:00

doesn't look like there is, you know,

22:01

the capsule is nicely delineated.

22:03

Um, there's a little bit of dark signal here,

22:05

but don't see much going extending beyond that.

22:08

So, um, and obviously we will have to now measure.

22:12

Now the question is, um, where do you measure?

22:15

And you know, there are, uh, certain stipulations

22:17

by the pirates documentation.

22:19

You can follow that. I would say measure

22:21

it where you see it best.

22:22

And you, we usually try and measure it in two different

22:24

planes to kind of get a sense

22:26

and then give them the maximum dimension.

22:28

So in this case, it would be something like 1.4 to these,

22:33

A measures about one centimeter.

22:34

So it'll be around 1.4 centimeters that you're seeing.

22:38

And so if you go by the classic rads, uh, uh, 2.1, uh,

22:43

descriptions in the peripheral zone, this is less than 1.5,

22:46

we don't see any obvious extra capsular extension.

22:49

So this would be a PYS four, uh,

22:51

and you would mark the lesion for them to, um, uh, to,

22:56

uh, uh, to sample.

22:58

Now, it turns out that, um, this was, uh, targeted

23:01

and this came back as a grade group four

23:03

or a four plus four, um, lesion.

23:06

So obviously that put them in a high risk category

23:08

for metastasis.

23:09

And this patient ended up getting a, uh, PSMA scan,

23:15

and this is the patient's PSMA scan

23:19

to show you the fusion.

23:21

Um, and as we scroll down,

23:25

we don't see any abnormal uptake in the bones

23:28

and don't see any, these are the ureters that you see, uh,

23:32

with the big excretion.

23:33

And as we come down, again, that's the ureter, uh,

23:37

you'll see that that lesion does show increase, um,

23:41

PSMA uptake and nothing beyond the gland in terms of,

23:44

uh, metastasis.

23:45

So, um, that's how he was staged

23:48

and then appropriately treated with that, uh, you know, with

23:51

that, uh, staging information.

23:55

So just a nice example of a peripheral zone

23:57

and going over some anatomy, et cetera.

23:59

Now, moving on to the second case.

24:01

This is a patient who is, um, against, uh,

24:05

somewhat 60-year-old, uh, comes in with the PSA value of,

24:08

um, uh, 4.8.

24:11

And the PSA, uh, density here is 0.07.

24:15

So PSA density is not very high.

24:17

And, um, the question is, um, uh, you know,

24:22

when, when the p will you still see,

24:25

and what do you do if the PSA density is low?

24:27

So as I mentioned earlier,

24:29

it's when the PSA density is high, you are going to,

24:32

you know, we look very hard

24:34

and make sure that there is no lesion.

24:35

If the PSA density is not very high, you still are going

24:38

to follow the same pyre schema and call.

24:41

It's not that you will not call.

24:42

So the value of PSA density is when it is high, not,

24:45

you know, when it is below the 0.15.

24:47

If you see, uh, a frank Pyre lesion,

24:50

you will then end up calling that lesion.

24:52

So just keep that in mind.

24:53

That's why I, I mentioned the, the value here.

24:56

So now again, same thing looking at the, um, uh, the, uh,

25:04

sorry, somebody has put a question, is pet good assessment

25:07

of uptake in prostate cancer mets and primary lesions?

25:09

So I think the, you know,

25:14

this has been studied

25:15

and, uh, it clearly there is a, there is no, um,

25:19

question about the utility in looking for metastases as far

25:23

as looking at primary lesion.

25:25

I think, um, the MR definitely does better in terms

25:29

of detecting, because the problem with PSM A,

25:32

you can have false positives

25:33

and you can also have false negatives.

25:35

And then that begs the question is, you know, where, uh,

25:39

how do you then triage those patients?

25:41

So it's still desirable to do mr, obviously, you know,

25:45

you're not giving any radiation.

25:46

That's a clear advantage and benefit.

25:48

And this, and the third thing is, uh, the precise, um, uh,

25:52

location, atomic location becomes critical, uh, in terms of,

25:56

you know, where it is localized and that,

25:57

and that clearly is much better done with MR than with, uh,

26:01

PS PSMA pet.

26:03

Now, one could make the argument is, can you do a,

26:05

uh, MR pet?

26:07

And now that those instruments

26:09

or scanners are not, uh, ubiquitously a available.

26:12

So I think, uh, you know, that's question is sort of, um,

26:16

uh, not relevant in a sense.

26:18

So for practical purposes, for primary lesion,

26:20

you still want to do the MR

26:21

for looking at distant metastasis.

26:23

It's, uh, PSMA.

26:25

Alright, so let's look at the, um, the tri plane here.

26:37

And so, um, starting,

26:39

and let's bring up the T one images

26:44

that's actually post, lemme see if I can bring up the dynas.

26:47

Here we go. Um, so again, you know, there are certain tiny,

26:53

as I mentioned earlier, you may see occasionally some little

26:55

bit of bright foci.

26:57

Um, you know, that does happen sometimes

26:59

with these degenerating, um, uh, BPH H nodules

27:03

or even in the peripheral zone spontaneously,

27:05

we can have some punctate hemorrhage.

27:06

Uh, nothing to be alarmed about,

27:08

but nothing, uh, overtly abnormal here.

27:11

So let's look at the axial now.

27:13

And, um,

27:18

this annotation

27:24

going from the base to the apex.

27:30

Um, so as you can see in, as compared

27:34

to the prior case in this case, um,

27:36

there is a fair amount of BPH.

27:38

Now, uh, BPH uh, comes in two flavors

27:42

or other three flavors, uh, what we call

27:45

as a typical hyperplastic nodule that is bright on T two.

27:48

Uh, then we can have stromal components which

27:51

are dark on T two.

27:52

And then you have the mixed variety

27:54

of already you have both stromal

27:55

and hyperplastic components.

27:57

The goal is to have, uh, to make sure that there are lesions

28:01

that are very well circumscribed

28:02

or have a very clear defined capsule

28:04

because that, uh, tells you that this is, um,

28:07

VPH rather than something that you need to be, um,

28:10

uh, concerned about.

28:12

And so clearly now in this case,

28:14

the enlarging transition zone is, is, uh,

28:18

pushing the peripheral zone

28:19

or cau causing the peripheral zone to be, um, you know, uh,

28:24

compressed, if you will.

28:25

And on the left side, you can nicely see the, uh,

28:29

mixed signal intensity where have bright

28:31

and dark areas, which is typical in these cases

28:33

where patients have had prior episodes of inflammation.

28:37

And so again, just going back to, um, uh, to

28:43

get rid of and

28:50

going back to the, um, sag.

28:53

And as you will see here in this case, um,

29:01

some vesicle.

29:02

And in that area on the, the, we go to the left side first.

29:06

So this is the, uh, peripheral zone on the left side

29:10

where you can nicely see the CS shaped, uh, right signal.

29:14

And when I go to the contralateral side, you can see

29:16

that right from the base almost reaching up to the apex,

29:20

which you are also seeing right here that there is a, um, a,

29:25

uh, dark signal or a dark area.

29:27

And on the coronal also you can nicely,

29:29

if I cross correlate this location, you will see

29:32

that it's sort of spanning all the way from base, uh,

29:35

almost reaching to the apex of the, um,

29:38

uh, apex of the gland.

29:40

And so that's, um, uh, sort of clearly concerning.

29:44

Now the question is, uh,

29:45

how does this pan out on the high B value?

29:48

So let's look at it on the high B value.

29:50

So you can clearly see that there is bright signal, uh,

29:54

window, it asymmetric bright signal on that side.

29:58

Plus, in addition to that,

29:59

there are some interesting features here.

30:01

So if you look on the left side, this is the outline

30:03

of the capsule, uh, here is the rectum.

30:06

And this angle that you see is referred to

30:08

as a rectal prosthetic angle right there.

30:11

Um, if I was to, uh,

30:13

let's see if I can take a pencil and draw it.

30:16

So it's this angle would be the prostatic angle,

30:20

but on the other side you can see that

30:22

that rectal prostatic angle is obliterated

30:24

with clearly the same soft tissue density that you're seeing

30:28

in the peripheral zone extending into and,

30:30

and causing blunting of the recto prostatic angle.

30:33

So clearly there is tissue going beyond.

30:36

So this clearly is, uh, concerning

30:38

for extra prostatic extension.

30:40

There is restricted diffusion.

30:41

And if we also look at the, uh, gadolinium enhanced images

30:47

as we go through the temporal phases, you will see

30:51

that there is early enhancement

30:54

and that also is getting beyond the, um, uh,

30:57

the outline of the gland.

30:58

So that clearly is extra capsular extension.

31:01

And so this was sampled

31:03

and this came back as a Gleason pattern, three plus four.

31:07

Uh, so Gleason seven, uh, with extra,

31:10

uh, capsular extension.

31:11

So this clearly is a, is a, you know,

31:14

it puts the patient into higher grade.

31:16

Uh, the other important thing is they want

31:18

to know about this is because, uh, as you know, one

31:21

of the definitive therapies they give patients, uh,

31:24

or patients opt instead of surgery,

31:25

they may want to get radiation therapy.

31:28

And if they have to do radiation therapy,

31:30

what they don't want to do is unnecessary, um, radiation

31:34

of the rectal wall, which here is closely applied.

31:36

So what they do is they put a biologically inert, um, gel,

31:41

which is called a spacer, that's the commercial name

31:44

that basically is a biologically inert gel in

31:46

between the rectum and the prostate.

31:50

And if they have to do that, they have to know this anatomy

31:53

configuration because they go trans

31:55

perennially to install the gel.

31:56

And if there is a certain bulkiness of the disease,

32:00

they don't, they are not able to adequately dissect

32:03

or get a clear plane.

32:04

And that can sometime lead to adverse, uh, complications

32:08

where the gel may actually be misplaced in the rectal wall

32:11

rather than in this potential space.

32:14

So this is, again, important information

32:16

to communicate not only from a prognostic um, factor,

32:19

but also if they are planning treatment, it may affect

32:22

what they want to do in terms of, uh, installing the,

32:25

uh, the HL.

32:27

So this was again, a peripheral zone

32:29

with extra cap extension.

32:30

And this patient that did have, um, um, uh, did have,

32:35

uh, uh,

32:39

it did have a low PSA density and despite that had a lesion

32:42

and a, and a extra cap extension.

32:45

So that's, uh, this patient.

32:47

Now we are moving on to the next patient, which is, uh,

32:49

a 65-year-old, uh, with a PSA

32:54

of 20.9.

32:56

So let me just bring up that case.

32:58

Uh, and

33:03

this patient, um, uh,

33:06

had a PA also had an elevated PSA density above 0.15.

33:10

And so again, um, the urologist

33:12

who did the digital rectal exam felt something

33:15

bilaterally, but was not sure.

33:17

But given the high PSA

33:18

and the high PSA density, obviously they wanted

33:21

to get the MR before.

33:23

Uh, so let's look at the, um, uh, the axial to begin with.

33:28

You can see that there is a little bit

33:29

of free fluid in the peritoneum

33:30

and you know, this is, um, men should typically, you know,

33:35

they don't typically have free fluid in the peritoneal

33:37

lining, but occasionally you do see that.

33:39

And one of the common, um, entities that we see is some kind

33:43

of bowel, you know, inflammation

33:45

or pathology higher up that can sometimes contribute to

33:48

that, or there's some non-specific

33:50

inflammatory thing going on.

33:52

Um, so that may be one factor

33:54

that this patient has, uh, free fluid.

33:56

So as we come down, you can see we are entering into the,

33:59

um, uh, or getting into the prostate from the base.

34:03

And you can see the bladder is thickened,

34:05

which is not unexpected that

34:06

that means there is bladder outlet obstruction.

34:08

But as we come into the, the prostate itself, um,

34:13

just me bring up the coronal

34:15

and the sagittal, so you can see them side by side.

34:21

So here's the coronal and this is the sagittal.

34:24

So now there are, um, this, uh,

34:29

is a, uh, protocol that was not done at our institution.

34:33

Um, so there are some, uh, institutions where

34:36

what they do is instead of bring all the three planes

34:39

as a classic turbo spin, e echo,

34:41

or a fast spin echo, they usually do one plane

34:43

as a single shot fast spin echo.

34:46

The reason we don't like that is

34:47

because, um, as you can see on this, uh, single shot, uh,

34:51

or a haze sequence that, uh, the contrast

34:54

to noise is blunted, it's not as good

34:57

as you see on the and coronal.

34:59

And so despite its, um, its speed

35:02

and relative lack of motion, the, um, the contrast

35:05

to noise is not as good.

35:07

And now with the current, um, uh, way of acquisition

35:11

or doing, uh, the turbos

35:13

or fast echo with the, what is referred to as deep learning

35:17

or DL based, uh, sequences, this take very little time.

35:21

In fact, our entire prostate protocol,

35:23

including the dynamic enhancement, is only about 15 minutes.

35:27

And so there is really no need

35:28

to dilute the protocol by doing this.

35:31

But again, you know, it depends on

35:32

various other circumstances.

35:34

So I'm not, uh, I'm, I'm just telling you

35:37

what you will lose if you end up doing one of the planes.

35:40

And, and it can sometimes be a challenge in terms of,

35:42

especially when you're looking at transition zone,

35:44

which is the case in this patient.

35:45

So when you look at the peripheral zone,

35:47

it's bilaterally symmetric.

35:49

But look, when you come to the transition zone,

35:51

what you see here is this sort of area.

35:54

Now, when do you start getting

35:56

concern in the transition zone?

35:57

You start getting concern in the transition zone when

36:00

you either have an interrupted capsule.

36:03

And what do I mean by that is that if you think about, um,

36:08

uh, a bpal and the green line here, refer to the capsule.

36:12

So you want to see a complete capsule, that's

36:15

what you want a BPH model to have.

36:17

If you have something like this, which is interrupted,

36:20

but it's still present, um, then you look at the diffusion.

36:24

If there is restricted diffusion,

36:26

then you start worrying about it.

36:28

And then if you don't have a capsule at all,

36:31

whether it interrupted

36:32

or complete, that's when you start worrying.

36:34

Now, if you don't have a capsule, then

36:36

what you do is you look in the inside of the lesion.

36:39

If the inside of the lesion is showing heterogeneity,

36:43

then you have to look at the diffusion.

36:45

But if it is relatively homogeneous

36:46

as you're seeing in this case,

36:48

then all you do is look at the size of the lesion.

36:51

So in this case, looking in all the three planes,

36:53

if I cross correlate this area, you'll see clearly

36:57

that this lesion, no matter how I,

36:59

which plane I'm looking at, I'm not seeing either a complete

37:03

or an interrupted capsule,

37:04

which means I'm already at a py at three

37:06

or higher in the transition zone.

37:08

And then when I look at the inside of the lesion,

37:11

I think it's relatively homogeneous.

37:13

Again, looking at all the other planes, that's

37:15

what you can see on the, on the, on the sagittal, on the,

37:18

on the coronal, on the alate is relatively homogeneous.

37:21

And if it's relatively homogeneous,

37:23

that means it's either a PYS four or a five.

37:25

And that's based on size.

37:27

And if you look at the size in this case, it's going

37:30

to be approximately, you know, two centimeters,

37:33

which is more than a, um, 1.5.

37:36

So of pyx five lesion in the, um, in the,

37:39

uh, transition zone.

37:41

The other interesting thing is in, in this lesion is, um,

37:45

remember we spoke about, um,

37:47

so here this dark signal that you see, right?

37:50

Uh, actually let me just bring up the DWI as well,

37:53

although not they, they ask you,

37:56

it's not the dominant sequence.

37:57

It's always good to also look at it when you are.

38:00

Uh, yes. So there you go.

38:04

This is the high B value calculated.

38:06

Let me just window it

38:11

and let's close this one out

38:13

and make this a little bit larger.

38:15

Okay, so now as you look here, you can see

38:18

that this dark area right here is the anterior

38:21

fibromuscular stroma.

38:23

And if I cross correlate that, you'll see

38:24

where that corresponds.

38:26

There is no restricted diffusion on the other side.

38:29

I'm not seeing this signal, which means this, um,

38:33

abnormality that is present in the transition zone is also

38:36

extending into the anterior fibromuscular

38:38

stromal region on the left.

38:40

'cause you don't see that, uh, dark signal anymore.

38:43

As you can see, as I, as I point to the outer margin

38:46

of this, it is where you see the restricted diffusion.

38:48

So, uh,

38:49

it clearly is involving the anterior fibromuscular stromal

38:52

region, which again, is important for them to know about.

38:55

'cause that is going to factor into how they, uh,

38:58

do the risk strat, uh, risk stratification.

39:01

So again, a large lesion in the transition zone

39:04

showing restricted diffusion.

39:06

And, um, uh, this came back as a on,

39:10

on the fusion biopsy.

39:11

This came back as a Gleason four plus four in the anterior,

39:16

um, mid transition zone.

39:19

So that's what it was.

39:20

And so this is one that is extending into the fibromuscular,

39:23

um, stromal region.

39:26

Okay, so then we move on to the next case, which is

39:37

eight.

39:47

So this is a case patient who, um, initially had a,

39:52

see if I have the right exam,

39:57

uh, had an elevated PSA

39:59

and the, uh,

40:01

urologist felt something on the, uh, right side.

40:04

And so the patient was sent for, um, a prebi MR

40:09

and the, uh, PSA density was less than 0.15.

40:14

Uh, so it was not, uh, above the cutoff value.

40:17

Now, as you look at the axial image here, you can see that

40:22

clearly there is a, the left side is nice

40:24

and pristine, the right side is nice

40:26

and coming closer to the midline in the right mid posterior,

40:29

there seems to be a bulge.

40:30

And there is a T two dark signal that is seen.

40:33

Um, and here is the calculated B value.

40:37

Now, if you look very closely at five window, this, well,

40:42

there is mild asymmetry, but compared to the left side,

40:46

but it is not as restricting as some

40:48

of the other cases we saw early on.

40:51

So now let's look at the enhanced images.

40:55

And as I go through the,

41:04

here's the early enhanced, uh, arterial sort

41:07

of early arterial phase,

41:09

and you'll see that compared to some

41:10

of the other earlier cases we saw, which were, you know,

41:14

lesions that had classically read the textbook.

41:17

Um, this one does not show much early enhancement.

41:22

And so let's look at the A DC as well.

41:25

So there is little bit of asymmetry.

41:27

And so this is what one would put in the RAD three category,

41:31

right, where there is some dark signal on on the A DC, uh,

41:35

which is asymmetric,

41:36

but correspondingly you don't see a lot

41:38

of bright signal on the DWI high B, high B value DWI.

41:43

And clearly there is no early enhancement.

41:45

If it was, uh, presenting like this

41:48

and did show early enhancement, then it would bump it up

41:51

to a PYS four.

41:53

Um, but in this case it's a PYS three.

41:55

Now at our institution,

41:57

we mark everything pys three and above.

42:00

And so this was clearly, uh, something that, um, uh,

42:03

looks very sinister on T two, uh, does not have the kind

42:08

of diffusion you would expect, um, to see, uh,

42:11

with a lesion of this size.

42:13

And, and, and, and you know, this, uh, sort of appearance

42:16

and clearly there is no early enhancement.

42:18

And so this was a pyre three lesion which was marked,

42:22

and the, uh, the lesion was targeted successfully

42:25

and the target targeted biopsy came back negative

42:29

and this patient ended up getting a follow-up.

42:32

Mr. So this is done in the year 2020,

42:35

and there is a follow-up Mr in, uh, 2023.

42:40

Uh, so let me just see if I can

42:45

open that in the new window.

42:47

Okay. And so I'll just bring it up here

42:49

so you can actually see the, uh,

42:55

so here's the old T two

42:56

and I'm gonna show you the T two in 2023,

43:01

same patient, and you can see that in that location,

43:06

that thing that that area has totally cleared up.

43:12

And so why am I showing you this case?

43:15

I'm showing you this case. He actually has a slight, um,

43:18

herniated BPH Nole on the left side.

43:20

As you can see, it is contiguous with a surgical capsule,

43:22

very sharply de marketed there.

43:25

Um, the reason I'm showing you is that, um, this is one

43:30

manifestation of, you know, post-inflammatory findings

43:33

where, and they are reversible

43:35

as you're seeing in this case,

43:37

and they can look quite sinister on T two.

43:39

It looks almost like an aggressive looking lesion

43:41

with a capsular bulge.

43:43

Uh, but then what was, um, uh, what did tell us,

43:48

uh, uh,

43:49

or what tempered our T two weight appearance was looking at

43:53

the diffusion and relative lack of early enhancement

43:55

for the size of the lesion.

43:57

Uh, but anyway, the right thing was done.

43:59

You still follow the algorithm, it, it fall,

44:02

it fits the pyres three category.

44:03

And this was, uh, uh,

44:06

rad three category was biopsied was negative

44:08

and as subsequently cleared up.

44:09

So this is a classic example of a false positive on T two.

44:13

Uh, so, you know, again,

44:15

make sure you look at all the sequences, make sure

44:17

that you are, uh, adequately sort

44:19

of correlating the information from all the, uh, sequences

44:23

to, uh, to, to make the diagnosis.

44:26

So that's, um, uh,

44:30

so moving on to the next case.

44:36

So this is a, again, a 60 some odd year old patient.

44:39

Let me just bring that up just a second.

44:45

And, uh,

44:50

patient had a, uh, PSA level of, um, 3.7

44:55

and a PSA density of 0.11.

44:58

And so not, not very high PS density, uh,

45:02

it's less than 0.15 in the P

45:04

but the, the, um, the primary care physician who was,

45:08

you know, examining the patient was very adamant

45:12

that they felt something very, uh, hard on the left side.

45:16

And so they referred the patient for mr.

45:19

And so let's start with the axial T two again.

45:24

So as you can see on the axial T two here, that

45:27

there is bright signal, expected,

45:28

bright signal on the right side.

45:30

Uh, you know, the transition zone is not very large, uh,

45:33

and it's has that sort of bilateral symmetric appearance

45:36

that we are expected to see.

45:38

And in addition to that, what you're seeing here is, um,

45:42

the entire lobe, uh, left lobe

45:45

of the peripheral zone is dark,

45:46

and within that left lobe there is an area

45:48

that appears relatively more dark.

45:51

So clearly there's something going on there,

45:52

and let's now, um, uh,

45:55

look at it on the coronal and the diffusion.

45:57

So let's see,

46:01

maybe I'm missing the, well, let's see the sag,

46:07

if I cross correlate it, you'll see that that's the

46:10

entire pedophile zone, abnormal side,

46:13

and going to the normal side, you have normal signal there.

46:16

And now let's see the enhanced images

46:20

and the TWI.

46:37

Okay, so

46:42

sorry, I'm trying to bring up the correct.

46:44

Uh, yeah, so here's the A, DC,

46:49

and let me just window it a little bit.

46:52

So as you can see that on the left side,

46:56

the entire peripheral zone is abnormal,

47:00

but remember if you'll be saw on the axial T two,

47:04

as you can see on the

47:08

axial T two, that there was a more focal area

47:11

of dark signal, and that's also appears a little bit more

47:14

darker on the A DC compared

47:15

to the entire other left peripheral zone.

47:18

Plus, when you look at the enhancement, you'll see that

47:20

that's this area which is more dark on, uh, the, uh,

47:25

a DC shows what looks like a ring-like enhancement on the,

47:29

uh, and plus the entire peripheral zone is also enhancing

47:32

early, but that area is showing, uh, lack of enhancement.

47:36

It almost looks like an abscess.

47:38

And so when you see this ring-like enhancement

47:40

with this low bar, um, change on the PWI, along with sort

47:45

of low bar enhancement,

47:47

you start thinking about, you know, tumor.

47:49

Typically most asner adenocarcinomas, the,

47:53

the most common type

47:54

of adenocarcinomas we see in the prostate,

47:56

they don't typically cause this kind

47:58

of rim like enhancement.

47:59

When you see like that appearance

48:01

and you start thinking about is there some kind

48:03

of a history here that we are not being provided?

48:06

And on probing

48:07

and biopsying the patient's chart,

48:09

what we found was this patient actually had bladder cancer,

48:12

uh, and, and had been given BCG, um, um,

48:17

a a few months earlier for treatment

48:19

of the superficial bladder cancer.

48:21

And so, uh, this was sample, this came back as chronic,

48:25

uh, oma prostatitis.

48:26

So this is a post BCG prostatitis,

48:29

and this is what it looks like.

48:31

Uh, typically it has this sort of ring,

48:32

ring-like enhancement, um, which, you know,

48:35

tumors don't typically show that.

48:37

And so just be very, you know, look at the history.

48:41

I mean, again, looking on the T two and the, and the, um,

48:45

and if you were doing just a bi parametric approach,

48:47

you can imagine that, you know, one could, uh,

48:50

easily confuse this for a, um, aggressive looking cancer.

48:55

It's the ring enhancement that sort of helps you, um,

48:59

accurately, you know, put it into the right context

49:01

and of obviously you need the correct clinical

49:03

history to go along with that.

49:04

So, so this is a, uh, a good example of, uh,

49:11

uh, of a chronic titis, uh, prostatitis.

49:15

Um, okay, moving on to the next case.

49:18

This is a bring it up one second.

49:24

Okay. So this is a patient

49:29

who is 70-year-old

49:31

and comes in, um, with a, uh, uh,

49:36

slightly elevated P-S-A-P-S-A density is not very

49:38

high, it's 0.08.

49:40

And, um, the, um, again, something was felt digitally

49:45

and so the patient was referred.

49:47

So let's start with the axial.

49:50

Uh, let's take a look at the, uh,

49:53

T one also before we start.

49:54

So this is the pre contrast T one,

49:57

and as, I'm sorry, that's GC galin here.

49:59

So that's d let me bring up the early,

50:05

let's see, this is, yeah, so

50:11

this is the early sort of run

50:12

before giving, I guess this must have been

50:14

a slight test bolus.

50:15

That's what it's there. But this is the pre contrast run.

50:18

And you can see that in this case there is bright signal in

50:21

the peripheral zone bilaterally,

50:23

and you can see that there is, um, and,

50:26

and the reason this happens is, you know, we used

50:29

to see this more commonly when, you know,

50:31

before, uh, sort of the, uh, advent of, uh,

50:35

using multiparametric mr to guide the biopsy.

50:39

Um, but um, and so we used to see this a lot.

50:42

And the reason why you see hemorrhages,

50:45

because the prosthetic secretions, they contain citrate

50:48

or citrate and citrate is a naturally

50:50

occurring anticoagulant.

50:51

It's also present in pleural fluid

50:53

and some of the other fluids.

50:55

So that prevents blood from clotting.

50:56

And so hemorrhage can stay for a longer time, um,

51:00

before, um, you know,

51:02

before it gets, uh, resolved with the, uh, uh,

51:06

after, after the biopsy.

51:08

But here in this case, the patient has not had a biopsy.

51:10

This is spontaneous bleed.

51:12

The patient is 71 is on, has some cardiac issues, and

51:15

therefore is on anticoagulation.

51:17

And this is what I was referring to.

51:19

Now, this can sometimes be a helpful thing for you

51:21

because there is a, uh, uh, not very sensitive,

51:26

but quite a specific sign, which is referred to

51:28

as a hemorrhagic, um, exclusion sign.

51:30

And so if you look the, you know, there is involvement,

51:33

but there is a certain area on the right side

51:36

where you don't see hemorrhage.

51:38

And now remember, uh, I said the, uh,

51:41

normal prostate contained

51:42

or prostatic, uh, uh,

51:44

secretions contain citrate if you have tumor

51:46

that replaces the normal prostate

51:48

and that part of the gland does not

51:50

secrete the normal secretions.

51:51

And so that area will not have the citrate

51:54

and blood may not stay there for a long duration.

51:56

That's sort of the underlying premise

51:58

for the hemorrhage exclusion sign.

52:00

And so you can see in this case

52:01

that there is dark signal there on the right side

52:04

where there is no hemorrhage on the, um,

52:07

on the pre contrast T one.

52:09

So let's look at the, uh, DWI

52:12

to see what's going on in that location.

52:14

So this is the high B value, that's the A, DC.

52:15

And let me just window this a little bit better.

52:21

And so as we come down to that location, you will see that

52:25

that area where there is lack of hemorrhage,

52:27

T two dark signal, there clearly is bright DWI

52:31

and dark A DC.

52:32

So there clearly is restricted diffusion.

52:34

And then just to see what it's doing on the, uh,

52:39

enhanced sequences

52:45

for which you'll need subtraction,

52:46

because obviously there is bright.

52:48

So we'll take a look at the subtractions.

52:51

You can see that there is early enhancement in

52:53

that location on the subtraction,

52:56

which nicely corresponds to.

52:57

Um, so again, uh, a useful sign that may help you out.

53:02

This is a hemorrhage exclusion sign, um,

53:06

which clearly showing restricted diffusion.

53:08

Uh, one other point to keep in mind is, you know,

53:10

there used when our high B values were not, um, quite

53:15

as high, uh, you know, even till about, uh,

53:18

a decade ago when we were doing Mrs, you know,

53:21

our typical B values were in the range of, um, you know,

53:24

800, the highest B value, 800 to a thousand.

53:28

Uh, and we used to rely more on the ADCs in terms

53:30

of dark signal than the high B value.

53:33

Now with the high B values being close to two, close to 2000

53:36

or even 2,500 in some instances, uh, you know,

53:39

this confounding issue of, um, hemorrhage causing, uh,

53:43

problems is, is less of a issue.

53:46

So, you know, you can clearly see through some, uh,

53:48

hemorrhage within the peripheral zone

53:50

and can actually identify the, um, uh, the tumor nicely.

53:53

And so the, the take home here is also if you end up doing a

53:57

DC make sure reduce subtractions,

53:58

which you always should do when you,

54:00

whenever you give gadolinium, uh,

54:02

you can nicely see the lesions against the backdrop

54:04

of bright signal and there clearly is a restricted,

54:07

uh, diffusion here.

54:09

So I think I'll stop there because it's 1254,

54:12

but, uh, I would like to take the, um, uh, opportunity

54:16

to answer some of the questions

54:17

that have been raised in the, uh, in the q and a.

54:22

And let me see if there's anything in the, uh,

54:29

so somebody has said, would it be a good idea to use clocks

54:32

for location of the lesion?

54:33

So, uh, that's an interesting,

54:36

just like we do in our fistulas, um, obviously the,

54:39

the problem there is, you know, the reason we use a clock is

54:42

because in fistulas that's

54:44

how the surgeons also foresee their surgical field.

54:47

So it becomes easy to correlate.

54:49

The urologists are not doing it that way

54:50

because it depends on how they do the biopsy.

54:54

You know, most of our biopsies are done trans perennially,

54:56

which is not exactly the way we are looking at it,

54:59

so it would not serve any purpose in terms of directly

55:03

or directing them, whereas the description actually gives

55:06

them an idea as to where it is.

55:07

So that may be a useful, uh, case

55:10

to follow the way I describe rather

55:11

than doing a clock phase.

55:13

So let's see what some of the, um, uh,

55:22

why do you call that early enhancement?

55:24

Well, so I think, I don't know which case they're, um,

55:27

they're referring to, but uh,

55:29

the question is when do you call it?

55:31

And you know, we used

55:32

to in years paths do quantitative metrics of looking at,

55:36

you know, certain maps for, um, uh, comparing the area

55:40

that is in question

55:41

and comparing it that to the arterial input

55:44

or femoral arterial input function.

55:46

We don't do that anymore. It's all qualitative assessment.

55:49

So what you're doing is you're doing two things.

55:51

One is you can do a rough region of interest on that area

55:55

and you can temporarily plot the, uh,

55:57

time intensity curve on your packs, compare that

55:59

to the contralateral

56:01

or normal site, uh, as well as compare that to the artery.

56:04

So that gives you a good frame of reference as

56:06

to whether the lesion is enhancing early or not.

56:09

Uh, so sometimes, you know, just visually looking,

56:11

you may not be able to make the assessment doing this quick,

56:14

um, assessment on pacs, where you do draw a region

56:17

of interest and do a time intensity curve,

56:19

uh, that does help you.

56:22

So why not an abscess?

56:23

It's not an abscess

56:24

because, uh, I mean it, it's a matter of semantics,

56:28

what you call the post oma, um, inflammation.

56:31

You know, some people argue

56:33

that this is an infection from the attenuated basi

56:36

that are instilled, but majority

56:38

because you never can isolate the basi from that,

56:41

from these biopsies.

56:43

Majority failure, it's a hypersensitivity reaction.

56:45

So to call it an abscess is sort of a misnomer in a sense.

56:49

It's more post-inflammatory changes rather than an abscess.

56:54

Um, so let's see, what,

56:57

what rads would you ascribe

56:59

to gran matters prost, and would you follow?

57:01

So that's actually a good question.

57:03

If you are a purist, uh,

57:04

and again, as a matter of reporting, what we would do is

57:08

the way we would phrase it, we would say

57:10

that this lesion shows a restricted diffusion.

57:12

Let's say the lesion did not show the peripheral ring

57:15

enhancement, but there was a history of prior

57:17

VCG installation.

57:19

So then what you would do is you would say while there is a,

57:22

you know, large lobar area of restricted diffusion that, uh,

57:25

that, uh, shows early enhancement, given the prior history

57:29

of, um, al prior history of, uh, VCG therapy,

57:34

this likely represent Altus Prostitis, uh,

57:37

although the lesion meets criteria for a S five lesion,

57:40

so they, they know that, you know,

57:42

despite your calling it a PYS five, they have to target it.

57:45

If they get, if it comes back as negative,

57:47

they shouldn't be surprised as what they see it as.

57:51

Would it help if PSA density be routinely competed

57:53

for all new cases encountered?

57:54

Yes, I think, uh, uh, that's part of our standard, uh,

57:58

reporting template.

57:59

When we are reporting these cases, uh, we typically, uh,

58:03

always put the PSA density,

58:05

and I told you the reasons for that

58:06

because it does help you in your, um, in your readout.

58:10

What do you do with TZL defined mixed

58:12

or stromal com by BPH looking tissue that has abnormal DDI?

58:17

Do you ever, uh, recommend follow up?

58:20

So again, this is a, um, a very common occurrence

58:22

and I'm glad somebody asked this question, uh,

58:25

because, you know, not everything is very clear cut

58:28

as we lay it out in our pirate schematics.

58:31

When you see a, a fair number of cases, as we do,

58:35

sometimes the BPH nodules don't follow the, you know,

58:38

all the rules and sometimes you may find one single area

58:41

that is way more restricting than the rest of the, uh, tz.

58:45

And no matter how, uh, many, uh, which planes you look at,

58:49

you're not able to clearly define the

58:51

capsule in its entirety.

58:53

So in that case, you know, we, if you are ever in

58:55

that dilemma, we call it a RAD three, um,

58:58

and we market, uh, so that it's targeted, uh, at the time

59:01

of biopsy, but we do indicate, let's say in the body,

59:04

as I said earlier, we will say, well,

59:06

this does show restricted diffusion

59:08

and appears to be asymmetrically more prominent than

59:10

as we think that this may be an atypical VPH.

59:12

So this way, again, when it comes back negative, they know

59:15

that this is not, um, uh, not a, uh, uh,

59:20

you know, not, and not something

59:22

that they should be worried about.

59:23

The last case, uh, the one with the hemorrhage exclusion

59:26

and somebody wants a diagnosis, that was a,

59:28

it was a Gleason four plus three cancer on, uh, sampling.

59:32

Uh, I think pretty much I've covered most, uh,

59:37

is 1.5 Tesla enough for three T required.

59:40

Um, you know, that's a very, uh, important question

59:43

and perhaps the last one that I'll answer where, um,

59:47

I think all our patients are done on three T

59:49

and they're done without the coil.

59:50

That's because of the spatial resolution

59:52

and also for the temporal resolution on the enhanced images.

59:55

If you do it on the 1.5, the problem is no matter how well,

60:00

uh, or how uh, good your phase coils are,

60:03

you still are at a loss of signal, especially with DWI.

60:07

And in those cases, in order to truly get the value,

60:10

you have to try and accentuate the signal within end coil,

60:14

which is not ideal.

60:15

So the only time you do 1.5 T is when the patient has

60:18

orthopedic hardware or there is a pacemaker,

60:21

or there is some other re reason

60:23

where the three T cannot be done,

60:25

but for most of the cases, our preference is

60:28

to do three T without a uh, Endor coil.

60:31

So I'll stop sharing and, um, thank you again.

60:33

And I don't know if, um, there are any closing comments,

60:36

but, uh, thank you so much for your attention

60:39

and uh, it's a pleasure.

60:41

It was a pleasure presenting.

60:43

Well, thank you so much for that awesome case review.

60:46

That was incredible and thank you so much

60:48

for answering all those questions.

60:49

Really appreciate you being here.

60:52

Thank you. Take care, guys.

60:54

Of course. Yeah, and thank you so much for everyone else

60:57

for participating in this noon conference

60:58

and asking great questions.

61:00

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61:03

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61:12

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61:15

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