0:00

This is an 83-year-old man with an elevated PSA.

0:03

I actually don't have the exact PSA number, which

0:07

might actually be helpful in this case, as we'll

0:10

see a little bit later on, when we evaluate how

0:13

to integrate the clinical with the radiologic.

0:17

But the point I want to make in this case

0:19

is that, like in breast BI-RADS imaging,

0:22

or BI-RADS classification, BI-RADS puts

0:26

you in a pinhole or in a hole that

0:30

may be square when your situation is round.

0:34

So you've got a round peg and a square hole.

0:37

So the PIRADS V2 is good for

0:40

intermediate-level practitioners and

0:42

beginners, but it takes a village.

0:45

It takes a lot more than that

0:46

to make an intelligent, cogent

0:49

decision about how to manage a case.

0:51

And this is one such case where the

0:53

original reader with modest experience,

0:56

read this as a PIRADS 2 lesion.

1:00

Now why did she do that?

1:02

She did that because the main criteria for

1:05

bumping up a PIRADS lesion in this area,

1:09

namely the AS, the anterior fibromuscular

1:13

stroma, and anterior TZ, is the T2 shape.

1:17

And the T2 shape is, at

1:20

first glance, somewhat oval.

1:23

But admittedly, the edges of it are ill-defined.

1:26

And she chose to, maybe appropriately,

1:30

if you're a strictly speaking PI-RADS V2,

1:33

ignore this area of exaggerated diffusion

1:37

restriction and conspicuity on the ADC map.

1:42

But when you take the case in its totality,

1:45

the degree of diffusion restriction is

1:48

pretty pronounced and it's different

1:49

than anything else in the TZ or AS.

1:53

And so is this.

1:56

So it stands out all by itself.

1:59

Second, this nodule isn't

2:02

really that well-defined.

2:07

I don't like that.

2:10

Third, we know that the anterior TZ and AS,

2:14

the anterior fibromuscular stroma, is gray,

2:17

and PIRADS V2 criteria are also not very

2:24

accurate and not very consistent in this area.

2:27

Therefore, the grading system itself is gray.

2:30

So it's gray and gray.

2:33

So when you take the whole case together,

2:35

and you choose whether you're going to go

2:37

PIRADS 2, you're going to straddle the

2:40

fence as a PIRADS 3, or you're going to

2:43

go PIRADS 4, I'm going to go PIRADS 4.

2:47

Even though the original reader read it as a

2:48

PIRADS 2, for all the reasons that I mentioned.

2:52

So this takes us towards

2:54

what I would call PIRADS 2.

2:55

The clinical radiographic Likert grading system

2:59

in which you use your overall experience,

3:02

you know, of hundreds of thousands of cases

3:05

to make a decision based on some nuanced

3:08

findings, many of which we described.

3:11

Now I might, I might add in or weave in another,

3:15

piece of information, like the, the PSA density.

3:19

Let's say the PSA density was three and a half.

3:23

That would also take me up in

3:25

the PIRADS V2 grading system.

3:28

More to the Likert grading system of a, of a five.

3:31

In other words, I would say,

3:33

this is most likely cancer.

3:35

Because people with prostate densities of

3:37

over two are more likely to have cancers.

3:41

So I might factor in, not

3:42

the PSA, but the PSA density.

3:45

Which is basically the PSA divided

3:49

by the volume of the gland.

3:51

Now, I, I don't know the density in this

3:52

case, but I might use that to push me one

3:55

way or the other from a three to a two.

3:57

The PSA density is low, or from a three to

4:00

a four or a five if the PSA density is high.

4:06

Now, there's another piece of

4:07

information here that is potentially

4:10

useful, and that is the DCE-MRI.

4:14

Which is, which is kind of a supplement, you know,

4:16

we don't use it as the primary decider.

4:20

But, but there are times when you have to use it.

4:23

For instance, if your, if your diffusion

4:25

is whacked out, in other words, your

4:27

diffusion is inconsistent or deficient

4:32

because there's air in the rectum or

4:33

there's metal artifact from the hips, then

4:35

you have to start relying on other things.

4:38

Now in this case, I might have downgraded this

4:41

lesion had it been completely hypovascular.

4:45

But it's not.

4:46

This is the very first arrival of the contrast.

4:50

And although it's not inordinately

4:52

hypervascular, it does stand out a little

4:54

bit on its own and it immediately enhances.

4:58

So in other words, and here it is again, as

5:00

we continue on the DCE-MRI, it keeps coming in.

5:04

So the fact that it is not completely

5:06

hypovascular doesn't cancel it out.

5:10

So in other words, this lesion

5:12

that by strict criteria, PIRADS V2.

5:17

You might have read it as a PI-RADS 2.

5:22

I would read it as a clinical

5:25

radiographic Likert 5.

5:28

In other words, this is

5:29

cancer till proven otherwise.

5:31

And the reasons, in summary, are the lesion is in

5:35

an area that is not that reliable with the classic

5:39

PI-RADS V2 grading system, the AS anterior TZ.

5:43

The borders of it are not that well defined.

5:47

In fact, they're ill-defined.

5:49

The diffusion is not only inordinately

5:53

conspicuous, but it's different than

5:56

anything else in the rest of the gland,

5:58

supplemented and proven by the ADC map, and

6:02

the lesion is not inordinately hypovascular.

6:06

So I'm calling this a cancer,

6:08

and this one's getting biopsy.

6:10

I'm not done yet.

6:11

We've got another lesion.

6:14

We've got a lesion back here.

6:16

You might say, well that's

6:17

a little curvilinear lesion.

6:18

It's pretty small.

6:20

There's an ill-defined area of hypo

6:23

intensity on the T2, right there.

6:26

It's a little darker than anything else.

6:29

It's not really bulging very much, but it is

6:32

present on the ADC map, and there's a little

6:35

bit of vascularity associated with it, and it's

6:38

in the PZ, the peripheral zone, posteriorly.

6:42

Kind of the P-Z-P-P-Z-M area.

6:45

So what are we gonna do with that?

6:47

Well, if we were going strict PIRADS criteria,

6:51

the most important thing in the PZ is diffusion.

6:54

The diffusion is weak.

6:56

Yeah, it's positive, but it's weakly positive.

6:58

The ADC map, weakly positive, the

7:02

enhancement weakly positive, and the T

7:06

two characteristics, they're positive, but

7:09

they're not all that concrete, you know?

7:11

No really discrete mass.

7:13

So this is one where I would straddle the fence.

7:16

In the PIRADS grading system,

7:18

and I would call this a PIRADS 3.

7:21

I don't think it matters that much because

7:23

we're going after this lesion in which

7:25

we're using the clinical radiographic Likert

7:28

system where we're integrating everything and

7:31

we're calling the anterior lesion a cancer.

7:34

Go get it, and while you're at it,

7:36

sample the one in the back on the left.