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Okay, we've got a 61-year-old man

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with an elevated PSA of 5.19 recently.

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4 00:00:09,300 --> 00:00:14,850 But there's a history of two negative biopsies,

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and the overall gland volume of 55.4

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yields a PSA density of

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0.09 nanograms per ml per cc.

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So, a very low PSA density.

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So, we've got a lot of factors swirling around us

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that point us away from the diagnosis of cancer.

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And that could potentially

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influence how we attack this lesion.

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So here's an axial T2.

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I'll scroll a little bit just

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to give you a feel for it.

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And some of you may see the lesion right away,

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others may not, but here it is right there.

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And there is a little bit of diffusion

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restriction, here it is right there.

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And that's going to make most of you nervous.

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So, the amount of diffusion restriction is

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mild, as you can see from the intensity, or lack

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thereof, on the high B-value diffusion image.

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The hypointensity is not that profound on

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the ADC map, so you probably would go with the

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see-saw in-between tweener PIRADS 3, or not.

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The original reader went with a PIRADS 3.

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But let's talk about another way

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to approach lesions like this.

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We're going to talk about the Likert

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grading system, which one of my Aussie

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colleagues has informed me is analogous to,

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you know, hotel grading on TripAdvisor.

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So let's see.

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What's a, what's a Likert 1?

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A Likert 1 would be no cancer.

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A Likert 2 would be normal, with some

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abnormalities present that are not cancer.

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A Likert 3 would be possibly cancer.

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A Likert 4 would be probably cancer.

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And a Likert 5 would be cancer.

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Now you're saying to yourself, Okay, how is this

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any different than the PIRADS grading system?

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Well, you know, when you walk into a hotel,

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and you see all the pretty chandeliers,

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and you have a beautiful room, you

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say, okay, well that is a 5-star hotel.

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But what if the food is lousy?

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What if the service is bad?

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What if the beaches are smelly?

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You haven't incorporated all the

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factors that go into making it a

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really superior venue to vacation.

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And that's kind of what the

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Likert system is all about.

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It's not just about the strict PIRADS criteria.

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It may be about how much

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diffusion restriction you have.

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What the PSA rise has been.

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What the PSA density is, where the lesion

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is located, just how encapsulated is it,

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are there microcysts, and innumerable

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other indirect signs that you might

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use to assist you in your diagnosis.

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For instance, you know that in this area up

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front right here, it's a very dangerous area.

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So you might be more aggressive in

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that area with extreme diffusion

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restriction than you might be otherwise.

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Or if you get up high near the central zone,

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where things are very gray and intermediate.

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Let's go up high in the central zone area.

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You know, you're looking more for symmetry

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between the two sides to make a decision.

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Since signal intensities can be

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very amorphous in this location.

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So you're using the entirety of your experience.

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The compendium of your experience both

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visually and all of the clinical factors

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that will push you one way or another

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and improve your odds of being right.

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So the Likert system is more comprehensive.

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Both visually, intellectually, and clinically.

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So, in this particular instance,

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we might say, okay, we've got a little

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nodule abutting the capsule on the left.

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It has some diffusion restriction.

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The ADC map characteristics aren't that strong.

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And when I go to my diffuse,

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to my DCE MRI, let's go there.

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It doesn't look any different than anything else.

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There's no hypervascularity.

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Okay.

4:58

So because we have two negative biopsies and we

5:01

got a low PSA density, I would go with a Likert

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2 and I would follow this one up in a year.

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Plus again, the patient has

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already had two negative biopsies.

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And negative biopsies beget more negative

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biopsies just like they do in the breast.

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Now let's take another caveat.

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Let's take the reverse.

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We have this tweener lesion here.

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A little bit of diffusion restriction.

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But let's say the vascularity was,

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was pretty bright right in this location.

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So now we would say, okay, it's a PI-RADS 3,

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but now we have hypervascularity.

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We're going to use the DCE,

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Dynamic Contrast-Enhanced MRI, to add 3 plus 1

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to give us the equivalent of a 4.

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So we're using the DCE MRI to

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upgrade, or upgrade our nodule.

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Now that didn't happen here.

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But, I'm giving you a hypothetical circumstance.

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Now, a 3 plus 1 in this scenario is not

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as strong as a true PI-RADS 4,

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where you've got a nodule that's under

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1.5 centimeters, and the diffusion restriction

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is really intense, and the ADC is really black.

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That would be a much stronger scenario,

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or a stronger scenario, and more

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likely to have a higher Gleason grade.

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Then this 3 plus 1 scenario,

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which is equivalent to a 4.

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So this case, originally read as a Pirates 3,

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but downgraded, or downbraided, as a

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Likert 2 for all the reasons mentioned. ChatGPT 121 00:06:25,170 --> 00:06:27,030 That would be a much stronger scenario,

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or a stronger scenario, and more

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likely to have a higher Gleason grade.

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Than this 3 plus 1 scenario,

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which is equivalent to a 4.

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So this case, originally read as a PI-RADS 3,

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but downgraded, or downgraded,

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as a Likert 2 for all the reasons mentioned.