0:00

So a common request

0:01

that I get either in my daily reporting or in an MDT

0:05

or in a case review meeting is

0:06

to compare the MULTIPARAMETRIC

0:08

or M-P-M-R-I of the prostate to the PSMA pet.

0:12

And we're essentially just looking to make sure

0:14

that the lesions that have been detected on MRI fit

0:16

with the pattern of uptake and whether

0:18

or not there is something

0:19

that perhaps we didn't see on the MRI or whether

0:22

or not the lesion itself is PSMA negative.

0:25

So this is one of those such cases.

0:27

So I've put the MRI loaded up, um, into Umbra as well

0:30

as the PSMA pet.

0:31

We'll start with our PSA reading and then we'll go back

0:33

and correlate our lesion to make sure it matches.

0:36

So as always, we're gonna start with our rotating mip,

0:39

we'll just zoom him down a little bit so we can see

0:41

and give it a bit of a spin.

0:43

And already you can see that there's a dominant area

0:45

of focal intense uptake in the prostate.

0:47

There was also kinda something controversially on

0:50

that left hand side as well.

0:51

So we need to look closely at that On the axials,

0:54

I don't see any extra dots through the pelvis to tell me um,

0:57

that there may be PSMA expressing lymphadenopathy.

0:59

There are a few kind of mildly

1:01

avid spots through the thorax.

1:03

Um, and at this level again, you know we within

1:05

what we would expect for reactive lymphadenopathy,

1:07

particularly if there is not disease elsewhere.

1:11

So coming back to our effusion imaging

1:13

and the patient has fiducials in situ so they probably plan

1:16

for radiotherapy and we'll see if they've got some hydrogel,

1:19

which I can't see in this case.

1:21

So coming down, as you can see,

1:23

systematically working our way through the prostate,

1:26

starting at the bladder and through the base it's a bit

1:28

of calcification that can be normal.

1:30

Um, a little bit of heterogeneous uptake

1:32

through the prostate and there is this intensely PSMA

1:36

expressing lesion in the peripheral zone at the apex,

1:41

probably extending up to the mid gland with these cases.

1:44

I really wanna check the seminal vesicles to make sure,

1:46

especially if you've got a posterior lesion, to make sure

1:48

that it isn't extending into it.

1:49

So here's the right seminal VSL on the left

1:52

and I'll just scroll up and down tracing it to the back

1:54

of the prostate, which is through here.

1:55

And that looks pretty clean coming up through here as well.

1:59

So we did see something else on that rotating mip,

2:01

so we need to check out that other dot.

2:03

So we've got this dominant lesion eccentric to the right,

2:06

crossing the midline, not involving the seminal VSLs,

2:08

but then kind of scrolling up a little to the mid gland

2:11

and just to the left of that fiducial here,

2:14

there's an area of focal uptake.

2:16

So is this a second primary?

2:18

Um, it is quite focal but they do have fiducials.

2:20

It could be inflammation. So we really wanna go back

2:22

and check on our MRI to see if there's something there.

2:25

So coming up through our lymph noses,

2:26

we really wanna check our pelvic sidewalls

2:28

and we'll see that there's this dot

2:29

that correlates to the ureter.

2:30

There's hyperdense contrast within it

2:32

and we can track it up as well.

2:34

So that looks fine. And then we're doing our scrolling up

2:36

and down following the vessels as they come through.

2:39

Pausing at the pelvic side while going up

2:41

and down to see if there's any nodes.

2:42

There's a couple of little nodes you can see in here,

2:45

but these are not particularly avid.

2:47

So we're gonna give them a pass

2:49

checking the internal iliac branches as we come up

2:52

to the common iliacs

2:53

and retroperitoneum, catch it at the aortic bifurcation

2:56

and repeat the process for the other side coming

2:58

Down through here. That

2:59

looks pretty good. Up

3:01

and down through the pelvic sidewall, there's another one

3:03

of those prominent lymph nodes.

3:04

Little bit of uptake.

3:06

I might mention this in the body of my report

3:07

but then rationalize it as no intense uptake and whether

3:11

or not this is right or not, I tend

3:12

to throw in some words like definite recurrence

3:14

because can I exclude like low volume disease?

3:17

No, I can't. But do I think this is an involved node?

3:19

No, I don't. So I'll say that there is no definite evidence

3:22

of suspicious PSMA expressing lymphadenopathy.

3:25

If I wanna hedge or depending on how I go, I might come down

3:29

and go, no, no evidence of.

3:31

So coming up the aortic ification, we'll run

3:34

through the retroperitoneum as always coming up

3:37

to those ganglia here.

3:39

So celiac ganglia on the left

3:41

and we're seeing just a little one there on the right

3:44

and checking the mediastinum

3:46

for those mildly at PSMA expressing lymph nodes.

3:48

And again, similar into the pelvis.

3:50

I don't think these are involved, um,

3:51

but there is just some mild avidity.

3:53

Um, I may talk about it.

3:55

And there was also this kind of inter lobar node as well.

3:58

Um, so with these ones, because it is a bit prominent

4:01

and the um, pattern is a little bit asymmetric,

4:03

I'll just mention it in my report.

4:04

Bilateral mildly PSMA expressing mediastinal

4:07

and hilar lymph nodes including an inter lobar lymph node,

4:10

um, likely reactive.

4:11

Alright, but we wanna go

4:13

and have a look at the prostate so let's get back through.

4:16

Um, and in a normal case in my reading,

4:18

I make sure I'd be checking the liver, turning it down, um,

4:22

as well as going up and through the lungs

4:24

and checking the skeleton very carefully.

4:26

Um, but I know

4:27

that in this case there was no evidence of met.

4:29

So we really wanna have a look at these lesions

4:31

within the prostate.

4:33

And so let's have a look at this patient's MRI

4:36

and we've got the, so I pulled in the DWI as well as

4:41

we wanna pull in the T two as well, um, for

4:44

that RADS classification.

4:45

And we're looking really for evidence of

4:48

abnormal diffusion restriction, um, in those regions.

4:51

And here is

4:52

that really intensely PSMA expressing primary lesion

4:56

with DWI, um, high signal.

4:58

And then on the A DC it is dark, um,

5:02

for diffusion restriction,

5:03

but interestingly in that other peripheral zone lesion,

5:05

I'm not seeing too much at all.

5:07

So in this case, what do we do?

5:09

Um, it is near the fiducial marker

5:10

so it could be inflammatory.

5:11

So the first thing I would do would be

5:13

to compare if they've had baseline imaging.

5:15

Was there A-P-S-M-A AVID lesion there in retrospect

5:18

on the prior study?

5:19

And if it was, I'd be coming down hard on it.

5:22

If there was not, then you know,

5:23

I'd be hedging a little more.

5:24

And also we can kind of make the argument

5:27

that maybe there might be smart effect in

5:28

the region of the fiducials.

5:29

But the other thing was we want you need

5:31

to do is correlate this with

5:32

what the clinicians have mentioned with their results.

5:35

So if they've done multiple, um,

5:37

prostate biopsies, what did the cause show?

5:39

Were they only getting positive cause

5:40

on the right side of the gland?

5:41

Did they see anything in that left peripheral zone?

5:43

And then we can have an MDT discretion about

5:45

how best to proceed.

5:47

And the reason we do that is we know

5:48

that this patient's being planned for radiotherapy

5:50

and our radiotherapy colleagues will use the PET

5:53

and the MRI to determine what areas they need to boost

5:56

for their therapy.

5:57

Um, and so they may decide to consider that as artifact

6:00

and just treat it as for the rest of the prostate.

6:02

Or if there is suspicion, they may give a little bit

6:03

of extra dose to that area of uptake.