0:03

Here's a 73-year-old man.

0:05

He's got an elevated PSA three weeks

0:07

prior to this examination of 8.1,

0:10

and his last biopsy performed in the 90s.

0:15

I didn't even know they did biopsies in the 90s.

0:18

I can't even remember what I was doing in the 90s.

0:21

He's had no other surgery, but he

0:25

does have a strong family history.

0:28

So let's take a look at this gentleman.

0:31

Who has bilateral hip replacements.

0:35

Now that's a problem.

0:36

Because now we've got susceptibility

0:38

effect and aspect ratio distortion

0:40

that precludes the acquisition of a

0:43

successful diffusion image and ADC map.

0:47

So, what's a mother to do?

0:51

We're gonna rely on the morphology and the

0:56

DCE, Dynamic Contrast Enhanced MRI, which

1:00

is useful in 10 percent or so of cases.

1:03

Thank you.

1:03

As a second line of defense, as a supplement, in

1:08

a case where some of the other primary sequences

1:11

are not available for various reasons, in this

1:14

case, because of bilateral hip replacement.

1:17

So let's scroll, we'll scroll down

1:20

towards the apex, and we see some

1:22

puffy, gray, nodular signal in the PZ.

1:28

In fact, it's in the PZA.

1:30

It's mostly apical.

1:32

And it's on several slices.

1:34

It does not involve the urethra,

1:36

which is right next to it.

1:38

But it is pushing out on the capsule,

1:41

and has quite a bit of capsular abutment.

1:45

Look at it on the coronal projection.

1:47

It's also disturbing.

1:49

Here we are down low.

1:50

This is all peripheral zone right here.

1:52

This is TZ, this is PZ, and within the

1:56

PZ, our mass is bulging the lateral aspect

2:00

of the capsule, and it's got some height.

2:03

In fact, I'm gonna trace over it

2:05

just so you can see it very nicely.

2:07

And we do a lot of tracing when we are mapping

2:10

out these lesions for our surgeons.

2:14

So now, we have to go to our DCE MRI

2:18

to see if it's a vascular lesion.

2:21

We don't have to.

2:23

But it would be helpful if it was vascular.

2:26

And we would rely a little more heavily on

2:28

the DCE MRI than we otherwise normally would.

2:33

And sure enough, there it is.

2:36

Maybe my cursor's a little bit off, but

2:38

I think you can see this lesion here

2:41

correlates to that lesion on the axial

2:44

T2 2D fast spin echo correlates to

2:49

this lesion in the coronal projection.

2:52

Just for interest, and for giggles.

2:56

We'll confirm that the neurovascular

2:59

bundle, these little spots surrounded

3:01

by fat, are not involved by our lesion.

3:05

So we'll go high, then we'll go low to

3:07

where the lesion is, to make sure that

3:10

we do have a fatty plane, and we do.

3:13

So we might have microcapsular invasion.

3:17

We probably do not have

3:19

neurovascular bundle invasion.

3:21

We've relied on the DCE MRI as a supplement.

3:25

Because our diffusion image has failed as a result

3:28

of bilateral hip replacement and our T2 fast spin

3:32

echo shows a morphologically highly worrisome

3:37

area of nodularity, mass, and mass effect.