 Our first case tells a story. It's one of our own, one of our own docs who came home from Florida to find his screening PSA, which he had obtained at a health fair, was in the 40s. He then underwent an MR examination and a visit to his position. The MR examination using the cardiac coil on a T2 water weighted and a T1 weighted MRI shows one of the typical findings of prostate cancer, namely an ill-defined area of low signal on the T2 weighted image that looks a little bit like the erasure sign that we see in osteomyelitis, the so-called charcoal, ill-defined, hypo intense sign in the right portion of the gland as opposed to the heterogeneous, lumpy bumpy, dark, some bright areas of the left portion of the gland which is normal. The right portion of the gland is where the tumor sits. I'd like to share with you some basic facts now before we plunge into cases like this and others. Prostate cancer affects about 250,000 Americans a year and it kills somewhere between 25,000 and 3,000. It kills somewhere between 25,000 and 30,000 Americans per year. There are two ways that we screen for prostate cancer. One is with the serum PSA which has become controversial and the other one is with a digital rectal examination. The United States Preventative Task Force has suggested that PSA shouldn't be used in American men at all, whereas the American Urologic Association in 2013 suggested that only symptomatic men should be screened with a PSA up to age 54 but after age 54 from 55 on then serum PSA can be used as a screening evaluator. And we're going to see how MRI fits in into the evaluation of these two groups especially the over 55-year-old group that has an elevated PSA. Let's come back to our case. Let's look at the prostate as a globe and within that globe we have several key anatomic areas which I'd like to share with you right now. So let's do that in a very simple mode. I'm going to use my drawing tool and I'm going to make the prostate into a globe. This is an axial view of the prostate and on either side of that globe we've got the neurovascular bundle which consists of nerves and vessels. I've got a couple vessels in there and I'll make the nerves pink and they're located near the base or upper portion or proximal portion of the bladder at about the 7 o'clock and on the other side the 5 o'clock position so let's put them in there and we've got our neurovascular bundle. The outer boundary of the prostate is known as the anatomic capsule. Around that anatomic capsule we've got a vascular plexus which is known as the periprostatic venous plexus and I've drawn it in here in green. Remember this is an axial projection. Within our axial view we have our urethra which I'll draw in yellow and then immediately surrounding our urethra which I'll draw in blue is the transitional zone which is part of the central region of the prostate. Around that transitional zone sits another area known as the central zone. Now this is a little bit confusing I'm going to make the central zone orange so the central zone orange and the transitional zone blue comprise the central portion of the prostate together so we have a central portion and then as you get older this gets a little bit bigger in fact it gets a lot bigger and then this outer area this black area which we haven't colored in is the peripheral area of the prostate which goes all the way around the prostate from top to bottom but gets thinner in various positions as we go from top to bottom which we'll see in a few moments. Now the peripheral zone contains about 75% of the glands of the prostate by volume. The transitional zone contains about 5% and the central zone contains about 20%. Now as you age the transitional zone will get bigger and bigger and press the central zone outward against the peripheral zone so that eventually when you're 70 years old the prostate may look something like this. You've got a big central region which is comprised of mostly transitional zone tissue that presses the central zone area out against the peripheral zone and the peripheral zone becomes thinner and thinner and thinner. Oh but we're not done yet. Let's use our eraser let's look at the prostate in the sagittal projection and I'm going to use my same color just for consistency and I'll make the bladder up at the top here's your bladder and coming out of the bladder we'll make this time in pink the urethra which comes down and around and around the urethra as you would expect you're going to have the transitional zone which I've got here this time in purple instead of blue and around our transitional zone as part of the central region we have the outer part of the central region which is known as the central zone and we said that these two zones particularly the transitional zone enlarges as you age note that there is quite a bit of peripheral zone tissue and that that peripheral zone tissue which I'll now color in in pink actually I better make it a different color maybe dark pink goes all the way down low like I need a darker color here let's find let's use light blue again and our peripheral zone goes all the way down fairly low and this low area is known as the prostate apex now the upper portion of the prostate is known as the base we have the anterior portion of the prostate to the viewer's left the posterior portion of the prostate to the viewer's right and there are several other key anatomic areas for instance in the front we've got a bunch of fat which is known as the prostatic space of ritius in the back we have a fascia layer which separates the prostate from the rectum which is known as the dinnel filier fascia we also have although not seen in this projection a periprostatic plexus which you saw in the axial projection there are also various sphincters an internal and external sphincter which we'll encounter and talk about a little bit later one more area of note is the anterior fibro vascular stroma or fibrous stroma the fibrous stroma is found in the far anterior aspect of the gland I'm going to draw it in blue and when there is an antero apical area of prostate cancer which would occur perhaps right here it'll grow right into this blue area the fibro vascular stroma or the fibrous stroma of the prostate gland this is a very common occurrence and very difficult to evaluate and analyze with conventional transurethral ultrasound assessment and or biopsy in fact biopsies will frequently miss cancers that are down low or in continuity with the anterior inferior fibro vascular stroma let's turn our attention now to the coronal projection so this time we'll make our globe coronally oriented I've drawn the globe in blue sorry about that I should use the same color and then you'll see the urethra coming down the center of the globe I'll make it green this time and sometimes the urethra will be a little bit exaggerated at the utricular level then we see the seminal vesicles coming off the prostate base I'll make those red this time there's one seminal vesicle there's the other seminal vesicle and coursing around the seminal vesicles will be the ductus deference the seminal vesicles are usually bright on the water weighted image except as you get a bit older now this upper portion of the prostate in this location is known as the base the central third of the prostate in this location is known as the mid prostate and the lower portion is known as the apical portion of the prostate with the deepest portion of the apex being down here we also divide the prostate at the mid level into what we call lateral and intermediate segments the lateral segment in the outer half the intermediate segment in the inner half that's pretty much the only place where we make that division because that's where the prostate is widest so we have base apex mid middle mid intermediate and these are going to get very unique names as we'll see a little bit later on when we go to use our nomenclature for pyrads 2.0 so that's our introduction to a patient with a prostate carcinoma in the right side of the gland and to prostate anatomy