 As Gauri already mentioned that Journal Club is an endeavor from Indian ideologist where we try to go through some recent articles because in our busy schedule we hardly get time to get through these updates. So it's like reading together for the next one hour we'll be doing the same. And without any further ado, let's just start with the topic for the day. So the article which we are going to review today is this one, which is diagnosis of typical and typical transition zone prostate cancer and it's mimic at multi parametric prostate MRI. So this is article which got published in year 2017. But it is relevant and let's go through it. Before we go to the exact article, we would like to go through few introductory slides regarding pirates, the latest version which is version 2.1, which was introduced in the year 2019. And then we will go through various aspects of reading the multi parametric prosthetic MRI for transition zone tumors. And then we will understand why are we choosing this topic. For all of you who have already been practicing reading these multi parametric prostate MRI must be realizing that transition zone is somewhere that we can have confusing pictures because the malignancies are very common in the peripheral zone, not in the transition zone, but we don't want to miss anything between the benign prosthetic hyperplastic nodules. So with the main article I have taken references to from few more places. One is the pirates version 2.1, the detailed descriptive article which has been given by ACR, and also radiographics update regarding the version 2.1. So we are going to see all these together. This has been taken from the exact words from the pirates version 2.1, which has been mentioned by ACR. And why have taken this as the first slide because there is a confusion regarding which techniques have to be performed as a part of multi parametric MRI imaging. Many times we get, still we get the reference where they ask for multi parametric with MR spectroscopy. Sometimes they want compulsorily spectroscopy as a part of MR. So version 2.1 includes T2 weighted sequences, diffusion with a higher B value and dynamic post contrast evaluation, BCE. However, it does not include tools like MR spectroscopy, DTI, DKI, that is diffusion, multiple B value assessment of fractional ADC, inter voxel incoherent motion or bold or blood oxygen level dependent imaging. So they have written that they would like to utilize these in future and they would like all of us maybe to utilize these promising tools, but that is not a part of pirates version 2.1, multi parametric MRI protocol right now. So what is the disclaimer which they have given that this is not a comprehensive prostate cancer diagnosis document and should be used in conjunction with other current resources. For example, it does not address the use of MRI for detection of suspected recurrent prosthetic cancers following therapy, progression during surveillance or use of MRI for evaluation of other parts of the body that may be involved with prostate cancer. So these are the additional details which we have to provide in our report and is not a part of the template which version 2.1 has provided. On 19, the pirates version 2 was revised and because the overall framework of the system was maintained, the updated version was termed as 2.1 rather than a version 3. So this is what we have to follow. Just a vision of the prosthetic anatomy, these slides have been taken from radiology assistant where again a good description of the anatomy has been provided with multiple examples. So this is a sagittal reformatted graphic image where we see this is the prosthetic urethra, prostate gland, urinary bladder, seminal vesicles, ejaculatory duct and the verumetanum. So the transition zone, the zone where we are going to discuss things today in details about that is the zone which is present in the central part of the gland surrounding the prosthetic urethra. Whereas central zone is the zone again part of the inner zone on the central gland but surrounding the ejaculatory duct. So this is somewhat place posteriorly. Anterior fibromuscular stroma, another important spot which we can see very clearly on MRIs and not on ultrasound evaluation or breast evaluation, but it is important to again note that these are the areas which can be hidden on ultrasound and other areas and may also get skipped during the biopsy and we may skip important core which have neoplastic process going on in the AFMS that is anterior fibromuscular stroma. So why do we try to do MRI before getting a patient for biopsy because it's a good way of mapping the area which is more suspicious for having the neoplastic process. So though the cores are going to be taken from everywhere, multiple cores but these areas will be targeted specifically. So in that anterior fibromuscular stroma is somewhere which can be easily missed if a proper MRI evaluation has not been performed prior to the biopsy. And next is the peripheral zone which is surrounding all these areas. So again from the same Pirates document, how they have described the anterior fibromuscular stroma which contains no glandular tissue. The transition zones surrounding the urethra proximal to the verumontanum containing 5% of the glandular tissue. The central zone surrounding the ejaculatory duct which contains around 20% of the glandular tissue and the outer peripheral zone that has 70 to 80% of the glandular tissue. So as we know that this is the tissue which is more susceptible for developing the adenoparcinoma part of the prostate. Therefore approximately 70 to 75% of the prostate cancers, they originate in the peripheral zone and 20 to 30% of them originate in the transition zone. So cancers originating in the central zone are uncommon and the cancers that occur in the central zone are usually secondary to invasion from the peripheral zone. So that is what the concept is that the central zone and transitional zones are the areas which are not very commonly areas where new plastic processes developed but still 20 to 30% of tumors may develop in the transition zone. Again, one important point from the same document, use of the term central gland to refer to the combination of transition zone and central zone is discouraged as it is not reflective of the zonal anatomy as visualized or reported on pathologic specimen. So basically the sectoral or the zonal anatomy which we have been using in our templates or which Pirat's version 2.1 recommends for using is to keep everything standardized. So that your report if it is read anywhere in the world gives the best idea about the location of the new plastic process, providing biopsies. And after that, when the biopsies course are sent for histopathology again the similar locations can be utilized and a good histopathology report can be created. After this few more important points from the Pirat's version 2.1 document. These I have just taken because we might miss reading all these during our routine practice. This sentence about a thin dark rim partially surrounding the prostate on T2 weighted image is often referred to as the prostatic capsule. It serve as an important landmark for assessment of extra prostatic extension, but prostate lacks a true capsule so prostate is an organ which doesn't have a true capsule. Whether it contains an outer band of concentric fibromuscular tissue that is inseparable from the prosthetics trauma and that is incomplete anteriorly and a pipe. So this is one thing that we don't have a true capsule to the prostate like again, there is something called as a surgical capsule. And what is this? This is the prosthetic pseudo capsule which has seen on T2 weighted MRI as a thin dark rim at the interface of transitional zone with the peripheral zone. So we will see one example and there is no true capsule in this location as histologic evaluation and this appearance is due to the compressed prostate tissue. So actually there is no capsule, no anatomic capsule between the transition zone and the peripheral zone. Even the benign prosthetic nodules we see them bulging into the peripheral zone and the neoplastic process which is epicenter in the peripheral zone getting entry into the transition zone. Nerves that supply the corpora cavernosa are intimately associated with the arterial branches from the inferior vesicle artery and a company weighs that course the posterior lateral that is five o'clock and seven o'clock position to the prostate bilaterally. So this is the neurovascular bundles which we keep on talking about. So when we are describing our prostate malignancy specifically in the peripheral zone, we try to inform whether there is involvement of the neurovascular bundles or not. So this is the important location posterior lateral aspect five and seven o'clock position. At the base and effect small nerve branches surrounding the prosthetic periphery and they penetrate to the capsule and they are a potential root for extra prosthetic extension of cancer. So these are the locations which are important. Five to seven o'clock position at the level of base and also small nerve branches from the prosthetic periphery. Therefore, whenever you have a tumor which is broad based towards the prosthetic capsule even if there is no extension, but the length of involvement is around 1.5 centimeters. You have to be putting it as concerning for involvement of neurovascular bundles. So this is just an actual T2 weighted image taken from a prosthetic protocol MR to show what we have just read about the anatomy. So there is this thin T2 hyper intense rim kind of which is separating the transition zone from the peripheral zone. So that is the pseudo capsule or the surgical capsule where exactly no obvious anatomic capsule exist. So everything from here can get into the peripheral zone and from peripheral zone can get into the inner zone for the transition zone. The five and seven o'clock position these triangular areas, they are important in terms of invasion into the neurovascular bundles. Whenever there is a tumor which is broad based towards the external capsule here with the area or length of contact more than 1.5 centimeters. Even if you are not seeing any extension outside, we should place it as a concerning feature for extra prosthetic spread or neurovascular bundle involvement. So this area coming to the sector map which we have to utilize as a part of our template. So as per the pirates version 2.1, there are total 41 sectors into which the prostate is divided into 38 for prostate itself, two for the seminal vesicles and one for the external urethral sphincter. These are all freely and easily available on the internet. The pirates version 2.1 document ACR has given, which is again freely accessible and it's around 78 to 79 pages, but very detailed description of how to report and also few examples. This is a good practice to give this kind of image depiction with your reports on MR and you can actually mark with some color like red color or somewhere wherever you want to show the lesion as per your MRI finding. So 41 sectors, 30 are in the cluster itself as you can see the ones in the pink are the peripheral zone, the yellow ones are the transition zone. These are along the urethra, two on either side of the midline, then along the ejaculatory duct where the seminal vesicles are going to open. These ones are the central zone and the anterior most are the anterior fibromuscular stroma. One is for the external urethral sphincter and two are for seminal vesicles. Same thing on approximation overlapped on an MR image. So this is sagittal T2, coronal T2 and axial T2s. So this is how approximate division is performed. It's a good practice that once you start reading your MR on axial T2s, which is the important sequence specifically for transition zone. The next thing is to compare the same lesion on the next plane, that is the coronal plane and sagittal will help you localize whether it is base midline or a pyrite level. This I've taken from another very interesting article which has utilized the pirates document and additionally given us various details about how to perform the scan and about how to report the scans. So what have they taken into a table that I have this brought? So patient preparation rectal emptying, that is one thing. Bladder emptying before starting, usually incomplete due to patient type BPH and all. It's a good practice to give the spasmolytic but you should avoid patients with contraindication like acute retention of urine, intraocular hypertension. So these histories may be asked for. Consider ejaculatory abstinence for three days. It's an optional thing and you have to give instruction regarding immobility, shallow breathing, duration, etc. Three tesla is the preferable modalities with three tesla we do not require endorectal coils so even if you get a requisition for prostatic MRI with an endorectal coil you can inform that with three tesla this is not needed. When you do perform the protocols, T2 is important. It has to be a good quality high resolution small field of view T2 for prostate, axial planes, consider plane perpendicular to the rectoprostatic angles. At least one additional has to be there either coronal or sad so usually sad is the first sequence we acquire to plan the rest of the sequences so sad you already will have such axial coronal. And after that you have to perform some isometric 3d sequences, which are post contrast dynamic and diffusion diffusion should be of a higher be value preferably more than 1400 seconds per millimeter squared. So that is important to have a good quality T2 good quality diffusion and then dynamic post contrast evaluation that will complete your multi parametric MRI protocol. The important thing central zone, which was around the ejaculatory duct and the anterior fibromuscular stroma. So that has been made as a clarification. If no abnormality identified in these two normal anatomic regions, you don't need to report them separately for central zone, focal early enhancement plus asymmetries on T2 weighted images and diffusion. That cannot be explained as BPH may help differentiate them from benign anatomy. For anterior fibromuscular stroma the assessment criteria should be those of the zone from which the lesion appears to arise so if it is from transition zone you go for T2 weighted if it is from peripheral zone you go for diffusion first. Now there are a lot of articles where they are talking about bi parametric MRI, which means that just to in order to save time and in order to save patient discomfort with contrast etc. They are going ahead without post contrast dynamic perfusion imaging only with the help of T2 and diffusion. So what is the concept regarding this DCE perfusion? The DC criteria has been clarified. It is considered positive if it is focal and occurs earlier than then or with the contemporary with enhancement of adjacent normal prosthetic tissue and correspond to the suspicious finding on T2 weighted imaging or diffusion. It has to correspond to that T2 finding or diffusion finding and it should be early as compared to the rest of the prosthetic tissue. So we will see few examples at the end how to read this perfusion PC sequences. It is considered negative if no early enhancement is noted. In addition, diffuse multi this is important. Diffuse multi focal enhancement not corresponding to a focal finding on T2 or diffusion and focal enhancement that correspond to BPH at T2 weighted imaging are considered negative. So many a times you will see that multiple nodular areas they start enhancing earlier as compared to rest of the prostate on these multi sequential dynamic contrast imaging sequence. So they are BPH nodules and that is also considered to be negative for malignancy. Now coming to another bit which is important from the version 2.1 document which is the pirates category. So again we have five categories of pirates which we have to use. Here again it has been mentioned that the combination of T2 diffusion DC correlates with the presence of a clinically significant cancer for each region in the prostate gland. That is the likelihood of probability we are talking about. What is this probability regarding histopathologically that is defined as Gleason's 4 of more than 7 or equal to 7. So as per this if you are saying pirates 4 or 5 you mean that we think that that histopathology will turn out to be either Gleason's score of 7 or more which is including 3 plus 4 with prominent but not predominant Gleason's 4 component. The volume can be as small as 0.5 cc. So we expect that MRI is as sensitive to pick up small lesions with volume equal to 0.5 cc and extra prosthetic extension as well. So pirates 1 is where you have very low suspicion of having a clinically significant cancer which is a normal prostate gland. Pirates 2 again is low. So usually BPH no duos and all can be kept here. Pirates 3 is the area which is most dicey that is what we have to learn. So that is indeterminate or intermediate. The presence of clinically significant cancer is equivocal. Pirates 4 and 5 they are both almost high likelihood of having neoplastic process with a difference of size criteria. So assignment of the category should be based on multi-parametric MR findings only. So you don't need to include anything else to change your criteria. From pirates 3 to 4 you don't need PSA or from pirates 2 to 4 you don't need anything like clinical history or anything else. It has to be completely based on your MRI findings. So although biopsies should be considered for lesion pirates 4 and 5 and not for pirates 1 and 2, Pirates 2.1 does not include recommendation for management. So we are talking about biopsy not about management as they must take into account factors besides MRI. So for management they can take care of everything else besides MRI. But for pirates category and categorization we have to rely only on MRI findings. Thus for findings assessment grade category 3 biopsy may or may not be appropriate depending on factors other than MRI only. So the importance of this paragraph is the management part the physician or the urologist concerned can decide on their own. Depending on various other parameters we don't need to change our pirates category based on those parameters. So that was about how version 2.1 document describe the utility and now let's move on to a graphic depiction of various descriptors. So this is the most important kind of a diagram with somebody who is doing or reading multi-parametric MRI often used and those who are just starting. They can start with this or revise this often. It's all concise into one. In the peripheral zone the sequence which is most important is diffusion. In the transition zone the sequence which is most important to be relied upon is T2. So that is first. Peripheral zone. Diffusion will be read first and what are the five options we have? One, when there is no abnormality on diffusion. According to pirates straight away you can call it as pirates one. Two is linear or wetship linear wetship the area of hyper intensity on diffusion and high point density on ADC. You can straight away call as pirates two. Three is somewhere which is the situation which is dicey and that's what we are going to learn. So focal diffusion abnormality in the peripheral zone can be considered as three. But what you have to go next as a choice of sequence is the perfusion. So this is important from peripheral zone. The next sequence to go for or the sorting sequences post contrast perfusion and not T2. So after diffusion if you are confused if you feel it's equivocal go for the post contrast perfusion. If there is early enhancement you can upgrade the lesion to pirates four. If not then pirates three. So either it goes to three or it goes to four not to directly to pirates five. If there is a proper focal mark restricted diffusion with the low ADC value we'll see what is a significant low ADC value. But a good quality diffusion B value 1400 or more straight away pirates four according to lesion size less than 1.5. If the lesion size is more than 1.5 or there is extra prosthetic extension then straight away to pirates five. So four and five are clear cut one and two are also normal. I mean they're very quite well defined. The one which are confusing is three. Right now the article and everything of point of discussion is about the transition zone. Because it is a zone where the tendency to have neoplastic process is little less only 20 to 30% not like peripheral zone which you will have more commoner lesions around 70 to 80%. So let us concentrate on this part of the table. So transitions on again five options and the sequence to go for is T2. So the first sequence we have to see here is T2. This diagram they have for me is really important and makes things clear. What is one normal uniform intermediate signal typical nodule completely encapsulated so a typical BPH nodule which is completely encapsulated is straight away pirates one. You don't need to see diffusion either. One thing to mention here is that it is a zone the inner or transition zone is an area where the cells are little compact because of presence of the pseudo capsule. Because of this there is a tendency of these BPH nodule to exhibit some amount of restricted diffusion and therefore diffusion is not a reliable sequence to start with for the transitions. So we start with T2 and just for residents they can remember T for transition zone and T for T2. So that is the sequence to go for T2 for transition zone. Then pirates to these are a typical nodule but this word is important encapsulated. So largely encapsulated circumscribe non encapsulated. So if we these are the terminologies which you want to use to describe your nodules that is encapsulated circumscribe then you can keep it safe in pirates two category. But here you see these are the pink arrows which have been marked out of pirates two and pirates three. So you cannot stop here. You have to go to the next sequence, which is diffusion. Even if you are thinking it is pirates two. See the diffusion. If the diffusion score is less than four means there is no restricted diffusion. Keep in pirates two. But if there is restricted diffusion you have to upgrade it to pirates three. So circumscribe nodule with restricted diffusion goes to pirates three. Now coming to three category that is ambiguous boundaries that is the term that is non circumscribed obscured margins ambiguous boundaries. This kind of a boundary. So erased kind of a pencil erased margins that is the sign they have described. That is a typical three category nodule. Again you go for diffusion. So they have just taken two sequence to diffusion. There is no option to see for your dynamic post contrast. Less than five. Keep in pirates three. Or if it is five that is a good restricted diffusion with a low ADC value which is significant that is below 750 ADC values below 750. Then you can upgrade it to pirates four. So straight away non circumscribed erased charcoal lenticular lesion. It goes into pirates four. You may skip seeing the diffusion also and same ill defined lesion with non circumscribed margins and area about 1.5 centimeters. It's straight away goes to pirates five. So this is how we have to read the lesions in transition zone and in the peripherals. So same thing you can get these tables from various references and they're all standardized as per 2.1 version. You can always refer to these whenever you want before starting your reports. As I told that the point of discussion today is all about the transition zone. Therefore in detail. The same thing what we have discussed so one is normal appearance transition zone. Two and three always remember you have to also look into diffusion just it will not be enough. The terms are circumscribed no use without encapsulation for two and obscured margins non circumscribed with erased charcoal appearance is for three. So both of these you have to see diffusion and upgrade or downgrade. Lenticular non circumscribed less than 1.5 centimeters is for and more than 1.5 centimeter is five. So this is the most important point which we try to make so two three always go and see diffusion and then decide whether to upgrade it to the next level or to keep it at the same level. So after advising everything just taken the same examples from the text. In the article. So you see this is how a peripheral zone will look like you will have some these wedged areas which are ISO to high point tense. We are talking about the transition zone. So this is a pseudo capsule and this is how a well encapsulated node you will look like and there is no diffusion restriction. You don't even need to see the diffusion as per the template. And you can straight away call it as one because of the well encapsulation. These are these are how the BPS node you look like. So here again they are largely encapsulated largely well defined and coming to pirates category number two. If it is to you should not stop here and you have to go and see the diffusion. If there is no restricted diffusion, you can keep it in two. If there is significant restricted diffusion, you have to upgrade it to three. So just revising everything once you practice it on actual patient, you will learn it more and sometimes we have to go back to the references when there is a confusion situation. So here you see that there is a partially encapsulated. So this is completely encapsulated a good capsule. So this is completely one, but here this is partially encapsulated with some amount of low ADC values on the corresponding ADC map. So this has been upgraded to category three from two. Same here. This is like almost non circumscribed area heterogeneous with obscured margins. So if these are the terms you want to utilize for describing that means you are dealing something with pirates three category. So ADC is not that much low. So this is final pirates three not upgrading it to four. Here you have a lesion which is like it is charcoal margins or those obscured margin with low DC. So good quality diffusion is important. So this will get upgraded to four. Again, this is a lesion which on T2 itself is full. You don't even need to see the DC etc. But when you have performed the sequences practical purposes you see everything. So it's not like we will just see T2 and give our reports. So we see D2 diffusion post contrast everything because we have performed all the sequences so why not make utilization of everything. So practically you have to see everything but this is how the according to pirates version criteria these are fit into. So this is this is a typical new plastic in our own lesion this one with lenticular shape and ill defined non circumscribed margin and low ADC values. So this is a typical five pirates five new plastic lesion in the transition zone lenticular shape homogeneous moderately high point ends with anterior extra prosthetic extension and low ADC values. So this was about the descriptors same descriptors when you are using when you have made your mind that this lesion I will put into pirates for make sure that you use the standard descriptors in your reporting. So various articles are there talking about the same explaining about the same thing like with good quality graphics like these. So now let's come on to the article which we were supposed to discuss and I try to make it clear why are we so much interested in transition zone because there may be confusion because of presence of the benign prosthetic nodules in the transition zone. And we do not want to miss those 20 30% of tumor which can happen in the transition zone. So let's go to the article I will shift from this PPT to the PDF, which I just marked for all of you so that we can quickly go through these. So this is the article we have shared the link in the chat box for this article if you want to download. And several other links are getting shared on the chat box. These are all our master classes from Indian radiologist which is coming up so to see the links and register in the area of your interest coming back to the article. The transition zone are estimated to account for approximately 30% of the prostate cancer and substantially contribute to morbidity and mortality from prosthetic cancers because of difficulty in detection so that is why we have taken this topic. Even though recent advances in multi parametric MRI have significantly improved the detection of cancers in the transition zone so it is important area not to miss tumors in the transition zone. Part of the difficulty is because this is composed of histologically to distinct issue glandular which is hyper intense on T2 and stromal which is high point ends on T2 so it has a normal stromal tissue, which will be high point ends and that will mimic the transition zone tumor so that is the problem. In addition a wide variety of typical imaging presentation as well as other anatomic and pathologic processes may mimic the tumor thing in the transition zone so that is why it is important. The key histologic features of transition zone pertinent to MRI and presence of cancer are increased cellular density, decreased luminal volume, reduced extracellular space and neo androgenesis which means with increased cellular density you are expecting T2 high point density on your imaging. With neo androgenesis you are expecting early enhancement on the dynamic perfusion images. According to Bayerad's version to T2 weighted images the most useful in transition zone cancers followed by diffusion ADC and then the dynamic contrast so that we saw in detail. This is the term which they use erased charcoal sign so if you think you can put this term when you are seeing the lesion that it looks as if the margins are obscured as if the margins are ill-defined as if the margins are corresponding to erase charcoal appearance. You can straight away think of pirates 3, 4, 5 patients. If it is lenticular shape absence of capsule invasion of anterior fibromuscular stroma it goes straight to pirates 4, 5 depending on the size. I'm just skipping a lot of part because we have discussed in details. I'm just taking the important ones which have marked several examples see how this is looking ill-defined with obscured margins. So that is what the term is and same thing they have put in table form what is to be seen on T2 the typical feature of a new plastic process in transition zone ill-defined margin absence of capsule lenticular shape focal high point density against a background of high signal intensity glandular tissue invasion of identity of fibromuscular stroma. Diffusion has to be restricted with low ADC values early rapid enhancement earlier and stronger than the rest of the prostate. We'll come back to this later after reading this paragraph. A typical transition zone cancer this is important something which is important from this article we are discussing today. It is common to have a peripheral prostate cancer of the transition zone present with a typical features specifically focal homogenous T2 high point density and irregular margin are characteristic of the transition zone cancers but they are present only in 51 and 58% respectively. So whatever since last half an hour we have been describing as typical findings they are present only in 51 and 58% of patients respectively. Therefore in order to achieve high accuracy in the diagnosis of the prosthetic cancers radiologist must be familiar with the typical MRI features. So that is important it can be well-defined margins it is not that always it has to be ill-defined or these erase charcoal thing that is important. And this is a table which they have drawn for a typical findings. So what are the typical findings it can be having well-defined margins. So it's not always ill-defined what are the key MR clues in diagnosis. So featureless appeal there will be some aspect of the boundary of the lesion where you will have this erase charcoal sign positive. Severe restricted diffusion abnormal early enhancement and possible presence of partially regular margin so go for everything else important and try to sort it out. P2 inhomogeneity or hyper intensity. This is another important thing we expect that the cancers are going to be hypo intense on T2 but the cancers can be hyper intense on T2 as well. So only 51% of tumors are typically T2 hypo intense in the transition zone. And because of presence of edema or new scene they can have inhomogeneous appearance or they can even be hyper intense on the T2 weighted images. So that is something which they have importantly marked about. So coming back to that typical table. So go for diffusion they are telling and then go for the DC post contrast. Again third important thing it's not always that the diffusion will be restricted on DWI and ADC low values. It can be sometimes that it is either present on ADC or in DWI and not on board. So that is also one of the things which can happen. So T2 can be hyper T2 can be well defined diffusion ADC they may not show concurrence but either diffusion will show restriction or either ADC will show low ADC values. So that is important. And the fourth thing that our dynamic contrast enhance also is not reliable not necessary. But it is just to increase the confidence in the diagnosis of these prosthetic cancers and typical finding of T2 and diffusion despite lack of abnormal enhancement so you have to rely more on T2 diffusion rather than contrast. So when you feel that it is fitting into tumor or pirates for as per T2 and diffusion still it is not enhancing it is okay. You don't need to go for the enhancement path to confirm your diagnosis. So all these four things can happen. Then a very good table which they have given, which is about the mimics. So chronic prostatitis can mimic your tumors but they will have a geographic appearance. They will have mild restricted diffusion means usually we see the ADC values are in the range of 900 to 1100, which is not significant their borderline values. Still if you are not confident, you can keep it for expirates three. They are again well defined. They have capsule. They can have small internal force of T2 hyper intensity and diffusion restriction will not be significantly present. Displaced central zone and period fibromuscular stroma is itself high point and so if it gets displaced into the transition zone it can mimic presence of a tumor and thicken surgical capsule. So all these things are the variant or normal findings which can mimic transition zone prosthetic cancels. So this was about the mimics or typical typical findings of the areas of new plastic process going on in the transition zone and the things we have to be careful about. So if you go through, we don't have much things to be revising about it is just T2 diffusion, dynamic post contrast, five descriptive words which they have used 1, 2, 3, 4, 5 and clear cut demarcation about how to go about staging these on the pirate scale. So difficulty in achieving high accuracy in diagnosis of prostate cancer or transition zone is well known. Due to the described stromal tissue in the transition zone and a typical presentation of the transition rule prosthetic cancers as well as its mimic. Knowledge of an attention to the MRI feature of typical or typical prosthetic cancers in transition zone and its mimic allow for definitive diagnosis or narrow differential diagnosis. Accurate diagnosis is important for clinical management and help avoid unnecessary intervention. So that is why we took this short article so very short articles you can quickly read and go through it links have been shared already. And even if you don't want to read the entire article these three tables are enough to summarize whatever we have been talking about in the transition zone. So with this, let's move on to the cases before we conclude today's journal club. So I have taken up three cases from our own hospital setting where we had lesion pertaining to the transition zone. So this is the first case. So you can see the sequences T2 weighted images in all three planes then we have performed pre contrast T1 diffusion with a B value of 1400 dynamic post contrast T1 with a larger field of view to cover the aortic bifurcation and presence of extra prosthetic or adjoining lymph nodes then a post contrast we just performed one actual post contrast even after the dynamic. So this is how we really do our prostate multi parametric pelvic MRI. So let's straight away go to the T2 and try to see. I'll just zoom it a bit. So here you have your prostate gland on actual T2. These are the seminal vesicles urinary bladder so going from superior base level downwards. And you see the peripheral zone, the pseudo capsule, the transition zone here. And this is the area. Can you see this one? This is what we were talking since last one hour or so T2 high point 10s area with obscure margins. The margins are not very well clear. So we feel that this is something dicey and we want to place it into pirates category four or five depending on the size. You see this is a well encapsulated nodule. So this is BPH that we are not concerned about. So now we want to check whether this is showing restricted diffusion or not. So let's see on workstation it is relatively easier. So you don't have to worry about this. This is on just a laptop. So you see this is diffusion. And what you see here that there is restricted diffusion. The ADC values were low in this case, which was around 700 somewhere. So this is how you see. So you see that there is an area with obscured margin. There is this area also showing restricted diffusion and size also is more than 1.5 centimeters. You can measure it on ADC if you want. It will give you better margins. See this. This is the ADC. This is totally dark. And even if you see on the size criteria, this is almost 2.4 centimeters. So this is a pirates five lesion in the transition zone. So that is one thing. These are the dynamic contrast images. And actually you can on a workstation you can draw the curves and the graphs to monitor these but sometimes you can just scroll through the images. And all these phases will keep on coming one after the other. And then you see this area is enhancing earlier as compared to rest of the prosthetic plan. But you don't have to rely to the contrast enhanced perfusion. T2 Refusion are enough. Even if the enhancement is not there, it doesn't matter. So this is a typical pirates five and we got a follow up as well for these lesion and it turned out to be leases four plus four eight. So this is one case. I'll just quickly show two more cases. And then we can wrap up another case. P2. This is the area here in particular importance. You can see this P2 hypotenuse areas with non circumscribed obscured margins. This one. We want to see the diffusion with this. Now here comes the diffusion. You can easily see the restricted diffusion in this nodule. We want to see ADC. This is the ADC on even on look you can see that it is low ADC the values were somewhere around 700 again. So this was again histopathologically proven case of new plastic process in the transition zone. See this is the node. Last case. Can we see one T2 actual see the nodule very high point ends on T2 even it is quite well like high point ends more than what we saw in the previous patient. This one. But the margins are quite circumscribed. They are quite well defined. These are the cases which can be confusing and with your experience you can confidently call them either pirates two three or four five. It is high point dense. No doubt it is not resembling those typical BPH nodules. The margins are quite circumscribed but there are segments of obscured margins. We want to see the diffusion now because that is the next sequence to go for. So taking out diffusion. Here it is as compared to the previous ones. It is not as restricting as the previous nodules. ADC values when we calculated they were somewhere around 900 to 1000. If you see the ADC also it's not as dark it is dark. There is something called as like T2 shine through where T2 hyper intense is hyper on diffusion. Similarly T2 hypo is dark on ADC. So that part also is there. So this was something skeptical we kept it as pirates three still patient underwent biopsy this area was covered well. And it turned out to be benign. So this is how slowly you learn but don't try to kind of skip these lesions nodules in the transition zone thinking that everything in the transition zone is BPH nodule. You can have tumors in the transition zone. Approximately 30% of incidents of having these tumor in the transition zone. Clear cut pirates version 2.1 describes how to tackle these nodules how to describe these nodules. So that is what we discussed throughout this particular journal club. I hope it was helpful to you. You can revise whatever we went through on YouTube channel of Indian radiologist because we are going to share it there as well. And also similar lectures and discussion to come up in the subsequent journal clubs and all are Indian radiologist teaching programs. So please be there and be a part of it. We have our best masterclass coming up soon in May. After that we have MSK masterclass followed by MRI teaching course which will be extensive one month almost program in August. Then we have CT bus and also we have Sonobus in January 2022. So a lot of offers going on for early registration for group registration. So do to become a part of it subscribe to our channel on YouTube Indian radiologist and you can get all the information. So with this I would like to end today's journal club. There's one question. What do the wet areas in the peripheral zone signify an Instagram. So most of the time if they're not very dark, their usual areas, they may be sequelae to chronic prostatitis. So in peripheral zone diffusion is the sequence you have to start with as per the pirates version 2.1. If it is not showing a restricted diffusion or significant restricted diffusion, you can be very safely calling them as C being sequelae to chronic prostatitis. So we see it quite often at the level of days they are normal, but still your urologist may feel that there is something so better to describe them, put it on your report and put them as findings which can be sequelae to prostatitis. So that is how we deal with them. So I hope the topic was useful. And with this, thank you all for your patient listening. You may revise this again as I told on the YouTube channel and stay tuned for all the updates from Indian radiologist. Thank you once again.