 Okay, I am back with my patient who is a 67 year old man Negative biopsy one and a half years ago PSA level of 24 pretty high I think you would have cancer, but remember all prostate glands make PSA if you have enough BPH and you have enough Glangular activity you can still have an elevated PSA and not have cancer My purpose in this vignette is to introduce you to some of the descriptors Some of which you're familiar with from breast imaging or MR if you do it. So let's start out with the term focus a focus is more of a pinpoint area like that a Little white spot that would be a focus a localized finding that's distinct from neighboring tissues and It's not three-dimensional space Occupying in other words, it doesn't have mass effect And a focal abnormality is kind of a synonym for a focus actually a focal abnormality is any sized abnormality And the focus is usually something that is more sort of pinpoint millimeters in size Whereas a focal abnormality has some size to it Little mass effect, but as well defined from the rest of the structures. So this there's a little bit of nuance there index lesion This is the highest pirates assessment category lesion So if we were to have a pirates 5 a 3 and a 4 the pirates 5 would be considered the index lesion And it is always measured and sometimes it's even traced in three dimensions It's also known as the dominant lesion and I will put in my conclusion dominant index lesion is pirates 5 located right PZ mid lateral etc a lesion well, that's a localized pathological or traumatic structural change or area of damage deformity discontinuity of tissue organ or body part a mass a mass Has three-dimensional space occupying characteristics those of you that do breast imaging know the difference between a non-mass lesion for instance duct acacia DCIS does not exhibit mass effect on surrounding tissues same thing for breast infarction Raz invasive ductal care carcinoma does same principles apply here if You've got a lesion that is more wedge shaped like this one right here more laminar in the peripheral zone Let's blow it up Then that is non-mass like Whereas if you have a lesion like this that is round and dark even though it's not malignant It is mass like and in fact, it's not completely smooth. It's got slight irregular It's got slight irregular edges along its anterior border, but it didn't diffusion restrict and it wasn't hypervascular So we would leave a lesion like that alone a nodule this would correspond to a Nodular form of mass, so it's a subtype of mass It's a small clump or swelling of collection that is rounded in shape now. I like to define my nodules This is just how I do it as nodules that are fully encapsulated versus nodules that are poorly encapsulated Because remember from one of our prior vignettes we said that if this gets really tense and really full of BP of BPH nodules they can't extrude into the peripheral zone and when they do They look like cancers, but they have a nice capsule around them a Non-focal abnormality is one that is not restricted to a single location in fact, maybe multi focal is a better term for that although the pirates to Designation lexicon does differentiate between non-focal versus multifocal in non-focal It's it's more amorphous, you know, it's here, but there may be a few areas nearby Whereas multifocal it is a situation of clear-cut multiple lesions in different territories So that's a that's a more Concrete term and I use it more freely. I hardly ever use the term non focal regional Regional means it conforms to a prostate sector sextant zone or lobe There's an abnormal signal other than a mass involving a large volume of Prostate tissue so for instance in a case where you might have involvement all the way down low in the apex And it invades the fibromuscular stroma We would say that it is regional It's regional apical with fibromuscular stroma invasion Or it could be completely right-sided in the middle of the gland. We would also Confirm that something like that would be regional And if it was in the medial as well as lateral we'd say it's regional mid-gland Both Medial or intermediate and far lateral or lateral Far lateral and lateral are synonyms medial and intermediate or synonyms shape Round That's self-explanatory. That's kind of round oval Well, you've seen previously some lentiform cancers and in fact when cancers get pretty big Pretty much have this shape see if I can do a little drawing for you You saw one earlier. It looked kind of like this look a little bit like a banana And a lot of big prostate cancers do that Especially when they cross from the CZ to the PZ. That's a very common appearance. It's also common on diffusion restricted scenarios or diffusion images Lentiform Having the shape of a double convex lens so perhaps I made a little little bit of an error here because lentiform would be This Actually, I didn't make a mistake you know, this would be a an oval lesion and This would be a lentiform lesion so You know, they're very similar in and in their appearance But one is a double convexity and the other one is concave and convex Not critically important except just to know the descriptor Lobulated composed of lobules with an undulating contour. So lobulated might look something like this Just like it does in the breast some people will use the term polygonal or Smooth but somewhat irregular water drop shape Water drop shape is a lesion that has I'll make my line a little bit thinner So water drop shape looks like a teardrop of water. So it kind of looks like this That's a little less common appearance, especially for Prostate carcinoma But it differs from these two in that it it comes to a point Wedged shape Well, here we have some examples of wedge shape right there. I'm not going to draw over it But I'll draw its edges That's somewhat wedge shaped and it doesn't have mass effect and it doesn't bulge the capsule and it didn't diffusion restrict And it wasn't low on the ADC map And those can either be fiber septa. They can be scars. They can be scars from sites of Prostatitis and the wedge can be slightly wedge shaped or It can be a very broad wedge Doesn't matter they're both described the same way so it can look like a piece of pie It'd be a large slice of pie or thin slice of pie linear Well linear is very self-explanatory. It's when you just simply have a line So let's see if I can spy something that is linear on our t2 Well, I think this is linear right here very hard to see but right there Very delicate and linear striations in the peripheral zone So linear is not going to have much thickness to it Irregular evenness Irregular or sorry irregular Irregular means lacking symmetry or evenness So irregular is kind of an amorphous term. What's the difference between irregular and lobulated? And lobulated you're denoting or connoting that even though it has this kind of edge to it See if I get my panda Even though it has this kind of edge to it. It's sort of smooth Whereas irregular It's going to have a much less Curvilinear shape to it. It may be more jagged. I think I need a thinner pen for that Irregular is going to be more jagged As opposed to this kind of wavy configuration and irregular tends to have a slightly more smudgy peripheral architecture margins You've got well circumscribed margins sharp zone of transition easy in Distinct margins or blurred margins for instance. This has a very distinct margin here But a little more a regular and blurred margin here It's not as easy for me to tell where this starts and or where this stops and this starts obscured Not clearly seen or easily distinguished Irregular uneven Jagged serrated now. We're just talking margins now Speculated well, that's easy. You know speculated is going to look something like this Kind of like a breast carcinoma radiating lines extending from the center of an area encapsulated encapsulated means you've got something that is usually pretty round or oval and it is bound by a complete Rim of a slightly different shade usually darker And that's going to happen with BPH nodules even the ones that are extruded Organized chaos Well, that's commonly seen in the central zone and transitional zone With multiple lesions having circumscribed margins. Let's take a look at our central zone in this case It's kind of organized chaos We've got a bright lesion with some pretty good encapsulation one. That's a little more Lobulated but also in cap capsulated one. That's a bit darker. You might say well, how am I going to sort those out? Well, you're not just going to use the t2 You're going to look at the diffusion image the ADC map and the DCE MRI But organized chaos is not the exception. It is rather the rule in The central and peripheral zone of the prostate my favorite sign is the charcoal erasure sign One that I actually coined for osteomyelitis on a t1 weighted image in the body for MSK But it applies here to blurred margins in Which you have a sensation of smudginess So it's almost like you took an eraser. You just started painting in I think I need a thicker line for this So you have your eraser and you just start painting painting in and you lose the anatomy of all the areas that have been painted in Usually with this type of smudging the internal architecture of the smudge itself is pretty smooth Which is a little bit misleading. It's almost like the karate kid thing, you know wax on wax off And it kind of has that waxy almost circular look to it, but again, it's not very heterogeneous and it has complete disrespect for The boundary between the CZTZ and the peripheral zone the so-called surgical capsule gets violated rather easily Hyper intense that's pretty straightforward. It's hyper intense relative to The surrounding background tissue and what I might use is the surrounding background tissue in the central and transitional zone Is the rest of the tissue so if one nodule were to stand out T2 hyper intensity is a term that's used that refers to higher signal intensity just in general ISO intensity refers to Equal signal to the standard tissue So if I said something was ISO intense to water it better look like cerebrospinal fluid in the CSF intradural space Hypo intense darker than a standard for instance the fibromuscular zone is darker than anything else It's hypo intense relative to the CZ and PZ T2 hypo intensity just means that there's less signal intensity of that structure on the T2-weighted image Compared to some of the other sequences and some of the other surrounding tissues and what about markedly hypo intense Markedly hypo intense means it's either almost black black or lossless no signal There aren't too many things that give you that Pure pure fibrous tissue that would be markedly hypo intense Calcium would be markedly hypo intense fast flow would be markedly hypo intense and the granddaddy of them all air is going to be Markedly hypo intense with lossless signal intensity that concludes our Discussion of what is meant by the terms that are put in the pirates 2.0 designation Remember these were created by men and women just like you. They are not set in stone they are meant to be guidelines to help you produce a Pattern that is recognizable to others in the profession others of your colleagues But also those in the urologic special specialties so that there's some consistency in how we talk to each other Thanks