help with MRI

Need help with understnding something with MRI report.
on active surellance-
DX on 4-18 BX-g6 1/12 5%, MRI on 6/18-pirads2/BPH/no dominant lesion, follow up BX on 6/19-all neg, follow up MRI pirads2/no dominant lesion/heterogeneous periferal zone, PSA3.1 to 3.7(stable) see signiture

interested in what heterogeneous periferal zone means, is this a concern, otherwise both mri essentially the same
below is copy of MRI report-included is a summary of first biopsy report

Will probably have additional questions
have appt on1/28

thanks in advnace for any help

STUDY: ENHANCED MRI OF THE PELVIS/PROSTATE

CLINICAL INFORMATION:
Age: 68 years
PSA: 3.7 on September 11, 2018 and 3.1 on May 22, 2019
Biopsy results: Surgical Pathology Final Report .Final Diagnosis: Slides (13) labeled P006447 from: NJU Diagnostics (obtained on: 4/13/2018)

A. Prostate, left base, needle biopsy: - Benign prostatic tissue.
B. Prostate, left mid, needle biopsy: - Benign prostatic tissue.
C. Prostate, left apex, needle biopsy: - Benign prostatic tissue.
D. Prostate, left lateral base, needle biopsy: - Benign prostatic tissue.
E. Prostate, left lateral mid, needle biopsy: - Benign prostatic tissue.
F. Prostate, left lateral apex, needle biopsy: - Benign prostatic tissue.
G. Prostate, right base. needle biopsy: - Benign prostatic tissue.
H. Prostate, right mid, needle biopsy: - Benign prostatic tissue.

I. Prostate, right apex, needle biopsy: - Prostatic adenocarcinoma, Gleason score 3 + 3 = 6 (Grade Group 1), involving 0.5 mm ( 5 %) of 1 out of 1 cores. Note: Submitted immunohistochemical stain for PIN4 performed on block I, with adequate controls (see
disclaimer) at outside institution, shows loss of basal cell markers and an increase in racemase expression consistent with the diagnosis above.

J. Prostate, right lateral base, needle biopsy: - Benign prostatic tissue.
K. Prostate, right lateral mid, needle biopsy: - Benign prostatic tissue.
L. Prostate, right lateral apex, needle biopsy: - Benign prostatic tissue.

PROCEDURE:

MRI of the pelvis with special attention to the prostate was performed using a high-field magnet (3 Tesla). Small field-of-view axial T1-weighted and multiplanar T2-weighted images were obtained along with diffusion weighted images. Dynamic contrast
enhanced imaging was performed before and after the IV administration of gadolinium contrast. Large field of view images were also obtained. The study quality is adequate.

INTRAVENOUS CONTRAST:

18 mL of GADOTERATE MEGLUMINE 10 MMOL/20ML IV SOLN

COMPARISON: Prostate MR 6/25/2018.

FINDINGS:

PROSTATE:
Size (AP x TRV x CC): 4.4 x 5.5 x 4.4 cm = 55 mL.
Post-biopsy hemorrhage: None.
Central gland enlargement (BPH): Moderate.

Focal lesions - No dominant lesion. Heterogeneous peripheral zone. PI-RADSv2 Category 2.1 - Low (clinically significant cancer unlikely).

Seminal vesicles: Normal.

URINARY BLADDER: Unremarkable.

LYMPH NODES: No pelvic lymphadenopathy.

BONES: No suspicious osseous lesion. Patchy enhancement along the left sacroiliac joint likely degenerative in nature.

Note: Clinically significant cancer is defined on pathology/histology as Gleason score greater than or equal to 7, and/or volume of greater than or equal to 0.5 mL, and/or extraprostatic extension.

DynaCAD segmentation of the prostate and dominant nodule(s) was deferred as no dominant nodule was identified.[DC0]


IMPRESSION:


1. PI-RADSv2 Category 2 - Low (clinically significant cancer is unlikely to be present). There is a known history of Gleason 3+3 disease.

2. Calculated prostate volume of 55 mL.


ATTENDING RADIOLOGIST AGREEMENT [ATT05]:
I have personally reviewed the images and agree with this report

(Learning as I paste and type).

"The peripheral zone is a thin layer of homogeneous high signal intensity with a hypointense, well-defined and non-interrupted capsula. The transition zone typically shows heterogeneity of intermediate signal intensities focally replaced by well-circumscribed hyperplastic nodules of BPH."

https://radiologyassistant.nl/abdomen/prostate-cancer-pi-rads-v2

Most cancers form in the peripheral layer, which, I'm learning, usually has a homogeneous signal in an MRI. So the heterogeneous signal noted may correspond to the "focal lesions" including the G6 (3+3) seen in the biopsy, which, being at the apex, would mean it's in the periphery, I believe.

If you're going to have prostate cancer, the way to go is a single G6 lesions that cries out active surveillance! In any case, ask your uro about this and any other concerns at your next visit -- uros are familiar with MRI interpretation, and, obviously, I am not in any case, when reading imaging reports, I focus on the Findings and especially the Impressions sections.

Djin

Ask your uro if this heterogeneity and focal lesions could mean there are additional G6 lesions. I don't know for sure, but I believe what counts as far as remaining on AS is what's actually found in your biopsies and your PSA. An MRI can only suggest areas and grade them as to the likelihood of being PCa, but only a biopsy can diagnose.

Djin

Post Edited (DjinTonic) : 1/18/2020 8:05:23 AM (GMT-7)

Thanks one and all for youre comments they were helpful and ultimately led me to the right answer

The hetergeneous result could indicate cancer but this result came from the t2 scan which has problems diferentiating from cancer and other abnormalities
With pirads2 they rely on the difusion weighted scan for the periferal zone ffg ore grading
Also when i went back and looked at the ultrasound report done with last biopsy there was the same comment. Last biopsy was all negative
Sent a note to my uro and she said all is stable.
I like to understand as much as i can before appt and prefer to send questions in advance that way they are on the table

Anyway the one i am seeing next is different. Previous one was a general urologist. This is the RN of an oncologist.
So should be interesting.
Have not really seen a good as plan laid out. But so far am satisfied with what has been so hanging tight. With penn medicine in phila

Again thanks all