23 Elevated PSA and Negative Biopsies

Role of MRI Following Negative Biopsy

I'm gonna continue with case presentations on a slightly different subject.

One of the most common reasons for prostate MRI today, and that's elevated PSA and negative biopsies.

Doctors Rosen, Krantz, and Tempe and I will presenting cases. Role speak about the role of MRI following a negative biopsy.

This is one area where I do think there's actually been a good amount of data that's come out.

We'll also review some of this data in our talks.

I start off with a couple of cases, and these will be analogous to many cases that have been shown so far.

This was a patient with two prior negative biopsies.

When an MRI comes with that history, of course, we look everywhere in the prostate, we pay particular attention to regions we know are likely to be missed by a standard non-targeted biopsy.

In this case, if we look in the anterior transition zone, there's an area of homogeneous decreased T two signal that's very dark in a DC and increased on a B 1500 image.

On fusion biopsy, this was Gleason four plus three and four four cores from that lesion.

In another patient who had three prior negative biopsies. Now checking down by the prostatic apex.

While this is a posterior peripheral zone lesion, the apex is an area that's more difficult to reliably sample during standard biopsies.

We see the again, the decreased T two signal low, a DC focal increased signal on the B 1500 and focal early enhancement.

It's also was a high grade tumor on fusion biopsy.

I think MRI after a negative biopsy is among the most compelling indications currently for prostate MRI with a large volume of supporting data.

This does, I found amongst the various context for prostate MRI has a good amount of urologist and patient buy-in from a reimbursement standpoint.

While maybe some payers are still hesitant to pay for a MI biopsy naive patient. This is a setting where there is more uniform reimbursement.

I think this could be a good area to impact care at least, when starting a prostate MRI program and trying to find the initial patients to select for prostate, MRI th this could be a good setting for that.

Just to kinda step back and look at and there's a standard trust biopsy. This is a high false negative rate.

Some of these percentage will be variable across literature, but up to about 40% of tumors missed by standard biopsy of around half of patients with a low grade tumor and biopsy estimated to harbor significant cancer based on prostatectomy studies.

There are various strategies for performing repeat biopsies in patients with clinical concern for tumor following a negative biopsy that all involve increasing the intensity of the course taking the repeat biopsy session, whether just sampling the transition zone in a non-targeted fashion or doing saturation biopsies or trans peroneal biopsy.

The current approach is not ideal.

There's over a million prostate biopsy performed annually in the us, associated with high anxiety and costs.

Patients will be prone to a large number of biopsy sessions where basically just being biopsied over and over again, description literature of patients being biopsied up to eight to 10 times in hopes of hitting the lesion.

There are constantly complications from all these serial biopsy sessions of doing trans peroneal biopsy.

This will now be associated with the risks from general anesthesia as well as a higher complication rate than for standard biopsy.

There's clearly a strong role for MRI in this setting.

Data from NIH Group

Here we showed data from the NIH group, looking at the ability of MRI to really select patients for repeat biopsy after initial ne negative biopsy, rading the MRI findings from low, moderate, and high suspicion with the orange indicating high grade lesions on targeted biopsy.

There were really no detection, no high grade lesions in the or high grade tumors in the low suspicion MR lesions, but that were present in the moderate and high suspicion lesions.

In overall from right to select patients here for biopsy.

These results are robust across repeat biopsy sessions.

These are patients image with MRI and then targeted biopsy after one or after two, 1, 2, 3 or f four more negative biopsies.

Seeing even after multiple negative biopsies, still identifying high grade lesions with high grade tumors, using MRI.

Likewise here, stratify, stratified by PSA, and here with our bars, again looking at low intermediate and high suspicion and similar concept, but even with men with no traumatic PSA elevations would've had PS a negative biopsy, MRI was identifying high risk lesions.

This actually relates to a point made earlier this morning, but I think this is a good setting when I think we can probably more agree upon moving away from the endorectal coil and using the phased array coil.

These patients aren't being staged, we're not assessing for focal extra prosthetic extension.

This is more trying to identify gross areas to target for fusion biopsy.

The ESUR guidelines describe the use of the endorectal as optional for tumor localization.

Key Locations Missed on Systematic Biopsy

When interpreting exams, you have to be alert for suspicious lesions and errors, particularly prone to under sampling on systematic biopsy.

The transition zone, the anterior stroma, anterior horns of the peripheral zone, and the prostatic apex.

This was study from about 15 years ago in general, urology not related to MRI, just looking at the ability of truss biopsy to identify tumor in various regions.

The sensitivity dropped markedly in the prosthetic apex, which they had attributed to just the actual technique obliquity of the or the the obliquity of the angle used for the needle in standard in systematic sampling, leading to less reliable sampling of the apex.

A similar case from earlier, this was a patient who had a prior negative biopsy. PSA was around five.

In the post DR apex, there's a lesion on all of the image sets, a concurrent finding.

RADS four, and this was a three plus four on fusion biopsy.

In this setting, we're not just localizing lesions for targeting. This is also just facilitating the decision whether or not to do a repeat biopsy in the first place.

If the M MRI is negative, then that would overwhelmingly indicate either no tumor or low grade tumor.

The MRI can also perhaps give an alternate explanation for the high PSA, which might be reassuring for the urologist and patient.

This was a patient with a prior negative biopsy. The MRI is this negative. Higher ed is one out of five, a nice clean peripheral zone, homogeneous and bright on T two and a DC, nothing on the DCE.

The data was suggested at least a 90% negative predictive value for significant cancer in the setting.

This patient of repeat biopsy was deferred in this case.

After a negative biopsy, interpreted this as a two out of five, a geographic kinda linearly marginated area of mildly decreased T two signal, and likewise, a mild reduction a DC.

These lesions are generally benign or possibly low grade tumor, and I think increasingly biopsy would be deferred in this setting as well.

A low risk MRI lesion. This patient had two prior negative biopsies. PSA is around 12.

We don't see any lesion on the MRI, it's a RADS one, but there's marked BPH with a volume around 200 ccs.

That information can be useful for the urologist in having an alternate explanation in this case for the high PSA, and in this case, heartening biopsy elevated PSA, and we see there was no focal lesion, but diffuse, decreased T two signal and increased enhancement bilaterally, symmetrically, which could suggest prostatitis.

That I think that'd be relevant information to communicate to potentially account for the PSA elevation.

Hemorrhage in Post-Biopsy MRI

In this side, I'm gonna shift for a little bit and talk about hemorrhage.

On the vis, this will come up in the post biopsy setting on MR mri.

There's increased T one signal from post biopsy hemorrhage bilaterally.

This generally, I find it can influence all the parameters. I find, will influence the T two the most in terms of the extent and degree of the signal abnormality.

Here, there's a lot of decreased T two signal bilaterally, but sometimes you can almost just kind of read through this and look for dominant lesion on the diffusion in DCE, and it will lower our sensitivity, but I think for a dominant or aggressive lesions where you can kind of see them through the hemorrhage.

While you wouldn't appreciate the T two there, there you do see the focal rounded low A DC and increased enhancement in the left posterior peripheral zone.

That was born out as the dominant lesion on prostatectomy.

That hemorrhage kind of gra gradually resolves with time. But it's variable from patient to patient.

There's really no magic number or amount of time to wait when that'll be consistent across all patients.

Some patients that will resolve rapidly in others, it can persist for months, if not many months, say six months or more.

We generally will recommend about eight weeks is, has been, as you've been hearing, which for most patients will work.

Sometimes you will still encounter a hemorrhage even after that in the negative biopsy setting, as opposed to in a patient who's had a positive biopsy and is being staged, this could be a good opportunity for longer delay as long as you possibly can.

These patients aren't awaiting treatment. They're unlikely to undergo a repeat biopsy right away.

In any case, they, urologist won't be performing a repeat biopsy after 8, 10, 12 weeks, even if we did the MI right at that time.

I think a longer delay in this setting compared to the staging setting, could be useful to achieve maximum accuracy possible for the repeat biopsy session.

Just again, a similar case here after a negative biopsy, this is, this was the so-called sparing sign.

There's diffuse hemorrhage bilaterally with a focal area of sparing on the T one weighted image.

We look there and we see it's a foley decrease on the T two 80 image and vocally reduced a DC.

The idea here that the extensive hemorrhage isn't penetrating into a densely cellular tumor, that the hemorrhage on T one will appear as a photographic negative of the area of tumor.

This isn't an absolute right. It is possible to see have a tumor in area of hemorrhage, and it's certainly possible to have areas of sparing that just aren't tumor, but it's nice or it's helpful when we see this, it can raise our confidence.

I wouldn't raise the suspicion just based on the sparing alone in T one, right? Certainly can see just hetero heterogeneous distribution of the hemorrhage throughout the peripheral zone, but look to confirm the area of sparing with the focal abnormality on diffusion or DC and if it does line up with the other sequences, then would raise the suspicion in the presence of hemorrhage.

It is important to use subtraction images when assessing the post contrast images here on T two.

We see a very prominent or kind of striking area of decreased T two signal if we just had the T two alone, right? We could be thinking, is this a would this be a RADS five and have a large lesion think, is there some capsular bulging?

But it's actually not all that dark in a DC kind of disproportionate is just a very mild reduction and no increased signal on a B 1500 image there.

If you just go to the DC image, it's very bright. You gotta remember, right, this is post contrast and there was already increased T one signal at baseline.

In the this was the pre contrast image, and again, we see the high signal from hemorrhage.

On the subtraction, it's actually less avidly enhancing on the contralateral side.

This is just a very pronounced decreased T two signal from the hemorrhage with without really a diffusion or DC abnormality.

Other Concepts in Post-Negative Biopsy Setting

I'm gonna kind of move on to just some other concepts that will come up in the post negative biopsy setting.

This patient had a prior negative biopsy that we see on the left posterior peripheral zone, A lesion on T two A, D-C-D-C-E, everything looks concordant PY RADS four, but then on fusion biopsy, the course from this area came back as high grade pin.

This had been mentioned in a talk from yesterday morning.

These are architecturally benign glands lined by atypical cells, described as a precursor lesion to prostate cancer.

There's been studies showing an increased cancer rate on subsequent biopsies after detection, high grade pain on initial biopsy.

The follow-up management guidelines for this are variable.

I think urologists are more inclined to do repeat biopsies in the setting of multifocal high grade pin.

A solitary focus of high grade pin doesn't necessarily lead to a more rapid repeat biopsy, but just to be aware that this can mimic tumor and MRI.

Sometimes this can be account for a false positive say like a PYS four lesion.

This is also after a negative biopsy that showed asap.

We call it a pyres three in this midline anterior peripheral zone, this poorly marginated lesion.

This came back as leasing three plus four tumor in four four cores from the finding.

A asap, this is atypical small cell ASIN nerve proliferation.

It's not a distinct histologic entity. This is a lesion suspicious for tumor, but insufficient for the pathologist to make the diagnosis.

Around it's been put up to around half of such cases will have, will harbor tumor on a follow up biopsy.

This is actually a higher rate than for high grade pin. And an early repeat biopsy in a setting of ASAP is standard.

To this point to be aware of and actually look for a lesion that can be targeted with fusion biopsy when you have that history.

PCA3 in Prostate Cancer Detection

Finally, I wanna just talk about this concept of PCA three.

This patient had a prior negative biopsy, and when the MRI came to us, it also had, in the history it said PCA three of 130.

I'll say a little bit more about what this is, but we call this a transitions zone lesion on T two, a DC, on the high B image fusion biopsy was a Gleason six lesion.

That went along with this very high PCA three value.

This is prostate cancer gene three, it's a non-coding mRNA that's upregulated by prostate cancer and shed into the urine.

It's assessed following a digital rectal exam with a prostate massage.

A positive value will be dependent on your lab, but can range from about 25 to 35.

This has higher specificity than PSA, the specific will will be over 90% when it's markedly elevated.

At our center, men with a prior negative biopsy, they're routinely getting both a PCA three and a MRI.

If really either of these are positive at this point, they're going on to biopsy.

This patient had two prior negative biopsies. The PCA three was 11, so that's that'd be a negative PCA three, this kinda linear area of mildly decreased T two signal and some kinda linear increase enhancement.

We re interpret this as a PY RADS two.

The MR MRI and PCA three are both considered negative and a repeat biopsy were deferred.

What's interesting is sometimes these won't, the PCA three and MR MRI won't really always be concordant with each other.

This patient had three prior negative biopsies and the but the PCA three was negative of was, it was 11 as well.

This is why we also need the MRI. There was a five, five out five large anterior lesion with gross anterior EPE, right? A very aggressive lesion confirmed as tumor on a targeted biopsy.

The flip, this was a patient with a negative biopsy, MRI was pyres, one out of five or a negative study, don't see anything in peripheral in transition.

Low transition zone PA three was approximately 600. So markedly high or almost certainly going to be tumor Andy.

The urologist just did a systematic biopsy in the absence of an MRI lesion.

There were scattered foci, Gleason three plus three tumor, which again, we know we won't always be able to see on MRI.

Conclusion

In conclusion, there's compelling data supporting the role of MRI, following negative biopsies.

Be aware of the key locations missed on biopsy, the anterior prostate in the apex MRI can be useful to help defer a repeat biopsy and be aware of the significance of high grade pin ASAP and PCA three values.

Thanks.

Pre-Biopsy Patients: Case Presentations

Alright, so back to the pre biopsy patients. You can see obviously focal prostate cancer.

Now we've seen so many cases. We'll continue to show you a few more.

Here's a patient where everything is concordant, which we really, really like because it increases our confidence level and all pulse sequences.

Clearly seeing the same abnormality. And our sector map, of course, will be helpful for describing that location.

RMPZ pl, the anterior prostate, I think is one of the places that we've all realized after a lot of literature has been coming out, particularly pioneered initially from the French group of RNA and others really describing the presence of cancer in this area. Anteriorly, and this is the most common scenario when you have the negative trus guided biopsies and repeated elevation of the PSA.

67-year-old man at persistently elevated PSA, the same story as you've been hearing repeatedly. Now the PSA just keeps climbing.

One of our urologists, the previous chair of urology at the Brigham would call PSA, not just prostate specific antigen, but in this case it stands for a patient stimulated anxiety as clearly you're sitting here with looking at going from six to 17 over three years with three biop or two biopsy sessions, all negative for cancer.

Once you really hit a PSA of 10, you have cancer. And it's just a matter of trying to find it or absolutely finding it.

This is our, as we will remember, our normal prostate that we've seen so many times. But this is the nice organized chaos based note. Sorry, no chaos here at all. Organized, well-defined encapsulated BPH areas, and this is one of the most challenging areas for all of us.

Every prostate exam you do, look at this central gland transition zone, really examine it carefully in everybody just so that you are getting your threshold of the interpretation of this challenging area better and better every time.

When a case like this walks in, hopefully you won't miss it and you'll see very clearly what's going on.

I'm gonna magnify that we'll come back with some blue, some red circles in a minute. But just to continue through the examination, dynamic contrast imaging showing hyper enhancement in the early arterial phase, both sets of diffusion, we do both five hundreds and 1400 separately acquired.

The raw data and then the A DC is acquired directly from this. So you can see a fairly significant lesion there.

The analysis of this, just to go through, again, look at that T two clearly abnormal in the front. Big thumbprint, charcoal smeared, whatever word we use, disorganized chaos in that area of BPH, right in front of the sphincter. An important location for surgical planning.

Of course, everything agrees. Again, concordance is makes us so happy when all three sequences agree.

Reporting that out, then it's a transitional zone lesion, you wanna measure this volume of it, whatever. On the T twos, we determined it was 1.5 centimeters.

This is therefore assigned a pyres five. As you know, in the transition zone, the T two dominates.

In this case, it was obviously a five. And so this is an overall pyros five.

This is how we would report the case out and determine that this needs to be sampled.

I didn't show the coronal until now, but you can see it sitting down there nicely on the coronal view where you should see homogeneous high signal T two coming right down to the urogenital diaphragm. And the external sphincter.

You can see clearly this lesion on the right side and a targeted biopsy is clearly advised here.

That patient did, sorry, I won't go back, but that patient did go on to trans peroneal sampling. And that was a four plus three lesion.

Case: 53-Year-Old Man with Clinical T1C

Another case a 50 53-year-old man with clinical T one C. And what does that mean? That means that on palpation, they didn't feel anything.

In this particular man, the PSA is 11, so it's a significant number. He's already had one biopsy that showed that it was a three plus three and one core.

So there's discordant data here. They're sort of assuming that this is low grade, but then the biopsy, sorry, is low grade and the PSA is a little too high for that grade.

This is a place where we're finding the MRI to be, again, very helpful. This is not a negative trusts biopsy. This is a positive case, but there's a discordant clinical data.

You look at the T twos in this patient at three TE coil examination. Pretty uniform ill-defined T two signal here. Nothing particularly exciting.

A little bit of increased signal there. This is sometimes happens. You'll have to be prepared to scale your images on every single slice as you work through these impacts.

You're trying to see both sides of the prostate. 'cause the coil will cause some high signals and call the nearfield bias field there.

Looking at the diffusion images here, you can see that there's a small, tiny little restricted area of diffusion there. High, high signal intensity.

The raw B images restricted here as well. Small lesion.

This one is an anterior focal lesion on T two. This was pretty much invisible. So we pretty much, well, mild ill defined diffusion when you went back and looked at the T twos.

We coded that as either a two or a three. We're kind of uncertain on that one. The diffusion certainly showed this to be a PI RADS four.

But this region is dominated by T two. So you're trying to determine, really is it in between these, we really didn't see a whole lot, but we lean towards this given that we had the diffusion.

You know, in theory, really the T two is supposed to drive us in this area, but we call this an overall a PI RADS three.

This is a patient who then went on to have a repeat biopsy and was found to have a some more significant Gleason grade in that region with a Gleason three, four.

That made everybody feel better that that PSA was elevated appropriately, and he wasn't just a simple three plus three.

Case: Patient with Outside Biopsy Negative

Now here's a different case. This patient was similar PSA level. He had an outside biopsy thrust negative in three, in six locations with 12 cores.

Here's his MRI and this is a three T in recal coil examination, which looks a little different than some of the ones I've shown you.

Really what's happening here is that the in recal coil's actually not working. So we have a quality problem here.

There's no signal coming from that endorectal coil. All the signal here is being obtained from those external torso wraparound coils, whatever you are using for pelvic imaging.

This leads to a fairly noisy grainy image here on the T twos, which makes the center and the peripheral look almost the same and low quality on the coronal view.

This is an important thing you can qa, you should hear technologists should know to look at the locator and determine whether there's high signal coming from that area of the end rectal coil itself.

We would, they didn't, they continued on with the exam, which fortunately turned out to be fine because we were able to detect a significant anterior lesion.

Again, up here on the B, sorry, that's not 1440, it's 1400, where you see restricted diffusion there in the front.

You can do okay without the in recal coil working. Well, the arterial imaging demonstrated abnormal hyper enhancement here in the front anteriorly.

Then when we came to coding this one or assigning an assessment score, it was challenging because the T two here wasn't good. And we had a QA issue, was it a one or two is really negative, which it should be an X here in this situation.

As Jeff showed us yesterday, the diffusion is clearly abnormal. So I think overall this probably has to be coded as a four because the T two failed us here.

We really should be X all the way down here and we're in here really, well, maybe that would be a three. Then we called it a pi RADS four went on to get biopsied, and it was a three four with a hundred percent of the core positive.

The patient went on to radical prostatectomy.

One thing I wanna just mention here, which hasn't come up yet, is that all of the data that's published about a risk assessment of men with prostate cancer on the percent positivity, of course, is all based on non-targeted trust. But guided biopsies, all those algorithms and nomograms and risk stratification schemes are going to have to be changed when we start using targeted biopsies more and more.

Because as you can see, the percent positivity of each core and the cancer core length is going to be much higher as we're doing targeted biopsies than it will be with trust guided biopsies.

I think that we're going to have to rethink with all of our colleagues who manage men with low risk prostate cancer, that what the core percentage really is going to mean and what the impact of that is on treatment, he went on to have radical prostatectomy and he had a stage two disease, another patient, 57-year-old, three prior negative biopsies.

His PSA is up in his PS is free. PSA is significant at 8% here. He had an MRI examination that was positive and he went on to have a targeted biopsy for tissue.

Let's look at his his MRI examination that was read as positive. Here's the t the T two axials. Too much signal there for you to really see very much.

There's the T ones to demonstrate no blood is present, and that's important to determine whether or not there is to contaminate things or not.

Abnormal area here, abnormal here, abnormal here, and maybe abnormal here. Let's go look at some more images.

Dynamic contrast and subtraction here show a lesion here at the three o'clock location.

In the subtraction view, you can see it nicely here, demonstrating the same thing.

This was went on to be classified as a pires four. And you can see here that we have the needle in the lesion and it turned out to be a Gleason three plus four.

The targeting is important, the location is important, and again, anything from a three to a four to a five should be biopsied.

Those are the limited number of cases that I have in this section. And so I will pass the podium on to my colleague.

Continuing Theme: Elevated PSA and Negative Biopsies

Alright, so I'm gonna continue on this theme of elevated PSA negative biopsies. But I want, I'm just gonna show you a couple of cases, but I wanted to show you this case just to emphasize to everybody that biopsy is not a benign procedure.

We've all seen cases like this. This is a patient who got a abscess following trans recal ultrasound guided systemic biopsies.

Just to add insult to injury, the patient had eight biopsies. None of them had sufficient tissue, okay?

Not a benign procedure all the time.

The other thing I wanted to show you before I go into these cases is show you this, this is a patient who had a biopsies in 2006 and 2011.

The last biopsy was three years ago, and there's still hemorrhage there in the prostate, okay?

The notion about waiting for hemorrhage to go away, you know, it sometimes stays there for a long time.

Maybe something we can discuss during our panel discussion later is how people handle hemorrhage.

Because there have been, there are people who suggest that you look for hemorrhage when you do the MRI. And if there is hemorrhage, you tell a patient to go away and come back in six weeks or something like that in the hopes that it'll dissipate.

But that's not always the case. It can stick around for a long time. Okay?

Case: 72-Year-Old with Rising PSA

72-year-old with a rising PSA and negative biopsies three months ago. And we've seen everybody's shown you these cases.

We have so many of these cases where you see something in the anteriorly in the gland, and this one is in the transition zone.

We're gonna look at the transition zone, and there it is. It's sort of non circumscribed large, that's gonna be a PI RADS four on T two.

That means it's gonna be a PI RADS four assessment category. And in fact, that turned out to be a gluconate.

As you've heard from lots of people already over the last two days, a high percentage of the cases we have where there's a rising PSA and repeat negative biopsies have these sometimes fairly sizable tumors in the anterior part of the gland.

I showed you this case though for another reason, and that is that this patient is 72 years old. And we have a whole variety of guidelines now about who should be getting PSA, including from the US Preventative Health Services Task Force.

These are some relatively recent guidelines from the American Urological Association, but most of them recommend not doing PSA on patients older than 70.

The problem that we, and yet we see a lot of these patients getting MRIs and IT in the real world.

A lot of patients over 70 are very concerned about prostate cancer particularly, and they do get PSAs. And if their PSAs are very high, they're very concerned that they've got an aggressive prostate cancer.

The fact is, the data just came out just in the last week or so. If somebody makes it to age 65, a male makes it to age 65 in this country, the average age, they will live on average till age 84.

That means half of the people, the men are gonna be living beyond that. So they still have a long life ahead of them.

I think this is all have has to be reevaluated. 'cause I think a lot of these guidelines just don't seem to jive with the reality and the kinds of patients that we're seeing.

Case: 57-Year-Old with Elevated PSA

Here's a 57-year-old and the PSA is elevated, and this one had a negative biopsy three years ago.

This is actually also a very common situation that we haven't talked about. Patient had an elevated PSAA number of years ago, had negative biopsy, and they're going, I'm not having any more of these systematic ultrasound biopsies, okay?

But now because we have targeted biopsies available, they're willing to have that exam. And if there's something to target, they're willing to undergo another biopsy.

But no more sort of systematic blinded biopsies. A lot of patients like that.

There's a whole bunch of patients who've just sort of been waiting around for targeted biopsies to become available.

In any event, this patient has an abnormality, which you see on the T two, that that's the axial and the coronal and the sagittal.

It's a you know, it looks like a pretty sizable lesion and it's got restricted diffusion in it.

This one, since it's in the transition zone, again, we're gonna map it out there. It is in the transition zone on the left side anteriorly, which is where most of them occur.

It's measured 1.3 cm on the axial images. And so according to PY rads, that would be a PI RADS four.

However, I just wanna point this out to you that you're supposed to measure on the axial image, but if it's got a larger dimension on another orthogonal plane, in this case, the coronal image where it measure two centimeters, now that makes it a RADS five, not a big deal.

Whether it's a PO a five, it's gonna be biopsied. And the only point here is just to get the correct RADS assessment category.

The larger the lesion, probably the more aggressive it is.

In any event, this patient un went a targeted biopsy and seven outta the seven biopsies in this area were positive.

But notice that they called it on the biopsy. They called it the peripheral zone, even though this is primarily occupying the transition zone.

This really gets to the point of why we have these sector maps is to work these kinds of things out, because this could be considered a false negative MRI, because we called it in the transition zone and the pathologist called it in the peripheral zone.

There was another thing in the right apex that was not seen on the MRI, which was positive.

It wasn't targeted 'cause we didn't see it on the MRI, but in looking at this retrospectively, probably what the systematic bio, what was shown on the systematic biopsy in the right apex is probably the same lesion extending over to the right side.

Case: 68-Year-Old with Family History

This last case is a 68-year-old with a strong family history. In may of 2013, he had a slightly elevated PSA, his biopsy was negative.

Here's a scan from 2014. So in 2013, the MRI just showed BPH in 2014. Now when this was read, this was seen anteriorly in the transition zone.

It looks like a lot of the other cancers that we've seen since this is in the transition zone and it's great measuring greater than 1.5 cm and its larger diameter, that's a PY RADS five, it's highly likely to be clinically significant disease.

In fact, this patient, again, we're doing systematic biopsies after doing the core biopsies in these patients.

This patient had a systematic biopsy, which showed just a really small tumor, and the Mr. Fusion biopsy showed a larger tumor, but they both showed the same thing.

Looking at this retrospectively going back in 2013, this lesion was clearly there and was not read. Okay?

This is it's important to go back to these cases where you've done serial MRIs on them. And if you suddenly see something that looks like a cancer, go back and look at the case because it may have been there before.

This thing grew a little bit over that period of time.

The other thing I wanted to show you on this case is that so this is the same patient, same scanner, same external phased array coils.

You can see we got a nice scan here when we did this this year. And when we did it last year, the dif fusion weighted images were you basically don't see half the gland on them.

The person who reported this didn't even commented on the report that the images were un were not satisfactory.

Had this been monitored appropriately, we could have done one of our ectomies and probably improved the scan at this time.

It didn't, you know, this whether or not this should have been seen prospectively is a different issue.

But if you don't monitor these scans when you're not using an ECT coil, or even if you're using an ENDORECTAL coil, you can really run into some big problems.

If you do have these problems, it's important to either deal with them at that time or at least comment them on the report so that everybody understands that it's a suboptimal examination.

I'm gonna stop there. Thank you.