Presentation
Screening MRI for increased PSA and positive family history
Patient Data
There is a prominent nodule at the right base transition zone (TZ) that displays homogeneous T2 signal (smudged charcoal appearance) but is very well-defined.
It does not enhance but has borderline signal on DWI and low ADC (8-900 x 10-6 mm2/s).
Despite its smooth appearance on T2 (dominant sequence in TZ), the well-defined appearance leads to a grading of 2 on T2 and neither DWI or DCE can upgrade. If the lesion was not encapsulated it would get a grading of 5 most likely.
PSMA PET shows no uptake in the right TZ nodule.
MRI biopsy report.
Case Discussion
This highlights the difficulty in interrogating the transition zone of the prostate. This nodule was biopsied and proved benign under MRI guidance and was also not avid at PSMA PET.
The well-defined appearance (in all three planes on T2W) is the key to defining this as a stromal nodule on T2W. If it enhances or restricts, it does not change this. If you feel it is ill-defined then a T2W grading of 3 or maybe 4 can be used. If a T2W grading of 3 then a DWI grading of 5 will upgrade the overall grading to 4.