High-volume Gleason 6 & high PSA density and PHI: AS or treatment

Can you share info from your biopsies?

Are you indicating 75% of 12-16 cores had 3+3?

Knowing length of cores and %length of cores with 3+3 will help some discussions.

Sharing actual MRI and Biopsy reports will generate best responses.

Best Wishes.

Sure, thanks for the suggestion. Here are more details. I forgot to mention that PNI was found on the second biopsy. I'll split the information in various parts.

Part 1:

Biopsies:

--2023 biopsy:

Diagnosis
1.Prostate, LEFT PERIPHERAL ZONE MEDIAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 10% of one (1) core.
2.Prostate, LEFT PERIPHERAL ZONE LATERAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) discontinuously involving 70% of one (1) core.
3.Prostate, LEFT BASE (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 5% of one (1) core.
4.Prostate, LEFT ANTERIOR MEDIAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) discontinuously involving 60% of one (1) core.
5.Prostate, LEFT ANTERIOR LATERAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 20% of a fragmented core.
6.Prostate, RIGHT PERIPHERAL ZONE MEDIAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 10% of one (1) core.
7.Prostate, RIGHT PERIPHERAL ZONE LATERAL (biopsy):
Benign prostatic tissue.
8.Prostate, RIGHT BASE (biopsy):
Benign prostatic tissue.
Benign portion of seminal vesicle/ejaculatory duct.
9.Prostate, RIGHT ANTERIOR MEDIAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 30% of one (1) core.
10.Prostate, RIGHT ANTERIOR LATERAL (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving 50% of one (1) core.
11.Prostate, TARGET #1 (biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) involving two (2) of two (2) cores (10% and 5%).

--2024 biopsy:

Diagnosis
1.Prostate, Left Lateral (Biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) in 10% of 1 core.
2.Prostate, Left Posterior (Biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) in <5% of 1 core.
3.Prostate, Left Anterior (Biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) in 5% of 1 core.
4.Prostate, Right Posterior (Biopsy):
Benign prostatic tissue.
5.Prostate, Right Lateral (Biopsy):
Benign prostatic tissue.
6.Prostate, Right Anterior (Biopsy):
Prostate tissue with small focus of atypical glands, suspicious for low-grade adenocarcinoma.
7.Prostate, Target #1 Right Midgland (Biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) in 10% of 2 cores.
8.Prostate, Target #2 Midline Midgland to base (Biopsy):
Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1) in 20% of 2 cores.

Note
Perineural invasion is identified.

Part 2:

MRIs:

--MRI November 2023:
MR PELVIS W AND WO IV CONTRAST
Results
Study Result
Narrative & Impression
PROCEDURE: MRI PELVIS W/ + W/O CONTRAST
COMPARISON: None.
INDICATIONS: Elevated prostate specific antigen (PSA)
TECHNIQUE: Multiplanar, multisequence MRI of the prostate was performed with and without contrast.
Contrast Dose: 8mL
Contrast Utilized: Gadavist
FINDINGS:
Prostate size: 31 mL
Hemorrhage: None
Peripheral zone: Heterogeneous T2 signal. Focal lesion(s) as below
Transition zone: BPH nodules are present.
Prostate lesions:
ROI# 1:
Size: 1.6 x 0.7 x 1.2 cm, 0.9 mL
Location: Right anterior peripheral zone at the mid gland, Series 5, Image(s): 17-20
T2: Heterogeneous low
Diffusion weighted imaging (DWI): Moderate restricted diffusion
Dynamic contrast enhancement (DCE): Positive
Prostate margin: Broad-based capsular contact.
PIRADS category: 3+1=4
Neurovascular bundles: Not involved.
Seminal vesicles: Not involved.
Lymph nodes: No lymphadenopathy.
Other pelvic organs: There is trace fluid within the inguinal canal. There are scattered colonic diverticuli. There is
a very
small umbilical hernia containing fat.
IMPRESSION:
1. Right anterior peripheral zone 1.6 cm PI-RADS 4 lesion at the midgland.
2. Intact seminal vesicles and neurovascular bundles. No lymphadenopathy or distant metastasis seen in the
pelvis.
3. Prostate volume of 31 mL.
PI-RADS v2.1 Assessment Categories
PIRADS 1 - Very low (clinically significant cancer is highly unlikely to be present)
PIRADS 2 - Low (clinically significant cancer is unlikely to be present)
PIRADS 3 - Intermediate (the presence of clinically significant cancer is equivocal)
PIRADS 4 - High (clinically significant cancer is likely to be present)
PIRADS 5 - Very high (clinically significant cancer is highly likely to be present)

--Second Opinion for the above November 2023 MRI:
Impression
IMPRESSION:
1. Second opinion interpretation of outside prostate MRI dated November 2023.
2. Focal suspicious abnormality, dominant nodule described above.
3. Overall PI-RADS = 4/5
Overall Assessment Categories (PI-RADS V2):
Likelihood that a clinically significant cancer is present based on MRI parameters
1. Very low (clinically significant cancer is highly unlikely to be present)
2. Low (clinically significant cancer is unlikely to be present)
3. Intermediate (the presence of clinically significant cancer is equivocal)
4. High (clinically significant cancer is likely to be present)
5. Very high (clinically significant cancer is highly likely to be present)

Narrative
** Outside film interpretation **
OUTSIDE FILMS PRESENTED FOR SECOND OPINION INTERPRETATION:
* Date reviewed on December 2023
* Date of study: November 2023
* Images presented: Prostate MRI
EXAM: MRI PELVIS W/WO CONTRAST
INDICATION: Elevated PSA
PSA Unknown
Prior biopsy: None
COMPARISON: None available
TECHNIQUE:
Imaging at 3 Tesla.
FINDINGS:
IMAGE QUALITY: Diagnostic.
HEMORRHAGE:
No areas of high T1 signal suggesting hemorrhage.
PROSTATE VOLUME:
Prostate measures: 4.9 cm TV x 3.1 cm AP x 3.8 cm CC, volume 30 cc.
Prostate volume: 29 cc
PERIPHERAL ZONE:
Abnormal signal on T2-weighted images, ADC maps, or DCE in the peripheral zone, as follows:
Lesion #1:
- Side: right
- Level: midgland
- Zone: peripheral zone
- Location: anterior
- Diagram - sector: PZa
- Size: 1.1 x 0.9 cm on T2-weighted imaging
- Relation to capsule: may abut capsule
- ADC: B values 50, 800. Average ADC value 978, standard deviation 153, range 775-1144.
- Representative image(s): 5/18, 10/16
- DCAD label: ROI #1
Assessment categories for this lesion:
- T2 = 4/5
- DWI-ADC = 4/5
- DCE = (-)
- PI-RADS for this lesion = 4/5
TRANSITION ZONE:
Mild hypertrophy with heterogeneous T2-signal.
No focal areas with suspicious morphology.
SEMINAL VESICLES: Normal, symmetric.
NEUROVASCULAR BUNDLES: Normal, symmetric.
BLADDER NECK: Thickened and trabeculated bladder wall, likely related to outlet obstruction.
MEMBRANOUS URETHRA: Normal
LYMPH NODES: None enlarged.
BONE MARROW: Normal signal intensity.
OTHER: Small fat-containing right inguinal hernia.

Part 3:

--MRI August 2024:

FINDINGS:
IMAGE QUALITY: Diagnostic.
HEMORRHAGE:
No areas of high T1 signal suggesting hemorrhage.
PROSTATE VOLUME:
Prostate measures: 5.0 cm TV x 3.0 cm AP x 4.2 cm CC, volume 33 cc.
Prostate volume: 33 cc
PERIPHERAL ZONE:
Linear T2 hypointensity without restricted diffusion or asymmetric perfusion, which can be
seen with prostatitis.
Abnormal signal on T2-weighted images, ADC maps, or DCE in the peripheral zone, as follows:
Lesion #1:
- Side: right
- Level: midgland
- Zone: peripheral zone
- Location: anterior and posterior
- Diagram - sector: PZa and PZp
- Size: 1.2 x 0.8 on T2-weighted imaging
- Relation to capsule: abuts more than 1 cm or bulges capsule
- Relation to prostatic urethra: Cannot assess.
- ADC: B values 50, 800. Average ADC value 1188, standard deviation 206, range 893-1678.
- Representative image(s): 7-20
- DCAD label: ROI 1
Assessment categories for this lesion:
- T2 = 3/5
- DWI-ADC = 3/5
- DCE = (-)
- PI-RADS for this lesion = 3/5
- Follow-Up Score (PRECISE) for this lesion = Reduction in volume and/or conspicuity of
previous features suspicious on MRI. 2/5
TRANSITION ZONE:
Mild hypertrophy with heterogeneous T2-signal.
Abnormal signal on T2 weighted images, ADC maps, or DCE in the transition zone, as follows:Lesion #2:
- Side: midline
- Level: midgland and base
- Zone: transition zone
- Location: anterior and posterior
- Diagram - sector: TZa and TZp
- Size: 2.0 x 1.7 on T2-weighted imaging
- Relation to capsule: does not abut capsule
- Relation to prostatic urethra: May abut the urethra.
- ADC: B values 50, 800. Average ADC value 934, standard deviation 105, range 776-1100.
- Representative image(s): 7-20
- DCAD label: ROI 2
Assessment categories for this lesion:
- T2 = 3/5
- DWI-ADC = 5/5
- DCE = (+)
- PI-RADS for this lesion = 4/5
- Follow-Up Score (PRECISE) for this lesion = Stable MRI appearance: no new focal/diffuse
lesions. 3/5
SEMINAL VESICLES: Normal, symmetric.
NEUROVASCULAR BUNDLES: Normal, symmetric.
BLADDER NECK: Normal
MEMBRANOUS URETHRA: Normal
LYMPH NODES: None enlarged.
BONE MARROW: Normal signal intensity.
OTHER: None
IMPRESSION:
Focal suspicious abnormality, dominant nodules described above.
Overall PI-RADS = 4/5
Overall Follow-Up Score (PRECISE) = Stable MRI appearance: no new focal/diffuse lesions. 3/5
Overall Assessment Categories (PI-RADS V2.1):
Likelihood that a clinically significant cancer is present based on MRI parameters
1. Very low (clinically significant cancer is highly unlikely to be present)
2. Low (clinically significant cancer is unlikely to be present)
3. Intermediate (the presence of clinically significant cancer is equivocal)
4. High (clinically significant cancer is likely to be present)
5. Very high (clinically significant cancer is highly likely to be present)
Overall Assessment Categories (PRECISE):
1. Resolution of previous features suspicious on MRI - Previously enhancing area no longer
enhances.
2. Reduction in volume and/or conspicuity of previous features suspicious on MRI - Reduction
in size of previously seen lesion that remains suspicious for clinically significant disease.
3. Stable MRI appearance: no new focal/diffuse lesions. - Either no suspicious features or
all lesions stable in size and appearance.
4. Significant increase in size and/or conspicuity of features suspicious for prostate
cancer. - Lesion becomes visible on diffusion-weighted imaging; significant increase in size
of previously seen lesion.
5. Definitive radiologic stage progression. - Appearance of extracapsular extension, seminal
vesicle involvement, lymph node involvement, or bone metastasis.Eur Urol. 2017;71(4):648-55.

Part 4:

--MRI November 2025

Impression
IMPRESSION:
Follow-up, comparison is made to August 2024 MRI.
No interval suspicious prostate lesions or extra prostatic involvement. Grossly stable appearance of previously
described lesions, as above.
Overall PI-RADS = 4/5
Overall Follow-Up Score (PRECISE) = Stable MRI appearance: no new focal/diffuse lesions. 3/5
Overall Assessment Categories (PI-RADS V2.1):
Likelihood that a clinically significant cancer is present based on MRI parameters
1. Very low (clinically significant cancer is highly unlikely to be present)
2. Low (clinically significant cancer is unlikely to be present)
3. Intermediate (the presence of clinically significant cancer is equivocal)
4. High (clinically significant cancer is likely to be present)
5. Very high (clinically significant cancer is highly likely to be present)
Overall Assessment Categories (PRECISE):
1. Resolution of previous features suspicious on MRI - Previously enhancing area no longer enhances.
2. Reduction in volume and/or conspicuity of previous features suspicious on MRI - Reduction in size of
previously seen lesion that remains suspicious for clinically significant disease.
3. Stable MRI appearance: no new focal/diffuse lesions. - Either no suspicious features or all lesions stable in
size and appearance.
4. Significant increase in size and/or conspicuity of features suspicious for prostate cancer. - Lesion becomes
visible on diffusion-weighted imaging; significant increase in size of previously seen lesion.
5. Definitive radiologic stage progression. - Appearance of extracapsular extension, seminal vesicle
involvement, lymph node involvement, or bone metastasis.
Eur Urol. 2017;71(4):648-55.
Images and interpretation personally reviewed by: Vikash Gupta, MD
Narrative
EXAM: MRI PROSTATE W/WO CONTRAST WITH 3D
INDICATION: on surveillance for restaging
COMPARISON: August 2024.
FINDINGS:
IMAGE QUALITY: Diagnostic.
HEMORRHAGE:
No areas of high T1 signal suggesting hemorrhage.
PROSTATE VOLUME:
Prostate measures: 4.6 cm TV x 3.5 cm AP x 4.0 cm CC, volume 34 cc.
Prostate volume: 34 cc
PERIPHERAL ZONE:
Abnormal signal on T2-weighted images, ADC maps, or DCE in the peripheral zone, as follows:
Lesion #1:
- Side: right
- Level: midgland
- Zone: peripheral zone
- Location: posterolateral
- Diagram - sector: PZpl
- Size: 12 x 9 mm, previously measuring up to 12 mm. on T2-weighted imaging
- Relation to capsule: abuts more than 1 cm or bulges capsule
- Representative image(s): 501, 14; 602, 164
- DCAD label: 1
Assessment categories for this lesion:
- T2 = 3/5
- DWI-ADC = 3/5
- DCE = (-)
- PI-RADS for this lesion = 3/5
- Follow-Up Score (PRECISE) for this lesion = Stable MRI appearance: no new focal/diffuse lesions. 3/5
TRANSITION ZONE:
Moderate hypertrophy with heterogeneous T2-signal.
Lesion #2:
- Side: left
- Level: midgland
- Zone: transition zone
- Location: anterior
- Diagram - sector: TZa
- Size: 18 x 15 mm, previously 20 mm on T2-weighted imaging
- Relation to capsule: may abut capsule
- Representative image(s): 501, 15; 605, 208
- DCAD label: 2
Assessment categories for this lesion:
- T2 = 3/5
- DWI-ADC = 5/5
- DCE = (+)
- PI-RADS for this lesion = 4/5 on a separate DynaCAD workstation, to
- Follow-Up Score (PRECISE) for this lesion = Stable MRI appearance: no new focal/diffuse lesions. 3/5
SEMINAL VESICLES: Normal, symmetric.
NEUROVASCULAR BUNDLES: Normal, symmetric.
BLADDER NECK: Normal
MEMBRANOUS URETHRA: Normal
LYMPH NODES: None enlarged.
BONE MARROW: No focal suspicious marrow signal
OTHER: Circumferential bladder wall thickening and trabeculation. Diverticulosis. Cystic focus abutting the
right inguinal canal

It seems that you have been having a good run on AS. What is important though is strict monitoring and it seems that you may be do for another MRI and biopsy then you will be better able on whether to stay on AS.

The MRI looks Like there could be a problem. Have they talked about doing a biopsy recently?

You could get a PSE test. They are 93% or 94% reliable in detecting whether or not you have prostate cancer. It is used to decide whether or not you need a biopsy.

You seem to be holding off doing a biopsy and that could make the difference.