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Any thoughts on my husband’s prostate MRI Ha been on surveillance 12y
Posting copy of MRI
PI-RADS v2.1 score 5: clinically significant cancer is highly likely to be present. Lesion in the left anterolateral transition zone near the apex. Lesion saved in DynaCAD for biopsy localization purposes. 2. No lymphadenopathy. Note that MRI is relatively insensitive for low grade, low volume disease such as Gleason 3+3 or Gleason 3+4 disease. 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) I, as the teaching physician, have personally reviewed these images and concur with this interpretation. Gregory Motzkus, D.O. - Central Illinois Radiological Associates
Narrative
DICTATING PHYSICIAN: Lukas LaHood, M.D. EXAMINATION: MRI PELVIS W/WO CONTRAST 7/15/2026 11:19 AM DEMOGRAPHICS: 69 years, Male INDICATION: Malignant neoplasm of prostate PSA trend: Uptrending, PSA 5.7 on 7/12/2024. Pathology results: Biopsy in 2014 showing group 1 prostatic adenocarcinoma on the right side. COMPARISON: MR pelvis 3/20/2023. TECHNIQUE: Multiplanar, multisequence MRI Pelvis performed on the 3.0 Tesla magnet utilizing phased array pelvic coil. Multiparametric Prostate MR consisting of diffusion weighted images as well as DCE images. IV contrast dose and type documented in the medical record. Image analysis was performed on a DynaCAD workstation. FINDINGS: Prostate volume: 68 mL, calculated from 3-D volume contour. The following lesion(s) are at least mildly suspicious: ----------------------------------------------------------- Target #1 / ROI # 1 (representative axial T2 series, image #21) Location: Left transition zone, anterior lateral prostate within the apex. Measurements: 1.6 x 0.9 (in-plane cm); 0.9 (extent in cm). Volume 0.8 mL. Capsular involvement: No evidence of macroscopic extraprostatic extension. T2: On T2-weighted MR imaging, the lesion is seen as a focus of low signal intensity (T2 score = 5/5). DWI: The lesion demonstrates marked restricted diffusion (DWI score = 5/5). DCE: The lesion is associated with early enhancement (DCE positive). PIRADS V2.1 suspicion level: 5/5 ----------------------------------------------------------- The peripheral zone T2 signal is heterogeneous with indistinct ADC, typically reflective of sequelae of inflammation and fibrosis. The remaining transition zone T2 signal is heterogeneous with hypertrophic changes demonstrating matched areas of restricted diffusion and focally increased perfusion that are not clearly suspicious on T2-weighted imaging. Neurovascular bundle: Unremarkable. Seminal vesicles: No evidence of seminal vesicle invasion. Lymph nodes: No pathologically enlarged lymph nodes. Urinary bladder: Partially distended without focal abnormality. Anorectum and bowel: Normal anorectal wall architecture. Visualized bowel is unremarkable. Vasculature: Regional vasculature is patent and normal in caliber. Soft tissues: Small fat-containing right inguinal hernia. Bones: No suspicious marrow signal.
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Here reply from Copilot:
🧠What the MRI actually shows
1. Location
Left transition zone, anterolateral, apex
Transition‑zone tumors can be harder to detect on DRE and sometimes produce less PSA per volume than peripheral‑zone tumors.
2. Size
1.6 × 0.9 × 0.9 cm, volume 0.8 mL
This is a small lesion, but small does not mean low‑grade — TZ tumors can be aggressive even when small.
3. PI‑RADS 5 criteria met
The lesion hits all high‑suspicion markers:
T2 score 5 → very low signal, sharply demarcated
DWI score 5 → marked restricted diffusion, typical of higher‑grade cancer
DCE positive → early enhancement, consistent with angiogenesis
Together, this is the strongest MRI signature for clinically significant cancer.
4. No signs of spread
No macroscopic extraprostatic extension
No seminal vesicle invasion
No lymphadenopathy
No suspicious bone lesions
This is extremely important: the disease appears organ‑confined.
5. Prostate background
Peripheral zone shows heterogeneous T2 and ADC, likely inflammation/fibrosis, not cancer.
Transition zone shows BPH‑type changes, common in a 68 mL gland.
🧬 How this fits with your history
Prior biopsy (2014): Gleason 3+3 (Grade Group 1) on the right side
Current lesion: left, transition zone, new, high‑suspicion
PSA trend: 5.7 ng/mL, uptrending
Prostate volume: 68 mL → PSA density ≈ 0.084 ng/mL/mL
PSA density <0.15 is not high, but TZ tumors often have lower PSA output.
This pattern is typical of:
A new, clinically significant tumor developing in the transition zone
Not recurrence of the old right‑sided Gleason 6
🎯 What this lesion is most likely to represent
Based on MRI characteristics alone, the most probable pathology is:
Most likely
Gleason 3+4 (Grade Group 2)
Gleason 4+3 (Grade Group 3)
Possible
Gleason 4+4 (Grade Group 4) — less common in small TZ lesions but possible
Unlikely
Gleason 3+3 (MRI rarely gives PI‑RADS 5 for pure Gleason 6)
🩺 Risk of extraprostatic extension
MRI shows no macroscopic EPE, and apex TZ lesions have:
Lower risk of early capsular breakthrough
Higher likelihood of being organ‑confined at diagnosis
This is favorable.
📌 What happens next
1. MRI‑targeted biopsy (fusion biopsy)
The lesion is already saved in DynaCAD, which is ideal.
You will need:
Targeted cores from the PI‑RADS 5 lesion
Systematic cores from the rest of the gland
This will determine Gleason grade and treatment options.
2. If biopsy confirms ≥ Gleason 3+4
You will likely be offered:
Radical prostatectomy, or
Radiation therapy (IMRT/SBRT) ± short‑course ADT
3. If biopsy shows Gleason 3+3 only
Active surveillance might still be possible, but PI‑RADS 5 lesions almost never turn out to be pure Gleason 6.
🧠Your prognosis based on MRI alone
Because:
The lesion is small
There is no spread
No EPE
No SV invasion
No lymph nodes
No bone lesions
Your prognosis is excellent, assuming timely biopsy and treatment.
I am not sure about MRI results, my MRI showed one PI‑RADS 5 spot and no Seminal vesicles issues. Then they did the 3 biopsy on that spot and it turned out to be all 3+4=7 grade group 2.
But while doing that biopsy they did 12 more one from each lobe in prostate. Then they found 2 cruciforms and I believe 6 4+3=7 grade group 3.
The whole point is that the MRI wasn't able to detect what was really serious, but it was a good starting point to get more investigation done.
Not much there. With a PIRADS 5, the next step is an MRI-guided biopsy of the suspicious lesion(s) and a few random areas.
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Hug
1 ReactionAgree about getting a fusion guided biopsy. The other poster made a mistake about TZ having a lower PSA output, it's actually the opposite, Transition Zone lesions typically produce higher PSA.
Transition Zone and PSA ProductionBenign Growth: The transition zone is the inner part of the prostate where benign prostatic hyperplasia (BPH), or non-cancerous enlargement, commonly occurs.
Higher Volume: Most PSA in the body is produced within this hyperplastic transition zone tissue. A larger transition zone volume from BPH generally leads to a higher baseline serum PSA level.
Transition Zone Cancers: While most prostate cancers start in the peripheral zone, tumors that do develop in the transition zone can also be quite large and produce significant amounts of PSA.
Clinical Considerations PSA Density: Because a larger transition zone naturally raises PSA levels without necessarily indicating cancer, doctors sometimes use transition zone PSA density calculations to better interpret test results and avoid unnecessary biopsies.