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Discouraging MRI Report
Not the MRI I was hoping for……and words of advice. I’ve gone from a pirads 2 with no lesions to this in one year. PSA currently 8.8. Feeling a little devastated after all my efforts seem to have failed.
Impression
IMPRESSION: 1. At least 4 regions of concern on a background of relatively diffuse signal abnormality of the peripheral gland of the prostate, with the highest PI-RADS category: 5. 2. No pelvic lymphadenopathy by size criteria. 3. Additional chronic findings as described. PI-RADS v2.1 is designed to predict the probability of a cancer which is deemed clinically significant as defined by: pathology/histology Gleason score greater than or equal to 7 (including 3+4 with prominent but not predominant Gleason 4 component), and/or volume greater than 0.5cc, and/or extraprostatic extension (EPE). PI-RADS v2.1 Assessment Categories: PI-RADS 1: Very low (clinically significant cancer is highly unlikely to be present) PI-RADS 2: Low (clinically significant cancer is unlikely to present) PI-RADS 3: Indeterminate (the presence of clinically significant cancer is equivocal) PI-RADS 4: High (clinically significant cancers likely to be present) PI-RADS 5: Very high (clinically significant is highly likely to be present) http://www.acr.org/Quality-Safety/Resources/PIRADS/ Dictated by: Will G Larison, M.D. on 9/22/2026 9:08 AM PDT Electronically signed by: Will G Larison, M.D. on 9/22/2026 9:33 AM PDT
Narrative
MRI PROSTATE W WO CONTRAST CLINICAL INFORMATION: Elevated PSA. COMPARISON: 10/6/2025 TECHNIQUE: Multiplanar multisequence 3T MR imaging of the pelvis performed without and with intravenous contrast utilizing the prostate protocol. Dynamic contrast enhanced series as well as multiple B-value diffusion-weighted series with ADC mapping were acquired. CONTRAST: 9 mL of intravenous Gadavist (Gadobutrol). FINDINGS: LIMITATIONS: None. PROSTATE Size: 4.1 x 6.2 x 6.3 cm. Volume: 83 mL based on ellipsoid calculation. Central Gland BPH Changes: Moderate with large median lobe. Pre-Contrast T1 Changes (Blood): Absent. LESIONS: Persistent signal abnormality throughout the bulk of the peripheral gland now with suspected regions of superimposed concern as described below. LESION # 1. Best seen on series 7 image # 23. Location: Peripheral zone within the mid gland at the 5 o'clock position. Size: 1.1 cm. T2 Characteristics & Score: The lesion demonstrates a T2 score of Peripheral Zone 4: Circumscribed, homogeneous moderately hypointense focus confined to prostate and less than 1.5 cm in greatest dimension. DWI Characteristics & Score: The lesion demonstrates a DWI score of 3: Focal hypointensity on ADC and/or focal hyperintensity on high b-value DWI. Dynamic contrast enhancement: (+ ): Focal, and earlier than enhancement of adjacent normal prostatic tissues, corresponding to suspicious finding on T2W/DWI. LESION PI-RADS CATEGORY: PI-RADS 4 - High (clinically significant cancer is likely to be present) LESION # 2. Best seen on series 7 image # 23. Location: Peripheral zone within the mid gland at the 7-8 o'clock position. Size: 1.4 cm. T2 Characteristics & Score: The lesion demonstrates a T2 score of Peripheral Zone 4: Circumscribed, homogeneous moderately hypointense focus confined to prostate and less than 1.5 cm in greatest dimension. DWI Characteristics & Score: The lesion demonstrates a DWI score of 4: Focal marked hypointensity on ADC and marked hyperintensity on high b-value DWI; measuring less than 1.5 cm in greatest dimension. Dynamic contrast enhancement: (+ ): Focal, and earlier than enhancement of adjacent normal prostatic tissues, corresponding to suspicious finding on T2W/DWI. LESION PI-RADS CATEGORY: PI-RADS 4 - High (clinically significant cancer is likely to be present) LESION # 3. Best seen on series 7 image # 16. Location: Peripheral zone within the base at the 7 o'clock position. Size: 2.1 cm. T2 Characteristics & Score: The lesion demonstrates a T2 score of Peripheral Zone 3: Heterogeneous signal intensity or non-circumscribed, rounded, moderate hypointensity; Includes others that do not qualify as 2, 4, or 5. DWI Characteristics & Score: The lesion demonstrates a DWI score of 5: Focal marked hypointensity on ADC and marked hyperintensity on high b-value DWI; measuring at least 1.5 cm in greatest dimension or demonstrating definite extraprostatic extension. Dynamic contrast enhancement: (+ ): Focal, and earlier than enhancement of adjacent normal prostatic tissues, corresponding to suspicious finding on T2W/DWI. LESION PI-RADS CATEGORY: PI-RADS 5 - Very High (clinically significant cancer is highly likely to be present) LESION # 4. Best seen on series 7 image # 22. Location: Peripheral zone within the apex at the 3 o'clock position. Size: 1.7 cm. T2 Characteristics & Score: The lesion demonstrates a T2 score of Peripheral Zone 3: Heterogeneous signal intensity or non-circumscribed, rounded, moderate hypointensity; Includes others that do not qualify as 2, 4, or 5. DWI Characteristics & Score: The lesion demonstrates a DWI score of 5: Focal marked hypointensity on ADC and marked hyperintensity on high b-value DWI; measuring at least 1.5 cm in greatest dimension or demonstrating definite extraprostatic extension. Dynamic contrast enhancement: (+ ): Focal, and earlier than enhancement of adjacent normal prostatic tissues, corresponding to suspicious finding on T2W/DWI. LESION PI-RADS CATEGORY: PI-RADS 5 - Very High (clinically significant cancer is highly likely to be present) Prostate margin: EPE: Threatened. Local invasion: No local invasion identified. Pelvic Lymph Nodes: No lymphadenopathy by size criteria. Bowel: Colonic diverticulosis. The imaged small bowel and colon is otherwise normal. Bladder: Thickening and trabeculation of the urinary bladder, often seen in the setting of chronic bladder outlet obstruction physiology. Left ureterocele again demonstrated. Abdominal Wall & Pelvic Girdle soft tissues: Bilateral fat-containing inguinal hernias. Bones: No acute or suspicious lesion. Other: No ascites.
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Another good video.
appreciate your response. In my case now that there are Pirads 4 and 5 lesions to target I just need to get one done asap so I know where I’m at. Did you have any EPE with your lesions? Have you considered treatment options? My doctor did not offer general anesthesia for the in office transrectal but I guess that is something that they would do in the hospital.
@copyman appreciate the response. I would prefer a transperineal but I also don’t want to wait months. If my urologist offers a MRI fusion transrectal sooner I will probably go with that.
@ezupcic Hi, I have similar pathology to what you have. My MRI shows 2 lesions; 1.0 and 1.9. The pathology from the MRI is interpretation from the imaging, which means a post fusion biopsy may change the actual results to be the same, or go up or go down. I went from 3+3 a year ago (active monitoring) to post MRI fusion biopsy which confirmed a lot. Gleason now 3+4 with some evidence of cribriform. My RO said he would do SBRT without ADT, and if recurrence occurs, he would do brachytherapy with some ADT. I am seeing my robotics surgeon tomorrow to make my final treatment decision. You will know much more after a fusion biopsy. Best of luck...
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1 ReactionReading medical reports often involves separating the wheat from the chafe. As a layman, much of that you can throw out - most of it being descriptive - and just focus on the parts that add value to your next decision.
> previous MRI: PIRADS 2;
> PSA currently 8.8.
(With your initial MRI, did you get a 2nd opinion? One of the (many) truisms I’ve found since being diagnosed with prostate cancer (in 2012) is that a PIRADS score is a specialist’s educated and experienced opinion of what he (she) believes he sees in a scan image. However, much of the interpretation of images (as well as tissue slides) is often as much an art as it is a science, and depends on the skill and experience of the person interpreting them. What one sees as a PIRADS 2, another might see as a PIRADS 3 - and that might change your decisions. This is why it’s so important to get a 2nd opinion of results.)
> are you getting a 2nd opinion of these latest MRI results?
Current MRI results —>
LESION # 1. PI-RADS 4 - High (clinically significant cancer is likely to be present)
LESION # 2. PI-RADS 4 - High (clinically significant cancer is likely to be present)
LESION # 3. PI-RADS 5 - Very High (clinically significant cancer is highly likely to be present)
LESION # 4. Demonstrating definite extraprostatic extension; PI-RADS 5 - Very High (clinically significant cancer is highly likely to be present)
(None of those are definitive of prostate cancer; they do however, indicate a high probability of prostate cancer; only a biopsy is definitive.)
Prostate margin: EPE: Threatened.
Local invasion: No local invasion identified.
Pelvic Lymph Nodes: No lymphadenopathy
Bowel: Colonic diverticulosis.
The imaged small bowel and colon is otherwise normal.
Bladder: Thickening and trabeculation of the urinary bladder, often seen in the setting of chronic bladder outlet obstruction physiology.
Left ureterocele again demonstrated.
Abdominal Wall & Pelvic Girdle soft tissues: Bilateral fat-containing inguinal hernias.
Bones: No acute or suspicious lesion.
Other: No ascites (meaning no abnormal collection of fluid inside your abdominal cavity).
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The next typical step is to get a biopsy.
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2 Reactions@ezupcic
If your father or brother has prostate cancer it more than doubles your chance of getting it. Definitely sounds like you are in need of a biopsy before anything.
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1 Reaction@jeffmarc my dad had a radical prostatectomy at my age (63) so I know I am in a high risk category. At this point I will pursue a biopsy asap and hope the EPE is only threatened. Definitely a stressful time but I appreciate your response.
@brianjarvis appreciate your comment. With this MRI I’m proceeding straight to biopsy as soon as possible. In the past I’ve had second opinions when they were Pirads 2 or 3 but this one has many things that are concerning. I’m just hoping the EPE that is threatened is not yet out of the prostate. Odds are not in my favor.
@jeffmarc Hi Jeff, thanks as always for your involvement and advice. I wanted to ask you your thoughts on SBRT vs RARP at my age of 68. My history is below as you likely read at some point over the past few months. *Can you give me your thoughts on treatment choices since my priorities are: Cure, Continence and Sexual Health. I do have a RARP surgeon consult tomorrow and have already had the RO consult who said SBRT without ADT now, and then if recurrence happens, then brachytherapy. See my history below and please advise from your vast experiences: Pathology Picture post MRI & Fusion Biopsy
PSA last three years were: 13.3, 16.6, 12, and 10.8 most recently
Grade Group 2 (Gleason 3+4=7)
7 of 15 cores positive, <10% volume
Bilateral disease
Pattern 4: 6–10% overall in systematic cores; ≤5% in targeted cores
<5% Cribriform glands: present
Intraductal carcinoma (IDC/IDC-P): not identified
Maximum reported core involvement: 21–30%
Seminal-vesicle invasion: not assessable on biopsy
MRI: PI-RADS 5 right anterior transition-zone lesion
MRI: “Likely involvement of AFS”, but no definite EPE stated
MRI: no seminal-vesicle involvement, enlarged pelvic nodes, or suspicious bone lesions
THOUGHTS regarding treatment? I want to be cured but surgery does scare me somewhat...
7 out of 12 cores positive is a little high. Are some of those 3+3, or are all 3+4?
The one thing I’m missing is your T level? Are you a T2c by any chance, since it’s on both sides of the prostate. Not a T3 which is more aggressive.
You could get SBRT. It’s very commonly used and works well. It’s more likely one and done with what appears to be a lower level case. It actually is more recently the preferred method for handling cribriform. In the past, they thought surgery was better but more recent testing has shown that radiation is more effective. Some doctors still want to do surgery.
If you get surgery, make sure to get Retzius sparing surgery which can keep you continent. If you could also have the nerves spared that would make getting an erection more likely. With it on both sides of the prostate, there may be a problem. This has to be discussed with the surgeon.
After SBRT most people can still get an erection. Overtime it usually fades because they have burned the nerves.
In either case erection problems can be resolved. You can use injections to get an erection, Sometimes Cialis or Viagra will work and if not the implant is really popular 90% like it.
It will take a few months to be acclimated after surgery. You may have incontinence issues for a few weeks. You may not be able to get an erection right away.
I think I would probably prefer radiation if I were in your exact situation. If ED Problems eventually come, you can always resolve them.