Discouraging MRI Report

@handera my October 2025 MRI was a Pirads 2 with no focal lesions so at the time I did not pursue a Biopsy just continued with regular PSA tests. It just seems like Urologists are reticent to order non standard of care tests like PSE or MPS 2.0 so I’ve done none of those. My PSA has fluctuated between 4.5 and now 8.8. My changed diet, HITT work ( more recently cycling rather than running), supplements from the evidence zone like MyPhyto and MyGutPlus, weight loss, etc have caused me to feel great but seem to have had no impact on prostate health. My dad had this at my age and had surgery so maybe that’s where I’m headed or SBRT depending on what the biopsy will show. Hopefully it will be transperineal if I can get one in a reasonable time frame. But you were the first person who I reached out to when this started for me and I appreciate your approach in dealing with this and all the research and wisdom you have shared.

@ezupcic
I noticed your prostate density is only 0.106 (8.8 PSA / 83 ml). My prostate density was originally 0.179 (7.8 PSA / 43.6ml). So that is definitely in your favor...0.15 - 0.20 is usually where some concern regarding aggressiveness can occur.

I've attached my 3 mpMRI reports.

My original MRI (10/23) indicated the following about the largest (PIRADS 5) left posterior peripheral zone lesion: "There is indistinctness of the prostatic capsule in this region, for example seen on series 4 image 19 that is suspicious for mild local extraprostatic extension."
Two other right posterior peripheral zone lesions were also found, one with "early enhancement" and one without "early enhancement"....so I also had suspected EPE.

The second mpMRI (10/24) indicated that "Mild focal extra prostatic extension not excluded." in the largest (now somewhat smaller) left posterior peripheral zone lesion. The other two lesions could not be found: "Previously described additional lesions in the right peripheral zone are not well visualized today."

The third mpMRI (02/26) mentioned nothing about ANY peripheral zone lesions, simply indicating "Diffusely striated appearance of the peripheral zone on T2WI may reflect prostatitis"...this is why my urologist suggested the three original lesion were likely just inflammation all along..... A new (much smaller) PIRADS 4 lesion was found in the "left; apex; anterior central gland", with some early enhancement, but no "No evidence of extraprostatic extension" and my PSA density had dropped to 0.145.

When I received that first mpMRI report, I also was quite concerned, mostly because I knew little about what it may or may not have meant. As mentioned, I had a TRUS biopsy two weeks later and received my Decipher information a month after that. That information, plus my research, put a whole new spin on my condition and I started a rigorous AS program.

It's been almost 3 years since that first mpMRI and the initiation of my modified ERASE program. The attachments show my level of aerobic effort over the last three years. This morning's run results are also included. My current routine is to run a Zone 2 10K on Monday, and a Zone 2 5K with two 0.25 mile HIIT runs on Wednesday and Friday...a total of about 10.5 miles per week.

Once you get your biopsy results (and Decipher score, if necessary) you will have much more information with which to assess your overall situation.

If my PCa is ever proven to progress, I probably will go with either MRI guided SBRT or proton therapy.

Meanwhile, I'll keep up with my modified ERASE protocol. IMHO even if you choose active treatment, one can't go wrong by implementing a rigorous aerobic/strength exercise program that is sustainable for you.

All the best going forward!

@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.

@ezupcic

I am 1-week post RP surgery. I am 61 years old.

Sept 2025, 1st MRI indicated possible ECE on a 2cm Pirads5 lesion, I had biopsy at local urologist/hospital. Within a week of getting biopsy results (5 cores of 3+3), I made appointment at a cancer center with one of the best Urologists in the area. Both he and Radiation Oncologists indicated MRI’s often indicate possible ECE. This does not mean actual ECE. The possible ECE did allow approval of a PSMA PET scan.

Since initial biopsy was 3+3 cores, lots of discussions for Active Surveillence.

Further consultations/decisions initiated a repeat MRI/Biopsy in April of this year. This MRI stated lesion was along the capsule wall (vs the more generic possible ECE statement). Biopsy had 4 cores of 3+4.

Evaluated radiation vs surgery and ultimately chose surgery. Doctor called me this week to discuss post-op pathology. Grade stayed 3+4 and only a small spot did not have 3mm negative margins. This does not mean ECE (at this time), since it can be due to damage removing prostate, bagging prostate, removing the bag thru stomach opening, and preparing tissue for pathology. For me, if my PSA is near zero at 12 weeks, assume all cancer was removed. No further treatment, until a rise in PSA.

Each person is different. Find great doctors and facilities, obtain Biopsy and other tests.

Best wishes

@charlesprestridge interesting. how do you arrive at removal versus SBRT or other Radiation. I’m trying to get a MRI guided fusion biopsy transperineally but my doctors PA-C said that the standard 12 core transrectal would address all lesions. I asked “how” and have not heard back. I think it may be time to get a referral to another Urologist who can really look at my slides not just the report and give me feedback I can live with. My only concern is waiting another month or two with two pirad 5 lesions and 2 pirad 4 lesions to establish care elsewhere. I just hope I’m doing the right thing.

@ezupcic
I agree, you need a doctor that is fast to reply and explain things.
Also, I would like to suggest that you ask for "saturated" biopsy since you have 2 lesions AND pirad 5 . They should take more than 12 samples. Twelve all around and couple of more from lesions directly. My husband had 16 cores taken since he had 2 lesions and still the worst core was not sampled properly. Just a suggestion - you will decide with your doctor what works the best for you. Wishing you the best of luck with it all 🍀.

@charlesprestridge interesting. how do you arrive at removal versus SBRT or other Radiation. I’m trying to get a MRI guided fusion biopsy transperineally but my doctors PA-C said that the standard 12 core transrectal would address all lesions. I asked “how” and have not heard back. I think it may be time to get a referral to another Urologist who can really look at my slides not just the report and give me feedback I can live with. My only concern is waiting another month or two with two pirad 5 lesions and 2 pirad 4 lesions to establish care elsewhere. I just hope I’m doing the right thing.

@ezupcic

Thru work, I have had annual PSA test for over 20 years. Looking back at PSA progression and size of my lesion, I think my cancer started in my mid-40’s about 15 years ago. This was a big data point for me.

My PSA has never been high. Have only had 2 tests over 3, with the highest at 4.0 in 2025. This 4.0 test result is what had me make earliest appointment possible for DRE and push for an MRI.

I felt very comfortable with my Radiation Oncologist. I felt either HDR monotherapy or SBRT would take care of current cancer. Prostox test results rated me having a very low-risk long-term urinary toxicity for SBRT.

I felt peaceful choosing either surgery or radiation.

At 61, I felt surgery gives me more options if cancer returns. If I was closer to 70, I think I would have chosen radiation.

My surgeon converted to Retzius-sparing surgery two years ago. This again gave me more comfort in choising surgery.

Then alot of praying.

Since June of 2025, when my annual PSA increased from 2.7 to 4.0, I have felt peace in trying to obtain information in order to make consultations and decisions. I have never tried to predict where new data would take us, just what information can we get to help us figure out this puzzle.

October 2025, local general urologist said all biopsy cores were 3+3, this meant AS and see you in 6 months for a followup PSA test.

I immediately started researching and asking every medical friend, friends of friends and family, who was the best prostate cancer doctor for 2nd opinion. Quickly found the name of the head of urology at City of Hope. I called 1-800 number to get an appointment. Was able to see him in less than 2 weeks, plus an incredible RO at the same site. I listened to them, asked questions, got decipher results within another week. Decipher was a 0.48. Not too high, but not low.

Kept working with these two doctors to get PSMA PET, 2nd MRI/Biopsy at the 6-month mark (Both felt the initial biopsy probably missed some of the Gleason 4 in the lesion). They both helped me obtain Prostox test (I was the 1st patient to ask and get this test, at this center), genetic hereditary testing, Dr Epstein outside review of 2nd biopsy pathology. I did not feel like I needed all possible test data, just kept trying to obtain information Myself and Doctors could review and discuss for me to make decisions.

I sent information and had phone consultation for TulsaPro. I was willing to travel and pay out of pocket, if I felt it was a good path. Size of my lesion and distance from urethra, excluded me from being a good candidate.

Best wishes on finding a great cancer center and great Doctors. I have been very blessed with the team at City of Hope. My surgeon and RO have just been incredible.

@surftohealth88 the anxiety from my MRI is difficult but then trying to organize care just adds more. I’m obviously not a Doctor but when Pirads 4 and 5 lesions appear on an MRI with threatening EPE you would think Doctors would ensure that you get the best and most accurate biopsy approach available. And my Doctor and this clinic is highly regarded. How did your husband proceed after biopsy? Appreciate your response.

@ezupcic
I wish I can tell you some encouraging story but for us every step of the way was the same as yours - endless waiting and numerous calls for everything. We had to claw out information, work on slides being transferred for second opinion, wait for PSMA, wait for Decipher , wait to see surgeon, wait to see RO and on and on and on.
By the time my husband had surgery (5 mos later) his gleason got worse and even uni-focal EPE happened. My advice is simple - PUSH AND CALL AND CALL relentlessly. Nobody cares what is your gleason score or if you have IDC or cribriform - you will be placed in the same waiting line as a guy with 3+3 unless you demand attention. I wish I knew all of this : ((( ... I did not.
Luckily I was ready for BCR event and made them do what needed to be done in timely manner. If there was no opening in their hospital, we would go to do PSMA in another. If there was no "opening" for fiduciary markers than we called and bothered them and guess what - all of the sudden - OPENING !
Be pushy (but calm and courteous) ) and be persistent until you get what you need 👍 .