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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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@jeffmarc it is a long wait but I'm concerned that if I have the standard untargeted 12 core biopsy I might not get the most accurate read on my lesions. And in order to get the MRI Fusion I have to first establish care with a clinic that is connected to a University Hospital which is the cause of the delay. So I'm hoping that during this time my Pirads 5 lesion doesn't escape my Prostate! The radiologist characterized it as "threatening EPE"........
@ezupcic
I know it hard not to get overly anxious. I was in your shoes when I received my initial mpMRI that indicated three lesions, including a PIRADS 5 lesion.
One thing to understand is that a PI-RADS 5 lesion indicates NOTHING about the tumor's aggressiveness. This is one of the most common misconceptions in prostate cancer.
PI-RADS is a probability score, not a danger score. It answers one question only: how likely is it that clinically significant cancer is present at this location?
PI-RADS 1: Clinically significant cancer is highly unlikely
PI-RADS 2: Unlikely
PI-RADS 3: Equivocal
PI-RADS 4: Likely
PI-RADS 5: Highly likely
"Clinically significant" in the PI-RADS system means Gleason 3+4=7 or higher, OR a tumor volume ≥ 0.5 cc. That OR is VERY IMPORTANT...as I found out!
The size and detection-confidence rating is based on how the lesion LOOKS on T2, DWI/ADC, and DCE sequences. A big, clearly visible lesion scores PI-RADS 5. A small, ambiguous one scores PI-RADS 3.
My particular case proves the point perfectly. My PI-RADS 5 lesion was 2.2 × 1.1 cm (huge!) and unmistakable on MRI. The radiologist was highly confident cancer was there, and she was right....but....
It turned out my targeted biopsy showed the center of that PIRADS 5 lesion was Gleason 3+3=6, the least aggressive cancer grade. The targeted cores were aimed towards the center of the PI-RADS 5 lesion and they came back 3+3, with only 5% involvement.
Then I also had the normal 12 core systematic portion included in my biopsy (I had 21 cores taken). Two of these "systematic cores" were taken near what is called the "apical edges" of this large PIRADS 5 lesion.
These two "systematic cores" found small sections of cancer (one 0.14 cm and the other 0.22 cm), where 10 & 20% was pattern 4. This meant that the pattern 4 sizes were 0.014cm and 0.044cm - very tiny sections...definitely too small to be seen with a 3T MRI.
Studies have shown that large lesions with Gleason 3+3 centers and trace non-cribriform pattern 4 at the apical edges are the most favorable configurations for active surveillance within the Grade Group 2 category.
If I were in your shoes (especially with a PSA density of 0.106), I would wait to to get the targeted biopsy (make sure it includes the 12 core systematic portion), because it will provide a more in-depth overall picture....but that's just me.
Only you can gauge your own risk tolerance between getting a more limited picture quickly versus a bigger picture later.
All the best as you consider your options!
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Hug
4 Reactions@ezupcic I had transrectal fusion biopsy in office. Might be able to get one sooner than transperineally. Random may or may not hit the lesions; better chance if they are large. As long as the lesions can be reached no difference in pathology. Had 3 cores taken from each lesion + the random pattern. Local only so was able to drive home a few minutes after the biopsy. Most painful part was the antibiotic shot prior to procedure. P3 and random negative; P4 was G8 all 3 cores. No side effects except blood in semen (fairly universal with that many holes in the prostate).
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1 Reaction@ezupcic
If you decide to go trans rectal earlier, it can still be an MRI guided fusion biopsy with multiple bites specifically out of the lesions and then the additional 12 random grid.
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2 Reactions@jim18 as long as its MRI fusion I'm fine with it at this point. As I transition to a new urologist connected to a University hospital, two of the four lesions that were initially Pirads 5 were downgraded to 4 and they are both significantly smaller than the initial interpretation. So maybe a little better news about the EPE which was also sort of downgraded from "threatening" to "indeterminate".
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3 Reactions@handera...... interesting. As I transition to a new Urologist for a MRI Fusion biopsy connected to a University hospital today the two Pirads 5 lesions from the 9/21 MRI were downgraded to Pirads 4 and the largest one was downgraded from 2.1cm to 1.3cm and a volume of 0.08ml. So now all my lesions are Pirads 4 and significantly smaller than the initial read. As well as the language regarding EPE. This Urology department has its own people read external MRI's and the slides to make their own interpretations. So a little bit of good news!
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Hug
2 Reactions@handera, I appreciate your post because it really explains well the need for a targeted biopsy in addition to the systemic cores when you have multiple lesions as I do all of which could contain different levels of cancer (or maybe no cancer)..... At some point I need to take a break from this for a bit and go for a run, eat some sprouts and maybe a glass of wine.
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Hug
3 ReactionsNot sure if this will work, but here is an AI generated visual of my MRI interpretations which I found sort of helpful.
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Hug
1 Reaction@ezupcic
Your PSAD of 0.106 brings down clinical significance probabilities; but if you truly have four separate PIRADS 4 lesions, that raises clinical significance probabilities that at least one maybe at least be 3+4.
You can have AI provide those probabilities, if it matters to you….of course you need to proceed with the MRI fusion biopsy to get the actual specifics.
Are they going to include the 12 core systematic biopsy with the targeted cores?
In my case the 3+4 cores (as tiny as they were) were not found in the targeted lesions….but in the 12 cores portion of the biopsy…something to consider and discuss with your urologist.
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Hug
3 Reactions@ezupcic Coordinates of the fusion biopsy come from the MRI reading so that can introduce as much error as the urologist being off target in aim. It looks like your biopsy results will be more accurate with the new doctors. It is standard to take cores from all 12 areas. Random cores from the targeted areas may not be taken, especially with multiple cores on the 4 targets.
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