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Any thoughts on husband’s prostate MRI? 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.
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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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.
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1 ReactionNot 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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2 ReactionsAgree 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.
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Hug
3 Reactions@raljms, welcome. MRI and other imaging results are best interpreted with your husband's cancer team. An MRI is only one piece of information his oncologist uses to determine next steps.
Since your husband has been on active surveillance for 12 years, I can imagine that he has received regular testing during that time. This MRI cocerns you. Do I have that right? When do you and your husband have an appointment with his doctor to review the results together?
The only MRI report I've ever seen was the one my urologist had ordered for me. It had the same top line result as yours: "PI-RADS v2.1 score 5: clinically significant cancer is highly likely to be present".
My research had turned up reasons to suspect the MRI could be in error, but I took this report as a warning sign to pay attention to. Up until then I was very reluctant to have a biopsy. I agreed to one right away.
A reason the MRI could be in error:
Eg: Dr. Matthew Cooperberg at UCSF discussed a study done by Stanford of their own MRI readers, that found:
"depending on which stanford university radiologist happens to read your MRI the likelihood that a PI-RADS 5 meaning a high you know bad looking lesion actually represents a high grade cancer grade group two or higher ranges from forty percent to eighty percent…"
Cooperberg noted, imagine what a study of community MRI readers compared to high volume prostate cancer institutions would show.
I found myself in agreement with Cooperberg on this point:
"every single aspect of prostate cancer care after the PSA I'm talking about the MRI, the biopsy, treatment discussions, having surgery, radiation - this should all be done at centers of excellence"
I had insisted that my MRI be done at the nearest center of excellence, i.e. Fred Hutch in Seattle, which is an NCI designated cancer center, even though I was still receiving care from a community urologist in Bellingham. I transferred my care to Fred Hutch soon afterwards.
By the way: my MRI was quite accurate. The biopsy confirmed it. I was diagnosed as cT3b, "at least high risk". Definitive treatment aimed at a cure was still regarded as possible. This is the last stage where, traditionally, treatment aimed at a cure is offered.
Further delay, after getting the MRI, to avoid a more definitive diagnosis, would have been a really bad idea.
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2 Reactions@colleenyoung
Why is AI an issue when medical groups like Duke Health are using it to determine how to best use ADT? AI may lead to much better prostate treatment in the near future.
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2 Reactions@colleenyoung
Hi Colleen: how/where can I write a thank you message to those generous members responding to my message (prostate group). I tried the 'initiate a discussion' field) but my messages vanished in the process. Thank you..
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Hug
2 Reactions@climateguy Heartily agree regarding moving to a COE after initial diagnosis or strong suspicion (PSA reading), or even after an MRI that is done and interpreted by your community urologist. After decades of looking at satellite imagery professionally, I was a bit appalled at the rather poor resolution of MRI images relative to the "precision" and impact of judgments based on them. It takes an oncologist who is aware of that, and willing to say "I'm not sure what we're seeing here. Let's investigate further." In my opinion (and experience), such people are more likely to be at a COE than at a commercial urology outfit. Image interpretation is an art, and you need to be in the care of someone who has the humility to understand that.
A large amount of the info you wrote regarding your journey is similar to my journey. I was Active surveillance for 15 years until PSA took a sharp upturn. An mri located the spot. A fusion biopsy confirmed 4+4 in two cores and 4+3 in another. Then a psma scan to confirm disease was localized. Then a decision to use beam radiation and short course of adt to treat it. Oncologist wanted me to do 12 month minimum on adt but I ended it after the fifth month. I am now 10 months post first injection in October 2025. At last blood draw both PSA and testosterone were undetectable. I am quite glad that I ended adt (firmagon) at five months.
As said above, the next step is a biopsy. Insist on a trans perineal fusion guided one. Most med facilities will give option to undergo with anesthesia if patient is apprehensive. I did it under local lidocaine only. But if there is any apprehension at all I would say take sedation or anesthesia.
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