Continued Monitoring or Biopsy?

Regarding the MRI results - first a PIRADS 3, then a PIRADS 2 —> Always remember that PIRADS results are just one specialist’s educated and experienced opinion of what is seen in the scan. It’s recommended to get a 2nd opinion on the scan — not necessarily because you don’t trust the 1st one or don’t like that opinion. But, because much of the interpretation of images and scans is often as much an art as it is a science, and it’s dependent on the skill and experience of the person reading the slides. It’s good to have an independent set of eyes reviewing the scan (especially one where the PIRADS results change).

Yes, it could simply be due to BPH.

How are all of your other test results: Bone scan results, CT scan results, and genomic (biomarker) test results?

With your family history of prostate cancer, have you had a genetic (germline) test?

With all that additional information, you can have confidence in your next decision regarding a potential biopsy or just continued surveillance.

Your prostate is pretty large. That results in a higher PSA. I know a guy whose PSA was 50 and had a huge prostate. Had multiple biopsies they never found anything.

As @brianjarvis says, The family history of prostate cancer is your biggest worry. My father died of prostate cancer at 88. My brother and I both got it, I got it at 62. He got it at 77 after years of active surveillance..

The fact that your father had it doubles your chance of getting it. Getting a biopsy is pretty straightforward. The doctor can use the MRI for direction with some of the biopsy cores By targeting the tumor that is PIRADS 2.

I had a couple of Transrectal Biopsies and they were really, no big deal. Of course, today I would want a transperennial biopsy, since it can access more of the prostate and reduce the chance of infection.

I also had a prostatectomy at 62. I got it a lot earlier than my brother because I have BRCA2.

The fact that your father got prostate cancer so young and that you may face it means that There may be a genetic reason for it. You could get genetic testing to find out if it could be a factor. Does anybody else in your family have cancer? You can get it here for free, takes 2 to 3 weeks to get the results and a genetic counselor will call you. They will send you a kit that you return in the mail. You have to live in the USA to get this test for free.

Prostatecancerpromise.org

@brianjarvis I’m waiting on a second read of my MRI from ProstatID. As for some of the other markers it seems like you either have to have a cancer diagnosis or they are not standard of care as in the PSE. Appreciate your response.

@jeffmarc appreciate your response. I tried that but did not qualify because I have not been diagnosed with cancer yet. On my pirads two MRI there are no lesions so my urologist said there would be nothing to target. Essentially what he offered was a standard 12 core transrectal essentially blind,

@ezupcic
The only way you can get a PIRADS Score is if there is a lesion, they are scoring. Very weird.

It sounds to me like he Is unable to do a fusion biopsy, which would use your MRI to direct the ultrasound to find that lesion and at least get three samples from it.

@jeffmarc according to AI......"you don't need a discrete lesion to have a Pi-Rads category. A prostate MRI with no focal suspicious findings can still be reported as a Pi-Rads 1 (normal) or Pi-Rads 2 (benign appearing changes).

@ezupcic here was the impression from the radiologist
IMPRESSION:
1. Persistent relatively diffuse signal abnormality throughout the
peripheral gland of the prostate typically representative of
prostatitis without discrete suspicious underlying lesion identified,
with the highest PI-RADS category: 2. Diffuse
neoplastic involvement remains of consideration but felt
significantly less likely given appearance.
2. Prostatomegaly as described.
3. Sequela of chronic bladder outlet obstruction physiology, left
sided ureterocele, colonic diverticulosis, and bilateral
fat-containing inguinal hernias.

@ezupcic
What you say is true, a lesion is not necessarily there, but there is a specific area abnormality found to get a PIRADS 2 score, So that could be targeted in a biopsy just like a lesion.

AI says the following

Yes, a PI-RADS 2 score indicates a low probability of clinically significant cancer, but it's assigned to specific suspicious lesions or areas (like linear/wedge-shaped abnormalities in the peripheral zone, often from prostatitis) that have certain characteristics, not just a completely normal prostate, though a score of 1 is very low likelihood, and PI-RADS 1 or 2 often means deferring biopsy. You need to have a focal finding (a "lesion") that meets PI-RADS 2 criteria for that specific score to be given, rather than just a "normal" scan, which would be a PI-RADS 1.

@jeffmarc interesting. My urologist said there would be nothing to target but if I understand you correctly you are saying there is a focal finding which is what makes my score a Pirads 2 that could be targeted and the MRI scan could be utilized to do that?

@jeffmarc my AI saying the following:

"With a Pi-rads 2 MRI and a PSAD of 0.086, the odds of clinically significant cancer are generally low. Your family history nudges risk up, so a reasonable plan is to refine risk using biomarkers and trends, and proceed to a systematic transperineal biopsy only if those signals become concerning or if you prefer definitive sampling now for peace of mind."

So back to square one. Biopsy now for peace of mind potentially or follow trends and continue with biomarkers..........