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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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Transperennial biopsy is probably the best option.
You could get a PSE test, which could tell you if you have cancer snd should get a biopsy. With multiple high PIRADS scores this is probably wasted time.
After that, you might get a PSMA pet test, Depends on what the biopsy shows.
@jeffmarc you are probably right about the PSE being wasted time at this point. I'm just hoping to get a transperineal fusion MRI biopsy within a reasonable amount of time and if not I'll just have to do a targeted transrectal. I'm obviously very concerned about "threatening EPE" in the report. Hopefully the biopsy will lead me to treatment options that can be successful. Maybe SBRT. Thanks for the response.
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2 ReactionsBest wishes on this journey.
What do you mean in stating all your best efforts have failed?
What is your PSA history?
How many MRI’s have you had?
Ever had a biopsy?
In your situation, in parallel to getting a biopsy performed, I would be searching for a great cancer center, surgeon(s) and radiation oncologist(s).
Biopsy results may show gleason 3+3 or 3+4, instead of higher grades. In general, I think it is better to concentrate on obtaining more information and not assume it will be worst-case.
If you share age and where you live, others will provide more help.
Possible ECE is not too unusual to be noted on an MRI. In your case, it may be correct, or just a possibility. This notation on your MRI may allow you to obtain faster insurance approval for PSMA PET scan.
Best wishes.
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3 ReactionsSorry to hear of your news!
In active-surveillance terms, what you have described would generally be considered radiologic progression, BUT it is not yet proof of biologic cancer progression until a targeted biopsy shows a higher grade, greater volume, or extension.
Inflammation can imitate cancer on an MRI….this is what likely happened in my case….but my situation was the reverse of your recent MRI experience.
In my case the initial 3, 4 and 5 PIRADS lesions were no longer visible after 28 months and my PSA had dropped.
In your latest scan, four focal lesions, two scored PI-RADS 5 and showing early enhancement, are not something that should simply be attributed to inflammation without tissue confirmation.
Unfortunately, you can’t know what’s really going on without a biopsy.
You mentioned “Feeling a little devastated after all my efforts seem to have failed.”
What efforts have you been doing since your last mpMRI?
Was that mpMRi followed by a biopsy?
If so, what was your Gleason score?
Did you get a Decipher score at that time? If so, what did it reveal?
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5 Reactions@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.
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1 Reaction@handera I’m also wondering if lesions were missed on my prior two MRI’s or if these 4 are new over the last year.
@charlesprestridge I’m 63 and live in Portland Oregon. My challenge will be trying to get a transperineal biopsy within a reasonable amount of time. But I may just do the targeted trans rectal MRI fusion and go from there. This will be my first biopsy after 8 PSA tests and 3 MRI’s. I’m trying to not assume the worst but it’s definitely a challenge. Appreciate your response.
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1 Reaction@ezupcic and I’m currently seeing a Urologist at Providence NW Urology but my urologist doesn’t do transperineal biopsies.
@ezupcic Find a urologist that does fusion guided Transperineal biopsy. Even it means traveling a few hours. This type of biopsy is becoming more common so shouldn't be hard to find a urologist that does them. Teaching hospitals usually do them as well. This is a big important part of the puzzle. And after that a PSMA will be the final piece of puzzle to help decide on treatment. Of course there are genetic tests that can be added to see if adding ADT, or how you will do with SBRT, etc. But the main parts of the treatment puzzle are the MRI, Biopsy & PSMA. I know you mentioned SBRT which might be a good option with perhaps a brachytherapy boost and maybe ADT? Best of luck
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1 ReactionGood video to watch providing information about transperineal not showing to be superior to transrectal.
In the past year, I have had one transperineal and one transrectal biopsy.
1st biopsy was transperineal. It showed 5 cores of 3+3 (with a pirads5 lesion)
When preparing for 2nd biopsy, Urologist/Surgeon gave me the choice of either transperineal or transrectal. He preferred transrectal and that is what I agreed to. This 2nd biopsy had one core of 3+3 and 4 cores of 3+4. One core was 17mm in length with 100% cancer and 40% gleason 4.
I do not provide this data to indicate transrectal is better than transperineal. More to indicate they are very similar and biopsy sampling is limited to a small percentage of tissue sampled.
Transrectal has shorter needle paths and some areas of prostate are difficult to sample unless needle path is transperineal.
In either type, a fusion biopsy is still difficult for Doctor to precisely sample lesions from MRI.
As far as pain (I was put to sleep for both), the transrectal was almost painless after going home. Transperineal was not too painful the night of procedure, but could feel it some.
Best wishes.
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