PI-RADS Score of 5 - Next Steps

JasonB176 · January 19

Hi all,

Just to give a bit of background - my father died of prostate cancer as did my maternal grandfather. Both my mother and her sister died of breast cancer.

My PSA has been followed since my early 40s. At age 50 which was 2 years ago, it tested at 5.1. I had an MRI that indicated only a benign condition. My PSA actually dropped to 3.5 in the following checks and last year following a normal DRE, my urologist was even talking about discharging me.

Fast forward to last month and my PSA was back at 5.1. I saw my urologist earlier this month and for the first time, his DRE indicated a problem. He ordered another MRI which I had done yesterday. To my utter horror, it came back with a PI-RADS score of 5! I found this stunning as things looked good a year ago. With the problem noted on the DRE, I expected something to be wrong but didn't think it would go to the worst level at 5.

I'm scheduled to only see my urologist in a week. I've done some research but would really appreciate the advice of those with far more experience. I read about two different types of biopsies - a more general one and a targeted one. Given by RADS score, should I push for the targeted one? I almost certainly have prostate cancer based on the RADS score, so is watchful waiting even a consideration at this point?

I can post details from the RADS report if that would help.

Thank you!

Jason

Old Salt · January 19

Yes, you should ask for a targeted biopsy. Or, in other words, a procedure that includes all of your prostate plus the PIRAD 5 area identified by the MRI.

I can totally understand that you are scared, especially considering your family's background, but prostate cancer can only be identified by a biopsy. The waiting will be hard, I am sure.

I don't know what kind of biopsy is being planned. Nowadays, the transperineal route is preferred over the transrectal one. I hope that your urologist is experienced in the former method.

Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis | World Journal of Surgical Oncology | Full Text (biomedcentral.com)

PS: It's way too early to discuss 'watchful waiting'.

Oldernow · January 19

Hi Jason - sorry to hear of your troubling test results.

I had 4 biopsies over a period of 20 years due to chronic high PSA (5 to 9). They were all the standard trans rectal biopsies which cannot easily sample all of the prostate. None of them found cancer but the second one back in 2001 left me hospitalized for 10 days due to a blood infection. My last biopsy was very different - trans-perineal. There is much less chance of infection with that protocol.

In 2022 (at age 75) my PSA jumped to 20. My urologist ordered an MRI which showed a number of PI-RAD lesions. This led to a trip to Cleveland Clinic for the trans-perineal biopsy using the MRI (MRI fusion) results to guide the sampling. That biopsy found cancer with a 3+4 Gleason. A genomic test on one of the biopsy cores (Decipher test) indicated my cancer was at the high end of a moderate chance to spread.

I was started on ADT therapy (three 6 month Lupron shots) along with 28 radiation treatments. I finished the radiation in June of 2023. I am due for my last Lupron injection in early April 2024.

So far things are looking good. My PSA dropped from 20 to <.03 (considered non-detectable). The Lupron injections lower your testosterone to starve any remaining cancer cells of their favorite food. My testosterone dropped from 550 to <10. I have had many troubling side effects from the Lupron but, if it is truly killing off any remaining cancer cells, I guess the side effects are worth it.

To answer your question more directly, if you have the option, I would go with the trans-perineal biopsy. Mine was done with nitrous oxide and local anesthetic. I only had minor discomfort. It was totally "outpatient" as I was able to drive home within about 45 minutes of the procedure.

Good luck as you move forward and keep us posted...

JasonB176 · January 19

Thank you Old Salt and Oldernow for your comments. I'm trying to absorb as much info as possible and appreciate your feedback.

I thought I'd go ahead and post the results from my MRI. So much of it is medical jargon which I don't fully understand. It's concerning when it talks about "definite extraprostatic extension/invasive behavior". Does extraprostatic mean that the cancer has already escaped outside the prostate?

Here's the report:

General:

The prostate measures 3.7 cm AP x 5.6 cm transverse x 5.0 cm

sagittal. This yields an estimated prostate volume of 55 cc.

The transitional zone is diffusely moderately enlarged, and contains

multiple circumscribed hypointense and heterogeneous encapsulated

nodules. The findings are consistent with moderate benign prostatic

hypertrophy.

There are scattered linear and/or wedge shaped signal hypointensities

in the peripheral zone on T2 and ADC map without conspicuous

enhancement on DCE images (PI-RADS 2). Findings are consistent with

prostatitis.

Lesion analysis:

Lesion 1:

Location: Right peripheral zone posterolateral mid gland (series 601,

image 18)

Size: 1.8 x 1.1 cm

DWI: 5: Focal markedly hypointense on ADC and hyperintense on high

b-value DWI; >1.5 cm in greatest dimension or definite extraprostatic

extension/invasive behavior.

T2: 5: Circumscribed, homogenous moderately hypointense focus or

mass >1.5 cm in the greatest dimension or definite extraprostatic

extension/invasive behavior

DCE: Positive: Focal, and earlier than or contemporaneously with

enhancement of adjacent normal prostatic tissues, and corresponds to

suspicious finding on T2 and/or DWI (series 1001, image 977)

Extraprostatic extension/ Neurovascular bundle: Lesion abuts > 1 cm

of the prostate capsule. No overt extraprostatic extension.

Overall assessment: PI-RADS 5: Very high (clinically significant

cancer is highly likely to be present)

Seminal Vesicles: Normal bilaterally.

Rectum: Unremarkable, no involvement

Pelvic Sidewall: Unremarkable, no involvement

Lymphadenopathy: No significantly enlarged or abnormal appearing

iliac, obturator, or inguinal lymphadenopathy is identified

Osseous: No evidence of osseous metastasis is identified.

Other findings: None

IMPRESSION: Newly identified 1.8 cm PI-RADS 5 lesion in the right

peripheral zone posterolateral in the midgland (series 601, image 18).

Findings consistent with prostatitis in the remainder of the

peripheral zone.

Moderate BPH.

Overall PI-RADS Score: PI-RADS 5: Very high (clinically significant

cancer is highly likely to be present)

VascodaGama · January 19

Hi,

I would add to the comments of above survivors, the importance of the positive DRE identified by your doctor.

The DRE does not diagnose cancer and the MRI doesn't identify extraprostatic extensions but the fact is now a possibility that should be considered later. This would be a point for discussion went talking or deciding on a treatment if you ever get a positive diagnosis of cancer from the pathologist.

Let's hope for a negative result.

Best

VG

JasonB176 · January 20

https://csn.cancer.org/discussion/comment/1712505#Comment_1712505

So despite the DRE exam showing something and especially the RADS 5 score, there's still a chance I don't have a cancer? Or if I do, that nothing will be suggested as an immediate treatment option?

Thanks for your comment!

Old Salt · January 20

Focus on the fact that if cancer is found, it is likely to be very treatable.

VascodaGama · January 20

Hi again,

I just read the MRI report. It wasn't here when I posted my above comment.

In any case, you need the biopsy to confirm what the report describes. The biopsy is the ultimate way to diagnose cancer.

Surely, you can start a treatment making decisions based on the report, therefor avoiding the risks of a biopsy. You could dissect the whole gland, slice it and get it checked by a pathologist who would give you information on the Gleason grade, volume of cancer, extraprostatic extensions, etc. It would be most unfortunate if in fact the issue was BPH and not cancer.

If you do a biopsy, the lesion indicated with 1.8 cm will be aimed, not just to verify existing cancer but to indicate the extent of the extraprostatic extension.

The report also suggests BPH due to the size of the gland 55cc and the image of "hypointense and heterogeneous encapsulated nodules". This alone could be the reason for the high PSA of 5.

However, the radiologist describes a "lesion abutting 1 cm" on the prostate capsule at the "Neurovascular bundle" which typically leads to high probabilities of a non contained case. In such cases, radiation treatment would be preferred to surgery, and if you decide to go that way (without a biopsy) you would never know the grade of the cancer.

I can't see the need in having an "immediate treatment". I understand the worries in regards to the actual death occurrences in your family, but you have time to check everything, investigate on treatment options, their risks and side-effects, and make a decision that is most satisfying to you.

At some point we all have to decide and need luck.

Best wishes

VG

JasonB176 · January 20

https://csn.cancer.org/discussion/comment/1712529#Comment_1712529

It is concerning about the lesion and the extraprostatic extensions which even when I first read the report indicated to me that it might not be contained in the prostate. This is the part that tends to be alarming to me given the two facts that I had an MRI 2 years ago that showed NOTHING and a DRE a year ago in which the prostate felt fine. So in this comparatively short period of time, not only is my prostate most likely cancerous but it would appear that it's not even contained. I thought prostate cancer was typically slow moving and that by getting the yearly checks, I'd at least catch it in a contained state.

I'm sure there are aberrations and it's not always slow moving. I can't blame my urologist for putting out my appointment to yearly though I am questioning the fact that he even mentioned last year about discharging me.

Would it be completely unheard of to begin treatment without a biopsy given the severity of that report? My father went the radiation route and I'm sure it bought him some time but I was thinking more of surgery but that might not even be an option for me.

Thanks for sharing your insight.

VascodaGama · January 20

Well,

The initial MRI could have in fact shown something that wasn't reported by the radiologist of that time. He could be someone without much experience.

The urologist usually takes into consideration those reports and at that time gave you his recommendation based on erroneous information.

DRE is never credible. They only touch one side of the prostate.

You could request a second opinion on the films of the initial MRI but this is too late to blame someone.

Prostate cancer doesn't explode overnight. Get second opinions and continue your research.

Best

VG

Josephg · January 20

https://csn.cancer.org/discussion/comment/1712535#Comment_1712535

One thing to remember about a DRE is that it can 'feel' only part of the prostate. The rest of the prostate is unreachable with a DRE. In my case, my PCP did the DRE for 5 years and felt nothing, but when I was finally biopsied, 3+4 and 4+3 cancer existed in my prostate.

JasonB176 · January 22

I went back and looked at the report from my MRI from two years ago that showed only a benign condition. I was quite surprised that it listed the prostate volume of 40 cc whereas the one from last week says it's now 55 cc.

That's a huge jump for a two year time. Does anyone have thoughts about what this increase might mean? Could that increase be solely due to cancer likely now being present?

Thank you.

PI-RADS Score of 5 - Next Steps

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