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PI-RADS Score Info Please

tonycue
Posts: 39
Joined: Aug 2016

Hi Guys...Went for my biopsy today...Nowhere near as bad as I was expecting, 12 cores and only 2 of them were uncomfortable....Very nice Doc and Nurse...Was able to ask them a few questions, and even had a couple of laughs....Asked this doc about the PI-Rads Score (which I have since learned about)....Apparently my scan showed a PI-Rads score of 4.....Bummer!...I should have asked while I was in there, but although I knew this wasn't good didn't know the exact implications.  Have now looked this up via Dr Google and it staes that a PI-RADS score of 4 means high likelihood of "clinically significant cancer"....My question is, what counts as "clinically significant"? does this just mean a malignancy of any kind, or does this mean a higher gleason grade?.....Don't want to scare myself, but at the same time I don't want to go in for my results completely naive.

    Thanks in advance

      Tony

Will Doran
Posts: 207
Joined: Sep 2015

Tony,

This was new to me, so I Googled.  I found this.  It might help.  This wasn't something I was told about when I went through the biopsy, etc.  I think we are just now getting this at our Hospital.  In fact we donated to the Hospital Fund to help buy the equipment for this testing.  Very technical and hard for me to understand.  You can click on the blue links and it will go to other info. 

Good luck

Peace and God Bless

Will

Prostate imaging reporting and data system (PI-RADS)

PI-RADS (Prostate Imaging Reporting and Data System) refers to a structured reporting scheme for evaluating the prostate for prostate cancer. It is designed to be used in a pre-therapy patient.

The original PI-RADS score was annotated, revised and published as the second version, PI-RADSv2 6by a steering committee with the joint efforts of ACR, ESUR, and AdMeTech Foundation. The following article reflects this newest revision.

The score is assessed on prostate MRI. Images are obtained using a multi-parametric technique including T2 weighted images, a dynamic contrast study (DCE) and DWI. If DCE or DWI are insufficient for interpretation the newest guidelines recommend omitting them in the scoring 6.

A score is given according to each variable. The scale is based on a score from 1 to 5 (which is given for each lesion), with 1 being most probably benign and 5 being highly suspicious of malignancy:

  • PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)
  • PI-RADS 2: low (clinically significant cancer is unlikely to be present)
  • PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal)
  • PI-RADS 4: high (clinically significant cancer is likely to be present)
  • PI-RADS 5: very high (clinically significant cancer is highly likely to be present)

Parameters

T2-weighted imaging
Peripheral zone (PZ)
  • 1: uniform high signal intensity (SI)
  • 2: linear or wedge shaped hypointensity or diffuse mild hypointensity, usually indistinct margin
  • 3: heterogeneous signal intensity or non-circumscribed, rounded, moderate hypointensity; includes others that do not qualify as 2, 4, or 5
  • 4: circumscribed, homogenous moderately hypointense focus or mass confined to prostate and <1.5 cm in the greatest dimension
  • 5: same as 4 but ≥1.5 cm in greatest dimension or definite extraprostatic extension/invasive behavior
Transition zone (TZ)
  • 1: homogenous intermediate signal intensity
  • 2: circumscribed hypointense or heterogeneous encapsulated nodule(s) (BPH)
  • 3: heterogeneous signal intensity with obscured margins. Includes others that do no qualify as 2, 4, or 5
  • 4: lenticular or non-circumscribed, homogenous moderately hypointense, and <1.5cm in greatest dimension
  • 5: same as 4, but ≥1.5cm in greatest dimension or definite extraprostatic extension/invasive behavior
Diffusion weighted imaging (DWI)
  • 1: no abnormality on ADC or high b-value DWI
  • 2: indistinct hypointense on ADC
  • 3: focal mildly/moderately hypointense on ADC and isointense/mildly hyperintense on high b-value DWI
  • 4: focal markedly hypointense on ADC hyperintense on high b-value DWI; <1.5 cm in greatest dimension
  • 5: same as 4 but ≥1.5 cm in greatest dimension or definite extraprostatic extension/invasive behavior
Dynamic contrast enhancement (DCE)
  • negative: no early enhancement, or diffuse enhancement not corresponding to a focal finding on T2 and/or DWI or focal enhancement corresponding to a lesion demonstrating features of BPH on T2
  • positive: focal, and earlier than or contemporaneously with enhancement of adjacent normal prostatic tissues, and corresponds to suspicious finding on T2 and/or DWI
Changes from PI-RADS v1 to v2

Determining sequences for PZ and TZ were defined. 

For the PZ, DWI is the primary determining sequence (dominant technique).

  • PIRADS score for a PZ lesion is based on DWI, unless the DWI score is PIRADS 3.
  • In this scenario, DCE is used to decide between PIRADS 3 (no focal or early enhancement) or upgrade to PIRADS 4 (focal and early enhancement present. 

For the TZ, T2W is the primary determining sequence. 

  • PIRADS score for a TZ lesion is based on T2W, unless the T2W score is PIRADS 3. 
  • In this scenario, DWI is used to decide between PIRADS 3 (DWI score <5) or upgrade to PIRADS 4 (DWI score 5). 

The number of mapping lesions was limited up to four findings with the highest PIRADS Assessment Category of 3, 4, or 5. The index (dominant) intraprostatic lesion should be identified. Thus, a smaller lesion with EPE should be defined as the index lesion despite the presence of a larger tumour with the identical PIRADS Assessment Category.

MR spectroscopy was omitted in PI-RADS scoring.

The sector map of v1 was adapted in v2.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

Tony,

Like Will, I had never heard of this 'PI-RADS Score.' It just sounds like an interpretive guide for various MRI results of the prostate, some new convention that a doctor is trying to popularize.  Periodically a medical team or equipment manufacturer will submit a new test that they tout as "revolutionary' in evaluating PCa. Most of these are forgotten about within two or three years.  I am not questioning the accuracy of PI-RADS, because I know nothing about it, except for the informative stuff Will shared. But based on what I read, it is a matrix of sort for intertpreting MRIs -- something most radiologists and urologists simply do on their own.  It must not be commonly employed in the US, since neither of us had ever heard it mentioned here before.  I did note that Will's article stipulated that it is used only on pre-therapy patients.

My definition of any "clinically significant" cancer: A cancer you have to spend a fortune on and that worries the hell out of you.  That is pretty much any cancer a person ever contracts.

I would not get concerned over evaluating the worth of the PI Score, since biopsy results usually take a week or less to get back themselves. The Gleason, the Volume of disease, and vectoring are what will be determinative in Staging and evaluating your disease.  As has been said numerous times, the Biopsy is what everything else revolves around.  Impressionistically, your initial PSA Vector (not referring to the free-PSA data) accords with the assessment in the PI-Rads judgement that the disease is significant.

I'm glad the proceedure went without much pain, and hope the Gleason is as low as possible,

max

tonycue
Posts: 39
Joined: Aug 2016

Hi Max & Will, thanks for the replies.....Funny thing is when I threw the question out a couple of weeks ago regarding the accuracy of the mpMRI I posted here and asked the same question on two other PCa forums that you may be familiar with ....."Healing Well" and the "New Prostate cancer info link social network"....Like this forum people write and ask and answer questions from around the world, but the majority of the members are from the US.....It was from both of those other sites and from US contributors that I first heard the mention of PI-RADS which is obviously being used, as you rightly state Max as a universal "scoring system".....When I met with the grumpy urologist 2 weeks ago I was ignorant of its existence or else I would have questioned him at the time......After being made aware I thought it germane to question the biopsy doc (who was a much more pleasant fellow) as to whether 1: he could be sure of spearing anything at all as I have an ultrasound determined 56cc prostate (70cc including seminal vesicles apparently) and 2: what my PI-RADS score was on my scan.....I was aware that 1 was good news and 5 Bad, but had not really read up too much.....as I stated previously I was just puzzled as to the term "clinicaly significant" in the wording and was hoping that others here had experienced similar.

 

Obviously this was not what I was hoping for......My results are in 9 days time and just wanted to be mentally prepared.....

    Regards

        Tony

hopeful and opt...
Posts: 2226
Joined: Apr 2009

I also just had a biopsy. My region of interest was graded at a 3. I was told that the results will be one week from the biopsy, which is Wednesday. 

I am currently reading a study

"Prostate Cancer Detection With Magnetic Resonance-Ultrasound Fusion biopsy: The role of Systematic and Targeted Biopsies" Christopher P Filson, MD, MS is the lead investigator. The article was published in the Interdisciplinary International Journal of the American Cancer Society, Volume 122/Issue 6, March 15, 2016  conceronlinejournal.com

I'm not familar with the term Pi Rads, but at UCLA there is a rating system of five grades, from 1 to 5, 5 being most likely to find a cancer in the suspicious lesions.

The multiparametric is done with contrast. There is a three dimenisional biopsy machine, Artemis that locks into, and targets suspicious lesions.

Here is information from one of the charts in the study. 

  here are the percentages of  patients where clinically significant cancers were found:

Grade 3 (N=435) 

systematic only  16%

Targeted only    16%

Combination      24%

Grade 4 (n=301)

Systemic only    26%

Targeted only     33%

Combination       37%

Grade 5 (n=89)

systemic  only 56%

targeted only   69%

Combination    80%

Clinically significant is a grade of 7 or more.

 

tonycue
Posts: 39
Joined: Aug 2016

Hi H&O....The scoring system that UCLA seem to be using sounds about the same, maybe it's just a different version of the same flavour (or flavor) a 3 in the PI- RADS score is classed as equivocal ie ambiguous.....Guess all this stuff is subjective at the end of the day, and it depends on the radiologist reading the scan....(would have preferred a lower number though) My Biopsy wasn't as fancy pants as yours....Just a straightforward TRUS..... Just got to play the waiting game now,,,,,Don't like that term "clinically significant"......Sounds a bit too final Frown

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

Tony,

It is worth poining out that Hopeful and Optimistic mentioned that his scaling proceedure at UCLA uses the Artemis device, a not brand new, but relatively new, MRI-based 3-D Imaging system that is in fact a large advancement in PCa staging.

My medical system last year installed one, and a friend was scanned on it about two months ago.  It is popular for use on men who are in Active Survelliance, but all PCa patients benefit from it.  It is indeed fancy pants !  I plan to look up H & O's referenced article.

max

hopeful and opt...
Posts: 2226
Joined: Apr 2009

rcorrection:

The categories in the study were developed before PI RADS. They are very similar but not the same. PI-RADS is now the industry standard.

Vasco wrote on your other thread.

" At the same annual conference of 2015, Dr. Dan Margolis (a radiologist at UC Los Angeles) introduced the PI-RADS score which ranged from 1 to 5 namely highly unlikely to highly likely. These wordings are of prediction and that’s how we should consider it, or....... Can we trust that radiologists are now more coherent in analyzing an image study and do score it properly?"

Dr. Margolis is the radiogist at UCLA who developed both systems.

https://en.wikipedia.org/wiki/PI-RADS

Will Doran
Posts: 207
Joined: Sep 2015

Tony,

What H&O mentioned (Magnetic Resonance-Ultrasound Fusion Biopsy), is what we are getting here at our hospital (I think).  My urologist is the one who ask (actualy begged)  for the technology and they are  raising funds to help pay for the equipment.  The new room is being added at the hospital, onto the end of the Radiology Department right next to the radiation treatment areas, in the Cancer Center.  If I understnd it correctly, when the Urology Department does biopsies at the offices, about two miles from the Hospital, they will be able to connect to the MRI's that have been done on the patient and that helps guide the biopsies.  I know there is a number scale with that as H&O said.  Not sure if these are the same or not. 

Glad your biopsy went OK and wasn't as bad as expected.  I remember of a couple "snips" that were rather uncomfortable, and I sort of got very quiet.  The nurse came around and held on to me and that seemed to help.  Dr. Miller apologized, did the last couple "snips" and we were done.  I guess we've all been through that so we understand. 

Peace and God Bless

Will

tonycue
Posts: 39
Joined: Aug 2016

Hi Guys, Thanks for the responses .....My question really was regarding what the score meant in the terms of "clinically significant" which is what a PIRADS of 4 means...."Likely to have clinically significant Cancer".....Just wanted to know if that meant any form of malignancy, or a higher gleason grade....?

hopeful and opt...
Posts: 2226
Joined: Apr 2009

As mentioned, in this case clinically significant cancer is a score of Gleason 7 or more.

Each of the five scores  show how suspicious the tumors appear in the MRI, these are categories of suspicion. There is a correlation between these scores and the biopsy results.........I listed above the chance of  a man's pathology having significant cancer (gleason 7 and above) for a score of 4 in the post that I just made.

I hope that this clarifies the answer to your question

Will Doran
Posts: 207
Joined: Sep 2015

Tony,

I'm at a loss as to what your are asking.  I had no idea of any scores like that until the resuts of my biopsy came back and I was liasted as a Gleason 7, with 40% invovment.  Then the results of the post op pathology came back as a Stage pT3bN1.  Then I knew I was almost a Stage 4.  Then,  they treated me as a Stage 4. I had no idea I was that advanced until after the surgery.  Then it all soaked in, and we went from there.  That was three years ago.  I hope and pray you will have the same sucess, and better, from your treatments and folow up.  It's never over and done with.  I look at each day I continue on as a gift.  The technology is changing so fast and I'm sure in these past three years, there have been many improvements in diasgnosis and treatment.   

Best of Luck, Fight like hell.

Peace and God Bless

Will

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Tony,

I am glad to know about your biopsy endeavour. In your previous thread you have shown to be reluctant in do it, probably giving preferences to the lesser intrusive diagnosis based on the mpMRI exam. Now I wonder if the biopsy took into consideration those MRI PI-RADS results.
I guess yes it did, because the doctor involved informed you on the Score 4. I think you are in good hands and shouldn't worry about the outcomes. They will be what they should be. Just wait. Anxiety is friend of the bandit.

Regarding your inquire on the meaning of "clinically significant cancer" you may take it as Ira comments above. A prediction of a Gleason with a grade of 4 or 5 (equals to a Gleason score above 7). In any case, this is only predictions. The pathologist analyzing the cores under the microscopy will provide you with the real grade, that together with the other facts (commented by Max) will provide you a clinical diagnosis and stage, if any. The pathologist report will also indicate any other evident feature like the existing BPH and/or calculi. It will also describe on the type of the cancer (acinar adenocarcinoma, small cell carcinoma, etc) and its aggressivity.
You will also find about the reason for the large gland (56cc).

Surely you have not been yet diagnosed with a positive result but it may be wise to be prepared for the next meeting when they give you the results. I would recommend you to be accompanied by a family member. We all experienced nasty feelings in particular if we hear the word; You Have Cancer. I still cannot recall how I got home from the hospital. The last image is that of leaving the facilities and then seeing my wife at home asking me on the results. I do not recall the in-betweens. Did I travel by subway? by taxi? Did I walk? 

If uneasy while waiting for the results, I would recommend you to prepare a list of questions that would include not just matters related to the biopsy but also in regards to the cancer (aggressivity), the advanced status and type of treatments. This may give you a sence of being doing something positive.

From these links you can get ideas for your list;

http://csn.cancer.org/node/224280

http://www.cancer.net/navigating-cancer-care/diagnosing-cancer/questions-ask-your-health-care-team

http://www.mayoclinic.org/diseases-conditions/prostate-cancer/basics/preparing-for-your-appointment/con-20029597

In regards to the biopsy report and its technical terms, you may find help from these links;

http://www.harvardprostateknowledge.org/understanding-your-prostate-pathology-report

http://prostatecanceruk.org/prostate-information/rare-prostate-cancer

 

 I would like to know the details of your mpMRI report. Can you provide us with a copy? How about the DRE results?

Your previous thread is here: https://csn.cancer.org/node/304417

Best wishes and luck.

VGama

 

tonycue
Posts: 39
Joined: Aug 2016

Hi VG, Thanks for your post and the assorted links, which I shall read later

When I first posted here I was already booked in for my biopsy, I had initially avoided the procedure not because of squeamishness (I'm one of those people who prefer not to be numbed at the dentist unless it's a particularly deep filling)....I avoided it because rightly or wrongly after the visit to the esteemed professor of urology in London who I consulted after getting the free PSA test from his lab , I was almost wholly convinced that it was an unnecessary procedure....When a guy who is world renowned and specialises in the prostate, has written many books and scientific papers and has done over 900 Robot RP's tells you unequivocally that you DON'T have cancer....you really want to believe him (this may have been denial on my part of course.....If you read my previous post you'll see that I also avoided referral to the hospital 2 and a half years ago at age 56 with a negative DRE but a PSA of 3.1)...I'll admit that I was worried at the time, but rationalised that as the cut off off for my age was 3.0 I was only .1 over and therefore "safe".....I only underwent the MRI because the Prof had said that if I wanted to know what was going on with my prostate (frequent urination, urine retention etc) then he would say that I should have an MRI (he mentioned this in passing)....I would have had one done at his clinic at the cost of £1700.00, but the NHS (whose conveyor belt ride I had then already just started) booked me one anyhow.

When I went for the biopsy yesterday I asked the doc what my PI-RADS score was as I had learnt of its existence in the last 2 weeks since my meeting with the grumpy uro who informed me that there was "something" on the scan.....He even said that if I wasn't bothered I could wait a few months and see if my PSA had dropped back down to my original number (which now seems a bit irresponsible of him) Since asking the question on here I have done some more research into the PI-RADS score and the ACR (American College of Radiology)

 http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/PIRADS/PIRADS%20V2.pdf

list a clinically significant cancer as one have a G score of 7 or over.....The score of course is subjective and is dependent on the radiologist doing the reading

Not what I wanted to hear of course, but nothing will be official until I get the results next week.

The MRI report I haven't seen and the only thing I know is that apparently this is a small lesion, confined to the prostate (which tallies with the PI-RADS 4 score)

Unlike in the US where you guys pay for your procedures and therefore your test results are considered yours, it's a bit different here in the UK....I could probably ask for a copy, but by then the cat will be out of the bag......All my DRE's have come back negative....and I have had 4 in the previous 8 weeks....It was the doc yesterday who told me that my Prostate was 56cc (after I asked him)....But he said that I wouldn't win any prizes as the largest he had seen was 500ccSurprised How did the poor guy get around??

As for going to the appointment alone...No way! My wife is a trouper and has been with me to every appointment thus far....

Thanks for your good wishes

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Tony,

I would recommend you to request copies of the reports (including the biopsy) and keep them in a file.

Interestingly I also have experienced similar dilemmas with the doctors and the NHS conveyor belt rides. I am Portuguese and the medical system in my country (Servico National de Saude) follows similar norms of those of the English NHS. We all have at front a GP that will pass us over to a specialist. The first doctor (specialist) we consult will then decide on our needs and next step (urologist in particular tend to be grumpy). If the medical condition makes us an outpatient then nobody keeps or files the paper results of exams/tests together. They simple register/input, in short words, the findings and the priority data in their computers, under our name. All paper reports and tests are kept at each responsible department (or outside clinic) for later consultation, if required. It is therefore important to outpatients to keep a copy of those results so that they can be presented to the doctor(s) one pass through.
The prime doctor will give you those reports if you ask. In fact these will be valuable information when we get second opinions from independent specialists.

I was diagnosed in 2000 when living in Japan. The local health system is must better than the Europeans because one is not dependent of a GP. We can visit any specialist we like or be tested at any facility of our choice, all free of charge. I was surprised when moved to Portugal and confronted this restrictive system of health care. Here we go private at our own pocket money (or insurance) or learn how to navigate within the free-of-charge NHS. A mixture of private+NHS is also possible but one needs to be in “command” of his steps.

I think that the £1700.00 mpMRI 3T is the common price in Europe if one goes private. The good in being a EU citizen is that we can avail those exams at a neighbor country under the NHS system free of charge. You need to shop around and find the place where the belt conveyor runs faster.

Best

VG

 

tonycue
Posts: 39
Joined: Aug 2016

Hi VG, Portugese! Now I understand the Vasco de Gama Nickname....

 The only copy I have been given at the moment is my cystoscopy result, which was sent the day after I had the test.....I will try and get a copy of any paperwork if relevant.....At this moment in time I am feeling very Low.....I think that after the lowered PSA test, the reasonable free PSA and the good word from the Prof I was starting to think that I was "out of the woods".....After the MRI "seeing something" and the biopsy doc telling me I was a PI-RADS 4 I have now starting the fretting all over again......I dare say that everyone on this board has "been there"....Just got to "suck it up" and wait and see....Thanks for the aadvice

    Best wishes   Tony

Swingshiftworker
Posts: 1013
Joined: Mar 2010

This "new" screening system is news to me too.  It's interesting but w/o standardization I think it just creates confusion and until there is uniformity in the use of this system, I'd prefer to rely on the "old" Gleason scale.

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