Pi-RAD score of 5

Thank you so much for your response. Very very helpful.  Please don’t apologise about the length it was what I needed to read! I’m having the Transperineal MR Fusion biopsy as it’s targrted to where the MRI Scan showed areas of abnormality. All the evidence suggests it’s a much more effective diagnostic procedure. But mainly it greatly reduces the risk of serious infection/sepsis. I’m actually in the UK not the US but I’ve had other guys from the US advise that I should have the Transperineal procedure. My urologist it brilliant and I have every confidence in him! 

Well, Thursday will be the procedure then I guess a week or so for the results x I’ll let you know the outcome and perhaps ask for advice re next course of action. Again huge thanks for taking the time to reply! Hope your next scan is as good if not better than you can hope! I’m kinda resigned to getting a positive diagnosis of PCa! And I’ll fight the buggar.... 

Davey 

Thank You I never though of this. There are three findings on my scan 

I’ll type these, just incase you have a better clue or anyone else who may read this thread! 

1. 1.Within the peripheral zone and base of gland on the left there is focal T2 low signal change with associated diffusion restriction measuring 2cm mac dimension: pirads 5 (10/11;14/5;1401/6)

2. Within the transitional zone and mid gland level on the right there is an ill-defined focus of T2 low signal change with associated effusion restriction measuring 13mm diameter, 

pirads 4(10/13; 14/6; 1401:5)

3. Within the transitional zone at the apex gland  on the left there is an ill-defined focus of T2 low signal change with associated effusion restriction measuring 18 mm diameter: pirads 4(10/16; 14/7; 1401:4)

WTF?? Not a clue what this means

After a load of other blurb there is s sentence which says!

There is no abdominal or pelvic lymphadenopathy?

That’s got to be good right? 

Then ultimately 

CONCLUSION: 

bilateral foci of signal changes suspicious of malignancy as described above. BPH. No other significant abnormality. 

Thanks for listening and advice. I will let you know ASAP 

are the pet scans superior to the 3T Pi RADS MRI? My concern is that if my Pi RADS this coming Friday is still inconclusive my urologist might resist ordering an additional test like the Pet Scan.

The best diagnostic tools to detect PCa in the prostate is the 3T MRI and the transperenial  u/s guided biopsy. If the MRI shows PIRADS 4 or 5 in at least one area, then I recommend  biopsy pretty darn soon.

A PSMA PET CT can indicate the extent, if any, of the PCa beyond the prostate.

The Axumin PET scan will detect PSA cancer cells not only in the prostate but also cells that might have traveled to other parts of the body

Well I'm going to have to bite the bullet and talking in two days to the urologist to actually be doing the Fusion biopsy. Yeah I'm still worried about septic and other infections as well as spreading the possible cancer cells through the needle tracking. It will unfortunately be transrectal as no one offers the trans perineal biopsy in Ohio. And the part that sucks the most is the unreliability in positively detecting cancer. I still really don't think that prostate cancer would be causing the intense rectal pain I'm experiencing but what am I going to do? Maybe the urologist during the procedure will be a little bit more forthcoming in his infection rates and the number of fusion biopsies he has done.

there's another type of PET scan to determine metastasis (spread) of PCa - involves radioactive vitamin, choline, mostly used to detect recurrent can. but also sites outside prostate. my urologist claims it's been known to give false positives, but i'm not sure all the research is in yet. here's the site i found 

https://www.mayoclinic.org/tests-procedures/choline-c-11-pet-scan/about/pac-20384628

Mike hi! 

I too had a PI-RADS 5 in three areas on my MR Scan a couple of weeks ago! I got the results of my MR fusion Transperineal Targeted Biopsy last week on Friday 13th October! Like you I was advised to expect a clinically significant cancer! So I’m surprised but delighted to tell you that my Biopsy’s were all negative! The urologist said that the areas that were pirads 5 were just inflammation! All I have to do is have a repeated MRI Tesla Scan in 6 months time! Hope yours is all ok too, but try not to worry too much until you have further results and info. Come back here for advice anytime or even just to sound off! Fingers crossed for your 

Thanks for your response.  I had a positive experience with this, and not sure how much it might relate to your situation.  I received a call from my urologist two days ago,  and he said he had received a call from the imaging center.  They told him that for all people who receive scores of 5, they do a second review with a senior radiologist.  The second review said that my lesion was a 3, not a 5.  My urologist said they called about me and another patient of his where their score was downgraded.  He felt, and I agree, that they should not be releasing results until that second review is done.  It makes the patients unnecessarily worried and I am sure he was concerned that it made him look bad. So I wonder how many of those who get a score of 5 that turns out to not be cancer actually had an inexperienced or unskilled radiologist reviewing the images.  It will make me more cautious the next time I go through this.  The technology seems like it is good, but relies on the skill of the person interpreting the images.

Thanks for giving me something new to worry about (just kidding). But your response is noted. I will definitely have my urologist at the Cleveland Clinic who I sent a copy of the MRI and report for a second opinion to have his radiologist review the MRI so that they are not just replying on the first radiologist report. I do seem to recall a major Scandal some years ago where the Radiologists for breast cancer screenings we're going through hundreds and hundreds of MRIs a day with predictably inaccurate results. Or reviewed out of the USA by god-knows-who. You never know what odd bit of information you run across might help someone else. Thanks again.

For context, I live in an area that is more a town than a city, and they just got the MRI to do prostate scans about six months ago.  I was hoping that whoever was reviewing them was a seasoned person, but seems like that might not have been the case.  On the other hand, Cleveland Clinic is considered top tier so I wouldn't have similar concerns about them.  My opinion for what it is worth. 

I did send my recent 3T MRI to the urologist I have seen at the Cleveland Clinic. And contrary to what his secretary predicted, the Cleveland Clinic urologist did refer the MRI to be re-read by his own radiologist. The pi rads scores of 4 and 5 reported by the radiologist from my Columbus urologist were interpreted by the radiologist at the Cleveland Clinic as Pi rads scores of 2. Whoever it was who told me to make sure that the MRI was read by a specialist in prostate MRIS was right on the money. Then my Cleveland urologist actually called me and spent a good half-hour answering my questions. To my surprise he still wanted to do a prostate biopsy but not a fusion prostate biopsy because it was only pi rads level 2. So on one hand i'm elated that the Cleveland Clinic radiologist downgraded me from PI RADS of 4&5 to Pi RADS of 2. On the other hand I'm surprised at the Cleveland Clinic urologist still wanted to proceed with the biopsy and not even a fusion biopsy. He attributed this to the fact that my PSA has been bouncing around between 7 and 3 for the past year-and-a-half. But he did concede that if I had another PSA done which I haven't had done for several months and it was 4 or below that a biopsy would not be indicated. So I'm conflicted - if I do need a biopsy why not go ahead with the fusion biopsy? I guess it just boils down to their protocols. It did occur to me that I could go ahead and have the Columbus group go ahead and do their Fusion biopsy but if the urologist doing the biopsy isn't any better than his radiologist who found Pi rad scores of 4 and 5... And I haven't decided how or even if I should approach the Columbus team to ask them to explain how their readings could have been so different from the Cleveland Clinic. I guess I'll be in a better position to make a more informed opinion once I get my new PSA done.

It is possible the your urologist doesn't want to use fusion biopsy because he/she would not be able to target a particular lesion as (I understood it) there are no clear sites of abnormality on your 3T mp-MRI (you did have a 3T mp-MRI with contrast, right?  And multiple b-value diffusion, dynamic contrast enhancement?).  That being said, it might be that he/she doesn't have access or proficiency with the technique.  My understanding is that with the fusion system one is able to reliably mark the biopsy paths, thus increasing reproducibility down the road, should another biopsy be necessary.  Discuss with your urologist.  No good reason that I know of NOT to do a fusion biopsy.  As for the changing Pi-RADS score, that level of inter-reader (un)reliability isn't reassuring.  But not every radiologist is doing this a lot.  If I were you I would send a disk to Dr. Dan Sperling in Florida.  He is one of the #1 people in the field.  I have no relation to him or any reason to suggest him other than my own experience.  There is someone in England who is very, very good, also, but I would start with Dr. Sperling, no doubt.

exactly same MRI report readings with me, but 2 lesions, both pretty big, in Transitional Zone (there are 3 zones to prostate: Peripheral, Central and Transitional). Can. cells from TZ are least likely to get out of the gland. seems the body naturally traps canc. wherever it can, and the more cellularity a neoplasm (tumor or growth) has, the more malignant (powerful) it is.   

so far, no bloody urine. i'm 71, if that's any encouragement. also scheduled for biopsy but i'm considering skipping it and going for one of various new non-invasive treatments that burn up the lesions or entire prostate if necessary. 

MR-guided focused ultrasound (MRgFUS) is available in US, FDA-approved and Medicare-covered. see youtube for videos of process.

Michael,

Can I please ask you what type of MRI you had? I am very worried and had a lengthy conversation yesterday with my urologist. I had it on a T2W- 3T ? Per Dr. it is very reliable and one of the best?  It sounded to me there are a few different types of MRI's and some stronger magnets or just some better than others.

I am 60 yrs old.  PSA slowly climbing from 4.0 to 6.3.  My MRI report shows a 1.7 cm lesion area of homogeneous moderate hypo intensity.  They are rating it as a PI-RAD 5  He has told me to basically expect cancer, small chance that it is not, but very probable. I have terrible anxiety after ready it and now even more after reading about the fusion biopsy.  I am scheduled April 2nd for a trans-rectal fusion biopsy.  This past June I had the standard trans-rectal biopsies (the standard 12) and they all came back negative.

Did your MRI show any lesions? Everything else shows normal on my MRI. Dr's talk like removing a prostate is better than cancer, but I am so confused.  I am a very young 60 and man I do not want to think about the side affects of radiation or prostate removal.

I am sorry to ramble, just really nervous about the trans-rectal biopsy again but much more scared about the Pi-RAD 5 diagnosis. I think I may be in worse shape because mine showed an actual lesion.

Thank you for any info 

Kevin

 If it was done on a 3T MRI it should be good quality.  Important is the person reading it - is the radiologist experienced?  You might want to have another radiologist read it.  As for the lesion they found, I assume they will be doing a targeted biopsy only?  If it is a concerning cancer  - rather than an area of inflammation (was your urine sample free of WBCs?) - it might very well be amenable to high intensity us treatment, which is being done at UCLA and other places although it is, to some degree, still considered investigational.  You have time to redo a PSA along with a PSA density and free PSA %).  I am no expert (although I am very well read in the field, with a medical background) but, given that you had a negative "blind" biopsy in the past, one can only hope that they sampled the current area of concern - no real way of knowing, however.  But, it isn't super, super likely that this "cancer" grew in less than a year.  Of course blind biopsies can give false negatives.  Still, even if you do have cancer, you have many treatment options.  I don't know where you live, but Dr. L. Marks at UCLA is one of the top people in the field.  Consider a discussion with him.  Here is an interesting article:

https://www.intechopen.com/books/high-resolution-neuroimaging-basic-physical-principles-and-clinical-applications/the-role-of-the-magnetic-resonance-imaging-for-the-accurate-management-of-focal-therapy-with-high-in

It is easy to be upset and get emotional, of course.  But, use the time you have to educate yourself.  My experience has been that urologists vary very widely on how to approach these issues.  You might also consider getting a "live" in-bore MRI of the lesion - for example, by Dr. Sperling in Florida.

kevin, you had a biopsy, 12 negative cores? go back to your life, buddy. sounds like you had a 3T mpMRI series of scans - the report should contain more than PIRADs. mine contained size of 2 lesions, but not in peripheral zones, which is where PCa occurs, most of the time. mine are in the Transitional Zone, could merely be BPH nodules. post more of the MRI report, let's dope it out. i'm not a doctor but have been researching for the last 3 months, will share what i know and will tell you what i don't know too. i've put off the biopsy until April 6, with Dr. Karamanian in Texas, one of the best there is - does the biopsy inside the MRI magnet - no one could talk me into a TRUS, fusion or otherwise. you're just starting out, with a relatively low PSA -- mines dropped to 14.9 - i've seen PSAs 800 and higher. one guy had a 5,006 !! relax, kev. take your time, friend, do your homework. don't panic, you have time.

Evan,

Thank you for your input, greatly appreciated.  I am going to take my MRi results to the Lahey Clinic here in MA for a 2nd opinion. I never thought about a 2nd radiologist reading it as I was thinking more about a 2nd opinion from a new urologist. Silly not to think of that but everything a bit confusing.  

To be clear, the standard 12 biopsies that I had back in June 2017 were all negative because the lesion is growing in the front of my prostate, against my pubic bone. They said it is contained within the prostate. My urine samples are always fine.

Results from last weeks MRI note "in the anterior aspect of the central gland involving the anterior fibromuscular storm there is a 1.7 cm area of homogeneous moderate hypo intensity  compatible with a PI-RAD 5"  I had no idea that the prostate is somewhat divided in the middle with tissue?

Urologist wanted the MRI because 8 months after the negative biopsies my PSA still climbed.  The thing I do not like about my current provider is they almost seem to say either removal or radiation if this is indeed cancer.  I don't agree with that.

Yes you are correct, it will be a targeted fusion biopsy of the lesion. I guess I will just have to wait and see. I just need to research more. I only knew of PSA levels, not familiar with density.  Again thanks for the reply. I am going to check out Dr. Sperling.

Kevin

 

Not quite that easy Rich to go back to normal.  PSA's are not always a true indication- my buddy had a PSA of 5 and had P/C- Radiation for 9 weeks.  I am amazed at the differences in PSA levels and cancer vs non cancer.

Reading prostate MRI is not a commonplace activity for most radiologists.  Therefore it is worth it to have a second radiologist read it - one who is very, very familiar with reading them.  Mine was read by Dr. Robert A. Princenthal in Sherman Oaks, CA.  It was done under his protocol (at a satellite center).  His reading was seconded by the radiologist at UCLA (although I didn't doubt him at all, my new Urologist is at UCLA and they always have their docs read any outside MRIs).  I would think Dr. P. would be willing to read yours - but I can't say for sure, of course.  All you would need to do is send him the CD-ROM, not difficult at all.  I paid $900 out of pocket for the MRI and reading!!

Yes, there are various layers of the prostate, it isn't just one homogeneous gland.  Certain parts are easier to access depending on the approach.

I don't think you are interpreting the results correctly (no criticism intended here) the abnormality they are referring to is IN the prostate, not in front of your prostate.

I understand your fears and worries, 100%.  I have been through this too.  However, take it step by step.  The first thing to do is figure out what the abnormality is.  Worry about cancer treatments if you have cancer!  There are a variety of ways of interpreting the PSA.  One of them is PSA density.  In other words, normal for someone with a larger prostate will be a higher number than someone with a smaller prostate.  Since you've had the MRI, you can figure out the density.  There are a number of other blood and urine based tests - however, they only will give you a range of possibilities, low, medium, high risk.  Some of them PCA3, for example, can be somewhat reassuring.  However, as you have an apparently abnormal MRI, I would move beyond these and get to what has to be the next step - a biopsy.  Only getting tissue can tell you what you have.  That being said, a negative biopsy can be wrong - if you don't get the right pieces (false negative) there are cases of false positive too, but that is more complex.  That is why I did NOT get a biopsy when my community urologist was all about biopsy.  I wanted an MRI first.  He didn't feel that was appropriate, but the newest research supports this approach more and more.  NEJM has an article right now which moves strongly in MRI before biopsy  (in patients with PSA < 10).  This is standard of care in Europe.

If I were you, I would get a second read on the MRI.  Then, assuming the two reads are somewhat in sync, I would plan to get either a TRUS biopsy or an in-bore MRI.  I know Dr. Sperling does the in-bore MRI guided biopsy.  Not too many other places do them, and it would be very hard to say that one is vastly superior to the other.  As long as whoever does the biopsy can be 99% certain that they are in the right place, you should be good.  1.7 cm shouldn't be a problem.

Again, if I were you, once I had the second read, I would call Dr. Sperling and get his take on how he would approach it.  Risks/benefits, etc.

I hope this helps.  This is a stressful situation, I know.  Right now we have some new options.  Not all doctors are on board with them (or even understand them).  You are in MA, so you have access to the highest level of care, in Boston.  Have a look at the tertiary medical centers Urology websites.  I would think their approaches would be somewhat similar to what we are seeing here on the West coast at UCLA, USC, etc.

Thanks again Evan, appreciated. Yes, sorry, poor wording on my part, I meant in the prostate, on the anterior wall.  It states it is straddling the midline from base to mid gland.

Lymph nodes and SV's reported normal.

I have been researching several hospitals in Boston along with the Lahey Clinic to get another opinion.

This

While most of what you wrote seems reasonable, a 12 core blind biopsy in no way rules out cancer.  They have a fairly high false negative (and false positive) rate.  That is why we are looking at 3T mp-MRI, Trus/MRI biopsy etc. - because the old style blind biopsy failed in so many ways - too many of them done, too many were wrong.  Nice to hear about Dr. K in Texas.  In bore MRI biopsies are the way to go, I think.

 

A second opinion on the MRI is the first thing, then a discussion with a Urologist with a more modern approach to biopsy, if you both decide it is the right step.  Best of luck!

So what's new? Did you get a 2nd opinion?