On AS with Pi Rad Question

I've been on AS for 4 years with PSA bouncing up and down along the way but generally rising from 5.1 to 7.3 over that timeframe. I've had two biopsies at 5/13 and 7/14 totaling 33 cores and only two showing PC both Gleason 6, one < 1% involvement and the other at 5%. I've also had two 3T MRIs at mass general in Boston one at 7/13 and one at 9/15 and both were totally clean with no marks or lesions.

Just had my third MRI and it showed a sizable lesion graded as a Pi Rad 4 so something to be concerned about for sure particularly because it's gone from being clear to a sizable Pi Rad 4 lesion in just 18 months. I'm going for a fusion biopsy but have to wait a month before I can get in for it. Waiting never fun!

Pi Rad 4 is described as likely to be clinically significant cancer which i believe is G7 or higher. From what I can find, it looks Pi Rad 4 carries something like a 60% probability of finding that result. My question is if the lesion isn't a G7 or higher what could it be? Does G6 PC or anything else show up as lesion? Does prostisitis ever show up as a lesion?

Thanks in advance

PIRADS is designed to pinpoint areas of suspicion that can be targeted during a followup biopsy, if one is warranted. It does not diagnose cancer.

I have read posts from men with PIRADS 4 and even 5 who then had negative fusion biopsies.

Personally, I have had a lesion that was PIRADS 4 get downgraded to PIRADS 3 when they upgraded the software to PIRADS 2.0. The last biopsy on that area was negative for cancer.

HGPIN, atypical cells, hemorrhage, and benign lesions can all appear as PIRADS 4. But, you probably need a biopsy now to resolve this latest finding.

Thanks to each of you for info and personal experience.

My worry from MRI is both grading and the fact that something has shown up tha wasn't in previous two MRIs.

Ray Paul, out of curiosity, what was it that caused you to leave AS? I couldn't tell that from your history.

Yes - it can be any kind of lesion: cysts, benign growths, local swelling, and prostatitis can all show up - anything that restricts the normal fluid flow found in and around healthy prostate cells.

Always base a treatment decision on a biopsy result. Recall that what an MRI (magnetic resonance imaging) shows is basically water and fat tissue concentrations in a black and white picture. Its the hydrogen atoms that are magnetic, not the cancer. Cancer can only be seen in a microscope.

I'm sure this MRI result has added alot of uncertainty to your situation. But hang in there and wait for the biopsy. The MRI did what it was supposed to - identify suspicious areas to look at. The biopsy results will make the next steps clearer for you.

Good Luck,
Paul

I was able to finally see my MRI report. It indicates that the lesion is 19mm in the transition zone. Its rated as PIRAD 4 but it indicates "could be a either BPH nodule or clinical history prostate cancer which could be targeted on a future biopsy". Not quite sure what "clinical history prostate cancer" even means.

The good news is that there is no disruption of prostate capsule and seminal vesicles, lymph, bladder all listed as unremarkable. Also, what I have noticed is an increasing prostate size. My first MRI at 6/13 it was 27cc, 2nd MRI 9/15 33c and now 41cc. Seems like its growing. Over same timeframe PSA has gone from 6 to 7.3 with some ups and downs in between.

Again, I've had two prior biopsies -- at 5/13 with 1 of 12 cores showing <1% G6 and a second biopsy at 7/14 with 1 of 19 cores showing 5% G6. Both prior MRIs were clean although uro mentioned current MRI at mass general is more powerful than when I last went and seems to be picking up more marks.

I would love to hear anyone's interpretation of this. Also, is there anything to be gleaned from the lesion being in the transition zone?

thanks again in advance.

Thanks TallAllen. Appreciate the advice on BPH something I've spent no time researching to date.

Would you know if the transition zone any more or less likely for PC to develop and to get hit or missed on a random biopsy?

So TA, would you conclude or think that if the only lesion that shows up on the MRI is in the TZ and its rare to have PC only in TZ, its less likely that the lesion is PC (and more likely a BPH nodule)? Or is that wishful thinking?

The PC that was found on my biopsies was low volume and G6, so less likely to show up on MRI. For what its worth, my doc said he tried to go deep on the 2nd biopsy as the reason I might be more sore afterwards...that and the fact it was 19 cores, when he claimed he gave me a few extra for free!

Thanks Allen. 1st Biopsy was 2 cores in each of six sections as you described and in 2nd, he took 4 each in both mid areas and all sections on the right side as 1st biop had the one g6 core in right mid.

I guess the pessimistic view would be that lesion on MRI being in TZ may have been missed in biopsies as you indicate that area wouldn't have been hit. That would explain elevated PSA with not much to show in biopsies. Two previous MRIs that didn't pick it up but maybe it's grown since then.....although PSA not much higher since last MRI, 7.1 to 7.3.

For me, analysis and research helps while waiting for next test result. Thanks for help on that