My 72 yr old Brother MRI Result Question what to do next?

[Shorehousejam]

Should he continue active surveillance?

He is going for a biopsy and most likely radiation

Have his prostate removed or radiation?

Any helpful advice appreciated

EXAMINATION: MRI prostate without contrast

 

IMPRESSION:

 

Lesion #1: Apex left posterior peripheral zone, 1.7 cm, slightly increased since/the prior study. PI-RADS category 3 (the presence of clinically significant cancer is equivocal)

 

Lesion #2: Previously identified lesion not well-visualized on this exam.

Lesion #3: Base left posterolateral/posterior medial peripheral zone extending into the right posterior medial peripheral zone, not significantly changed the prior study. 2.5 cm transverse. PI-RADS category 3 (the presence of clinically significant cancer is equivocal)

 

No new lesions concerning for clinically significant prostate cancer.

 

CLINICAL INDICATION: prostate cancer :: C61 Malignant neoplasm of prostate

 

TECHNIQUE: MRI of the prostate was performed. The following sequences were obtained: T1 weighted without fat suppression in the axial plane with full field of view and coned-down field of view, T2 weighted without fat suppression in the axial, coronal, and sagittal planes with coned-down field of view and axial T1 with fat suppression with large field of view. Diffusion-weighted images were obtained as well. Images were reviewed on DynaCad.

 

COMPARISON: 9/21/2022

 

INTERPRETATION:

 

PROSTATE: The prostate measures 5.3 cm in craniocaudal by 4.2-cm in AP by 4.5-cm in transverse dimensions.

 

BACKGROUND PARENCHYMA:

 

* CENTRAL GLAND: BPH

* PERIPHERAL ZONE: Multiple linear/wedge-shaped T2/ADC hypointensities (PI-RADS 2).

 

DISCRETE LESIONS:

 

Lesion #1

Location: Apex left posterior peripheral zone

Size: 1.7 cm (506:136), previously 1.4 cm when measured in a similar fashion

T2 Score: 3 (Heterogeneous signal intensity, 401:12)

DWI/ADC Score: 3 (Focal hypointense on ADC and focal hyperintense on high b-value DWI; 506:136, 505:144)

Overall Assessment: PI-RADS category 3 (the presence of clinically significant cancer is equivocal)

Extraprostatic Extension: Absent

 

Lesion #2

Previous identified lesion 2 not well-visualized on this exam.

Lesion #3

Location: Base left posterolateral/posterior medial peripheral zone extending into the right posterior medial peripheral zone, not significantly changed the prior study

Size: 2.5 cm transverse (506:208) previously 2.5 cm when measured in a similar fashion

T2 Score: 3 (Heterogeneous signal intensity, 401:18)

DWI/ADC Score: 3 (Focal hypointense on ADC and focal hyperintense on high b-value DWI; 506:208, 505:192)

Overall Assessment: PI-RADS category 3 (the presence of clinically significant cancer is equivocal)

Extraprostatic Extension: Absent

 

NEUROVASCULAR BUNDLES: Intact bilaterally.

 

SEMINAL VESICLES: Atrophic, unchanged.

 

URINARY BLADDER: Underdistended, limiting evaluation.

 

LYMPH NODES: No pelvic lymphadenopathy.

 

OTHER: There is a lobulated cystic structure below the prostate and posterior to the left lateral aspect of the corpus spongiosum measuring 1.6 x 1.3 cm (4 1:5), new from the prior study. This is most consistent with a Cowper's duct syringocele.

 

[Bret5]

I had a prior MRI Jan 2022 with a couple of pi rads 3 findings. That basically means it might or might not be cancer. That was followed by a guided biopsy Feb 2022 where they sampled the pi rads 3 areas plus 12 random samples. At that time, all lab findings from the biopsy were negative. So we did nothing at the time other than continued monitoring.

I don’t believe you would ever remove a prostate or do radiation or any other significant steps without a definitive cancer diagnosis from a physical biopsy.

That said, 8 months after the biopsy I refer to above, my PSA spiked, I had another MRI Dec 2022 that showed pi rads 5, and a subsequent biopsy was Gleason 10. Fast forward another 6 months and even though I had my prostate removed Jan 2023 the cancer went metastatic. This was very unusual but I say that because you don’t want to ignore. I would think a biopsy is the next logical step.

[mperloe]

He might consider ExoDX if PSA is less than 10. If so, and the ExoDX score is less than 15.6, he might continue AS without biopsy.

[Tall_Allen]

I don't understand your cause for concern. MRI isn't any reason for therapy - only grade progression on biopsy.

[FMOH_N]

It is worth to mention that biopsy can also deviate and don't display the exact details of actual disease, grade, type, etc. unfortunately, this has impacted and occurred in my case, where the disease was upgraded with adverse molecular and morphology of cancer type.

[jackcop]

TA: "MRI isn't any reason for therapy - only grade progression on biopsy."

With that said, if you choose more understanding then a physical biopsy is warranted.

[Shorehousejam]

Yes left that out scheduled for Biospy