MRI and Biopsy Results: PI-RADS, Gleason and PCa

The waiting is brutal.  Three weeks ago, I was shown my prostate TRUS MRI fusion results.  I was given a PI-RADS score of 4 on a scale of 5, with a 5 being most likely for cancer.  For reference, ten years ago, my MRI report score was a  PI-RADS 1, or “highly unlikely” to have clinically significant cancer.  A score of 4 means that, “Clinically significant cancer is likely to be present.”  The modified scale used by the NIH was only slightly better, “Moderately likely for prostate cancer.”

As you can imagine, it considerably freaked me out to learn this in the hours of worrying while I waited to be taken for my biopsy procedure.  On the plus side, it also told me that I was doing the right thing.  A half-centimeter size lesion was shown on the MRI, and a random biopsy might miss that small of a lesion altogether.  Armed with the MRI results, they were able to precisely target this tumor with two separate biopsy samples from different angles, along with 12 other random cores to see if cancer was present or had spread elsewhere in the prostate.  Ten years ago, I did not have any cancer, nor was any type of lesion or tumor indicated on the MRI.   Things were not  nearly as promising on this one:

Making lemonade out of lemons, the fact that only a single lesion was present was relatively good news.  Plus, there was no indication it had spread beyond the prostate or into any other tissues within the prostate.  These might all be positive considerations for less invasive focal treatments.  There are a number of studies out there showing the correlation of PI-RADS to biopsy results for cancer.   Thankfully, it seems that a PI-RADS score of 4 isn’t nearly as bad as a score of 5, but on a scale of 1-5, even a 4 feels pretty bad to a patient.   The correlations for a score of 4 just aren’t as well established yet, and that’s why these studies continue.  On the other hand, a PI-RADS score of 5 is usually bad news and has a much higher correlation to cancer.

Suffice to say that while a score of 4 does not usually indicate the presence of the most aggressive cancers (Gleason score of 8 or more), it often shows concerning cancers with a Gleason score of 7.  PI-RADS 4 lesions also can be benign or less aggressive cancer with a Gleason score of 6 or less.  In plain English, based on the MRI results and on various studies I have read over the three longest weeks in my life, I figured I had about a 50-50 chance of having a clinically significant cancer that required some sort of treatment in the near future.  For the optimist, maybe only a 40% chance or even a bit lower, depending on which study you read and whether or not the physician recommends treatment for Gleason grade 7 cancers.

Yes, I intentionally put off discussing my biopsy results to the end of this article.  This was to give anyone reading only a tiny fraction of how it feels to wait THREE WEEKS after seeing a PI-RADS score of 4 on my MRI.   Some days it has been almost paralyzing to wonder why it was taking so long, when I was originally told 5-8 business days.  Were the results so bad that a second opinion on the biopsy cores was needed?  Did they have to develop a treatment plan before contacting me?  Was a radical prostatectomy and all its risks, side effects and quality-of-life issues now a given for me in the near future?  Yeah, that stuff and worse goes through your mind every night at 3am, and even during the day.

I am both blessed and greatly relieved to say that I dodged a second bullet, both in terms of infection and biopsy results.  My phone call came an hour ago and NO cancer was indicated in the results.  Presumably, the targeted lesion is simply a benign tumor or other abnormality, one to be monitored for changes in the future.

Of course, prostate biopsies have a significant false negative rate.  Even with MRI/Ultrasound targeting guidance, they can miss cancerous cells that exist elsewhere in the prostate.  Sadly, no better diagnostic exists today, which is why I participate in this NIH study.  Trans-rectal prostate biopsies are not at all pleasant, and if you get a resistant infection, they can even be fatal in rare cases.  Improving non-invasive diagnostics like MRI, blood and urine tests is critical to reducing the need for random rectal biopsies that seem like a holdover from 1960s medicine.

Suffice to say I am very thankful to God, the universe and to the NIH/NCI Urology team, not only that no cancer was found and that I have no major side effects of the biopsy, but also that I hopefully don’t have to see them again for many years!

 

 

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