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!



12 thoughts on “MRI and Biopsy Results: PI-RADS, Gleason and PCa”

  1. I too am a doc, retired Family Medicine, 73yo, with rising PSA over past 7 years; currently still only 3.6. Had the MRI, and seemingly like all the rest of you (!) I have 2 PiRads 4 lesions, L peripheral 6mm and R peripheral 9mm. This MRI result suggests a 65% likelihood of CA–or 35% chance it is benign, however you choose to look at it. Yes there is angst. But frankly YOUR outcomes give me hope; thank you for sharing! MRI is not perfect, but I practiced through the years of NO MRI just the good old “finger wave” and PSA, and old Doctor Gleason’s methods for the past half century. I am grateful for all the advances made, but we still lack perfect knowledge. But, and I say this with the deepest sincerity, I do not fear death. I am secure in Christ Jesus, and as Paul says, “To live is Christ, to die is gain!” I will post again after my fusion biopsy next week, let you know how it went. I will not say good luck; I will say pray for God’s peace.

  2. 2022-23. August 24, 2022=My 1st PSA was 25
    Oct 3= 1st Urologist visit DRE. Nothing abnormal. Nov 13= MRI. Results 2 weeks later! Pirad 5 with no indication on spread from prostate. Jan. 20, 2023 =MRI fusion biopsy. Follow up Feb. 7. (Next week). The scheduler said something about another MRI and CT bone scan? It looks like I could be into April or May before I can schedule any treatment! My point is: Our medical system is lacking. The mental stress probably is worse than the disease.

  3. I have low PSA. 9mm lesion in left peripheral zone. Bi Rads 4. An appt in 3 months for a biopsy at a State University medical facility. This is the first available appt. No answers to MyChart msg. from Dr as to what’s going on with a 3 month wait for a biopsy. Talk about 3 months of anxiety!

  4. I am a doc- 58 fit, healthy, no meds or med problems. PSA climbed 2.7 2 yrs ago to 4 this year to had MRI- 8mm peripheral PIRADS 4 headed for biopsy at USC KECK next month. fingers crossed. would love to hear about treatment decisions from people too as it can be challenging to make the decision of risk/benefit of AS, RP or radiation. Data supports all and data refutes all as best option in isolated PIRAD 4 Gleason 7 – certainly Gleason 6 prob AS and Gleason 8+ perhaps RP or radiation but under age 65 this is overly stressful I agree Have plenty of sleepless nights. Being a physician/surgeon (not UROLOGY) I have seen many great things and horrible things – from colleagues and during training. Very challenging to stay positive but the universe and God chooses what happens (never really committed to this idea previously but HAVE to). God bless all of you who come to this forum

  5. I fully sympathise with your wait for biopsy and results after the concerning MRI. I have now had 3 MRIs and am less than impresses given the agonising waits for biopsy results. The first was a 4/5 Likerts = 4/5 PIRADs with 3/5 Likerts. A targeted biopsy found a 3+3 spot 0.4mm outside the MRI targeted area. So ironically it was correct to have a biopsy despite the MRI targeted areas being negative although I have been on active surveillance. I then had AS routine one last year all PIRADS 2.
    Just had another finding 2 areas 4/5 PIRADS and 5/5 PIRADS. Obviously they were already aware of the existing lesion. The 5/5 worried me to death. After a targeted and fusion [i.e. of whole prostate outside as well as in the targeted area] of no less than 42 cores, they simply confirmed the existing lesion. All the 5/5 area and everywhere else was negative. Given the number of cores I am surprised I have any prostate left. However given what I went through during the wait I am actually very angry. My view of MRIs is at an all time low, although to be fair I suspect this is more down to an incompetent technician unable to distinguish true problem areas from things like inflammation, atrophy or calcification, all common in the peripheral zone. Actually the 3 monthly wait for PSA results is difficult but the MRI is supposedly more predictive of cancer. To get a 5/5 PIRADS with no malignancy on biopsy is for me an indicator that urologists should stop filling with patients with anxiety and particularly stress this is just an indicator of suspicion. Also technicians getting it this wrong should be investigated as they are a menace.

  6. I have a biopsy scheduled for 11 Oct 2021 after an MRI w/ contrast revealed two Pi-Rad 4 lesions measuring 1.0 cm x 1.0 cm in size and another Pi-Rad 3 lesion measuring 1.5cm x 1.7 cm. The MRI results came in 3 weeks ago and my mind has been swirling since. Hoping to have your outcome.

  7. So it has been 2 years since you wrote this article. How is your prostate? Is your psa going up? Did you do any more MRI fusion scan?
    I really enjoy reading your article. Thanks for sharing.


    1. I have not had any results since 2 years ago. Once I am vaccinated, I will get my routine checkups and likely only another MRI/biopsy if something is unusual.

      1. Happy for you
        Hope all is still good
        Just had mri and pi-rads 4 small mass
        Have biopsy in 2 weeks
        My psa was 3.5

  8. Quite helpful. I am waiting for a Trans-rectal prostate biopsy procedure after being told my MRI report score was PI-RADS 4 abnormality in the left transitional zone and the right peripheral zones. I am only 58 and pretty scared it could be prostrate cancer.

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