How to proceed after PI-RADS 5 in the MP-MRI, when on active surveillance? (2025)

You're 64, with a fairly low, and lowering PSA. PIRAD-5 just means that yes, the anomaly's detected are in all probability cancerous. With a Gleason of 3+3, does this mean you need to "act"... Probably not, not yet anyway. And there are noninvasive focal treatments available for small lesions still contained within the prostate. The good thing about PCa is it is a very slow moving cancer for all but a very small percentage of patients. So you have time, time for more tests, time to watch, time to wait and see if any treatment is necessary. A lot of things come into play, ie, family history, physical health, PSA history, etc., and additional tests which will help assist making a decision. Addition to this is the time to make appointments for secondary consults to measure against any initial prognosis performed. 2nd opinions are very useful.

Best of luck and regards!

Hi Educt

Coolone gives good advice. This report just means that you need a biospy to understand if there is cancer (the MRI cannot tell you if there is cancer - only that something is suspicious).

You may have a very benign neoplasm that requires no intervention- but you can’t know until the lesion is targeted and looked at by a pathologist under a microscope.

One thing I did learn as part of journey is that single most important thing for you to right now is to have a second review of the pathology specimens by Johns Hopkins.

Over-Grading is rampant according the leaders from the Center of Excellence. The “why” is speculation- but it is well documented by Professor Klotz, and Johns Hopkins. Some propose that the Pathologists are so worried about malpractice- that they over-estimate to be “on the safe side”. This may help keep them safe- but according to the leaders- it leads towards unnecessary and over-treatment.

“Numerous publications show the clinical and economic benefits of obtaining a second opinion for Pathology specimens. Obtaining a second opinion in Pathology can in a small percent of cases lead to a complete change in diagnosis in a wide range of conditions including non-cancerous growths, inflammatory disorders, infections, and cancer. In terms of cancer, changes can be from cancer to benign (or vice versa) or from one type of cancer to another, which could have a significant impact on treatment and prognosis. A second review of Pathology more frequently also brings changes to the cancer grade or stage, which can affect prognosis as well as therapy. Jonathan Epstein, M.D.

Director of Surgical Pathology- Johns Hopkins”

Here is a link

http://pathology.jhu.edu/department/services/secondopinion.cfm

It just takes a quick phone call to your provider. DO NOT accept a 2nd pathology review from any other place. Johns Hopkins is arguably the worlds leader in this.

You may consider having a additional molecular / genetic analysis performed on your Pathology specimens by a Decipher and/or ConfirmDx (or similar).

Below is some information on that.

Molecular diagnostics is a rapidly evolving area of surgical pathology, that is gradually beginning to transform our diagnostical procedures for a variety of tumors. Next to molecular prognostication that has begun to complement our histological diagnosis in breast cancer, additional testing to detect targets and to predict therapy response has become common practice in breast and lung cancer. Prostate cancer is a bit slower in this respect, as it is still largely diagnosed and classified on morphological grounds. Our diagnostic immunohistochemical armamentarium of basal cell markers and positive markers of malignancy now allows to clarify the majority of lesions, if applied to the appropriate morphological context (and step sections). Prognostic immunohistochemistry remains a problematic and erratic yet tempting research field that provides information on tumor relevance of proteins, but little hard data to integrate into our diagnostic workflow. Main reasons are various issues of standardization that hamper the reproducibility of cut-off values to delineate risk categories. Molecular testing of DNA-methylation or transcript profiling may be much better standardized and this review discusses a couple of commercially available tests: The ConfirmDX test measures DNA-methylation to estimate the likelihood of cancer detection on a repeat biopsy and may help to reduce unnecessary biopsies. The tests Prolaris, OncotypeDX Prostate, and Decipher all are transcript tests that have shown to provide prognostic data independent of clinico-pathological parameters and that may aid in therapy planning. However, further validation and more comparative studies will be needed to clarify the many open questions concerning sampling bias and tumor heterogeneity.

https://www.ncbi.nlm.nih.gov/pubmed/29297492/

In reply to Cooolone's comment

In reply to Virginianorthern's comment

Virginianorthern, thanks for your reply. I have been following most of your comments on many questions raised by other folks, and I see that you always provide good insights on how to proceed. In my case, the only problem that I see is that I am located in southern Brazil in South America, and I don´t know if Johns Hopkins does second review of pathology for specimens from outside the US. But I will check with them. Thanks again.

My best regards.

In reply to educt00's comment

Hi Educt

Thank you for the kind words.

I would not be concerned about the distance. People from all over the World have contact with Johns Hopkins for all kinds of needs. They are very accustomed to working with international situations.

Near the bottom of the page link below is a pull down menu that describes how to have the slides sent either from your doctor’s office- or how to FEDEX the yourself.

http://pathology.jhu.edu/department/services/secondopinion.cfm

In reply to Virginianorthern's comment

Many thanks! I will check with JH and send them slides/blocks when I get them after the biopsy results.

Best Regards

As the others have said, try not to get ahead of what you know. The targeted biopsy should provide you what you need to know before considering any treatment option.

I have seen posts from men with PIRADS 5 who then had multiple negative biopsies.

If you want to research possible treatment choices, I would recommend Dr. Mark Scholz’ new book The Key to Prostate Cancer. He interviewed 30 prostate cancer experts and presents their descriptions of the treatments that they provide for men at different risk levels.

In reply to ASAdvocate's comment

Thanks! I will take a look at the book.

Kind Regards

In reply to adf2529's comment

Thanks! The comments from all of you suggest that the best course of action is to wait for the fusion biopsy results, get a 2nd opinion regardless of the results (as it can change from cancer to benign and vice-versa), identify treatment options if this is the case and do I thorough research of the pros and cons associated with each treatment option. Thanks again.

Best Regards.

In reply to burpy200's comment