Understanding PSA, PIRADS, Tumor Size, & Location | Answering YouTube Comments #59 | Mark Scholz, MD

Mark Scholz, MD, is a medical oncologist who specializes exclusively in the management and treatment of men with prostate cancer. Here, he answers patients' questions from our KZbin comments on the relationship between MRIs and biopsies.
0:09 I am 74 years old and have a PSA between 3.9 and 4.2. I had an MRI with a PI-RADS 5. Should I get a biopsy or recheck my PSA?
2:42 How does the PI-RADS system work?
4:56 Are lower-grade tumors like Gleason 6 usually smaller than higher-grade aggressive tumors?
6:38 What is the significance of the number of cores positive, and does it matter where the cores are positive (e.g., anterior vs. posterior parts of the prostate gland)?
7:45 Do tumors tend to grow in certain areas of the prostate gland?
8:52 How often do you suggest second opinions on biopsy reports? Are there certain criteria that would cause you to suggest seeking a second opinion?
Don't know your stage? Take the quiz: Visit www.prostatecancerstaging.org
To learn more about prostate cancer, visit www.pcri.org
Who we are:
The Prostate Cancer Research Institute (PCRI) is a 501(c)(3) not-for-profit organization that is dedicated to helping you research your treatment options. We understand that you have many questions, and we can help you find the answers that are specific to your case. All of our resources are designed by a multidisciplinary team of advocates and expert physicians, for patients. We believe that by educating yourself about the disease, you will have more productive interactions with your medical professionals and receive better-individualized care. Feel free to explore our website or call our free helpline at 1 [phone] with any questions that you have. Our Federal Tax ID # is 95-4617875 and qualifies for maximum charitable gift deductions by individual donors.
The information on the Prostate Cancer Research Institute's KZbin channel is provided with the understanding that the Institute is not engaged in rendering medical advice or recommendation. The information provided in these videos should not replace consultations with qualified health care professionals to meet your individual medical needs.
#ProstateCancer #Prostate #MarkScholzMD

[@ThePCRI]

If you have questions about prostate cancer and need help from our Helpline team, you can email us here: [e-mail]

[@MrGuitar1458]

My 13 needle, 26 core biopsy showed NO CANCER! Very grateful, and very appreciative of all the wonderful info on the PCRI videos!! ❤️😊

[@haroldclark1787]

This is very elucidating. What a wise, measured and pragmatic Dr. Scholz is, and his information is enlightening and very helpful. I wish I lived near his practice.

[@kantibhaipatel8332]

i see such videos 20-21 times , very informative. iam apatient veterinarian - 74 yrs old, thanks - continue- dr k patel

[@kantibhaipatel8332]

i am 74 yrs old prostate cancer patient and working at== Queens Animal hospital, ==woodside, new yor==k as a Veterinarian , i see such videos multiple times as informative, my psa is steady this times.i am on lupron and radiation therapy done 6 weeks I believe in treatment but my angle towards life is little different. i come to realize that of course reading a lot about meditation and of course before my Diagnosis and others that you did not ask for life . life was spontaneous . we do not have control of life . because life is not ours.and then death is not ours too. so why to worry . because we always think and describe 100 things we do not have. but we never mentioned one thing which we have.so life is beautiful and enjoy till death. no matter whatsoever. my message you can not revolutionize life without remembering death.so many things to write but let me end.Live life joyfully, singing and dancing regardless what cancer stage is. Because this only option we have.

[@Giovan_Nino]

A very thorough, interesting and helpful interview.. thanks…👍

[@John-the-Bass]

Very helpful, thanks for your opinions. I took a second opinion for an initial Gleason 3+4 report and the second expert found 4+5 from the same MRI scan! A subsequent PSMA PET scan confirmed the second opinion. It looks as if a second opinion is always the correct thing to do.

[@johnj9267]

@John...Have you made a decision on the type of treatmenat you'll pursue? Thanks and good luck.

[@chuck7432]

What was your PIRADS score?? I am not a doctor but only a pathological report from biopysy tissue can yield a Gleason score; not so with MRI. Although, PIRADS 5 tumors most always biopsy to Gleason 7 or higher. You should get a new doctor. Been down this road already.

[@daxmac3691]

another Excellent talk about interpreting tests...prostate anatomy+ Ca location 07:50, transition zone (TZ) and PZ

[@s.chaisrisuk4956]

So so very valuable, right at the point. In the most simple way.

[@dr.mahmad7303]

Hi, very informative video. Isn’t it better to get PET PSMA done rather than biopsy in case of PIRADS 3 and above because biopsy has a lot of chances for infection. Thank you.

[@ransomcoates546]

I was sceptical about my urologist doing a random biopsy in addition to a targeted one of the lesion shown in the MRI. But he did find two 3+4 cores in addition to several 4+3 in the lesion. Even if the 3+4’s are indolent it suggested to me that things were brewing all over the gland and I definitely needed treatment.

[@ransomcoates546]

@@justdoesntaddup8620 All I can find is 7.6 mm with 25% involvement.

[@pries95132]

I have 3+4 based on random biopsy. No tumor (so T1c), got MRI, pirads score was 2, so again no identifiable tumor. Finally sent biopsy sample for Decipher testing which showed very low risk. I'm gonna hold out ... 4 just means they don't like the shape. It could still be indolent. Monitor PSA diligently, get more MRIs and then seek treatment at a life stage where you are ready for the side effects. Also seek out the best doctor you can find. Just because you were referred to a urologist doesn't mean he is great. However since you did have an MRI, I'm more impressed with your doctor than my first who didnt even mention the option (changed doctors, since). Of course it all depends on your risk tolerance, etc. I found a lot of help going to a prostate cancer support group. Also got 2nd opinion on biopsy, which told me a bit more.

[@pries95132]

@@justdoesntaddup8620 total % Gleason 4 from original biopsy report was 15%. This was from 3 cores out of 6 from left side of prostate (right side clean). I had a second opinion in which they identified some cells in the fourth core (also left side) as cancerous (first report said that core was suspicious). With the inclusion of that fourth core, the percentage went down to 10%. In the two reports total involvement (both types) was 10.6mm however the second report considers the tissue between discontinuous foci to be cancer, so says 28.5mm out of a total of 126mm (the combined lengths of all 12 cores).

[@leslieperera5589]

My psa test 3.2... It was 10.5 one year ago. Duprost and urimax capsuls using nearly 10months, but some times I feel little backpain when i wake up.

[@premiumyt8625]

Hola gracias por compartir..necesito de su ayuda. Saludos cordiales desde Patagonia Chile

[@soufienetchantchane2839]

I decreased PSA from 9 to 5 just with lose weight and diet ! Be careful from PSA never go directly to Biopsy !

[@tomslick2058]

Psa dropped is a good sign but you still need a mri. And if the mri shows nothing than great. Your doctor is probably OK with you waiting 6 months for another psa. Never do a blind tranrectal biopsy. And if your doctor wants to do any biopsy without a mri first than run.Find another doctor.

[@michaelrichmond3315]

Wow what foods did you eat to loose weight and lower psa

[@nelsongb9995]

I did intermittent fasting and my PSA dropped from 9.42 to 6.35 in 5 weeks. Continuing doing this.

[@bel.sat.9051]

@@nelsongb9995 thanks

[@Elvis0870]

Hello I just want to say there’s a great showand have a question about myself I had the brachytherapy surgery 2years ago with 61 seeds also write ration 25 times my PSA was 1.4 1.6 and last month 3.1 so the question is this is going to bounce about three years like I was told or I should worry about it Thank you very much for answering my question

[@Blanco83]

I have a 3 with a negative previous biopsy two years ago do I need a biopsy, I am crazed.

[@tomcat7661]

As someone else has commented on Transperineal biopsies, how good are these? I had that type of biopsy, 34 cores taken. Do they look at the MRI image to map the transperenieal grid and aim more at the lesion area?

[@jaimemarun2841]

If someone has a Pi-RADS 2 in what cases it is necessary a biopsy? before a prostate procedure (PAE or Laser)?

[@MrGuitar1458]

Such useful information. Having a trans-perineal biopsy for a PI-RADS 4 lesion on the left peripheral zone next week. Fingers crossed.

[@irishravr632]

How did your biopsy go if you dont mind me asking, I have a biopsy for 26th of this month, mine is a PI-RADS 3 lesion, I'm getting a bit anxious about getting the procedure done, I'm clinging on to the idea of it coming back clear, sorry again I hope you don't mind me asking., fingers crossed all is good with you.

[@MrGuitar1458]

@irishravr632 it went very well, and thank you for asking! The procedure itself was quick and, because I was under general anesthesia, painless. I had no issues with post-op pain either, and very minimal blood in the urine, a bit more blood in the semen, for the first four ejaculations or so, and I had feared those would be painful but they were not. Best of all, my feared PI-RADS 4 'lesion' turned out to be "mild focal chronic and active inflammation," and none of the total 26 cores taken (the whole gland was sampled) were positive for malignancy--no cancer! I will have my PSA rechecked in a few months, and unless it comes back worrisomely elevated (say, 8 or so) I should be all done with invasive diagnostics for awhile. My biopsy proved my elevated PSA's have clearly been due to BPH, which itself was proven to be present by MRI. I'm very glad to have had such good news, of course, and pleased to confirm the procedure itself was no big deal...though it did cost Medicare and my Part B supplement about $25 k...Best of luck to you with yours, please let me know how it goes and what you find out! 🤞🤞

[@irishravr632]

@@MrGuitar1458 I went for my procedure yesterday morning, I was awake for it, just given a numbing shot, I wouldn't describe it as painful, a slight stinging sensation to begin with followed by mild discomfort, I'm passing urine normally with just slight traces of blood, no ejaculation as of yet, I'll give it a day or two yet, now the waiting game begins to hear back from Urology with my results, fingers crossed I receive good news. Best of luck to you going forward.

[@MrGuitar1458]

@irishravr632 so glad it went well, best of luck to you on your results, please keep me posted! 🤞🤞

[@Gary65437]

@@MrGuitar1458 I'm just starting my cancer journey after a PIRAD 5 mri. Pretty clear I can't get up to date treatmentor even choose on my medicare advantage plan. Do you also have a plan G and D to handle the big bills. I have to decide to switch or not in a few weeks before I get in too deep. TY

[@j.jsjourneysouthafrica3806]

What is the chanc that one person has cancer cells in both sides of the prostrate.... and is stage 2 / 3 high risk???

[@maxthemagition]

Could you comment in over diagnosis of PC?

[@anthonymiller6081]

Can an MRI PiRad 4 be Benign???? What is the percentage

[@artmaltman]

Questions please: (1) Do imipramine and/or myrbetriq help with incontinence post-prostatectomy? (2) is incontinence after prostate surgery a random occurrence, a roll of the dice? OR is it due to specific surgical practices such as cutting away too much urethra. Thank you. Art

[@artmaltman]

Please tell your audience that permanent incontinence due to prostate surgery is VASTLY more damaging to life that one might think. I am isolated and very, very depressed. When I go out, every step is a squirt of urine. Drives me crazy. Urinate during sex destroys sex life. Physically it's not as bad as cancer but I'd much rather have my 4+3 Gleason, and take my chances, than still be dealing with this incontinence 15 months after surgery. The surgeon thinks the whole thing was a success (PSA is undetectable) but to me surgery was a catastrophe that destroyed my life.

[@janetw9430]

My husband has a 9.5 mm lesion with a PI-RADS score of 2-3. He’s on watchful waiting. Cancer?

[@danilocruz423]

my psa test 4.0 11.1 is this normal last oct 2021

[@bosan8164]

How is the process of getting a second opinion for the prostate biopsy? How aggresive is the cancer with Gleason 7 with perineural invasion?

[@scottgraves4754]

You can request to have your slides sent to someone like Dr. Jonathan Epstein at Johns Hopkins. I thought I heard he retired, but there are pathologists at JH that trained with Epstein. I sent my Gleason 3+3=6 to him for confirmation. Since my Uro had the slides read at the UW, by a pathologist that trained with Epstein, he was reluctant but sent my slides to JH, but did anyway. He had it at 3+3=6 too. I'm on AS, but my PSA has gone up to 16.3, so my annual biopsy has been pushed up. 3T MPMRI shows "evidence suggesting prostatitis and BPH", so that makes using PSA levels to do AS a little more challenging, since BPH and prostatitis elevate PSA levels too. I've had two MRIs that show PIRAD 5 lesion, so kind of scary. I'm wondering if higher grade cancer missed on targeted biopsies. So, is the elevated PSA from cancer, or BPH and prostatiits? I would like a PSMA PET scan, but Uro not on for that at this time, and medicare may not pay for it anyway. Lesion appears to be close to margins as well, so probably not a good candidate for focal, or maybe even surgery anyway, since they like "clean" margins after surgery. I'm taking a risk by doing AS, but until they find a higher grade cancer, I'm not opting for treatment, although I know a lot of men would.

[@michaelsettevendemie4946]

I have a Gleason 3-4 and a right side tumor of 2.4cm which may have breached the prostatic capsule but is contiguous, can a focal intervention be considered? Thanks

[@hkleealan]

my mri report a lesion 20 x 15 x 7 pirads3 ,is it necessary for me to do biopsy

[@johnmchale8308]

Dr Scholz, I have a PIRADS 4 one lesion, PSA steady range at 4.2, doing a targeted fusion Transperineal biopsy, no transrectal for me this Monday June 24, found a great Doctor in Manhattan affiliated with Weill Cornell. He will be doing a 12 core biopsy...is this necessary? The risk of infection is almost nill with this method. Please advise

[@michaelrichmond3315]

Can prolonged sitting 6 to 10 hours a day in an office chair increase psa? Can diet and alcohol cause psa to go up? What are potential causes of chronic prostatitis with absolutely no symptoms just seen on mri thanks

[@moodybarzandoost4406]

psa 20 prostate size 113 and pirad 3 biopsy or not?

[@johnsnyderjr.1505]

71 yrs. old ,no family history, 3 DRE's normal, 3 PSA tests in a year 4.2 and an MRI with dye pirad score of 1. Am I missing something? Urologist still pushing for biopsy.

[@gshenaut]

In my case, with PSA fairly steady at about 9.5, I had a PIRADS-5 MRI, and two targeted fusion biopsies. The first showed a small amount of Gleason 3+3, the second was 3+4, which was also found in the post-RP path report.

[@steveg6978]

Why did you decided on a RP ?

[@gshenaut]

@@steveg6978 I think the main reasons were that the MRI showed the tumor had gotten into the “anterior fibromuscular stroma” which I interpreted as implying that the tumor was on its way to growing outside the prostate, the fact that the second biopsy found Gleason 3+4, the fact that the tumor being located anteriorly limited the availability or efficacy of alternatives, and my desire to get rid of the cancer. I was also experiencing much slower urinary flow, and from what I had read, surgery was more likely than radiation to improve this (and radiation had a somewhat greater likelihood to worsen it, and to interfere with later procedures to improve flow). In fact, my flow is back to very good after surgery. I have now had a Decipher (genetic analysis of the tumor tissues) result of 0.45, which puts me slightly above the line between low and intermediate risk of metastases (3.9% risk in 10 years). My 3 & 6 month ultrasensitive PSAs were undetectable; the 9 month test is soon, so fingers crossed. Recovery from surgery was not painful, and recovery of function (continence, ED) is going well. All in all, I have no regrets about my decision.

[@biblioeditor9355]

PSA 8.0 in May; 8.7 in December; PIRAD 5-is it necessary to get Prostate Biopsy or is it “over testing” as I have read; so many different views that it is difficult to make an informed decision I am 73 years old

[@edwardyang8802]

I am 76YO now and had a transperineal biopsy about 3 years ago with PSA around 8 and PIRAD5. That was my sencond one. The first one done about 9 years ago. The results of the biopsy, the first and second one, are all negative. If you are in healthy and over 10-15 years life expectancy, It is my opinion that you may need a biopsy.

[@BackonTrailasia]

I did a PSA test, just to rule out any issues with cancer, but to my surprice it came back 124,2. I had prostatitis so was given antibiotics for a month, did a new PSA and now it dropped to 97. Urologist suggested biopsy, but knowing it would take 3 months after a biopsy before they could make an MRI, if they found something, I thought MRI was better to do first. It showed two big tumours category 4 and 5. Now I am caught in a dilemma. Doing biopsy is the only way to verify it is in fact cancer, but in doing the biopsy I now I have to wait 3 months before they can take action. I am concerned about the risk of spread, which the MRI says they found no trace of as of now. But how does one proceed in this case? And what is best, TRUS or TPUS, when I already got MRI?

[@irishravr632]

Hi there, I had an mri scan on the 30th of Augest, it showed up a PI-RADS 3 lesion on the right hand side of the prostate, I go for a biopsy on the 26th of this month, I'm starting to get a bit concerned about the procedure, fingers crossed my results come back clear, my psa reading was 10.7, I had a catheter inserted since the 9th of June, my GP said it could of caused my psa levels to rise, the catheter wasn't a very pleasant experience, not to mention having to take laxatives on a daily basis as the prostate was enlarged it was pressing on my bladder as well as the bowel, they prescribed me dutasteride which after 6 weeks I could go to the toilet without the catheter & the laxatives, sorry if my text is a bit long winded fingers crossed everything is good at your end.

[@chuck7432]

TRUS

[@markE946]

52 year old male, have been on finesteride for the past 26 years for male pattern baldness, came off finesteride (5mg 1/4 daily) in March, psa went from 2.6 to 4.5 in 14 weeks, free psa % was 12.6%. Had an MRI 1 week ago, a 5mm lesion was identified with a PI RAD = 4 score. Urologist recommending a biopsy. Could this lesion have been in my prostate for a number of years whilst on finesteride and it has now become more aggressive from ceasing the 5 alpha blocker?

[@geraldwalsh6489]

In January 2022,my psa was 36.....in June it went down to 31. Those figures indicate cancer,but is the lesion getting smaller and would that mean the Gleason score is also reducing? Had an mri and am waiting on results of transpetineal biopsy,here in Cork, Ireland. Have been on anti cancer diet O

[@schmingusss]

How are you doing now?

[@JB-be8co]

My husband has prostate enlarged and his psa is 16.57* MRI reveals PIRADS-3 of the transitional zone. There are PIRADS -2 nodules in the transitional zone bilaterally as described. He has no complaints, except a little frequent peeing. He is 73 of age. Please suggest, here we need to go any further medical treatment?

[@larry__6052]

In the video, Dr Scholz said it is important to get the MRI done at a “quality center”. How can I tell whether my MRI was done at a “quality center”? Is there a list or website somewhere that lists the quality centers, and perhaps even ranks them? Dr. Scholz also mentioned the personnel need to be adequately trained. How can I tell whether the radiologist who read the MRI had adequate training? Also, it was done using a 2T MRI. However, I have read where the newer 3T MRIs are better. Do you think the 2T MRI was adequate enough to give an accurate PIRADs score?

[@ThePCRI]

Hello Larry, here is a list of MRI centers that do 3T MRI's: pcri.org/prostateimaging#mri-us For further help, please contact our helpline: pcri.org/helpline

[@kipanderson1479]

So…looking at the list of facilities offering 3T MRI imaging, looks like Oregon must be in the dark ages. Also, Utah! Do only large population areas have access?

[@seascape35]

@@kipanderson1479 Husband speaking here. I have found some centers with a 3T MRI machine that were not on any list. Things change constantly. You may need to just start calling hospital x-ray departments. Good Luck.

[@robertdatorsr.3147]

Dr Scholz I was diagnose with Stage 4 Cancer that spread to my spine. Had radiation December 2020 for 23 days. Was given Lupron and x Geneva and XTANDI to prevent from spreading. Now at present I have .116 PSA. Does it mean my prostate is cured. What is my next plan of treatment should my Dr advice me to do. Need help Dr Schols

[@ThePCRI]

Hello, Feel free to contact our free helpline. We have a patient advocate who will call you and may be able to provide you with some information: pcri.org/helpline

[@Shawny460]

Prostate cancer needs testosterone as fuel to grow and spread. Lupron takes your testosterones and your PSA to near zero and the cancer is slowed down or stopped completely. If they got all the cancer with the radiation, the only way to tell if you are in remission, is to stop the Lupron (not without a doctors permission) and if your PSA stays constant over a period of time you are in remission.

[@shashimoghe3920]

Very informative and patient friendly awareness spreading contents of this video thanks and good wishes 18/04/2024

[@NablusRain]

I am 69 and I have been treated with Hormone therapy for (prostate cancer after I went under biopsy and operated on to clean up the hemorrhage but no Prostatectomy was performed) and since February 2018 by taking an 80mg Firmagon Shots every 28 days. My TPSA went down dramatically to below 4 ng/ml until it started to go up so my Doctor put me on Zytiga 250 mg with cortisone since July 2020 including the shots each month. Now my TPSA is 0.05 ng/mg What does this mean? Should I do an MRI? Or another biopsy? Thank You 🙏 I am afraid that a biopsy may aggravate the situation.

[@ransomcoates546]

If I may ask, was such a long course of hormone therapy bearable?

[@NablusRain]

@@ransomcoates546 Not really a very difficult journey filled with weight gain water retention constipation fatigue upset stomach depression zero sex Drive among many other things

[@denisfinnegan7314]

You didnt mention transperineal biopsies. Aren't they safer from infection?

[@ransomcoates546]

They’re supposed to be, but if you’ve seen a KZbin of one being done you might not like the idea so much. They gave me profonol for my trans-rectal. No infection or pain. Only one time afterwards was there blood in the urine.

[@nancywhite3212]

Much safer to go through the perineum. Why risk sepsis if you don't have to?

[@johndemerse9172]

@@ransomcoates546 Trans rectal are for dinosaurs.

[@tjl5419]

Im 58. Just got a prostate MRI. Pirad s 3. How serious is that? The urologist wants me to get a biopsy

[@ThePCRI]

For specific questions and information, please reach out to our Helpline here: pcri.org/helpline

[@tjl5419]

@@ThePCRI thank you

[@tucao6187]

Here is replied from my urologist about MRI vs biopsy. Seems a different direction from Dr. Scholz answer? “A prostate MRI cannot be used to diagnose prostate cancer. It can be used to suggest there could be a cancer inside the prostate. If the MRI comes back is suspicious, you still need to do a prostate biopsy. If the MRI comes back as negative, unfortunately MRI does not detect low-grade prostate cancer, so there could still be a cancer in your prostate that is missed by the MRI. The place for MRI is for men who have already undergone a prostate biopsy where we are concerned that we have missed something potentially. It is not reliable as a primary tool to diagnose prostate cancer”

[@mactheslovac8673]

Fmri shows nothing just do your watchful waiting and your routine PSAT and that's all there is to it don't let these money-hungry urologist sucker you into some barbaric painful procedure