Case Study #3: A PI-RADS 4 Lesion

This case is hypothetical — written for teaching, to help you understand how I think through decisions about elevated PSA. It is not based on any real patient.

History

Tom is a 64-year-old man who came in for a second opinion about a rising PSA. He feels well and reports no urinary symptoms. His prostate exam was normal. He is otherwise healthy and takes no daily medications.

PSA trend

2023 — 3.9 ng/mL

2024 — 4.6 ng/mL

2025 — 5.2 ng/mL

October 2026 — 5.8 ng/mL

A slow, steady climb — mildly elevated and clearly rising.

Secondary testing

• Prostate MRI: PI-RADS 4 lesion (12 mm, peripheral zone) — clinically significant cancer likely

• Prostate volume by MRI: 40 cc — PSA density: 0.15 ng/mL/cc

Previous biopsy

Tom has never had a prostate biopsy.

Family history

No family history of prostate cancer.

Other health considerations

None — Tom is healthy, with no conditions or medications that affect the decision.

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What I would recommend for this patient

An MRI-fusion targeted biopsy of the lesion.

Rationale

Tom's MRI shows a PI-RADS 4 lesion — a finding where clinically significant cancer is likely. In practice, a targeted biopsy of a PI-RADS 4 lesion finds clinically significant prostate cancer roughly 40 to 50 percent of the time. Those are not odds to watch and wait on, especially with a PSA that has climbed steadily to 5.8. A targeted biopsy samples the exact area the MRI flagged, which is far more precise than a blind systematic biopsy alone. In practice, urologists often take systematic samples alongside the targeted cores, since guidelines support doing both. If the MRI had shown no suspicious lesion, close monitoring would have been the reasonable path — but a PI-RADS 4 finding changes the calculus.

By Chad Ellimoottil, MD — urologist at Michigan Medicine specializing in prostate cancer detection.

Disclaimer: This information is for general educational purposes only and is not medical advice. Please consult a qualified healthcare professional about any medical condition, diagnosis, or treatment decision.