Case Study #4: A PI-RADS 5 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

Steve is a 68-year-old man referred by his primary care doctor after a PSA of 8.2. He reports mild urinary urgency but no weak stream or nighttime urination. His prostate exam was normal. He is otherwise healthy and takes a daily statin.

PSA trend

2024 — 6.1 ng/mL

2025 — 7.0 ng/mL

October 2026 — 8.2 ng/mL

Elevated and rising — well above the reference range.

Secondary testing

• Prostate MRI: PI-RADS 5 lesion (17 mm, peripheral zone) — clinically significant cancer highly likely

• Prostate MRI shows a PI-RADS 5 lesion (17 mm, peripheral zone) — clinically significant cancer highly likely — with prostate volume 38 cc and PSA density 0.22 ng/mL/cc.

  Previous biopsy

Steve has never had a prostate biopsy.

Family history

Steve's brother was diagnosed with prostate cancer at 70.

Other health considerations

None — Steve is healthy with a normal life expectancy.

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What I would recommend for this patient

An MRI-fusion targeted biopsy of the lesion.

Rationale

Steve's MRI shows a PI-RADS 5 lesion — the highest-risk category on prostate MRI, where clinically significant cancer is highly likely. A targeted biopsy of a PI-RADS 5 lesion finds clinically significant prostate cancer roughly 70 to 80 percent of the time or more. Combined with a PSA of 8.2, a PSA density of 0.22, and his brother's history, this is about as clear an indication for biopsy as we see. The MRI target lets us sample the exact area of concern rather than sampling blindly. Urologists often add systematic samples alongside the targeted cores, as guidelines support doing both.

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.