PSA & MRI suspicious but biopsy benign

I had PIRAD 4 and PIRAD 5 lesions that were both 3+3 Gleason upon TRUS targeted fusion biopsy.

As far as I know, the PIRAD scoring system doesn’t tell you anything about the aggressiveness of your PCa. It certainly didn’t in my case.

Instead of subjecting yourself to additional biopsies, with such a favorable initial biopsy result, you may want to ask your doc about the genomic ExoDx test. It only requires a urine sample to perform the test.

ExoDx test has Level 1 evidence, based on a 1000+ patient study, with a 91 % Negative Predictive Value (much higher than the PSA test). It designed to indicate the likelihood of GG2 (or greater) PCa. I’m going to ask to have this done before deciding on having my next biopsy, due in October.

ExoDx test is covered by Medicare.

You can read much more about it (including study trial paper) here:
https://www.exosomedx.com/physicians/exodx-prostate-test

All BX sites came back benign except core pirad 4 area& it was focal atrophy with inflammation. I just did 6 month PSA & it fell from 5.0 to 4.1. Urologist email message “PSA stable. I suppose I will get another PSA in 6 month via internist yearly checkup.

Read your other post to get more background info.

From what you’ve indicated NONE of your 13 core samples came back with 3+3 Gleason, even those targeting your PIRAD 4 lesions, correct?

Were all 13 cores “benign”?

Sometimes a core will come back “suspicious” or HGPIN, but not cancer.

All BX sites came back benign except core pirad 4 area& it was focal atrophy with inflammation. I just did 6 month PSA & it fell from 5.0 to 4.1. Urologist email message “PSA stable. I suppose I will get another PSA in 6 month via internist yearly checkup.

lyricw,

That is a great news. What have you been doing to lower the PSA, if anything?

Transrectal. I may seek second opinion from Mayo if PSA stays elevated.

I was tested with PSA 5.3 on November 2023, and 3T MRI shows 2 lesions (6 x 9 mm and 5 x 3 mm). Both PI-RADS 4. The locations are:

T2 signal 4 o'clock left lateral lower mid peripheral zone.
T2 signal right 7 o'clock upper mid peripheral zone.

I had a MRI fusion transperineal Prostate Biopsy few days ago. The pathology report shows all 13 diagnosis benign. The detail of diagnosis shows each diagnosis with the corresponding number of cores. (See attached). Total number of cores added up to 26.

I am ready to meet my urologist in few days to discuss the pathology report results. The report only shows that my urologist did not fine cancer, but it does not mean caner is not there giving my PSA number and PI-RADS numbers. I feel that I am back to square one.

I am ready to ask for more tests, but not sure if my Medicare/Medigap would pay without a positive diagnosis. Tests such as PSMA PET scan.

I read that a second biopsy can be requested though it requires a 3 month wait. There is a more focused biopsy technology:
Direct MRI-guided In-Bore Targeted Biopsy of the Prostate: A Step-by-Step How To and Lessons Learned | RadioGraphics (rsna.org)

"This potential optimized sampling makes in-bore biopsy an excellent second-tier strategy offered to patients in a scenario such as prior fusion biopsy with negative results and highly suspicious lesions (PI-RADS category 4 or 5). This technique can also provide improved accuracy in challenging clinical scenarios such as small lesions in a large gland or suspected local recurrence after surgery. A disadvantage of in-bore biopsy is the higher cost. Also, because systematic sampling is not routinely performed during in-bore biopsy, MRI-invisible lesions could be missed with this approach."

This seems to fit in my condition. I just do not know where I can request such a second biopsy. I am here seeking any suggestions, and guidance so I can have a constructive conversion in few days when I meet with my urologist. Thank you for listening.