High PSA, but MRI is negative. Biopsy or Not?

@lookin4answers
Hopefully the MRI will find lesions, but there are cases where there are none found, but the cancer is in the prostate tissue.

In that case, the doctor randomly selects different spots in the prostate.

I would recommend you go for a biopsy. I was 68 last year (July 2024) with a PSA of only 2.0. The MRI was negative, DRE negative and ultrasound negative. When I requested a biopsy. The doctor guided the procedure with ultrasound since MRI was negative. While doing the procedure he commented that there were no shadows no nothing . He went ahead and took the 12 cores saying there was likely no cancer. Two weeks later he tells me I have PC.. Gleason 3/4. Pathology after surgery was a large tumor occupying 10% of the gland with Gleason 3/4 (30%- gleason 4).
So to answer your question about ultrasound, it did not see anything in my case. Everyone is different and to be honest the biopsy was not that big a deal and in my case it was the only tool that found the cancer.

@beachflyer
Can I asked. When you had your biopsies where they done MRI/Fusion? Or since MRI was not showing suspicious areas they did a ultrasound? Is not a ultrasound a lot less informative than a MRI?

When you had your MRI did they use a contrast? The contrast gives a much clearer and defined picture of the prostate.

In my case I had MRI done with contrast. Did not find tumors/lesions just suspicious areas. Many many PCs are at the cellular level meaning only the cells are different than normal cells not that you have a tumor or lesion. This was my case I had not tumors or lesions.

I am not sure the hesitation of biopsies as they really do reveal if you have PC. With the caveat that need to be done correctly and enough areas of prostate to get a good report.

Over the course of 6 years I had BPH with a volume of 68(high). My PSA rose over time to 7.7. I had two MRIs over that time and both were negative. My first biopsy in 2016 negative as well. My new doctor decided another biopsy might be beneficial(this was weeks after my 2nd MRI). It came back with two cores of cancer, one at 3+4. I decided on removal. My pathology report indicated my cancer was actually 4+5. I also had a high risk decipher score(you may want to request one). Bottom line, I was glad I had it removed(no problems with the surgery including ZERO incontinence). Now two years later, my PSA remains undetectable-6 tests over that time). Based on my experience, I would suggest you do everything you can to make sure you are confident with the results and then can make a pretty knowledgeable decision. Best wishes.

@jc76
Hi jc76

The original scan was a contrasting MRI. I think it came out pirads 1 or 2. So with poor MRI scan the doctor planned to use ultrasound to guide. Once on the table he inserts the wand and sees no shadows, nothing. Seeing nothing on the ultrasound scan , he actually said “this is an unnecessary procedure” and suggested we stop. I responded something is really wrong (due to hematuria) and we are here so lets do it. At this point the samples were essentially taken at random with no guidance.
I am glad I did the biopsy for sure. I understand biopsies can miss things however …nothing is fool proof. The surgeon (Dr Ahlering ) at UCI told me that 8 -10 % of us can get scan negative PC and it can go undetected until is is quite advanced.

@handera would you say that a saturation biopsy is still a good way to go even when there are no focal lesions to target, a somewhat clear MRI (pirads 1 or 2), fluctuating psa, lower PSA density, enlarged prostate? or more diagnostic testing?

@beachflyer
For most of us the good news is that Scan negative PC is usually low grade Gleason 6, but for a small percentage of us it can be advanced which is why we need to gather all the information we can (including biopsies) prior to treatment and pay close attention to subtle clues. In my case occasional small brown spots in semen (hematuria) was a pretty good sign of trouble. Both my family physician (who is a friend) and Urologist dismissed the hematuria since my PSA was so low and scan was negative. I did not fit the medical and insurance bellcurve for treatment. We are all our own best advocate.

@ezupcic

Personally, I wouldn’t pursue in the case you mention; but I’m sure there are those that might.

My personal significant negative side effect experience with a lot of biopsy cores (21 in my case) definitely clouds my opinion against a so called “saturation biopsy”…when there is nothing to target.

My opinion is also based on the strongly held medical opinion (in some circles) that “MRI invisible lesions” are undoubtedly small…. therefore why not wait until there is clear evidence of something to actually target, since PCa is generally slow growing.

I know others may strongly disagree, thinking a 2mm 4+5 lesion may be lurking just under the radar…

At the end of the day it’s all about one’s individual perspective of risk/reward.

All the best!

@handera, appreciate that. How is your running going? I’ve added brussel sprouts to my routine based on a post of yours I believe. Also some spin cycling to my workouts and moved my running to a treadmill for a bit. take care.

@ezupcic broccoli sprouts!