PSA/MRI not too bad, Biopsy not too good. What?? [updated]

Posted by jeff1963 @jeff1963, Sep 1, 2025

61 years old, both brothers have had Pca, one died from it, other RARP and no issues since

PSA over last 4 years, from 1.8 to 5.7
Last PSA two weeks ago 2.4 (Mayo Rochester)

Transrectal Biopsy 2021, 1 out of 12 positive, Right Base Lateral: 3+3, 2% of sample positive, Oncotype DX (biomarker) very unlikely to spread
AS for 4 years
MRI 2024 no tumors, nothing at all, clean MRI totally

June 2025 - first visit to Mayo (Jax)
MRI 2025 (Mayo Jax) - one tumor 1cm/0.21cc Right Posterior Lateral, PIRADS 3, no spreading at all

Tranperineal Biopsy one week ago (Mayo Rochester), 9 are negative, 6 are positive:
Right Posterior Lateral Apex: 3+3, tumor is 30% of specimen
Right Posterior Lateral Base: 3+3, tumor is 20% of specimen
Left Anterior Horn: 3+3, tumor is 60% of specimen
Left Anterior Apex: 3+3, tumor is 5% of specimen
Left Anterior Medial: 3+4, % of pattern 4 is less than 10%, "tumor involves 30% of overall specimen (1 of 2 cores). Most affected core is involved by tumor over 60% of its length"
Right Posterior Lateral: 3+4, % of pattern 4 is less than 10%, "tumor involves 20% of overall specimen (3 of 3 cores). Most affected core involved by tumor over 40% of its length"
For the 3+4s they did multiple samples, for rest one core sample only
Pathology report does not mention anything like criboform or IDC (not sure if this is because they found none or because that level of detail is not included in my report)

Have not had Decipher, have not had PSMA PET, no treatment at all up to this point.

Meet with Mayo Rochester NP next week to review results.

Not sure what to make of this. Seems like MRI missed some tumor(s)? Maybe was MRI also wrong when it found no spreading?

Not sure of next steps. Any advice? Thanks in advance!

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

surftohealth88 | @surftohealth88 | Jan 10 5:03pm

In reply to @kennyo "@jeffmarc my PSA is 5.7. Asking about the PET Scan when I see the dr on..." + (show)

@kennyo

Ask about Decipher test also ( it is done on biopsy samples) and it will give you information about aggressiveness of your cancer. It might help later with decision process about possible treatments. I agree with Jeff, PSMA should be done at this point.
Wishing you the best of luck on your next appointment !

heavyphil | @heavyphil | Jan 11 8:06am

In reply to @kennyo "@jeffmarc my fusion biopsy came back with 12 out of 14 samples positive. All 3+4 except..." + (show)

@kennyo While the PET scan is not infallible, it is a MUST when deciding on treatment. It could show areas of spread into lymph nodes which would render surgery useless…
Or it could show NO spread anywhere, which might induce you to have surgery. You have many options at this point but you CANNOT move forward without this piece of information.
Ask your doctor about PET and if he is not 100% in favor of it, run like hell because he/she is practicing in the dark.
Phil

jercalif | @jercalif | Jan 21 7:03am

Maybe a stupid question on my part since we are talking about Mayo here, but are you sure that it was a 3T multi-parametric MRI, and did they use intravenous contrast?
Sometimes they can't use the 3T because of a small amount of metal somewhere inside the patient's body, and so they have to use the 1.5T instead.
But I think that the commenter who suggested that perhaps the radiologist just missed some suspicious nodules that the urologist picked up on the MRI images makes sense as a possible explanation, assuming the biopsy was an MRI fusion biopsy.

jeff1963 | @jeff1963 | Jan 21 9:27am

In reply to @jercalif "Maybe a stupid question on my part since we are talking about Mayo here, but are..." + (show)

@jercalif Radiologist report says "Multiparametric MRI of the prostate was performed at 3 Tesla with surface coil. Hi resolution T2WI, DWI/ADC and DCE imaging with IV contrast performed". Don't know if that is 3T or 1.5T. No metal inside of me.

Biopsy was a transperineal MRI fusion.

After RP, two lesions were found. Sizes about 1cm x .5cm x .5cm and .3cm x .3cm x .3cm. I dunno, maybe one was too small to see on MRI?

jercalif | @jercalif | Jan 21 10:24am

In reply to @jeff1963 "@jercalif Radiologist report says "Multiparametric MRI of the prostate was performed at 3 Tesla with surface..." + (show)

@jeff1963
3 Tesla = 3T
So your smallest "lesion" was 3mm, and my only "nodule" was 4mm... I don't know the difference in the terminology but the size is similar.

Were you able to obtain your imaging so that you can view it?
I obtained mine by simply asking... In my case it includes a software program called Gearview.exe... allows me to see exactly what the radiologist sees and manipulate and mark up the images exactly as the radiologist would be able to. The radiologist didn't mark my 4 mm nodule on the MRI images, but I was able to find it pretty easily...and I have a severely enlarged prostate that is 57 mm across.

I'm kind of an interloper here because I'm in extreme Northern California... Perhaps this forum is only for Mayo patients... But the fact that you were able to get a transperineal biopsy illustrates the advantage of living near a major metropolitan area.

jeff Marchi | @jeffmarc | Jan 21 10:44am

In reply to @jercalif "@jeff1963 3 Tesla = 3T So your smallest "lesion" was 3mm, and my only "nodule" was..." + (show)

@jercalif
People in this forum are from all over the world. Many of us do not use Mayo, Probably more that don’t use it then do.

I’m in coastal California.

jeff1963 | @jeff1963 | Jan 21 1:29pm

In reply to @jercalif "@jeff1963 3 Tesla = 3T So your smallest "lesion" was 3mm, and my only "nodule" was..." + (show)

@jercalif This forum is for everyone, both Mayo patients and others. So you are very welcome, definitely not an interloper. I'd guess most people here are non-Mayo.

Yes, I got the MRI images and software, but I never even tried to look at them, I only passed along to doctors. I'll have to go back and take a look, as a non-medical person had no idea that it would even make sense to me. It's all moot now, my prostate was gone on 12/16/25, 3 month PSA is in March, undetectable is the hope from this point forward.

jercalif | @jercalif | Jan 21 2:39pm

In reply to @jeff1963 "@jercalif This forum is for everyone, both Mayo patients and others. So you are very welcome,..." + (show)

@jeff1963
Firstly, prepare to be horrified if you look at the MRI images, but if you do, the T2W is the easiest to understand for patients. Basically as you move forward and backward through the T2W images, at one point there will be two perfect circles directly to the left and right of the prostate...those are your hip sockets. And below the prostate will be your rectum and above the prostate will be your bladder.
Most cancers are in the peripheral zone, which is (very roughly) the bottom 1/3 of your prostate.
And then if you look at the DWI images, suspected cancer areas will be lit up white by the injected contrast agent.
I was able to find my single 4mm nodule by the MRI report's description of it's location and by it's size relative to the width of the prostate (57mm), but I can almost guarantee that a patient first seeing the MRI images trying to make sense of them is going to say "you have f****** got to be kidding me!".
Which was similar my reaction when I first learned how a prostate biopsy was performed..."You have got to be out of your f****** mind!". 🙂