New and MRI results: Biopsy recommended next?

Welcome. Sorry to meet you under these circumstances. Next step would be a biopsy. This will show a Gleason score. With a PIRADS 4 it's most likely cancer but hopefully with that low PSA and small lesion you will be a Gleason 6 and can do nothing but active surveillance.
If doctor suggests biopsy ask for the fusion guided Transperineal type, not the trans rectal. If your doctor doesn't do that type of biopsy go to a different doctor or better yet a cancer center of excellence like a teaching / university hospital. And always get 2nd opinions.
You can relax knowing prostate cancer is very treatable & curable with many options!
Wishing you the best!

Sorry you had to join our little group. You owe whoever the provider was that ordered the Hip MRI a beer. Catching a prostate lesion this early leaves the door open for all modern medicine has to offer. In the case of prostate cancer, that is substantial. Since PSA is still low, urology may want to see a rising PSA trend before jumping to biopsy but in all honesty, the only way to know for sure if its cancer or not is grab a piece and look at it. Best wishes and keep us in the loop.

A PIRADS 4 Can mean cancer or it may not. Most doctors would want to do a biopsy, but your PSA is awfully low. It is true about 10% of people with prostate cancer don’t produce much PSA.

You could get a PSE test, The most accurate test to tell whether or not there is prostate cancer in your body and that you need a biopsy. This would really confirm if there is cancer found.

If you do get a biopsy, get a transperennial biopsy. That goes through the perenium, not the rectum. It gives us smaller chance of infection and can get to more of the prostate than a transrectal biopsy.

I agree with the above. You have been given a gift. Biopsy is the next step unless they want to watch a bit. On your shoes I would want to just get it done and let them plan from there. Don't let the stories about biopsy scare you off.

Get it done, my MRI lesion was nothing bad 3+3, they did 3 biopsy of the lesion. But they also did 12 other biopsy one from each segment of prostate. I guess that is normal to just biopsy everything. They did find issues in those other 12 that needed attention. Bottom line MRI made them look, but did not show the serious spots.
Hope you have good results, but believe you should get biopsy, they are not that bad.

Yes, get a repeat PSA at the same lab that did the previous one.

At 64y, you probably have quite a few years of annual PSA tests to see if there has been any trend. How have those been?

You mentioned your MRI showed PIRADS 4 lesion(s). Was there any mention of extracapsular extension, seminal vesicle invasion, or perineural invasion in the report?

A PSA Density < 0.10 is good.

If it were me, I’d get a second opinion on the MRI scan. (A PIRADS 4 doesn’t align with a PSA of 2 and PSA Density of 0.07. A second set of eyes looking at it will build confidence in the results.)

See what the follow-up PSA test comes back with. If it’s higher, and/or the 2nd opinion confirms the PIRADS 4 and/or any EPE, SVI, and/or PNI, then yes, look into a biopsy.

@brianjarvis Thanks for the reply. The MRI also stated there are no spacious nodules identified in the transition zone, the prostatic capsule appears maintained, the neurovascular bundles and posterolateral periprostatic fat are normal without evidence of tumor extension. No suspicious lymph nodes identified. I have had many PSA tests over the years as part of annual physical. All but 2 were within normal range. When rechecked again a few weeks later then returned to normal range. I have had recurring prostatitis over the years that has been treated with antibiotics.

@dan06, how are you doing? What has been recommended as next steps by your doctor?

Doing ok thanks. Saw two doctors on this, one quickly said a biopsy is the next step (guided trans perineal) and the other said get ExoDx urine test and then consider biopsy. Also caveated the ExoDx test doesn't rule cancer in or out, but provides a ref point for biopsy consideration. So, I did the urine sample for the ExoDx test and I also scheduled the biopsy. I should know in a few days the result of the urine test. But, I am definitely leaning towards the biopsy no matter what urine test says. Biopsy is tentative set for last next week.

I had rationalized my erratic PSA numbers with my fighting prostatitis and my 1st mri showed what appeared as prostatitis scarring so I was even more confident in my decision to hold off on biopsy. I was sure wrong. I even got my urologist to agree to the long term cipro 90 days to absolutely clear any prostatitis and redo psa’s. Did not help but likely was not good antibiotic decision. My Urologist also commented my PSA was okay for my age regardless of the erratic behavior. It was a ExoDx that helped turn my ship in the right direction towards the biopsy as you said another ref point