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

@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.

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.

@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.

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.

@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.

@jeffmarc I've thought a lot about this and am getting further convinced that before I schedule a biopsy, I will insist on the EpiSwitch PSE test, then if PSE says cancer is present, I'll get another MRI to find lesions, and then schedule the biopsy so they know where to target the needle.

Thanks to all here for providing me with some insight and direction.

@kikito1
You can get an MRI second opinion in the United States are about $250 if I remember correctly.

Here is a video about the company and procedure
https://ancan.org/
ProstatID is the procedure .

Founder and Developer, Randall Jones, PhD, explains the technology and its uses in the video.

More info
https://botimageai.com/prostatid/

@hikerbruce2025
While you had 3 cores At 3+4 what was the percentage of carcinoma in those three cores and what was the percentage of four in those three cores?. If the percentages were very low 5% or 10% 4 then it is not an emergency, If it’s a high percentage, it could be something you need to treat right away.

My biopsy showed a 3+4 but when I had a prostatectomy, it was 4+3. Some people I know had 4+5 after a prostatectomy, but only 3+4 in the biopsy. They can only get about one percent of the prostate when they do a biopsy.

It should be interesting to hear what the urologist recommends. You should also see a radiation oncologist to see what other options you have If the urologist recommends surgery.

Were any of these things found in the biopsy intraductal, cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). Those can mean that the cancer is much more aggressive than it appears from the Gleason score.

I am in similar shoes. I’m 68 and have had a PSA number in the 5 range for probably 7-8 years. My regular doctor was never overly concerned because I have an enlarged prostate and have had for a long time. However over the last two years my PSA number went to 6.8 and then 8.6. I was referred to a urologist but before seeing him my regular doctor ordered an MRI. I had the MRI done on 9/12 and it was negative. However, upon seeing the urologist he strongly urged me to get a biopsy because of the percentage jumps of the PSA number. He said that because of those jumps I had a 20% chance of having cancer. I did the biopsy on 11/5. Twelve cores were taken and prostatic adenocarcinoma was found in six cores (3 cores were Gleason 3 + 3, which I understand are not usually concerning; 3 cores were Gleason 3 + 4). I now have another appt. With the urologist to consider what action to take. He told me over the phone that active surveillance was not something he would be comfortable in suggesting. I’m reading and talking to as many people as I can about their own personal journey and issues like side effects from the different treatments (surgery, radiation, etc). I am very fit, no issues other than the 2X normal size prostate and peeing twice a night fun. I’m looking hard at a prostatectomy for various reasons. Good luck and positive thoughts for all fighting this “fun”.

@jeffmarc Very useful. Thanks.