PSA & MRI suspicious but biopsy benign

I'm no doctor, but, here's my $0.02
Is there "any chance", unfortunately there's almost always a chance but there's also a good chance you're one of the lucky ones.

Given what I've learned from reading over the last couple years. I'd probably just keep an eye on the PSA. 5 is elevated for a 66 year old but not by a great deal. How fast PSA rises is an indicator but you're showing a 9 year period here. Your "rate of doubling" shown in your numbers is over 10 years. If my math is right, your increases are...the first two numbers are a 2 or 2+ year period, the third year it goes down then has an increase this year. There are a lot of things that can increase your PSA by small amounts.
2014 Baseline
2017 15.38%
2019 31.58%
2022 -5.56%
2023 28.00%

If the biopsy really got a core from the lesion, sounds like you've pretty much identified that as BPH. BPH can raise your PSA levels as well as PCa.

If it was me and I was concerned about it, maybe get a PSA test every three or six months for a year at this point, to see if the rise continues and at what rate it does so if it indeed does rise. Then if it continues to rise, or the rate increases perhaps another biopsy down the road.

For now, I'd take the "win" but just keep an eye on it. "Trust but verify"

Best of Luck to you sir!

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I read prostate focal atrophy & inflammation can be a precancerous lesion. I wondered if it was worth sending pathology slides to Mayo.

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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.

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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.

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How I would consider all this if it were me…..

A PIRADS 4 indicates that “Clinically significant cancer is likely to be present,” and is not a diagnosis of cancer.

Did you request a 2nd opinion on the MRI scan and the biopsy slides? It’s often recommended to send them out for a 2nd opinion to an independent facility specializing in reading and interpreting scans/biopsies — not necessarily because you don’t trust the 1st one or don’t like that opinion. But, because much of the interpretation of images and scans is often as much an art as it is a science, as well as dependent on the skill and experience of the person reading them. It’s good to have an independent set of eyes reviewing the results.

Depending on your age, your PSA of 5.3 may only be slightly elevated. How old are you?

With all of the tests and information that you have, it’s not quite back to square one. In addition to your PSA, PIRADS, and Gleason, do you know what are your: % Free PSA, PSA Density, PSA Velocity, and PSA Doubling Time are? Those provide additional information as to the status of your disease.

Can you have your biopsy tissue sent out for biomarker (genomic) testing (like Decipher, Prolaris, OncotypeDx, etc.). That will provide even more information as to the status of your disease.

If those are all within good range, then things might not be as bad as the PIRADS 4 led you to believe.

For now, there’s probably no need or definitive justification for more invasive tests (or a PSMA PET scan). What you have so far and what you can get with those additional numbers I mentioned above should get you to the next step - a repeat PSA with a “Free PSA” test in a few months.

If those lead to the possibility of something more serious being there, then perhaps the repeat biopsy you’re considering.

If it were me, I’d do least invasive steps first. I wouldn’t want to turn my prostate into a pincushion with many biopsies in an attempt to find something.

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