PSA & MRI suspicious but biopsy benign

@lyricw I had lesion on right anterior apex, they can't reach that well with trans-rectal. Only transperineal biopsy can you properly sample. Is that what you had?

How big is your prostate? What is your PSA density?

Thanks for the reply.

I am 68 years old. I only tracked my PSA from February, 2022. It was 3.9. By November, 2023, it jumped to 5.3.

I am meeting with my Urologist next Tuesday to discuss biopsy results. I will request he send the slides and MRI to John Hopkins for a second opinion pathology. I hope he is willing to help me.

From my last PSA test in November, 2023. PSA is 5.3. Free PSA is 31.3%.
From my MRI: PSA density: 0.12. Prostate is 47cc. There is no PSA Velocity data.

As part of the biopsy, there is a request to do Polaris test, but I do not have that report now. I will ask Urologist next week.

Thanks again for your suggestion. I will report back what my Urologist recommend next week.

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.

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.

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.