PSA & MRI suspicious but biopsy benign

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.

@lyricw, if you would like to get a second opinion at Mayo Clinic, you can self refer or get your doctor to refer you. Find out more here: http://mayocl.in/1mtmR63

How are you doing?

Diagnostic tests are not 100% accurate but I won't be too concerned as long as the biopsy was on the MRI lesion (guided by your MRI data). Good practice to keep monitoring it by PSA and MRI.

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

Also before the next PSA, make sure to avoid sex/ejaculation and bicycle riding 48-72 hours prior. Those cam stimulate release of the chemical from the prostate.

One other test that is available at a growing number of cancer centers is the PSMA PET scan. This test specifically identifies prostate cancer cells. This would be another “tool in your bag”.

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!