What are the next steps for a patient with elevated PSA (Prostate-Specific Antigen) levels, negative MRI (Magnetic Resonance Imaging) results, and nocturia (nocturnal urination)?

Management of Patient with Elevated PSA (10 ng/mL), Negative MRI (PI-RADS 2), and Nocturia

Despite a negative MRI (PI-RADS 2), a systematic prostate biopsy is strongly recommended for this patient with PSA of 10 ng/mL due to the high risk of clinically significant prostate cancer that may be missed by imaging alone. 1

Risk Assessment and Rationale

• PSA level of 10 ng/mL falls into the intermediate-risk category (4.0-10.0 ng/mL), which carries a 17-32% risk of biopsy-detectable prostate cancer regardless of MRI findings 1
• A single elevated PSA should be verified with a repeat test before proceeding to biopsy to rule out temporary causes of PSA elevation 2, 1
• The large prostate size (91g) may contribute to PSA elevation but does not exclude cancer
• Previous PSA of 7 ng/mL with current level of 10 ng/mL indicates a concerning upward trend

Recommended Next Steps

1. Confirm PSA elevation with a repeat PSA test 2, 1

2. Proceed to systematic prostate biopsy if PSA remains elevated 1, 3

   • Standard biopsy scheme should include at least 10-12 cores targeting the peripheral zone
   • Consider additional sampling of the transition zone given the large prostate size (91g) 1

3. Consider additional biomarkers before biopsy to improve risk stratification:

   • Free/total PSA ratio
   • 4Kscore or Prostate Health Index (phi)
   • PCA3 test 1

Important Considerations

• While negative MRI (PI-RADS 2) suggests lower risk, it cannot rule out clinically significant cancer:

  • Studies show negative predictive values of 79-95% depending on the definition of clinically significant disease 4
  • The AJR Expert Panel recommends systematic biopsy in high-risk patients despite negative MRI 3

• Nocturia should be evaluated separately but may be related to:

  • Benign prostatic hyperplasia (suggested by large 91g prostate)
  • Nocturnal polyuria (evaluate fluid intake patterns in the evening) 5
  • Other causes (diabetes, sleep apnea, heart failure)

Follow-up Plan

• If biopsy is negative:

  • Continue PSA monitoring at 6-12 month intervals 1
  • Consider repeat MRI and biopsy if PSA continues to rise (especially if velocity exceeds 0.75 ng/mL/year) 1
  • Evaluate and treat nocturia symptoms (consider alpha-blockers for BPH component) 5

• If biopsy is positive:

  • Treatment options will depend on cancer stage, grade, and patient factors 1
  • May include active surveillance, surgery, radiation therapy, or androgen deprivation therapy

Pitfalls to Avoid

• Do not rely solely on MRI to exclude cancer in a patient with PSA of 10 ng/mL
• Do not attribute elevated PSA entirely to BPH without excluding cancer
• Do not delay biopsy if PSA elevation is confirmed, despite negative MRI
• Do not overlook evaluation and management of nocturia, which impacts quality of life

The combination of elevated PSA (10 ng/mL), rising trend from previous value (7 ng/mL), and large prostate size warrants thorough evaluation with systematic biopsy, even with a negative MRI.