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Old 08-25-2011, 01:08 PM   #1
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False Positive Prostate Biopsy

I'm 66 years old. My PSA has steadily (close to linear on a graph) risen since 2005 from 4.6 to 9.0 in March 2011. Free PSA varies between 17.5% and 21.5% with no trend. DRE finding: Nodule left mid. Two previous biopsy results in 2005 and 2006 were negative.

Biopsy performed in April 2011 showed High-grade PIN in Left Lateral Mid core and in the Left Apex an Adenocarcinoma, Gleason Grade 3 + 3= 6 involving 4mm/33% of needle core, negative for perineural invasion, negative for extracapsular extension. The other 10 cores were benign, some with finding of acute and chronic inflammation. P63/p504s double IHC stains were performed and evaluated on the Left Lateral and Apex biopsies. The slides were evaluated by an independent pathology lab confirming the pathology diagnosis.

I talked to a urologist about robotic surgery and another about intensity modulated radiation treatment and from these discussions decided to have a pelvis MRI with spectroscopy done to better stage the cancer and hopefully determine if treatment was really necessary at this time.

MRI results state "FINDINGS: The prostate is moderately enlared veasuring 6 x 4.3 x 5.2 cm in dimension, giving a calculated gland volume of 67.1 cc. Mo post biopsy hemorrhage is identified within the prostate gland. There are no abnormal foci of decreased signal intensity within the peripheral zone of the prostate on the T2-weignted images. Specifically, no MRI abnormalities are identified in the region of the left prostate apex. No abnormal zones of malignancy are identifed using MR spectroscopy. There is no evidence of extracapsular extension of disease into the semial vesicles or nerovascular bundles bilaterally.... (Few comments on spine, hip, and bowel observations deleted) No pelvic adenopathy is seen. No osseous metastasis are identified.

IMPESSION: No MRI or MRS findings within the prostate suspicious for malignancy.

No evidence of extracapsular extension of disease into the seminal vcsicles or nerovascular bundles bilaterally. No pelvic adenopathy or asscous metastases."

In other words, other than being enlarged, MRI shows the prostate is normal. I asked my urologist what monitoring should be done from here and didn't get any reassuring reply. I'm wondering if I should look for further imaging (color doppler?) continue with PSA monitoring, or just don't worry, be happy.

 
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Old 08-25-2011, 03:29 PM   #2
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Re: False Positive Prostate Biopsy

Hi Oldkenoplayer,

Welcome to the Board, and I hope we will be able to give you information you want and assurance.

I'll start out by saying that the positive biopsy was very likely not false, but the limited and low-risk nature of the cancer probably allowed it to pass under the radar of the MRI with spectroscopy. That technology has improved steadily over the years, with Dr. Jon Kurhanewicz at UCSF being the world's leading expert I believe, but my strong impression is that it is not yet up to biopsy standards for effectiveness. (It will be a great day if and when that occurs: no more intrusive biopsies!) Did Dr. Kurhanewicz or an associate of his do your MRI with spec?

I'll insert some points in green to parts of your post #1. I am now a fairly savvy layman regarding prostate cancer, but please bear in mind that I have had no enrolled medical education.


Quote:
Originally Posted by Oldkenoplayer View Post
I'm 66 years old. My PSA has steadily (close to linear on a graph) risen since 2005 from 4.6 to 9.0 in March 2011. Free PSA varies between 17.5% and 21.5% with no trend. DRE finding: Nodule left mid. Two previous biopsy results in 2005 and 2006 were negative.
Even though you have been diagnosed with PC, those findings suggest that the already discovered benign enlargement and inflammation, perhaps also with some infection, are accounting for a substantial portion of the PSA elevation and steady upward trend. That's good, from a cancer standpoint.

Quote:
Biopsy performed in April 2011 showed High-grade PIN in Left Lateral Mid core and in the Left Apex an Adenocarcinoma, Gleason Grade 3 + 3= 6 involving 4mm/33% of needle core, negative for perineural invasion, negative for extracapsular extension. The other 10 cores were benign, some with finding of acute and chronic inflammation. P63/p504s double IHC stains were performed and evaluated on the Left Lateral and Apex biopsies. The slides were evaluated by an independent pathology lab confirming the pathology diagnosis. ...

MRI results state "FINDINGS: The prostate is moderately enlared veasuring 6 x 4.3 x 5.2 cm in dimension, giving a calculated gland volume of 67.1 cc.
There are a number of research-based rules-of-thumb for estimating the amount of PSA produced by prostate cells not affected by cancer. One rule of thumb is to multiply the size in cc by 0.066 (coincidentally resembles your size estimate - not a mistake). That would give an estimate of non-cancerous based PSA of 4.5. Another rule of thumb would be to multiply the size, 67.1, by .1, which yields a non-cancerous PSA of 6.7. Inflammation would likely add to this. As you can see, you are accounting for at least half of your March 2011 PSA from non-cancerous sources. Even a PSA of 9.0 still counts in the "low-risk" zone, as does a Gleason of 6. Moreover, even using that PSA of 9, your PSA density (PSA divided by the volume of 67.1) is .13, which is on the good side of the .15 threshold used in assessing suitability for active surveillance.

Quote:
Mo post biopsy hemorrhage is identified within the prostate gland. There are no abnormal foci of decreased signal intensity within the peripheral zone of the prostate on the T2-weignted images. Specifically, no MRI abnormalities are identified in the region of the left prostate apex. No abnormal zones of malignancy are identifed using MR spectroscopy. There is no evidence of extracapsular extension of disease into the semial vesicles or nerovascular bundles bilaterally.... (Few comments on spine, hip, and bowel observations deleted) No pelvic adenopathy is seen. No osseous metastasis are identified.

IMPESSION: No MRI or MRS findings within the prostate suspicious for malignancy.

No evidence of extracapsular extension of disease into the seminal vcsicles or nerovascular bundles bilaterally. No pelvic adenopathy or asscous metastases."

In other words, other than being enlarged, MRI shows the prostate is normal.
I asked my urologist what monitoring should be done from here and didn't get any reassuring reply. I'm wondering if I should look for further imaging (color doppler?) continue with PSA monitoring, or just don't worry, be happy.[/QUOTE]

At some point color Doppler would be an option. It would show whether there was any new blood vessel creation, which is a sign of a growing tumor. It should be done at one of the few centers of excellence. I know of one in California in Ventura, near LA. UCSF and the San Francisco metro area are well known for excellence in imaging, but I'm not aware of a top line color Doppler doctor there. It takes special color Doppler equipment as well as a highly expert doctor.

Monitoring with a PCA3 test is also a possible option.

Of course, continuing those PSA tests is very important. Even though the benign enlargement, inflammation and possible infection are clouding the PSA signal from cancer, a sharp acceleration in the PSA rise would be a warning to get more evidence, such as another biopsy.

However, there are some other tactics you could try - should try in my view. The doctors I follow sometimes recommend either f i n a s t e r i d e (generic, much less expensive version of Proscar) or Avodart, for low-risk prostate cancer where men are on an active surveillance program. There is strong evidence that these drugs are at least partially effective againt low-grade prostate cancer with Gleason scores up through 6.

Quality pomegranate juice or extract capsules have looked very good in two small clinical trials. In the first trial of men recurring after surgery or radiation, they extended doubling time from an average of 15 months to more than 50 months after two years on the juice! (UCLA study, Pantuck)

Other lifestyle tactics also look promising. The book "Beating Prostate Cancer: Hormonal Therapy & Diet" is excellent on those tactics. (Note however that the author now recommends curcummin in the Super Bio Curcumin formulation that aids absorption.

Take care,

Jim

Last edited by IADT3since2000; 08-25-2011 at 04:37 PM. Reason: Stretched out spelling of f i n a s t e r i d e due to glitch in site's software that automatically substitutes asterisks.

 
Old 08-28-2011, 12:53 PM   #3
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Re: False Positive Prostate Biopsy

Thanks for your insight Jim. It may be pomegranate juice aided in the encouraging results on the MRI, I've been drinking a glass a day since the biopsy, just ordered some extract, and also have ordered the book you suggest. MRI/MRIS was done by Dr. Susan Stevens at California Pacific Medical Center, Pacific Campus. One of the urologists I've seen gave her work a very high recommendation.
Best regards,
Bill

 
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