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Old 07-16-2012, 05:00 PM   #1
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Psa 90

Hi,

My father did a PSA test, which came back at 90! He has subsequently undergone DRE (nothing abnormal felt) and biopsy (4/14 cores w/ cancer; Gleason 4+3). After that: bone scan, MRI and CT -- all clear, except one enlarged, thus suspicious, pelvic lymph node.

Doctors say they can't really stage him, but wouldn't that be somewhat obvious from all these tests -- especially the CT? I am particularly thinking of the T staging in this context.

He has started treatment with some injection (don't know the name), plus 50 mg Bicalutamide daily, presumably followed by radiation. I am very concerned and also puzzled by the extreme PSA in conjunction with negative scans, but also by the fact that doctors can't even assess local spread given all tests. Decision of RP vs RT would partly depend on that, as I understand.

Last edited by MSN; 07-16-2012 at 05:12 PM.

 
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Old 07-16-2012, 05:49 PM   #2
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Re: Psa 90

Staging is based on the DRE and imaging, so if all that was clear he would be T1c. His high PSA and enlarged lymph node may very well be the result of concurrent prostatitis. However his very high PSA puts him in a "high risk" category, irrespective of staging or Gleason grade.

Lupron (presumably) + Casodex are started before RT (sometimes with a brachy boost as well), because they improve the radiation's effectiveness. The radiation can treat the local nodes as well.

RP with lymph node dissection would have been an alternative. There would be no reason to start hormone therapy before RP. IMHO, if there is a high probability that the cancer has escaped the capsule, as there is with someone with that high a PSA, he will need RT anyway, so there is no point in beginning with RP. RT on top of RP has worse side effects than RT alone.

- Allen

 
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Old 07-16-2012, 06:59 PM   #3
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Re: Psa 90

On the prostatitis issue...

If he had a blood test before his biopsy that showed an elevated white blood cell count, particularly neutrophils, that would be a good indicator that he has concurrent prostatitis, which is not uncommon. If he has that, a course of Cipro might clear it up, bringing down his PSA somewhat and shrinking the swollen lymph node. If he had done that before the CT scan, it might have been possible to rule out lymph node involvement. It is too late now, however, because the hormone therapy will also bring down his PSA and shrink the lymph node if it is cancerous, so it would be impossible to distinguish which effect is due to what.

Even though it can't help with the Dx at this point, if he was having urinary symptoms, he may want to ask his doctor for a couple of weeks of Cipro anyway.

- Allen

 
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Old 07-16-2012, 07:10 PM   #4
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Re: Psa 90

Thanks,

He actually mentioned something about vague urinary symptoms -- speculating that the PSA value was a combination of both this and that. However, how do you reckon "Cipro" (to be honest, I don't actually know what it is) would be of assistance at this point in clarifying the extent, prognosis and desired treatment?

Edit: sorry, I see now that it is to late for this.

Last edited by MSN; 07-16-2012 at 07:21 PM.

 
Old 07-16-2012, 07:18 PM   #5
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Re: Psa 90

Bacterial prostatitis often responds to Cipro. Sometimes it takes a longer course of treatment. Sometimes other antibiotics are required. Many of his urinary symptoms may get better if he takes it.

It will also improve the diagnostic accuracy of the effectiveness of the hormone therapy. It will get rid of that confounding source of PSA increase. When he is on hormone therapy, you want to be able to read his PSA level as purely a result of the cancer, not including any prostatitis.

- Allen

 
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Old 07-16-2012, 07:27 PM   #6
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Re: Psa 90

Also, I also wonder why they can't determine local T stage based on DRE, biopsy and CT scan. They didn't say "T1c", they said we can't tell...

 
Old 07-16-2012, 10:18 PM   #7
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Re: Psa 90

I also wonder -- given that there are no confounders -- to what extent 1) unknown local growth outside the prostate, 2) regional lymph node engagement and/or 3) undetected micrometastases can contribute to elevating a PSA value to almost 100, in the case of unsuspicious DRE, bone scan, MRI and CT (except an enlarged lymph node).

Also, why can't you assess local stage based on CT? Don't you see the tumour clearly?

 
Old 07-17-2012, 12:02 AM   #8
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Re: Psa 90

They all can contribute -- there is no formula, it's different in each case. Sometimes very small amounts of tumor generate large amounts of PSA. Sometimes large tumors generate almost no PSA. Sometimes lower grade tumors put out more PSA than higher grade tumors. Sometimes the tumors cannot be seen or felt, so the official stage designation is irrelevant, as it seems to be for your father. This is why the risk category or prognostic group for PC is based on different combinations of PSA, Gleason grade and staging information.

Bone scans, CTs and normal MRIs or Ultrasounds cannot see tumors until they are quite large. The imaging of PC is an evolving discipline. There are various kinds of PET scans, multiparametric MRIs, SPECTs, and specialized ultrasound imaging techniques that in well-trained hands can reveal much smaller cancers. I'm not familiar with any experts in Europe. You may be able to find someone still doing Sinerem, Combidex or feraheme MRIs in Europe -- they may be particularly good at imaging lymph node metastases.

However, unless they are able to find a distant metastasis, all that imaging would be pretty useless -- your father would still have the same potentially curative treatment.

- Allen

 
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