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Question about Father's very high value of PSA


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Old 03-17-2018, 11:50 AM   #1
jetski76
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Question about Father's very high value of PSA

Hello Members,

Thank you for reading my message.

My father is 81 years old and lives alone. He was diagnosed with Recurrent Urethral Stricture in 2001 by his Urologist. He was on Tamsulosin and Darifenacin for a lot of years and was fine until Sept 2016, when he had pain in the entire penis shaft and part of his pelvis just above the penis. He rated the pain as 3/10. In Oct 2016, his PSA was 0.522 and the ultrasound of the kidney and abdomen was normal(with a normal prostate). His Urologist did a flexible cystoscopy and dilated his stricture and he had no pain until Dec 2017.

In Dec 2017, he had a penis pain of 3/10 and EColi infection in his urine. After antibiotics and repeat urine cultures, the urine was clear. An ultrasound of the kidney and abdomen in Jan 2018 was normal(with a normal prostate).. For the last three months, his penis pain has been 1/10 or 2/10 and his Urologist prescribed him some creams, which helped.For the last two days, his pain stayed at 2/10 and so went to see the Urologist again. The Urologist is doing a flexible cystoscopy on Monday, March 19. Several blood tests were done today. The following values were abnormal and they worry me a lot:



1)Prostate Specific Antigen(PSA): 11.22 (0-6.5)

2)Prothrombin PTE: specimen blood citrate - clotting assay - 14.2 (9.5-12.5)

3)Urine ph - 7.5 (Acidic)



Urine:

•Urine leucocytes: Present

•WBC pus cells: 10-15 (3-5)

•RBC - 2-4(0-1)

•Epithehleal - 1-2 (2-3)

•Remarks: Bacteria seen



He has no other symptoms. No pelvic pain or issues with urination. The urine stream is fine, no burning sensation or dibbling, change in skin color or discharge. His primary care physician does a physical every six months. The last physical was done a week ago and the tests of Complete Blood Count, Urine, Lipid Profille, HBA1C were all normal. He is 5 ft 3 inches in height, weighs 125 lbs, with a waist size of 36 inches. He walks twice a day and uses his exercise bike once daily. He is physically and socially active and eats a healthy vegetarian diet.

Questions:

1) In a span of 15 months, his PSA has jumped from 0.522 to 11.22? I am very worried as a 21 fold increase in his PSA over 15 months could be an aggressive form of prostate cancer? What are your thoughts?

2) What specific tests should be done to get further information? 3D MRI of prostate? DRE? Biopsy?

3) I will be talking to his Urologist on Monday after his cystoscopy. What questions should I ask him about his PSA of 11.22?



Thank you,

Zent

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Old 03-18-2018, 05:09 AM   #2
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Re: Question about Father's very high value of PSA

Hello Zent and welcome to the Board!

Your father clearly has infection ("bacteria seen"), and that typically affects PSA. In fact, infection can affect PSA a lot and fast. It can drive PSA to very high levels. Then, when the infection wanes, the PSA often drops back to normal levels, only to climb again when the infection becomes more active again.

In the past week there was another patient on this board with a situation similar to your father's, and comments there would apply to your father too. Here are some thoughts for your Monday meeting.

There could be prostate cancer hidden within the rapid rise in PSA, contributing just a little. If so, and if it were the mild type of prostate cancer, most likely "active surveillance" would be appropriate for a man of 81. There is some chance that your father has aggressive prostate cancer, though it seems much more likely that the PSA rise is due to infection and not that type of prostate cancer. It could be that your father's previous infection has recurred, or it could be that he has a new infection caused by a different bacterium. You could ask your father's doctor about these possibilities.

A DRE would be wise.

Follow-up PSAs would also be wise to see if the pattern of PSA results is consistent with prostate cancer or inconsistent with prostate cancer but consistent with infection.

My own layman's impression is that a biopsy at this time would not be warranted, but your father's doctor would be a far better judge of that. An MRI, especially a "multiparametric" MRI that is now so useful in resolving prostate issues, is probably also premature; again, your father's doctor is in a better position to assess that.

The lifestyle practices your father is following seem to help in coping with prostate cancer (and health generally).

I am not sure of the meaning of the other lab results that are out of the reference range. You could ask the doctor about those too.

Good luck with helping your father. I hope this issue resolves as an infection and that he has relief from his pain.

 
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Old 03-18-2018, 10:29 AM   #3
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Re: Question about Father's very high value of PSA

Hello IADT3,

Thank you so much for such a detailed and helpful reply!!

I will certainly ask the questions you described in your reply to my father's Urologist this week. I will ask about DRE and repeat PSA testing and probably a newer antibiotic for his bacterial infection. In December, when a EColi was found in the urine culture, he was on Nitrofurantoin for a month. The repeat culture in January showed no bacteria. It seems like he has a new bacteria as you stated.

My father had had the same urologist ever since his diagnosis of recurrent urethral stricture in 2001. The Urologist has always stayed away from any surgical procedures for my father's urethral strictures (like urethroplasty) and had him on Tamsulosin and Darifenacin for almost 15 years without much issues for my father. The Urologist is thorough in testing etc.

If you don't mind, I have some follow-up questions for you:

1) How well can a Urologist see the prostate when a cystoscopy is done? Is the resolution as good as a trans-rectal ultrasound? I am asking this because my father's hospital probably does not have a multi-parametric MRI (have not checked - has regular MRI's, CT and PET scans), but probably has trans-rectal ultrasound.

2) If a prostate looks suspicious during cystoscopy, is a trans-urethral biopsy as good as a trans-rectal biopsy in selecting parts of the prostate that may have cancer? Since a cystoscopy is being done currently, if the prostate looks suspicious, does it make more sense to do a trans-urethral biopsy now?

3) The Urologist has not performed a DRE on my father for 10+ years. He would do periodic (once in 6 months) ultrasound of his abdomen and kidney and urine tests to check on his strictures. The ultrasounds always had a normal prostate and my father has never had any prostate issues before. I realize DRE is a quick test in the office, but if the prostate is better visualized in a cystosocpy, is a DRE needed?

4)My sense from knowing my father's Urologist is that he will dilate my father's stricture tomorrow, prescribe antibiotics for a month or so and then repeat the urine culture and PSA. Is this adequate for now?

Thank you!!
Zent

 
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Old 03-19-2018, 05:22 AM   #4
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Re: Question about Father's very high value of PSA

Multiparametric MRI in India, other resources

Hi again jetski76,

I don't have much time this morning, and I expect your father has already had his appointment, but here's the kind of search you can do on the US government website www.pubmed.gov. Try this search string - India AND multiparametric MRI AND prostate cancer . I got 9 hits, 3 of them with free links to the complete papers.

The endorectal coil MRI is another resource that is quite capable, but it is also quite uncomfortable for the patient, and I suspect that is especially true for an older man like your father.

My impression is that your father is getting good care and that his doctor knows what to do with his available resources.

Good luck.

Last edited by Administrator; 03-21-2018 at 10:39 AM. Reason: Added sentence.

 
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Old 03-19-2018, 03:40 PM   #5
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Re: Question about Father's very high value of PSA

Hello IADT3,

Thanks again for you reply and your resources. It does not seem like the multi-parameteric MRI is available anywhere close to where my father lives.

The Urologist performed a cystoscopy today around noon and informed my father that his urethra was fine.

For my father's high PSA value, the Urologist told him that it could be prostate cancer and ordered a MRI.This is a regular MRI and not the multi-paramater MRI or endorectal coil MRI that you described in your previous message.The Urologist told my father that if the MRI shows any cancer, a biopsy would be done. The MRI was completed and the results of the MRI have been sent to the Urologist, who will discuss it with my father tomorrow.

There was a rectal examination done by the nurse before and after the cystoscopy. Not sure why the Urologist did not do it himself!!

Following are some of his previous values of PSA and prostate volume for the period of 2012-2016:

October 13, 2016:
PSA (ng/ml) : 0.522 (0-6.5)
Prostate Volume(ml) : 15

Dec 12, 2013:
PSA (ng/ml) : 0.79 (0-6.5)


April 1, 2013:
Prostate Volume(ml) : 10

March 14, 2013:
PSA (ng/ml) : 0.612 (0-4)

October 1, 2012:
Prostate Volume(ml) : 5


If you don't mind, I have the following questions for you:

1) How good is a regular MRI in detecting prostate cancer? I recall reading your other messages where you described that biopsy can miss the cancer as it is 12 random spots and only examines less than 1% of the prostate? Can the same problem arise in a regular MRI?

2) My father's last ultrasound of abdomen and kidney was performed in Jan 6, 2018. The prostate volume was 23 ml. There was no sonographic abnormality found in the ultrasound. For the period of Oct 2012 through January 2018, his prostate volume has increased from 5 ml to 23 ml. With this background, can this be a case of an aggressive form of prostate cancer as his most recent PSA has shot up to 11.22 on 03/17/2018?

3) If MRI/biospy do not detect cancer, is the only option to wait for 3 months and test for PSA again? If PSA has increased again, repeat MRI/biopsy?

I will update more tomorrow.

Thank you,
Zent

 
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Old 03-20-2018, 06:08 PM   #6
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Re: Question about Father's very high value of PSA

Hello IADT3,

Following are some more updates:

1) The MRI was negative for prostate cancer. A trans-rectal ultrasound was done this morning and it was negative for cancer as well.

2) The Urologist will measure PSA again tomorrow and will also perform a biopsy. He told my father that he needs to investigate why PSA is so high.


Questions:

1) From the above results, can we conclude that my father does not have a Stage IV or Stage III prostate cancer, but could have a Stage I or Stage II prostate cancer that is restricted to the prostate given the high PSA?

2) Does my father need a biopsy if his PSA tomorrow is less than 11.22? I am certain it will be a trans-rectal ultrasound biospy and not the multi-parametric guided MRI biospy. Just worried about risks of infection, bleeding etc.

3) Does it not make sense to wait for 3 months and test for PSA again? If PSA has increased again, repeat MRI/biopsy?


Thank you,
Zent

 
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Old 03-21-2018, 10:22 AM   #7
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Re: Question about Father's very high value of PSA

Hi again jetski76,

This reply is to your post before your latest post. I’ll address that later.
I wanted an advanced bone scan, the NaF18 (sodium fluoride) PET/CT scan and expected to have to travel far to get it.

Increase in prostate volume. I am used to cc rather than ml, but the values will be the same: 5 ml = 5 cc. First, your father had a remarkably small prostate in 2012 - 5 ml. The norm for a healthy prostate in the US is in the range of about 25 to 30. However, after treatment, it can be much smaller. Mine decreased from mildly enlarged down to 15 after treatments. The increase from

That increase of 5 to 10, a doubling, in about 6 months from October 2012 to April 2013 seems very rapid, but the prostate at that point is still unusually small. My layman's guess is that this is due to recovery from some treatment with some contribution from benign prostate growth; however, it does seem unusually rapid to my layman’s eyes. If that were all due to cancer, you would have a cancer doubling time, which is a standard characteristic universally used when represented by PSA – the “PSA doubling time" or PSAD, of 6 months. However, with a prostate volume of 15 at a point 3 Ĺ years later in October 2016, it is clear that that six months doubling time does NOT represent all cancer, perhaps not representing any cancer. Do you see why this is so? Also, keep in mind that these “measures” of prostate volume are often more like estimates based on DRE exams, which involve some uncertainty. On the other hand, if theses size assessments are all based on imagery, especially if the same imagery, that would build confidence in each estimate and in any trend. It is possible, if one of more of the size assessments is based on a DRE, that what you have reflects a fair amount – possibly a great amount – of uncertainty when such a small prostate is involved. It helps that the same doctor has been involved. The increase from 15 to 23 in January 2018, 15 months later, still means your father has a prostate on the small side, and it appears the doubling time for prostate growth is on the slow side even if it were caused by cancer and not benign growth. Perhaps the urologist could explain the likely rates of benign growth in older men who have had prior treatment in the prostate area for conditions that are not cancer.

You asked how good conventional MRI was at detection. My impression has been that unimproved MRI that is not multiparametric and without an endorectal coil is not so good. (Some modern multiparametric MRIs do not need an endorectal coil.) Here is a way you can find a paper that discusses this: go to www.pubmed.gov and search for : MRI AND prostate cancer AND kirkham [au] AND emberton m [au] AND 2006 [dp] .

Healthy cells – no infection, no prostate cancer – in a prostate that is only around 23 ml in size would generally produce a PSA of about 2, far below your father’s PSA. Based on the erratic PSA pattern and the overall evidence, I suspect that infection is the cause, or perhaps one of the other odd causes like infarction. A biopsy could reveal evidence of an infection, and of course also of cancer. I’ll add some ideas on this in responding to your latest post.

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Old 03-21-2018, 10:35 AM   #8
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Re: Question about Father's very high value of PSA

Hi again Zent,

The negative results from the two scans is consistent with the likelihood that infection, or some other unusual but non-cancer cause, is elevating your father's PSA. An infection can easily elevate PSA into the 50s or even more. The highest I've heard of is a PSA of about 200 that reduced to normal after the right antibiotic was found (which apparently was a real challenge).

I can understand your father's being concerned about the PSA level and wanting to do a biopsy. However, another option would be to hold off on the biopsy and do PSAs every month or so to see if the pattern is consistent with infection, as it has seemed to be in the past.

My laymans' impression is that your father has no cancer, but the results to date do not rule out any stage of cancer, though they do make it even less likely.

If your father does have a biopsy, his doctor should give him some medicine to help prevent infection. Also, in the US, especially in areas where certain infections are more common, doctors are doing a rectal swab first and analyzing it for certain bacteria so they can modify the preventive drug regimen. This is proving quite effective. He should also get a numbing agent before the biopsy to reduce pain. Many of us tolerate the procedure very well.

Good luck to you and your father!

 
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Old 03-22-2018, 03:02 PM   #9
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Re: Question about Father's very high value of PSA

Hello IADT3,

Thanks again for your informative and helpful replies!! Your generosity in helping others shines through in your messages.

If you don't mind, I have some follow-ups after reading your reply:

1) You wrote,

" My impression has been that unimproved MRI that is not multiparametric and without an endorectal coil is not so good".

"My laymans' impression is that your father has no cancer, but the results to date do not rule out any stage of cancer, though they do make it even less likely."

My father had the 1.5 T MRI without an endorectal coil. Do you think a 1.5 T MRI without an endorectal coil does not have the resolution and accuracy to detect metastatic and lymp node involvement? If yes, does it make sense to get a mp-MRI right away? That way, we will know all the details like lymph node involvement, metastasis, suspicious areas, PI-Rads score etc. I would like to know if there is a test that can confirm lymph node involvement andr metastatis at this moment?

2) As mentioned in my previous message, a TURP biospy was taken on Wednesday and we will get the report in 5 days. Antibiotics have been given for my father for his bacterial infection. He will probably be discharged tomorrow. The Urologist will mostly see my father in a month and test PSA again. Since the grade of cancer is unknown at this time and the random 12 core TURP biopsy are commonly found to miss high grade prostate cancers, if we wait for a month to repeat PSA again, will that be too late as the high grade cancer could have spread beyond the prostate?


3)Is it okay to wait for the bacterial infection to clear and then do a PSA? That way, if PSA is elevated again, a mp-MRI along with fusion biopsy (in a nearby city) would describe the proper grade of the cancer. If PSA is decreasing after a month, we can hold off on the mp-MRI and repeat PSA again monthly. Does this sound reasonable?


4) I did read that low PSA (less than 2.5) cancers tend to be aggressive. My father's PSA has always been in the range of 0.522- 0.79 until Oct 2016 when it was last measured. Since it shot up to 11.22 in 1.5 years, could this be such a case? Do the low PSA cancers stay low throughout or the PSA's increase as the cancer starts to spread? My father's 21 fold increase in his otherwise low PSA values over a period of 1.5 years does concern me a lot.

5)You wrote, " However, with a prostate volume of 15 at a point 3 Ĺ years later in October 2016, it is clear that that six months doubling time does NOT represent all cancer, perhaps not representing any cancer. Do you see why this is so?"

By this, do you mean that if the doubling time was consistent throughout the 3.5 years, my father's prostate volume would have been around 200 ml? Since it was not the case, there is a chance that the doubling from 5 ml in October 2012 to 10 ml in April 2013 could also not be a cancer? Also, please note that all the prostate volumes from Oct 2012 and beyond are from the Ultrasounds of Abdomen and Kindey. My father's Urologist never did a DRE for the last 10+ years. NOTE: I will know my father's prostate volume in the 1.5 T MRI tomorrow. I will update.



Thank you,
Zent

 
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Old 03-23-2018, 02:13 PM   #10
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Re: Question about Father's very high value of PSA

Hello IADT3,

My father was discharged today. He has been on antibiotics since Monday and will continue taking them. Urine culture was also done on Monday. The reports of culture must be available by Monday, but the biospy might take more time. My father was asked to see the Urologist on Monday.

The pelvis MRI is 1.5 T with an array coil. The cystoscopy was done a few hours before the MRI. I am not sure how that would affect the MRI accuracy. As per my amateur readings on PubMed, 1.5 T with an array coil is on par with 1.5 T with an endorectal coil. It may not be as good as a 3T Multiparametric MRI. The MRI report is described below:

-------------------------------------------------------------------------------------
Plain and Contrast Enhanced MRI of the Pelvis

Clinical Indication: Raised PSA levels. To rule out Prostate Cancer.

Comparison: none

Technique
: Using a phased array coil, small field-of-view imagining of the prostate was performed using the following sequences: axial T1-weighted, axial T2-weighted, sagittal T2-weighted, oblique coronal T2-weighted, diffusion-weighted.

Axial T1-weighted images with and without fat suppression through the prostate were obtained before and dynamically after the intravenous administration of contrast.

Using a large field-of-view, the entire pelvis to the level of aortic bifurcation was imaged with the following sequences: post-contrast fat suppressed T1-weighted, diffusion weighted, fat suppressed T2-weighted, STIR.

Findings:

Prostate: Size 3.2 x 2.8 x 3.9 cm

Volume: 17.472 cc

Area of altered echotexture; hypointense on T2w; showing restricted diffusion noted in the left hemigland. Area measures 19 x 11.22 mm. No extracapsular extension.

Seminal vesicles: Normal signal on T2-weighted images in bilateral seminal vesicle. No abnormal enhancement.

Extracapsular extension: No loss of interface with the right neurovascular bundle.

Bladder: Normal wall thickness and signal intensity. No invasion.

Lymph Nodes: No pelvic lymphadenopathy noted.

Bones: Normal in signal intensity.

Impression:

Area of altered echotexture; hypointense on T2w; showing restricted diffusion noted in the left hemigland. Area measures 19 x 11.22 mm. No extracapsular extension.

Suggested histopathological evaluation.


-------------------------------------------------------------------------------------

If you don't mind, I have a few questions again:

1) I have read in your earlier posts that restricted diffusion on a MRI is a classic sign of cancer. Also, my father's prostate volume has decreased from a 23 ml on Jan 8 to 17.472 ml on March 19. I have read on PubMed that cancers are usually found in lower prostate volumes rather than higher. Given the above facts, do the abnormal findings below in the MRI mean a cancerous tumor of 19 x 11.22 mm?

Area of altered echotexture; hypointense on T2w; showing restricted diffusion noted in the left hemigland. Area measures 19 x 11.22 mm. No extracapsular extension.



2) I am certain that the biospy was a TURP and not a MRI-fusion biopsy. The MRI was done on March 19 and the biopsy on March 21. Without the software for fusing MRI images on a rectal ultrasound, can an experienced Urologist biopsy the right parts of the prostate using TURP when the MRI says, "showing restricted diffusion noted in the left hemigland. Area measures 19 x 11.22 mm"? The concern here is that TURP being a random biopsy will miss high grade cancers if the Urologist is unable to biopsy the suspicious parts of the prostate.

3) Given the results of the MRI, can we make any judgements about metastasis and lymph node involvement?

Thank you!!
Zent

 
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Old 03-23-2018, 03:14 PM   #11
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Re: Question about Father's very high value of PSA

Hi again Zent,

I am responding to post #9 and will look at #10 later; briefly re #10, that hypoechoic (meaning low echo return of the MRI imaging signal) finding could be prostate cancer but could be something else. The recommendation to biopsy is reasonable based on that finding, which overrides the idea of waiting that I wrote about in response to post #9.

Iíll do my best to answer your questions in order.

Regarding the MRI concerns you have in the first paragraph, I do think a 1.5 T conventional MRI could miss cancer that has spread. In general, such MRI is not a great tool for that but is more used for the prostate itself, as I understand it. The traditional tools to assess distant spread beyond the immediate area of the prostate are conventional CT scans for lymph nodes and technetium based bone scans, but neither are usually used for cases that seem to be low-risk as the results for such cases are almost always negative. Your father has not been diagnosed with prostate cancer yet, and my own impression is that he does not have it. There are tests that are excellent for spread Ė quite superior to the older scans - in the soft tissue (including lymph nodes but also elsewhere) and bones, but they are expensive and would not be used at this pre-diagnosis stage. If your dad is diagnosed, these scans would be helpful.

Regarding question 2), please keep in mind that your father probably does not have cancer. If he does, and if it is high grade with an elevated PSA due to that and not to infection, the biopsy is more likely to find it because there will be more of it. In the context of likely infection, my own feeling is that it is reasonable to wait for the repeat PSA value as an important clue about what is happening. Of course that is easy for me to say from a distance, and I empathize with your situation as you try to come to grips with the possibilities.

Regarding 3), yes, I think it is reasonable. In the unlikely event the PSA result were to suggest the possibility of cancer rather than infection, then that mpMRI and fusion biopsy would be a good way to go. As you wrote, a favorable result would be a good basis for just monitoring with periodic PSAs.

Regarding 4), itís not low PSAs that tend to be aggressive but rather diagnosed prostate cancers with intermediate or higher risk in the presence of low testosterone. Generally, cancers with low PSAs are mild. An exception is very aggressive cancer where the cells are so broken down that they can no longer make much PSA, and in these cases the PSA can be low but the cancer very aggressive. As your fatherís PSA is not low, this seems unlikely. I may have said this before or in another post, but infections can boost the PSA very high and do it quickly. PSAs of 50 from infection can occur, and the highest I ever heard of was around 200 before finally resolving with the right antibiotic.

Regarding 5), yes Ė cancer unlikely. You have the right idea, but the figures are even more dramatic. If you start with a prostate of 5 ml and assume that most of that is cancer, and then it doubles in six months leading to a prostate of 10 ml, hereís what the doubling would actually be for the four years from October 2012 through October 2016:
6m 12m 18m 24m 30m 36m 42m 48months
5ml 10 20 40 80 160 320 640
The PSA would usually reflect that. As it is clear there was no such increase, it is clear that cancer cannot be a substantial cause of the earlier increase, and may not have been involved at all (highly likely). It is helpful that the volumes were measured with the same ultrasound technology; that should be quite accurate for this purpose of comparison.

I know it is hard to get your mind around all of this. The emotion involved and the complexity of prostate cancer make it difficult. I think you are doing well.

 
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Old 03-23-2018, 03:30 PM   #12
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Re: Question about Father's very high value of PSA

Hello IADT3,

Thanks again for your insightful and helpful replies!! I will wait for your reply before I ask any more follow-up questions.

Thank you,
Zent

 
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Old 03-24-2018, 01:36 PM   #13
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Re: Question about Father's very high value of PSA

Hi again Zent,

I'm responding to your post #9.

Regarding 1), that finding of restricted diffusion suggests there might be cancer in that area, but it could also be something non-cancerous. The MRI findings will help the doctor to probe that area when he does the biopsy.

Iím not aware that cancers are usually found in lower volume prostates rather than higher that are present because there are more cancers when the prostate is smaller. It is true that if you have the same number of probes going into a larger prostate and into a smaller prostate, it is more likely that the probes in the smaller prostate will hit cancer more often simply because each probe has less area to cover in a smaller prostate and is therefore more efficient.

As I understand it, the area of concern is 19 X 11.22 mm, but that does not mean that it is all cancer or even that any of it is cancer. Something is going on there, but it may not be cancer.

Regarding 2), I would expect that an experienced urologist would take advantage of the MRI image and make sure at least one probe or more targets the area of concern on the left side, as indicated in the MRI. Some of the other probes may be random.

Regarding 3), the information in the MRI report is favorable but not conclusive regarding metastasis and lymph node involvement. It is encouraging that they looked at the pelvis, where there are key lymph nodes that are often early sites for cancer spread, as well as the prostate. However, Iím doubting that an MRI is sensitive enough to find very small tumors that might be there. I may be wrong. On the good side, the findings indicate there are no large tumors, and that IS encouraging.

 
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Old 03-24-2018, 04:19 PM   #14
jetski76
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Re: Question about Father's very high value of PSA

Hello IADT3,

Thank you again for your replies!! They have been and I am certain will continue to be immensely helpful to clarify all the issues around prostate cancer. I have re-read them many times.

If you don't mind, I have a few questions:

1) When I look at online descriptions of multi-parametric MRI of prostate, they mention a 3 T MRI machine with four parameters: T2, diffusion, dynamic contrast and spectroscopy. Further, the MRI report contains the PI-RADS score.

In my father's MRI of pelvis report, under the technique section of the report, the following is described:

"Technique : Using a phased array coil, small field-of-view imagining of the prostate was performed using the following sequences: axial T1-weighted, axial T2-weighted, sagittal T2-weighted, oblique coronal T2-weighted, diffusion-weighted.

Axial T1-weighted images with and without fat suppression through the prostate were obtained before and dynamically after the intravenous administration of contrast.

Using a large field-of-view, the entire pelvis to the level of aortic bifurcation was imaged with the following sequences: post-contrast fat suppressed T1-weighted, diffusion weighted, fat suppressed T2-weighted, STIR."


So, is this a 1.5 T, multi-parameter MRI with an array coil (as opposed to an endo-rectal coil) as it describes T2, diffusion and dynamic contrast? That is, the MRI covers 3 out of 4 parameters of a 3T multi-parameter MRI. Also, there is no mention of a PI-RADS score. Is the spectroscopy needed for the PI-RADS score ? Or, the 1.5 T MRI simply does not have the requisite software to make the calculations for the PI-RADS score?

The key question: In your estimation, is this MRI machine adequate to diagnose high grade cancer in my father or monitor post-treatment?

2)I have asked you this question in many forms in my earlier messages. Kindly bear with me:

My worry is that since a 3T multiparametric MRI-TRUS fusion biopsy was not done and the biopsy that was done depends on the skill of the surgeon to get tissue samples from the 19 x 11.22 mm area in the left hemigland of the prostate, we will miss high grade cancers. If the biospy is negative and the cancer is high grade, we wait for a month to repeat PSA and by that time, its already Stage IV?

Bottom-line : If the cancer is positive, treat it, else, get a 3T multiparametric fusion biopsy right away rather than wait for a month do it. That way, we have done everything possible to locate high grade cancers at the current moment. Your comments?


3) Once a certain grade prostate cancer is detected on a biopsy as per the Gleason score, can it transform into a higher grade if we choose active survellience?

4) The hospital has the usual CT-Scan, Nuclear Bone scan and PET scan. What other scans would you recommend that might help diagnose metastasis and lymph node involvement once a cancer is diagnosed?

Thank you!!
Zent

Last edited by jetski76; 03-24-2018 at 04:21 PM.

 
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Old 03-25-2018, 02:21 PM   #15
IADT3since2000
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Re: Question about Father's very high value of PSA

Hi Zent,

Iím responding to your post #14.

1) Your fatherís MRI seems to have some of the characteristics of a mpMRI, though obviously at the lower resolution 1.5T than the higher 3T. By the way, does he have any ferrous implants that could be affected by the substantially more powerful magnetic field? Does he have other implants with shapes that could cause an unacceptable heat build-up due to the more powerful magnetic field? Some patients, I believe not many, are unable to get 3T scans for these reasons. Your father did get the standard T2 images plus T1 images, but he also got diffusion weighted imaging, which is one of the customary added mpMRI parameters. I suspect the contrast agent that your father got was simply to improve resolution generally and not the DCE (Dynamic Contrast Enhanced) technology to image blood supply. The radiologist who did his imaging could probably answer these questions. Spectroscopy has been a promising additional parameter for many years (and Iíve been tuning in to news about it for more than a decade), but it seems to me that it has not been widely adopted in mpMRI imaging Ė not enough payoff yet beyond the value contributed by the other parameters. Also, while DCE (Dynamic Contrast Enhanced imaging) does add value in enabling the radiologist to determine what is going on regarding blood supply (tumors need more blood), there is some thought that much of its value overlaps what is provided by the other parameters and may not be worth doing because of some very small but real and serious risk that is added by the use of the contrast agent. Nonetheless, I think that DCE parameter would be worthwhile for your dad for possible imaging after the biopsy.

At the moment even full-fledged mpMRI is not considered adequate for diagnosis, and the PI-RADS score is not accepted in lieu of a Gleason score (which itself is being re-conceived so that it is simpler to use), though that change in the role of PI-RADS is under active consideration and research. The scan your father had would not be able to identify high-grade disease (nor could a mpMRI), but it should be able to spotlight areas of the prostate that could contain high-grade (or any grade) prostate cancer to guide the biopsy; a high PI-RADS, 4 or especially 5, would suggest a strong likelihood of high-grade disease but would not be conclusive.

Regarding 2): My laymanís feeling is that your father has had enough imaging to guide the biopsy; while a 3T complete mpMRI resulting in a PI-RADS report would likely have been more helpful, what your father had is probably good enough. If the biopsy does miss some high-grade cancer that is fully contained at this point in the prostate, it is possible that detected lower-grade cancer would trigger treatment that would also cure the higher-grade cancer, which would mean that no value would have been added even if the high-grade cancer had been detected earlier.

If stealthy serious cancer evades detection by biopsy, it is still likely that subsequent PSA testing and other monitoring will soon smoke it out, with a good chance that it would remain in range for radiation, as research has shown that most metastatic cancer is close enough to treat for a while. If the cancer is already metastatic, an mpMRI might not pick it up even now. Even aggressive cancer that is now contained would be unlikely to become stage IV in the amount of time to wait for more PSA evidence. Therefore, the window of benefit is fairly small for a situation that could be just infection, perhaps with some other non-cancer elements (such as infarction, calcium deposits, etc.), and with what looks like fairly good imaging to guide the biopsy.

On the other hand, there is a small chance that a 3T mpMRI might pick up an aggressive cancer that would otherwise spread to a point that treatment is difficult; if money, convenience, and willingness of the radiologist to do the additional scan are not issues, there is some chance of real benefit, though small. If I were in your situation, I believe I would not seek the mpMRI at this time, but such a decision is always more difficult when you are the one actually making the decision and not just thinking about it. I remember well that I gave a lot of thought to whether to push for mpMRI prior to radiation, even though I had already had two excellent scans; I came to realize that the radiation dose would be the same no matter what the scan found, so I went ahead without the scan. A key question to ask is ďWhat difference will what I would like make to the next step I will be taking?Ē I believe that question is usually in the minds of good doctors.

If the biopsy turns out positive, at that point your dad could benefit from a mpMRI at 3T to help decide whether active surveillance would be a good choice (for low-risk cancer) or what treatment options would be a good fit for his case. Depending on potential treatment, various imaging options could be considered, including, if the case then appears challenging, some of the newer scans that are outstanding at picking up very small metastases in bone, in lymph nodes and in other soft tissue.

Regarding 3): It is now believed rather firmly, based on research, that Gleason score 6 and lower cancers Ė the ones most suitable for active surveillance (AS), never, or extremely rarely, change into more aggressive cancers. However, it is also known that biopsies which find only Gleason 6 cancers can miss higher grade cancers that will cause problems. The key concept of surveillance is that truly active surveillance will pick up any stealthy bad actors before they become serious. Research from many centers around the world has consistently shown that AS is excellent at doing that (and is steadily improving).

Regarding 4): This is getting ahead of the game, but I can really empathize with you as you try to visualize the future and prepare for different situations. There are now excellent bone and soft tissue scans that can very reliably (though not yet perfectly) detect and locate metastases in bone, lymph nodes and other soft tissues. Moreover, even better scans are emerging, though there seems to be not much ground for further improvement.

One of the best currently available scans is known in the US as the axumin scan. It is very good at both bone and soft tissue detection, picking up tumors of about 3 mm and larger (and even smaller, sometimes) and it does not require its radiation element to be produced on-site, which is a big advantage. I had a NaF18 PET/CT bone scan, which is very sensitive, but not so good for soft tissue. I also had a scan for soft tissue that was excellent but is no longer available due to safety concerns. Soft-tissue (and some bone value) scans that are available are the C-11 acetate and C-11 choline PET/CT scans, but both use radioactive carbon isotopes with short half-lives that must be manufactured at the imaging site, a big disadvantage in accessibility, as only a few facilities have the necessary cyclotron facility. Some other scans are also in use, I believe, and a number are in the investigational stage. All of these scans are very useful for monitoring whether metastatic cancer is developing or progressing.

CT scans can pick up tumors about the size of a pea or larger, but they will miss smaller tumors, and that means they miss a lot of tumors. The normal technetium bone scan, which is widely available, requires at least about 10% of cancer infiltration of bone at the metastasis site before it shows up on the scan, so it too is of some but limited usefulness. These two scans were routine at the time of diagnosis for all patients when I was diagnosed in late 1999, but they were soon discontinued unless the patient had higher-risk characteristics, as they were virtually always negative for men with low-risk and even most intermediate-risk prostate cancer. (Both were negative for me even though I had high risk cancer: a PSA of 113.6, all biopsy cores, positive, most 100% cancer, Gleason 4+3=7 cancer, a "rock hard" prostate, etc.)

The usual PET scan is a glucose based scan; it is useful for most cancers because they get their energy from glucose (sugar). Prostate cancer is different, getting its energy from fat, basically, until it is well advanced. Therefore, the glucose based PET scan is not useful for prostate cancer until it is well advanced. Non-glucose PET scans, for example the sodium fluoride (NaF18) PET/CT scan that I had, are useful for prostate cancer, but are not warranted unless the case has some higher-risk characteristics.

You are asking very good questions and are learning this fast. Keep it up and good luck!

 
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