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  • Why such a big PSA jump in 2 weeks and MRI thoughts...

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    Old 02-09-2012, 05:22 AM   #1
    jupaul
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    Why such a big PSA jump in 2 weeks and MRI thoughts...

    I'm 49, and my PSA has been steadily going up the past few years - had a biopsy in May 2011 that was negative, but since it keeps going up my doc ordered an MRI and at the same time had me take antibiotics for 2 weeks to see if that made a difference - boy did it - in two weeks I went from 3.3 to 4.8! Not the direction I wanted. I am scheduled for another biopsy in 4 weeks (they are booked solid).

    Here's my stats:
    49 years old
    Jul 2008 PSA 1.5
    Sep 2009 PSA 1.9
    Nov 2010 PSA 2.4
    May 2011 PSA 2.9 (free PSA 3%) - Biopsy done - Negative.
    Oct 2011 PSA 3.1 (moved to new city, new doc)
    Jan 2012 PSA 3.3
    Feb 2012 PSA 4.8 - just two weeks later!

    As you can see it's been a very consistently rising at a very predictable steady pace, then all of the sudden, bam in two weeks! Could the antibiotics have done something? Is it just an anomaly? I'm having another run in a week just to ease my mind.

    Also - here's what my MRI says - sounds like something is there, but if I have to look on the bright side, I think it's early????


    PROSTATE:
    The prostate gland measures 3.6 x 2.1 x 3.1 cm in greatest transverse, AP, and craniocaudal dimensions respectively.
    Peripheral Zone: Within the peripheral zone of the prostate gland anteriorly in the mid gland just to the left of midline, there is a 6 mm T2 hypointense area that demonstrates rapid wash in/washout kinetics and restricted water diffusion.
    Also on series 14, image 11 in the posterior midline immediately behind the urethra at the level of the mid gland, there is another 4-mm T2 hypointense area with restricted water diffusion. On dynamic imaging, this demonstrates early washin relative to
    other areas of the prostate gland when dynamic images are directly observed on the iCAD workstation although the color mapping does not reflect this rapid kinetics.
    Central Gland: There is mild enlargement of the central gland.
    EXTRAPROSTATIC ASSESSMENT:
    Periprostatic Fat: There is no irregular bulge of the prostate capsule. No tumor is identified penetrating through the low T2 signal intensity prostate capsule. The bladder, rectum, and pelvic sidewall are free of tumor invasion. The neurovascular
    bundles are free of tumor.
    Seminal Vesicles: Normal T2 hyperintense signal intensity is maintained in the seminal vesicles although evaluation is suboptimal as they are incompletely distended.
    Pelvic Lymph Nodes: There are no spherically shaped nodes in the obturator, external, internal, or common iliac node chains. All identified nodes maintain short axis measurements less than or equal to 6mm.
    Pelvic Bone Marrow: There is heterogeneous marrow signal intensity in the bones of the pelvis. There is degenerative disc disease at L5-S1.
    IMPRESSION:
    Two small distinct areas suspicious for prostate cancer as above.
    One is just to the left of midline in the anterior mid gland at the junction of the central and peripheral zones.
    The other is in the posterior midline peripheral zone at the mid gland immediately behind the urethra.
    No evidence of extracapsular disease.


    Is that good???

    Thanks for any thoughts and input

     
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    Old 02-09-2012, 02:47 PM   #2
    Tall Allen
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    I wonder if the endorectal coil irritated your prostate. I'd think that 2 weeks is more than enough, but a sudden jump like that is suspicious of an irritation other than prostate cancer. It is also possible that Cipro was the wrong antibiotic and it unleashed a resistant strain. Maybe try Bactrim.

    The MRI shows two very small suspicious areas that can be used to guide the needle on your next biopsy. It also shows no evidence that anything has spread outside the prostate capsule, which is great news. Based on the MRI and the negative biopsy, if you have any cancer, it is probably very small. Waiting 4 weeks for the biopsy should be no problem at all.

    Are you on finasteride/dutasteride? There is evidence that it may help prevent pre-cancerous lesions from becoming cancerous. It will reduce any PSA due to BPH (the MRI shows mild BPH) but have little effect on any PSA due to PC. It thus improves the diagnostic specificity of the PSA test.

    Are you able to get a PCA3 test or a pro-PSA test? Together with % free PSA, they give a diagnostic accuracy about the same as a biopsy, although they don't tell you Gleason grade.

    The other thing to consider is what you would do if you had a positive biopsy. If the Gleason score is 6 or less, you would probably be an ideal candidate for active surveillance. Another option is focal ablation -- just having the one or two small cancerous areas (if they are that) removed.

    - Allen

     
    Old 02-10-2012, 04:38 AM   #3
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Hi jupaul,

    Could you describe the timing of the MRI and the PSA that showed 4.8? As Allen suggested, an MRI right before the PSA could easily boost the PSA. That sharp departure from the PSA pattern looks quite odd. Even if you do have prostate cancer, it could be that an infection is causing that abrupt increase in PSA. Allen gave you some very useful suggestions, as I see it.

    Take care,

    Jim

     
    Old 02-10-2012, 05:16 AM   #4
    jupaul
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Thanks guys - you both seem very knowledgeable and I appreciate the responses!

    The MRI was actually done as a pelvic MRI to tell the Doc where to look if something is going on - it wasn't the endorectal MRI - and it was done a week prior. The Doctor did say that areas that look suspicious could easily have been missed on the first biopsy and are at areas they don't normally look or are more difficult to get to??? Does that make sense?

    The Doctor had me on Bactrum - he said if we have to do a biopsy again they see less infection with Bactrum? And it was for the two weeks prior to the new PSA test - that was the reason for the test, to see if it had any effect. I am wondering if it stirred up something??

    Lastly I forgot to mention that I have been taking Propecia for over 10 years (hair loss) - and I didn't take it for two days before the test, maybe that caused the jump?

    I am still a bit nervous about the impact of taking Propecia for so long and looking back wish I hadn't - according to Dr. Walsh's book (that I just started) if you've been on it for more than 5 years you should multiply your PSA by 2.5 - that's the first I've seen that! I've seen that you should multiply by 2 but after time you just watch for trend, if I multiply by 2.5, that puts me pretty high for my age.

    I'm still concentrating on the positive, the MRI looked good and it does appear small (I'm just hoping it's not one of the Propecia induced Gleason 8/9's) - but I assume even if that's the case, it's very early to be that small and not to have spread?

    I am having another PSA run next week just to see if it's staying on this faster trend and hopefully put my mind at ease a bit.

    So Focal Ablation - I really know nothing about, just been reading up on removal to prepare myself - if I qualify for Focal Ablation, and if it comes back later, can they still remove the rest of it? Or is it like radiation, once you're down that road they can't do surgery?

    Thanks again - it's so good to get some opinions from the experts!

     
    Old 02-10-2012, 10:18 AM   #5
    Tall Allen
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Quote:
    Originally Posted by jupaul View Post
    The MRI was actually done as a pelvic MRI to tell the Doc where to look if something is going on - it wasn't the endorectal MRI - and it was done a week prior. The Doctor did say that areas that look suspicious could easily have been missed on the first biopsy and are at areas they don't normally look or are more difficult to get to??? Does that make sense?
    Yes, it makes a lot of sense. Most biopsy sampling is done in the peripheral zone of the prostate where almost all cancer occurs. They poke holes in from the edge of the capsule. The second lesion especially is in an area seldom sampled, because it is close to the urethra in the middle. They have to be careful about poking holes there.

    Quote:
    The Doctor had me on Bactrum - he said if we have to do a biopsy again they see less infection with Bactrum? And it was for the two weeks prior to the new PSA test - that was the reason for the test, to see if it had any effect. I am wondering if it stirred up something??
    The reason I mentioned Bactrim is because Cipro is usually first line and Bactrim is second line. It is possible you have an infection resistant to Bactrim that was triggered by your taking it this time. You can try a different antibiotic for a few weeks. They can do a culture by massaging your prostate and collecting urine. The bacteria might (or might not) then show up in your urine and they could select the appropriate antibiotic.

    Quote:
    Lastly I forgot to mention that I have been taking Propecia for over 10 years (hair loss) - and I didn't take it for two days before the test, maybe that caused the jump?
    Propecia is a light dose (1 mg) of Proscar (5 mg). Your MRI report described your BPH as slight, but it is possible it was suppressing your PSA.


    Quote:
    I am still a bit nervous about the impact of taking Propecia for so long and looking back wish I hadn't - according to Dr. Walsh's book (that I just started) if you've been on it for more than 5 years you should multiply your PSA by 2.5 - that's the first I've seen that! I've seen that you should multiply by 2 but after time you just watch for trend, if I multiply by 2.5, that puts me pretty high for my age.
    I, and most urologists I've met, think Dr. Walsh has it backwards. PSA is often inflated by a factor of 2 by BPH. Once you get rid of the PSA due to BPH and the PSA due to prostatitis, you're left with the PSA due to prostate cancer. Finasteride improves the diagnostic specificity of PSA, which is otherwise quite poor.

    Quote:
    I'm still concentrating on the positive, the MRI looked good and it does appear small (I'm just hoping it's not one of the Propecia induced Gleason 8/9's) - but I assume even if that's the case, it's very early to be that small and not to have spread?
    I don't believe that finasteride "induces" Gleason 8/9s although some people do. I think it makes any 8/9s more detectable. In any case, the increase is very tiny and it is a very low probability event.

    Quote:
    So Focal Ablation - I really know nothing about, just been reading up on removal to prepare myself - if I qualify for Focal Ablation, and if it comes back later, can they still remove the rest of it?
    Yes, they can always give radical treatment (surgery or radiation) afterwards. Dr. Bahn uses focal cryoablation. Others use HIFU, laser or RF. I know of one man who had just one lobe of his prostate removed surgically. It is theoretically possible to use CyberKnife or brachytherapy to destroy just the tumor with radiation.

    The real issue is imaging. PC is only unifocal in about 20% of cases. There are usually small pockets of cancerous cells disseminated throughout, although those insignificant cancers may (or may not) remain indolent forever. Dr. Bahn uses color doppler ultrasound to locate the lesions, but there are only a couple of doctors in the US proficient at doing so. If your MRI lesions turn out to be cancerous, it may be enough to just destroy them. There is a theory, with some good evidence, that all PC cells originate from a mother tumor site, and that at a very early stage, it is only necessary to kill off the mother tumor to stop any further spread.


    Quote:
    Or is it like radiation, once you're down that road they can't do surgery?
    This is a wive's tale spread by urologists who can't do the surgery. Salvage surgery after radiation is tricky, but there are surgeons who specialize in that. Salvage radiation is also feasible, especially after cyberknife or brachy.

    I hope your next PSA sets you more at ease.

    - Allen

     
    Old 02-10-2012, 03:22 PM   #6
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Hi again jupaul,

    I have just read your latest post today and Allen's response. Allen covered the key points, and I see it as he does. I want to add further emphasis to just one point.

    You wrote: "... I'm just hoping it's not one of the Propecia induced Gleason 8/9's...."

    I'll join Allen and many savvy medical oncologists who are convinced that the 5-Alpha Reductase Inhibitor drugs - Propecia, Proscar (generically available now as finasteride), and Avodart - do not induce higher grade disease, even in just a few men. This is still controversial, and there is some evidence on both sides. However, after carefully studying the evidence myself, I'm convinced the 5-ARI drugs do not increase the risk of higher grade disease. I believe they actually decrease that risk, though the evidence is not as strong as it is for the absence of increased risk.

    One of the chief advocates of the "higher risk" view is the famed surgeon Patrick Walsh, who you mentioned earlier, and he has published his view in numerous places, including a now well-known statement at an FDA advisory committee hearing on 5-ARI drugs for prevention of prostate cancer. Did you know that Dr. Walsh is well known for avoiding hormonal therapy, including 5-ARI drugs, until patients have late-stage disease? A consequence of that practice is that he just does not see and track the effect of hormonal therapy drugs, including finasteride and Avodart, on prostate cancer. His view is based on the theory he prefers and on his impression of research. Medical oncologists have much greater experience with the behavior of prostate cancer for men on hormonal therapy; also, drugs are their stock in trade - they tend to keep up with research and understand the ins and outs.

    Moreover, Dr. Walsh has expressed contradictory views of the role and importance of finasteride in his latest book that advises men about prostate cancer. If you have his book, you can check "dihydrotestosterone (DHT)" in the index and see that for yourself. At the FDA committee hearing, he selected the view that DHT, the protein chiefly affected by the 5-ARI drugs, was relatively of far less important as a fuel for prostate cancer than testosterone. With a few exceptions, the rest of the medical community dealing with prostate cancer regards DHT as several times more potent as a fuel for prostate cancer than testosterone, and you will find that indicated at least once even in Dr. Walsh's book. Moreover, they treat this as a non-issue: a clear-cut fact based on solid evidence. Even some of Dr. Walsh's highly respected colleagues at Johns Hopkins who are dedicated to researching prostate cancer disagree strongly with his view that DHT is relatively less important and not significant.

    It is important that we patients understand some of this background. I am hopeful that at some point the FDA will come to what I'm convinced is a better understanding of the 5-ARI drugs and their effect on prostate cancer. I have been on either Proscar/finasteride or Avodart continuously since September 2000, and I am convinced they have played an important role in the success I have enjoyed.

    Here's one final point that Allen's response mentioned briefly: even if the opponents of 5-ARI use are correct in their belief that the drugs do increase the risk of higher grade disease, that increase in risk is miniscule. My recollection is that it is about half a percent for GS 8 to 10 cancer.

    Take care,

    Jim

     
    Old 02-11-2012, 07:15 AM   #7
    jupaul
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Thanks again guys for the info - I swear, you're both a huge wealth of information - really a huge help.

    I'm tending to agree - I don't want to think Propecia hurt me, if anything I sort of think it's kept my prostate small and fortunately I had a GP Doc that noticed a rise even though I was under 4.0 and sent me off for further testing. I do think it made the rise more likely attributed to PC vs BPH - helped rule that out.

    Aside from all that - even if I did end up with a higher grade, if I'm reading my MRI correctly, it's really early and all contained - so that's really good news.

    Isn't it better to catch it early an self contained? What does a higher grade really change when considering treatment if it's caught early - I wouldn't think it matters that much. If my biopsy is positive, from everything I've read so far, I'm probably one to lean towards surgery anyhow.

    I'm actually seeing Dr. Catalona - who I believe worked with Dr. Walsh (might be wrong) - but I think I'm in good hands.

    I'm trying to take the position that it does me zero good to worry - worry will not help change a thing.

    Thanks again guys!

     
    Old 02-12-2012, 04:41 AM   #8
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    Hi again jupaul,

    Yes, a clearly well-contained high-grade prostate cancer could be successfully removed by surgery. However, as the Partin Tables indicate, the odds of it being truly contained within the capsule drop sharply for the higher grades. Radiation would probably be a better choice if you have cancer and the Gleason is high. Radiation, these days, is excellent at killing cancer that is beyond the prostate, especially just beyond the range of surgery but close to the prostate.

    Dr. Catalona has an outstanding reputation as a surgeon, as you no doubt know by now. Regarding the 5-ARI drugs, his views a few years ago were similar to Dr. Walsh's views. Also, unlike so many of his colleagues, he was opposed to "active surveillance" for men with low-risk cases of prostate cancer. However, that was as of a few years ago, and his views may have changed as the evidence in favor of active surveillance has accumulated.

    Take care,

    Jim

     
    Old 02-15-2012, 12:16 PM   #9
    jupaul
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    Re: Why such a big PSA jump in 2 weeks and MRI thoughts...

    So I just got my PSA results back from an additional test run a week later - remember I went from 3.3 to 4.8 after two weeks of Bactrum - now a week later I'm at 4.66 - which I guess isn't statistically much different that the 4.8, but at least it didn't go up. Oh and this time they ran another free PSA, it's at 2% - bummer.

    Of course this is all conjecture and guessing right now until the biopsy, but based on the MRI, it looks like some PC is there - but I'm also wondering if that Bactrum really did stir up some underlying infection - does that make sense? I really have not heard of PSA suddenly going from approximately .5 increase per year to 1.5 increase in two weeks - but I'm new at this and I guess anything is possible.

    Also seems weird because literally the only thing I've done different is the Antibiotics - and since that last high result I haven't even thought of being "randy" - so that aint it.

    Again, I appreciate the education

     
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