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Cancer: Prostate Message Board


Cancer: Prostate Board Index


PSA MRI and pain
Nov 17, 2016
I am 49, and I am looking for help. I had PSA 3.7 11/14 after DRE at Mayo Clinic. Doctor said it is elevated, and rechecked again on 05/15 PSA 3.1. Both these times I did not know I must have no ejaculation for 48 hours. January 2016, I went to a local urologist, he did DRE and said normal, PSA 2.47 (after DRE?) Three weeks of Cipro PSA 2.5 Free PSA 29.2.
Two months later I started to have pain under my right rib, and in my left hip. I went to ER and the X-rays did not see anything suspicious. Three weeks later I went to Mayo Clinic to see gastroenterologist for scheduled procedures (endoscopy and colonoscopy) and asked to be referred to urologist. Urologist did DRE (nothing suspicious, but boggy) and checked for infection by prostate massage, all negative. Did not order PSA, because of the colonoscopy test it would not give an accurate number. Ordered 3T MRI with rectal coil., which basically said some diffuse changes, most likely prostatitis. I was told to take warm baths and ibuprofen to reduce inflammation and recheck in six month. Five months later I stated to have back pain, so I contacted the Mayo doctor and was told to come for MRI test. My PSA is 2.5 10/2016 and Free PSA 25.6.
Here is my MRI report.
[SIZE="2"][B]24-Oct-2016 07:58:00 Exam: MRI Prostate w&wo
Indications: Elevated Prostate-Specific Antigen (PSA);Frequency
Urinary
ORIGINAL REPORT - 24-Oct-2016 10:54:00 GONDA
EXAM: MRI Prostate w&wo IV contrast using endorectal coil.
COMPARISON: MRI prostate 03/30/2016.
IMPRESSION: Increased diffuse hyperenhancement and only mild
diffusion restriction primarily seen throughout the peripheral zone
and bilateral seminal vesicles, which most likely represents diffuse
prostatitis and seminal vesiculitis in the setting of a decreasing
serum PSA.
PROSTATE: The prostate gland is again mildly enlarged and measures 35
cc in volume. Mild nodular enlargement of the central gland consistent
with benign prostatic hyperplasia.
As correlated with exam of 03/30/2016, again seen is scattered T2
hypointensities throughout the peripheral zone in both sides, most
pronounced from the apex to the mid gland. Corresponding
hyperperfusion and mild diffusion restriction are slightly more
prominent than previously (series 801 image 57; series 31002 image 23;
series 31200 image 21-23). These findings again most likely represent
chronic prostatitis, although any underlying low grade tumor cannot be
excluded.
LOCAL STAGING: Extracapsular extension is absent. Mild symmetric wall
thickening of the seminal vesicles with corresponding hyperperfusion,
likely inflammatory. Seminal vesicle invasion is likely absent.
LYMPH NODES: Nothing for suspicious nodes.
BONES: Nothing for suspicious bone lesions. Degenerative changes of
the spine.
OTHER: Tiny presumed right renal cysts. Trabeculated urinary bladder
wall. Colonic diverticulosis. Small fat-containing umbilical hernia.
Electronically signed by:[/B][/SIZE]

Mayo urologist told me to take Cipro for six weeks and let them know how I feel. I did not start Cipro yet.
At this time I have pain in my shoulder and some weird warm feeling in my left ear, no pain under my right rib, and no pain in left hip. I am afraid I have mets already. No family history.

What do you think about my situation, and what would you recommend I do next?
Thank you very much.

Ted.
Hi Ted,

You know quite a bit more about prostate cancer and its diagnosis than I did back in 1999 when I was diagnosed with a challenging case. However, a little knowledge can cause a lot of needless anxiety, which I believe is your situation, along with the benefit of motivating us to get things checked out, as you have. While I knew very little at the beginning and have never had any enrolled medical education, I’ve been through the School of Hard Knocks for prostate cancer for nearly seventeen years now, which resulted in my paying a lot of attention to the disease. (I am now apparently cured with the aid of radiation and hormonal therapy in 2013.) Here are some selected key facts you mentioned in your initial post:

“PSA 3.7 11/14 after DRE at Mayo Clinic. Doctor said it is elevated, and rechecked again on 05/15 PSA 3.1. Both these times I did not know I must have no ejaculation for 48 hours. January 2016, I went to a local urologist, he did DRE and said normal, PSA 2.47 (after DRE?) Three weeks of Cipro PSA 2.5 Free PSA 29.2…. Ordered 3T MRI with rectal coil., which basically said some diffuse changes, most likely prostatitis. I was told to take warm baths and ibuprofen to reduce inflammation and recheck in six month. Five months later I stated to have back pain, so I contacted the Mayo doctor and was told to come for MRI test. My PSA is 2.5 10/2016 and Free PSA 25.6…. PROSTATE: The prostate gland is again mildly enlarged and measures 35
cc in volume. Mild nodular enlargement of the central gland consistent
with benign prostatic hyperplasia….
I am afraid I have mets already.”

All of these facts are consistent with [B][I]not[/I][/B] having prostate cancer, :) let alone metastasis, though they do not absolutely rule out one of the exceedingly rare cases – a fraction of a percent – where such a presentation is for a patient with statistics like yours whose prostate cancer does not depend much for androgens (testosterone and dihydrotestosterone mainly) as fuel for the cancer.

That’s from my now savvy layman’s standpoint. I suspect an expert prostate cancer doctor, many of them practicing at the highly regarded prostate cancer unit at the Mayo Clinic in Rochester (e.g. Dr. Eugene Kwon, MD), would be convinced that the extensive, highly sophisticated and effective work-up you have had for the prostate itself [B][I]does rule out[/I][/B] prostate cancer. After all, that highly effective 3 Tesla endo-rectal MRI found no prostate cancer but did find evidence of inflammation in the prostate, and that is in conjunction with a highly favorable profile/pattern of PSA and free-PSA results.

You may not be aware that healthy prostate cells produce about .1 unit of PSA for every 10 cc of prostate tissue; since your prostate is 35 cc, the rule of thumb suggests that a PSA of 3.5 – well above your current PSA level - would be quite consistent with a prostate with no cancer, with the added consideration that infection and inflammation sometimes really boost the PSA even when cancer is totally absent, and even with that possible “handicap” your level looks good. Therefore, your recent PSAs are well within the range associated with a prostate with no cancer. (Another competing rule of thumb, with both based on research, suggests that a cc of non-cancerous PSA tissue produces .066 units of PSA, so 35 cc X .066 = 2.31, which is so close to your current value.) Moreover, your free PSA values rather strongly suggest the absence of cancer.

Regarding your pain, I would be shocked and amazed if it turned out to be due to metastases from prostate cancer! :) Actually, I would be surprised if you turn out to have even mild prostate cancer in the near future. :) That said, there may be other causes that are important to figure out. I’m glad that some of your hip and rib pain has gone away.

Chronic prostatitis can be hard to nail down and treat. Usually Cipro is used early in a try at knocking out the particular bacterium that is causing the problem. However, Cipro does not work on many of the bacteria that can cause prostatitis, so it may be necessary to try other antibiotics. I don’t feel I know enough about prostatitis to provide leads about whether and how long to take Cipro, or the side effects about which Jack has already commented and are worth some thought. I do know that many medications have long lists of side effects which in reality will only manifest in a small minority of patients as one or several more side effects, usually quite mild, with still fewer patients experiencing a particular side effect at a bothersome level, often with the option of discontinuing the problem medication and reversing the effect, and perhaps switching to an alternate tactic.

I wish you luck with this, but I envy your treatment at the Mayo Clinic: you are in good hands. :)





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