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Cancer: Prostate Message Board


Cancer: Prostate Board Index


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 ˝ 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
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.

I’ll 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 – 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), it’s 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 father’s 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 – 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, here’s 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.
Hello IADT3,

I hope you are doing well!!

The biopsy report will only be available later this week and my father will be seeing the Urologist on April 2. I have two questions. As you have mentioned in your earlier messages, I am asking you these questions to get a handle on the various outcomes that are possible.

[U]Question #1:[/U]

The findings on my father’s TRUS report from last week is as below:
--------------------------------------------------------------------------------------
Central Zone is heterogeneous in echotexture
Peripheral zone is normal in echotexture
No focal lesions
Bilateral seminal vesicles are normal
--------------------------------------------------------------------------------------

I read online the following points about zones and cancer in the prostate:
1)20-25% of prostate cancers occur in the central zone of the prostate and are hard to detect and also tend to be the highest grade.
2) The peripheral zone is about 70% of the cases of cancer and the rest are in the transition zone.
3)On a TRUS, the central zone is presented as a combination of central and transition zone.

If a TRUS can visualize the zones of a prostate, I take it that a pelvis MRI with T2 and diffusion weighting must be able to do the same with better resolution. Is this an accurate assumption? If yes, does , “Central Zone is heterogeneous in echotexture” on the TRUS and “Area of altered echotexture; hypointense on T2w; showing restricted diffusion noted in the left hemigland. Area measures 19 x 11.22 mm” on the MRI would more likely be a case of cancer in the central zone? Your thoughts on this?


[U]Question #2:[/U]

On March 17, a urine test was done for my father which showed the elevated PSA of 11.22 and the following abnormal results:

Urine ph - 7.5 (Reference: Acidic)
Urine leucocytes: Present
WBC pus cells: 10-15 (Reference Range: 3-5)
RBC - 2-4(Reference Range: 0-1)
Epithelial - 1-2 (Reference Range: 2-3)
Remarks: Bacteria seen

On March 19, when my father was admitted to the hospital for a cystoscopy (and eventually underwent MRI, TRUS and biopsy for elevated PSA), a sample of urine was collected for culture. He was also given antibiotics starting March 19 to be taken until March 30. The results of the urine culture came out on March 21 as, “No growth after second day”. Previously, his urine cultures always have taken 3-4 days to come back with results.

I am mentioning all of this because if there was no substantial bacteria in his urine culture and hence no UTI or infection, it seems to point to cancer as most likely to explain the findings on his MRI. Your comments?

Thank you,
Zent
Hi Zent,

Regarding 1): I believe that the MRI your father had will do a better job than the TRUS imaging. I am not sure about the finding of heterogeneous echotexture. I have heard one expert on mpMRI describe the image for normal tissue in some of the prostate as “organized chaos,” which would be consistent with “heterogeneous” in the imaging echo. In other words, I don’t know if “heterogeneous” indicates a likelihood of cancer. The finding of “hypointense”, meaning low intensity, does suggest something is going on there that could be cancer, as does the finding of restricted (water) diffusion, and what is going on could be cancer, but I’ll emphasize that it could be something else.

Regarding 2): I am not sure about the significance of most of the urine test results, except that the presence of bacteria does indicate infection, which is encouraging news when your main worry is cancer. That helps confirm that infection is likely accounting for some, if not all, of the PSA elevation, and this is consistent with the previous up and down pattern of PSA results.

Regarding the urine culture: The finding of “no growth after second day” seems, in my layman’s mind, to mean that this is evidence that the antibiotic your father was given was probably the right one for the bacteria that were found, as they did not grow or at least ceased growing by the second day. However, I’m not expert in this. I believe the results, contrary to what you are visualizing, indicate that there [I]was[/I] a substantial bacteria presence in the urine, but that it was controlled by the antibiotic. As mentioned above, that suggests that infection is at least (or was at least if now knocked down or cured) part or all of your father’s problem that was reflected in an elevated PSA.

At this point, as a likely infection has been knocked down, it would be helpful to have another PSA after the trauma from the biopsy has subsided. Of course, the biopsy report may short-circuit this process if the finding is cancer.

Good luck!
Hi Zent,

Congratulations to your father, and to you for your support, on this encouraging biopsy report! :) In essence, the report suggests that infection is responsible for that elevated PSA and not cancer, though it is possible (I think unlikely) that some cancer is present and playing what would probably be a small role in elevating the PSA.

Regarding question 1): I had to look up information about IHC marker Cytokeratin 34 Beta E12, but it is clear that it is an accepted and apparently widely used agent to check whether or not questionable tissue from a biopsy may be cancerous. Perhaps the doctor (or pathologist’s office) would answer how frequently they used this agent for biopsies; they might do it most of the time as part of their routine, or it might be that they are in some doubt. I’m almost sure they would use the tissue from the biopsy he just had for this test. Basically, it involves staining the tissue and observing the result.

Regarding question 2): Personally, were I getting a biopsy done for myself, I would want a more exact procedure and a more precise report. It may be that this kind of procedure and analysis are standard in India, but I expect that major centers would provide better information. If a biopsy is needed in the future, it might be helpful to research which centers would do a more meaningful job; perhaps a sample biopsy report could be obtained. That said, I suspect that this biopsy and its report are good enough.

The report does at least separate the specimens for each half of the prostate. Unfortunately, it does not identify how many there were, how long they were, and where any of them came from in the half of the prostate from which they were taken. :confused: That happens to not matter too much as all (both?) of them were negative for cancer, at least as judged prior to the staining. However, if cancer were to be detected, you would not know where in the prostate it was. I have seen cores that were even labeled at one end so you would know even more precisely where the cancer was located. Also, if cancer were to have been detected, you would want to know how much of the specimen was cancerous and what its Gleason score was.

The urologist who did the biopsy probably remembers or even has notes of where he took the cores, especially regarding the area of suspicion from the MRI exam. In the US core specimens are each about 10 mm to 14 mm in length. If that is so in your father’s sample of .3 cm (=3mm) per side suggests a very small sample or samples as they add up to just .3 cm; perhaps just one per side. In the US about 12 specimens is now the norm, though it used to be about six. This makes me wonder whether I am correctly understanding what was done. :confused: If I am correct, then, even though the findings were favorable, your father has some basis for concern that the sampling might have missed any cancer that was present. Perhaps tactful questions to the urologist and/or pathologist could clarify this. Also, a follow-up PSA in a few weeks could be reassuring if there is a nice drop in PSA, which would be consistent with successful treatment of infection.

What the biopsy did find was clear evidence of infection, and that could easily account for the elevated PSA and the MRI findings. The report noted the presence of inflammation, which is the body’s reaction to bacteria but not its reaction to cancer. This is consistent with the elevated WBC (white blood cell) count seen in the lab report, as these cells are part of the body’s defense system to clear up infection, as you likely know.

Regarding 3): Infection/inflammation can make prostates firm. They can also make prostates nodular. Therefore, while cancer can also do this, it strikes me that infection and inflammation are likely the culprits in your father’s case.

Regarding 4): This is a good question, but I don’t know the answer.

Again, congratulations! Your father’s case looks good at the moment, and I hope further evidence will be confirming. :)
Hello IADT3,

Sorry to bother you again! I have a question about my father's persistent penis pain. If you have any insights about it, I am eager to know:


My father first had pain in his penis (a 4 on a scale of 1 to 10) in Dec 2017. His Urologist did a Urine culture and the results indicated EColi infection greater than 10000 CFU/ml. Antibiotics were given and a repeat urine culture in January was normal.

His pain oscillated between a 1/10 and 2/10 in February and March. He was prescribed a few creams which made the pain manageable. When the pain persisted at 2/10 for a couple of days in the third week of March, the Urologist ordered urine and blood tests (11.22 PSA, positive for bacteria, urine had elevated WBC and leukocytes). A cystoscopy was performed on March 19, which did not find anything abnormal.

The elevated PSA took us down the path of ultrasound, MRI and biospy. For about a week after his cystoscopy (March 19- March 26), he felt no pain. This might be due to all the NSAID's he was give during his 5 days hospital stay (March 19-March 22).

His pain returned on April 2 and is currently between 1/10 and 1.5/10. Since the last few days, the pain is felt more in the tip of his penis than shaft. He saw the Urologist on April 9 and when I emailed his Urologist, he said that the pain will slowly recede. My father has no growth, no discharge, no changes in skin color or redness/rash or anything of that kind on his penis. He has no pelvic pain. His urine stream is fine.

My father had a similar complaint of penis pain in Oct 2016 and a cystoscopy was done in Nov 2016. He had no pain in his penis from Nov 2016 to Dec 2017. So, I am unsure why the pain is persisting so far.

Questions:
1) Does UTI in December explain the penis pain in Dec-Jan?
2) Does the detected UTI on March 17 explain the penis pain in Jan-March?
3) Since several antibiotics have been given March 17 for his UTI, can the Cystoscopy itself be the cause of his current penis pain due to inflammation of his urethra ?
4) Any other reasons for his persistent pain? I would be grateful for any comments from you.

Thank you!!
Zent
Hi again Zent,

I only have time now for the first set of questions. I will try to get to the later questions at another time. Before long YOU will be the expert on this! :cool: You wrote:

Prostate Cancer/PSA Questions:

1) My father's Urologist will check his PSA again in the last week of June (3 months from his biopsy). Does it make more sense to check PSA in the coming weeks in another lab rather than wait until June 21?

2) What other tests can be done currently to check for prostate cancer if PSA is not a reliable indicator of cancer (assuming my father has chronic prostatitis)?

3) My father's biopsy showed a low grade PIN. Given the poor quality of the biopsy, it might as well have been a high grade PIN/cancer. Does PIN(high or low grade) increase PSA?

++++++++++

My impressions/answers:

Regarding 1): My layman’s impression is that it makes sense just to wait and let the effects of the biopsy go away.

Regarding 2): There are some tests, but the question is whether it would be worthwhile doing them in view of the negative findings so far and the prostatitis that may be explaining the PSA pattern; my impression is that it would be premature to do these now, but you and your dad, and his doctors, are closer to the whole situation. A multiparametric MRI could be done and interpreted by an expert radiologist; that could also help spot prostatitis and help assess its extent. One or more blood or urine tests for prostate cancer could be done, at least one of which is not sensitive to infection, Here is one published paper from Italy about PHI, PCA3, and free-PSA, the latter known to misleading if there is infection: https://www.ncbi.nlm.nih.gov/pubmed/26162485 .

Some infrequently used blood tests could be done: CGA (chromogranin alpha); NSE (neuron specific enolase); PAP (prostatic acid phosphatase, used a lot before PSA), and CEA (carcinoembryonic antigen); for most of my earlier years with the disease, these were quite useful for patients with the unusual types of prostate cancer that made little or no PSA, but that would probably not be a good fit in your dad’s case as he makes a lot. However, he could have a rare case of prostatitis that made a lot of PSA combined with a rare and stealthy prostate cancer that made little or none. One fairly frequent unfavorable consequence is that your dad might have one or more results that were enough out of the normal range to cause further tests to be performed, but with no real problem, just personal variation – normal for him but not for most others. That happened to me with CEA, which we monitored for about two years as I recall it before deciding it did not matter. (CEA is one of the better tests for colon cancer.) Perhaps others on the board will suggest some tests that they have found useful.

Regarding 3) – high (and low) grade PIN and PSA: First, here’s another paper (involving at least one of the same authors) saying that PIN does not influence the PCA3 test: https://www.ncbi.nlm.nih.gov/pubmed/23116408 (includes a link to a copy of the complete paper). Here’s a paper based on a fairly small group of patients that indicates no influence of high-grade PIN on PSA: https://www.ncbi.nlm.nih.gov/pubmed/10524873. Here’s another study that reaches the same conclusion: https://www.ncbi.nlm.nih.gov/pubmed/8650867. I got these from searching www.pubmed.gov for - high grade PIN AND elevated PSA and prostate cancer – and also glancing on the right, after clicking on promising abstracts, for similar studies.

Good luck! Jim





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