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Cancer: Prostate Message Board


Cancer: Prostate Board Index


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)[B]Prostate Specific Antigen(PSA): 11.22 (0-6.5)[/B]

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 [B]21 fold increase in his PSA over 15 months[/B] 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
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
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
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
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
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.
Hello IADT3,

Thank you again for your replies!! They have been and I am certain will continue to be[B][U] immensely helpful [/U][/B] 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:

"[B]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." [/B]

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?

[U]The key question:[/U] 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?

[U]Bottom-line[/U] : 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
Hello IADT3,

I hope you are doing well! Thank you again for all of your insightful answers so far!!

If you don't mind, I have a few updates and then a couple of questions:

1) The pathology report from last week was all that was done with the initial biospy and the IHC marker test was recommended but not done. My father saw the Urologist yesterday and the IHC marker test was ordered to rule out prostate cancer. The results will take 10-12 days as the tissue samples are being sent to a bigger city (most probably Mumbai - major city with great hospitals).

2) At this point I have decided not ask the Urologist any questions about the tiny size of the biopsy tissues. The idea is to build a relationship over a couple of weeks and ask him later. I did ask the Urologist about the seriousness of finding inflammation with low grade PIN , chances of finding prostate cancer in the IHC test and why my father is having recurrent UTI's with pain in his penis over email. His only reply was, "We will have to wait for the final IHC report to decide on further treatment". (He has always been a cautious, methodical doctor who stayed away from doing any surgeries like urethroplasty or urethrotomy for my father's recurrent urethral structures since 2001 and was content with prescribing a few medications and periodic ultrasounds to check for any issues with the treatment).

3)When I asked a primary care doctor contact of mine in Bangalore (another major city with great hospitals) about how tiny the biopsy samples of my father's prostate were, he said its good enough(as you explained it to me) for the following reasons:
a)The prostate is 17.5 cc. Its reasonable to assume that anything missed will be found when the PSA is tested again in a few months.
b) The suspicious zone in the MRI might have helped the Urologist point to the right spot.
d) After reading through the profile of my father's Urologist, he feels confident in the Urologist's skill given that the Urologist is also an Uro-Oncosurgeon, has a FRCS degree from Scotland and has been practicing for 20+ years.

4) My father has been given a once per day Nitrofurantoin(antibiotic) and Cefpodoxime (used for BPH) for three months and a daily NSAID for one week.



Questions:

1) Does a Pathology report in a Johns Hopkins/Memorial Sloan Kettering and smiliar quality of hospitals in the USA assign a Gleason score to all the core biopsy samples if it shows, " Inflammatory Pathology with small foci of Low Grade PIN" under the microscope after the basic H&E staining? In other words, does each core of the biopsy get a Gleason score representing the high or low cancer grade whether its cancerous or not?

2)In the biopsy, is the microscopic detection (after basic staining) for prostate cancer given equal weight when compared with the IHC marker test?

3) If the repeat urine tests and urine culture over the next week or so show no infection and the IHC marker test comes out as positive for prostate cancer, it seems like we should get a multi-parametric MRI fusion biopsy right away at a hospital which does at least 10-14 cores like you explained to me in your previous message.Should we wait for a few more weeks to check PSA and then if the PSA is increasing, go for the biopsy or go for the biopsy right away?


Thank you!!
Zent
Hello IADT3,

Thanks a lot for your reply! I hope you are doing well.

I have a few updates and if you don't mind , a few questions after that:
[U]
Update #1:[/U] We received the IHC (34-Beta E 12) results today and it says, "had a positive staining for p 63: Immunoreactive, score 4+ in all myoepithelial cells present in all glands". In the comments section, the report say, " Absence of staining for 34-Beta E 12 in conjunction with positive staining for Alpha Methyl Acyl Co-A Racemase (AMACR) is useful in diagnosis of prostate carcinoma".

[U]Update #2: [/U]When my father asked his Urologist about this line, he was told that since he had a positive staining for 34-Beta E 12, there was no need for the AMACR test as it was conditional on the absence of 34-Beta E 12. The report mentions a benign prostate tissue but also warns about false negatives. Obviously, given how little of the tissue of the sampled, this warning seems especially valid.

[U]Update #3: [/U] My father's Urologist told me that he will see my father in 3 months , repeat PSA at that time and decide on how to proceed after that.

Questions:
1)I am confused if 34-Beta E 12 is a different test than p63. The report say the name of the test is, "34-Beta E 12 @Immunohistochemistry", but the impression mentions, ""had a positive staining for p 63: Immunoreactive, score 4+ ......". Your comments?

2) Your comments on the Urologist's reply about not requiring an AMACR test due to a positive staining for p63?


3) Given the lack of a reliable biopsy and with the above test results, is it too late to wait for 3 months for a repeat PSA? Does it make more sense to get PSA tested on our own in another lab in about two weeks (about a month after biopsy)?

4) If the PSA is increasing after a month of biopsy, does it make sense to get a 3T Multi-parametric MRI with a fusion biopsy right away?

I cannot thank you enough for educating me about the ins and outs of prostate cancer!! I am extremely grateful for your patience and knowledge!!

Thank you,
Zent
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





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