Rising PSA

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I am 71 and have had BPH for about 15 years. I tried Avodart for a year in 2012. I have been doing self cathterization (5/day) since May 2018. When I started catheterization my PSA went from 2.8 Aug 2017 to 5.3 Mar 2019 Which as I understand is somewhat normal due to the irritation caused by catheterization. Then PSA went to:

6.3 July 2019

7.55 Jan 2020.

I had a mp 3T MRI Feb 2019, The report says :

"1 & 2. Prostate size 85g, enlarged median lobe pushing into bladder.

  1. There are no focal areas of restricted diffusion demonstrated. There is a generalized restricted diffusion within the left side of the prostate when compared to the right side . There is a generalized decrease within the ADC map on the left side of the prostate. Following infusion of contrast there is a generalized increase in contrast enhancement within the left side of the prostate.

  2. PIRAD-3"

The place I had the 3T MRI is near a hospital 2 blocks from my home in Fremont California. I think it is a general MRI imaging center and does not specialize in prostate images, so don't know how accurate their report is, or if they did the imaging correctly.

I sent the images to Dr Karamanian in Houston, Tx. He said the quality of the images was not good enough to tell much about prostate cancer. He said the size of the prostate is roughly 85g.

I will see my urologist this week on March 4, 2020 and he will probably want to do a biopsy.

I had originaly wanted the 3T MRI to avoid biopsy.

Should I watch and wait getting another PSA test in 3 months and maybe another 3T MRI in 3 or 6 months, at a reputable institution like Stanford Univ, or University of California San Francisco ? Should I take my present images to Stanford or UCFS to find an expert to read them, for second opinion ? Can I get Medicare and my insurance to pay for another 3T MRI in less than a year?

Any help would be appreciated,

Thanks,

Thomas

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  • Posted

    Thomas,

    my path has been similar. 3t mri, visit with Dr K, first uro wanted to do biopsy, I refused, visited Dr G in Houston and he had the perfect solution. Median lobe was pushing in and restricting. He did the surgery and 3 yrs later i do very well. i am 68 now. Good luck!

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  • Posted

    My URO did a biopsy when my PSA went up to about 4.6. The biopsy was negative so that meant 85% chance of no cancer. Since then my PSA went up to 9.5, around the time I stopped being able to urinate so I spent 3 months dealing with Foley catheters. They had determined that I did have infections. After a couple of rounds of Cipro (500 mg x 2 per day for 7 days each), my PSA dropped from 9.5 to 3.5. Finally, in January 2020, I had TURP surgery so I can now pee again. As per usual procedure, the prostate bits were sent to pathology and I was told that I was negative for cancer. My URO says that large jumps in PSA over a short time usually don't mean cancer because the cancer grows very slowly. But at least I have reasonable confirmation. Still, nothing is 100% certain.

    My brother still insists that I shouldn't have had the biopsy because he believes the "old wives' tale" (per the NIH website) that needle biopsies can spread cancer. Of course, all those that tout that theory still say you should have a biopsy or you'll never know if you do have cancer and you'll eventually die from it. I spoke with a patient who was waiting for a cystoscopy just after I was done. His father had died from prostate cancer and told him to have his checked and get it fixed as soon as possible before the father died a horrible death. This guy I met, had an 80% removal of the prostate due to cancer and I forgot why he was having his first cystoscopy at the time I was leaving.

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    • Posted

      Howie,

      What kind of TURP did you have, that allowed prostate bits to be saved ?

      When you have a prostate infection the PSA can jump very quickly to a high number. I had a prostate infection in May 2018 (due to first use of a catheter), that caused my PSA to jump from 2.8 to 26 in one day. Antibiotics brought it back down.

      Can I ask how old you are now, and what size was your prostate before the TURP ?

      Thanks for you input,

      Thomas

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    • Posted

      Most TURP surgeries, that I read about, the parts of the prostate that are burned (or cut) away, fall into and are flushed into the bladder. After the actual surgery part, the device is replaced by an open-ended (per my uro) Foley catheter (mine was size 22) and the irrigation flushes the bits of "meat" out of the bladder. I had read this and checked, ahead of time, with the Uros and they said that they would be sending the bits for testing. It was odd that I forgot all about it when checking with my urologist after the surgery and he mentioned to me that they did not find any cancer. I had the type of TURP that uses a keyhole-shaped electrode to burn its way through the prostate to make a channel. I understand the TURP device (sorry, forgot what it is called) is a 1/2-inch pipe. No wonder they put me under BEFORE I entered the OR.

      As for the PSA numbers, I had a slowly rising number that reached 4.8 which was just out of range for my age (68-69) at the time (April 2019), so we did the biopsy.Amazing that I'm so bad at remembering numbers and dates without going to the Kaiser website). The PSA hit 9.5 right before the time I stopped being able to pee at all. The test was on October 3rd, 2019 and I passed a kidney stone and was diagnosed with an "infection" on October 27th. It was just in November (1st) when I stopped being able to urinate at all and had to get a Foley put in during an E.R. visit. This was also the time I began being diagnosed with infections that continued until the test I took just last week, over three months later. It was in the middle of my CIPRO courses that it dropped back to 3.5. And, yet, this was on January 3, 2020 but my TURP wasn't until January 22nd. So, it was not related to the surgery but, rather to the CIPRO 500 pills I was taking. At least I'm guessing that was the case. I don't have direct evidence that the CIPRO dropped the PSA.

      By the way, I was told that the PSA can not only go up due to an infection, but also use of a bicycle seat! I don't know if that is true or not.

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    • Posted

      I missed a question: as to what size was my prostate? I really don't know. I was new to all this and all I was told was that it was enlarged but they never sized it, at least, not to my knowledge. The decision to do the TURP was because I was 100% blocked and on Foley catheters for months plus my uro did a cystoscopy and pointed out that my passageway through the prostate was pretty well shutdown. I have a phone call with him tomorrow, so, if I remember, I can ask him if he ever really sized it, or if we just went based on the size of the tunnel through the prostate as shown in the cystoscopy.

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  • Posted

    I'll just toss out another anecdote to add to the fun. My PSA went from 3 to 11 in a 6 month span. My uro did a biopsy (the only thing that hurt was the antibiotic shot in the butt) and the analysis came back as "granulomatous prostatitus." I had no symptoms. Three months later I had a TURP and there was prostate cancer in about 15% of the specimen. Gleason score was 3+3 so active surveillance was recommended. I have had 3 PSA tests since my TURP (which was one year ago). First was 2.3, second was 4.3 and last week it was back down to 3.1. At this point, I'm feeling pretty good since the PSA went down to where it had been almost 2 years ago. FWIW, at age 70 the PSA level that most uros get concerned about is 6 (vs 4 for under 70).

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  • Posted

    Your PSA history is:

    2.8 Aug 2017

    5.3 Mar 2019

    6.3 July 2019

    7.55 Jan 2020.

    And you're unsure if the 2017-19 figures relate to matters other than PCa (cancer).

    In short, one can be confident a cancer is lurking if the PSA doubles in one year.

    I agree that 3T MRI is the gold standard as it's more accurate than 1.5T.

    But the most important issue is whether the reporting was done by a radiologist specialising in prostates.

    In my case, a 1.5T scanner was used but an expert reported on it. I was told that is much better than a 3T scanner with a non expert reporting.

    Of course a 3T with an expert reporting is ideal.

    Please understand that biopsy is INVASIVE. More so if it is trans rectal rather than my preferred option of trans perrenial, which has a far lower risk of infection.

    If your urologist is unhappy with the radiologist's ability then you must find an expert to ideally report on the images you had done rather than undergo another scan.

    FYI, I was diagnosed using a 1.5T MRI by an expert in prostates.

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  • Posted

    Your PSA history is:

    2.8 Aug 2017

    5.3 Mar 2019

    6.3 July 2019

    7.55 Jan 2020.

    And you're unsure if the 2017-19 figures relate to matters other than PCa (cancer).

    In short, one can be confident a cancer is lurking if the PSA doubles in one year.

    I agree that 3T MRI is the gold standard as it's more accurate than 1.5T.

    But the most important issue is whether the reporting was done by a radiologist specialising in prostates.

    In my case, a 1.5T scanner was used but an expert reported on it. I was told that is much better than a 3T scanner with a non expert reporting.

    Of course a 3T with an expert reporting is ideal.

    Please understand that biopsy is INVASIVE. More so if it is trans rectal rather than my preferred option of trans perrenial, which has a far lower risk of infection.

    If your urologist is unhappy with the radiologist's ability then you must find an expert to ideally report on the images you had done rather than undergo another scan.

    FYI, I was diagnosed using a 1.5T MRI by an expert in prostates.

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    • Posted

      "...one can be confident a cancer is lurking if the PSA doubles in one year"

      I kind of disagree with something you said here. Actually, my urologist disagrees. My PSA more than doubled in 6 months. Much less than a year. But there was no cancer. What my urologist said was that, if your PSA goes up due to cancer, it will go up way more slowly because prostate cancer is a very slow-growing cancer. If the PSA suddenly jumped in a short time, he said that it is more likely an infection and NOT cancer. When my PSA went from 4.8 to 9.5 in 6 months, my brother was screaming that I had cancer and that simply was not true. In fact, after a few rounds of antibiotic (CIPRO 500 mg), my PSA dropped to 3.5 which was less than the 4.8 it was just before my (negative) biopsy. After I was down to a PSA of 3.5, about the time I had my TURP surgery, the findings from that showed, also, no cancer. Since then I've been reading stories that the PSA test is NOT a good indication of cancer. Many here have seen their PSA skyrocket and the cause was a UTI. I've also heard that using a bicycle seat can raise your PSA but I have not discussed that with my urologist.

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    • Posted

      Barney,

      Here is my complete PSA history:

      Date PSA Notes

      8/22/2017 2.80

      5/24/2018 29.20 UTI

      9/5/2018 6.20 CIC

      5/9/2019 5.30 CIC

      6/3/2019 6.30 CIC

      8/13/2019 5.08 Stopped CIC 2 weeks

      12/19/2019 7.12 CIC

      1/26/2020 7.55 CIC

      I the person reading my MRI in Fremont Ca. was not a prostate expert.

      I did get a response from an Interventional Radiologist who is very experienced in interpreting prostate MRIs for cancer. I don't want to mention his name. This is what he said before looking at my MRI:

      "It is likely that your elevated PSA is due to BPH and inflammation as the MRI with diffuse one sided enhancement typically does NOT indicate the presence of cancer. You likely have areas of low grade prostate cancer (over 1/2 men your age do) but this generally does not require treatment."

      This is what he said after seeing my MRI:

      "I see your MRI and your prostate volume is about 103 cc. Given a PSA of 7.55, that gives you a PSA density of 0.07 (normal is less than 0.1)

      Because of the prostate size and irritation, your PSA is up but is really normal given the size of your gland (the bigger the prostate, the higher the PSA even when no cancer is present)

      If you get a biopsy, the results will likely show a low grade gleason 6 cancer --clinically not important. As the MRI is essentially negative, you can consider doing nothing or take medications for BPH (cialis, flomax, avodart, lupron). However, the side effects may bother you. In this case consider TURP, REZUM, URolift (probably not eligible as prostate is too large) or laser therapy (like we do here). Thanks for sending MRI and hope you get some relief soon!"

      Thomas

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    • Posted

      I did not know you were on antibiotics. If the course of antibiotics does not lower the PSA then it is unlikely that that you have an infection. If it does lower it, then GOOD NEWS.

      The bicycle issue and eating so-called "right" foods are both non-issues is your regular PSA testing is performed long after you rode a bike and your diet is stable.

      I am not a fan of "stab in the dark" biopsies. The best type to undergo is MRI/ultr sound guided biopsy, so that those parts of the prostate most likely to house the PCa are examined. A biopsy that is not so guided merely stabs the prostate in a dozen or so places hoping to capture a complete picture of the prostate.

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    • Posted

      Thanks for the reply.

      I am uneducated about BPH and UTI, having endured neither, only Gleason 9 PCa.

      I would side with the interventional radiologist (I know a couple and consider that subspecialty to be populated by many wise men and women). If the views of such folk are that you have a low grade PCa which may rise to a level of Gleason 3+3 then no invasive activities are called for.

      A G6 is a very slow growing "situation", which is not even deemed a "cancer" by experienced uro-oncologists and which at most demands infrequent monitoring.

      Good luck. You can certainly sleep easy. Sorry if I elevated your anxiety earlier.

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    • Posted

      Yes, and TURP surgery is also a form of "biopsy" since the material that is cut away from the prostate is sent to the pathology department for examination. I don't think there is any test, IMHO, that can tell you that you DON'T have cancer, short of complete removal of the prostate and slicing it up for examination. A regular needle biopsy was told to me to be 85% non-cancer since all 13 points were negative. The TURP pieces also were negative so that should increase things. Anyway, my PSA went from 4.8 to 9.5 and then DOWN to 3.5. Was mine ultrasound guided? I thought it was but there was no MRI involved. My brother said that the finger-up-the-butt is not a valid test, and he is right in that it is not "definitive" but is listed in most urology work as a valid tool as they are looking for texture, rather than size.

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