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Posted 3/24/2013 6:04 PM (GMT -5)

Hi All,

Went to Hopkins to the Multidisciplinary Clinic this week.  Thought we were prepared and was thrown off track with their advise. Since we are so new at this & learning as we go, I will try to explain.

Hopkins found the biopsy slides the same as what we had. Note in signature.

However the PSA  jumped from 4.58~ 11/12  to  12.1~ 3/13!   In four months? Was told to get another one in a week, they felt it was not right? Any ideas?

They said the prostate was enlarged as well.  Biopsy size was 50.7cc on 12/12.  Dont know why..maybe age, 62 very healthy.

Best treatment plan was radiation ( no brachy, prostate too large ). Or

Radical Prostatectomy.

I dont know if we were in some kind of denial because the 1st opinion was ok for AS! 

Im not sure what to do next?  Any suggestions were to go next, thinking RP ? Live in Delaware. Maybe thats a start.

Feel helpless.

Thanks,

Good Health 2 youL

            

 Age 62
 
4.58 PSA 11/12 ~ Slow PSA rise since 2009
 
(A1) Right Apex         Benign prostatic tissue with atrophic glands.
(B1) Right Mid           Benign prostatic tissue with atrophic glands.
(C1) Right Base         Benign prostatic tissue.
(D1) Right Lat Apex    Benign prostatic tissue with atrophic glands.
(El)  Right Lat Mid      Benign prostatic tissue.
(F1) Right Lat Base  ADENOCARCINOMA (GLEASON 3 + 3=6) INVOLVING 50% OF THE SPECIMEN
(1 OF 1 CORES CONTAIN CANCER).
 
(G1) Left Apex       HIGH-GRADE ROSTATIC INTRAEPITHELIAL NEOPLASIA.
                          Immunostains for basal cell-specific high molecular weight keratin (34BE12),p63, c-myc and racemase support this diagnosis.
 
(H1)  Left Mid       ATYPICAL SMALL ACINAR PROLIFERATION HIGHLY SUSPICIOUS FOR BUT NOT DIAGNOSTIC OF MALIGNANCY.
                        Immumostains for basal cell-specific high molecular weight keratin (34BE12), p63, c=myc and racemase support this diagnosis.
 
(I1)  Left Base        Benign prostatic tissue.
(J1)  Left Lat Apex   Benign prostatic tissue.
(K1) Left Lat Mid      Benign prostatic tissue with atrophic glands.
(L1)  Left Lat Base   ADENOCARCINOMA (GLEASON 3+3=6) INVOLVING 70% OF THE SPECIMEN
(1 OF 1 CORES CONTAIN CANCER).
                           Immunostains for basal cell-specific high molecular weight keratin (34BE12), p63, c-myc and racemase support this diagnosis.

                                                                                                    

Posted 3/24/2013 11:22 PM (GMT 0)
That 3/13 PSA test does sound suspect - a jump like that is odd. Infection or a bad day at the lab are the first things to mind. Good to get it confirmed with a retest. If it is confirmed, I'd skip the AS and move to do treatment. Either surgery or beam radiation would work I'd think. What would you be more comfortable with?

If it were me I'd start checking out the local surgeons and radiation facilities. What you find there might sway your choice one way or the other.

and it's hard to suddenly change plans. I was hoping to do AS myself - until they showed me my pathology report. I was stunned and it took awhile for me to mentally adjust to having to do treatment. It's a bit of an emotional hit. Take some time to adjust to it - at least until after the next PSA test.

Hang in there - you'll make it through.

All the best,
Andrew
Posted 3/24/2013 6:44 PM (GMT -5)
Intheshop's advice is good. Just take a breath and move forward step by step - not that I could do it. It is so stressful and confusing. Slow down, if you can. You have time to think this through. The final decision is yours. When you decide, just go with it. Thoughts.
Posted 3/24/2013 7:10 PM (GMT -5)
Well put Andrew. It was an emotional hit I didnt see coming.
I do have another appt. with a local Rad/Onc.
Dr Tewari sounds worth checking into. I love NY & its only a 4 hour drive.
Posted 3/24/2013 8:00 PM (GMT -5)
Yours is not a situation that I ever had to consider (see signature), but this forum has provided me with a tremendous amount of information and I remembered seeing this link posted in another thread, that may be something worth looking at... www.washingtonpost.com/national/health-science/when-his-psa-score-spiked-prostate-surgery-loomed-but-nih-offered-another-way/2013/02/25/077f66c0-42f9-11e2-8e70-e1993528222d_story.html

Clearly the PSA numbers that you're dealing with don't compare to this article, but it is always good to know of the other tools that are out there. Hopefully the link works, never tried this before.
My best to you!
Posted 3/24/2013 9:24 PM (GMT -5)
Sorry about that, I was sure I checked the "include signature" box with that post...still a newbie!
Posted 3/24/2013 10:31 PM (GMT -5)
I agree with most of the above. I would certainly ask my doctor about trying a course of Cipro for 10 days to see if the PSA comes down. It's not uncommon to get a prostate infection/prostatitis after a biopsy. After all, they are injecting fecal matter from your rectum into your prostate.

If the PSA increase is due to cancer and not just the prostatitis, there are several options you might want to explore, including SBRT and HDR brachy monotherapy (which is used for larger prostates). BTW- at 50cc, your prostate is not too large for LDR therapy (seeds) -- You just have to go to a good radiation oncologist - and not one at Johns Hopkins (they almost always poo-poo anything but surgery). I would recommend Dr. Mark Bouyyounouski at Fox-Chase in Philly for brachy. For SBRT, which is only 5 treatments, the closest I know of are Dr. Sean Collins at Georgetown, DC and Dr. Allan Katz in Flushing, NY. If you want surgery, Dr. Ash Tewari at Weill-Cornell would be my only recommendation.
Posted 3/25/2013 12:08 AM (GMT -5)

goodhealth2u said...
Hi All,

Went to Hopkins to the Multidisciplinary Clinic this week. Thought we were prepared and was thrown off track with their advise. Since we are so new at this & learning as we go, I will try to explain.

Hopkins found the biopsy slides the same as what we had. Note in signature.

However the PSA jumped from 4.58~ 11/12 to 12.1~ 3/13! In four months? Was told to get another one in a week, they felt it was not right? Any ideas?

They said the prostate was enlarged as well. Biopsy size was 50.7cc on 12/12. Dont know why..maybe age, 62 very healthy.

Best treatment plan was radiation ( no brachy, prostate too large ). Or
Radical Prostatectomy.

I dont know if we were in some kind of denial because the 1st opinion was ok for AS!

Im not sure what to do next? Any suggestions were to go next, thinking RP ? Live in Delaware. Maybe thats a start.

Feel helpless.

Thanks,

Good Health 2 youL END QUOTE]


Hi goodhealth2u,

Your Gleason score is good, but with over 50% involvement in the cores, AS would NOT be recommended by most doctors. My sense (which is only that of a humble patient) is that RP is your best route.

I say this because I also had an enlarged prostate (4x normal size). The doctors also said I was not a good candidate for brachy, but EBR or RP could cure me. They also advised that, while EBR could cure me, it could NOT relieve the severe urination problems being caused by my BPH.

Do you have any difficulty urinating at this time? Whether you do or not, it's a good bet that your BPH will continue getting worse, along with the associated urination problems.

So I had a daVinci RP and took care of both problems at once. Cancer free (they say I'm cured -- knocking on wood) and urinating like a firehose with NO incontinence.

As for your PSA, did you happen to have a DRE before the blood was drawn? Or did you happen to have sex or ride a bicycle, etc., in the 48 hours prior to the blood draw? Any of those above things can cause a temporary spike in the PSA reading.

Please feel free to give us more updates as time goes on. We'll be happy to offer our insight, comments, acquired knowledge, etc.

You might also want to purchase the 3rd edition of Dr Pat Walsh's great book, "The Guide to Surviving Prostate Cancer."

Good luck to you!
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.

Posted 3/25/2013 7:22 AM (GMT -5)
I'll also weigh in to most of what has been already said - particularly focusing on that 3/13 PSA, seems like an abnormal jump in such a short amount of time to have PCa causing it. Talk to your doc's about taking the approach of treating it as an infection/prostatitis first - you have time. When on to the next PSA be sure to comply with all of the "don'ts" before the blood draw.

It would also be good to start (continue) educating yourself regarding the various treatment options, as with your current stats you have options. During that part of my journey I downloaded and purchased a number of studies, reports, abstracts and so on and would be happy to share - so if you're interested shoot an e-mail my way and I'll reply.

Best to you.....
Posted 3/25/2013 8:05 AM (GMT -5)
You guys are so helpful, thank you!

Allen, thank you for the Md advise in my area.

Chuck, to answer your questions:

No urination problems so far.
I did have a DRE after the blood work.
No sex the night before.
Yes , went on a 16 mile bike ride on Tuesday, Hopkins on Friday.
That might be it, hope so....

Hopkins told me to take Ibuprofen for a few days before retesting my PSA. Should I wait 10 days, they said a week.

My biopsy was done 12/12. Could I still have an infection from that? I have some Cipro, I can take. Cant hurt, right?

My next appointment is with a RO in two weeks & I have to consider RP & make an appointment for that.

Many thanks!

Good health 2 you
Posted 3/25/2013 8:24 AM (GMT -5)
Goodhealth, I just noticed your comment that you have some Cipro you could take. I just wanted to point out that unless you have a complete 7 or 8 day regimen of Cipro, you shouldn't take it. You probably are aware of that, but my R. N. wife has drilled into my consciousness the dangers of creating drug-resistant bacteria by not completing the entire regimen of the antibiotic. I hope you get the answers to your questions soon. Good luck.
Posted 3/25/2013 8:30 AM (GMT -5)
I think Highlander gave you some very good advice. My PSA went from 3.50 to 5.25 in two months. The really suspicious part of your biopsy is that the 2 cores positive were 50% and 70% of the sample positive for PC. I had 2 cores with 15% & 20% but after my RALP pathology showed 60% of my prostate was tumor involved. So 10 of my biopsy needles missed a very large tumor. I also had a large prostate on post pathology, 69 grams which was not indicated in the biopsy.

If the next PSA test comes back as high I think it may be time for treatment as something is definitely going on in that prostate you do not want. If you have surgery do not be surprised if the Gleason score is upgraded as well.

Posted 3/25/2013 10:09 AM (GMT -5)
Water Guy , were your margins clear ? If you had RT would that have taken care of everything ? Sorry Im not sure in your signature if that was stated. You did have a higher Gleason score, both of my cores were 3+3, does that matter?

Thanks
Posted 3/25/2013 10:21 AM (GMT -5)
G,

The 3+3 Gleason is good, but the concern I would see is the very high percentage found in the two cores (50% & 70%)

Posted 3/25/2013 10:42 AM (GMT -5)
Good Health,

In water guy's signature the things that look like hyphens are read as "negative" so "Marg-Lymph-Sem-Vas-PNI-" means "Marg negative, Lymph negative, Sem negative, Vas negative, PNI negative".

Your lower Gleason score matters, but I think the conventional wisdom is that it doesn't matter enough. With a 50% core and a 70% core, even at Gleason 6 most doctors would not recommend surveillance, at least as I understand it.

It is worth following up that PSA jump with antibiotics to see if it was an infection but you should get a new scrip from your doctor and take them all. On the other hand, you shouldn't get too hopeful that it will make a lot of difference; based on your biopsy results alone you are a poor candidate for surveillance. You should probably look into some sort of treatment and the PSA result will affect the choice of treatment somewhat and will dial the urgency up or down depending; but it won't get you off the hook.
Posted 3/25/2013 11:14 AM (GMT -5)
Hi goodhealth2u,

Yes, it might be possible that that bike ride affected the PSA. Not sure if it would still have had an effect from more than 48 hours prior to the blood draw, but it very well could be possible.

Also, I continue to agree with the other guys -- having 50% and 70% in a couple of the cores indicates that you are NOT a good candidate for AS. Most likely, there is more PC in the prostate than the biopsy is suggesting. And the general rule is that AS is not recommended if any core is 50% or higher.

As for your 3+3. Yes, this is very good because it is a slower growing type of PC. But, once again, the biopsy is only an "educated guess" on the full nature of the PC. A post-op pathology report "could" show that there was also more aggressive cancer. No way to tell until they have the whole prostate in the lab to examine under the scope.

But it does appear that you should do very well after receiving treatment. There is no extreme rush to do something right now, but I would not wait very long before getting things taken care of.

Good luck once again,
Chuck
Posted 3/25/2013 11:42 AM (GMT -5)
Prostatitis
I agree with Clocknut that you have to take at least 10 days of Cipro - one guy I know stayed on it for 3 weeks before his PSA went down. Prostatitis is often symptomless and is notoriously hard to get rid of once you have it. I got it when my fiducials were placed. It came back after Cipro, and then I tried Bactrim, which finally got rid of it. Some guys never are able to get rid of it. It might show up in an elevated neutrophil (white blood cell) count, but it might not. You can ask for that blood test, but you could just call or email your urologist and ask him to call in a scrip for it so you don't have to wait for an appointment. I think it's important that you eliminate that source of PSA increase, as it may interfere with tracking AS or RT.

PSA errors
While it's true that sex, bicycle riding, and even constipation have been implicated in transient PSA increases, the effect doesn't last more than 48 hrs.

Active Surveillance
Protocols differ widely from hospital to hospital and across physicians. In the early days and still at many places, there are additional requirements that no single core has more than 50% involvement and that no more than a 3 cores are involved and PSA density<.15. Last year, NCCN hospitals, which includes Johns Hopkins and many of the top cancer centers in the US, changed their recommendation to include AS as an acceptable option for all low risk patients regardless of life expectancy or involvement. Low risk=Gleason≤6 and PSA<10 and stage≤T2a. You meet those requirements except for PSA, which is again why it's so important for you to eliminate prostatitis as a possible source of your elevated PSA. It's still possible that you can be on AS.
Posted 3/25/2013 11:48 AM (GMT -5)
For sure I have ruled out AS.. Its between RP or RT..
I called my Primary to get Cipro called in.

Many Thanks,


Good Health

Post Edited (goodhealth2u) : 3/25/2013 10:52:00 AM (GMT-6)

Posted 3/25/2013 1:09 PM (GMT -5)
Goodhealth2u.............where in Delaware are you, and who is your local urologist? You have other options close by in Philly as well. You can see my signature to see I was treated by Dr. Lee at U. of Penn..they also have Proton Beam capabilities there, and as as all the other modalities of treatment. We also have a Prostate cancer suppooirt group run through the Wellness Community here in DE. My sesne is, based on your description of time to NY, is that you're from "Slower Lower"---------let me know, or you can email me offline as well.

Arnie in DE

Posted 3/25/2013 6:34 PM (GMT -5)
Dear Goodhealth:

Welcome to HW...but sorry you have to be here.  I think it's very unlikely that such a quick jump in PSA is due to the prostate cancer so it's a good idea to figure out what's going on there before jumping to treatment.  If you haven't been reading on our disease, you might check out Dr. Walsh's, "Guide to Surviving Prostate Cancer" and Dr. Scholz', "Invasion of the Prostate Snatchers".  Between the two you will have a good view/perspective.

Re treatment, it's likely that any of the main ones will cure you so you need to also seriously consider the side effects.  Given that you don't have urinary issues, your prostate is NOT too large for brachytherapy.  Brachy generally has far less onerous side effects than surgery so it's certainly worth checking out an experienced brachytherapist to make sure you have that viewpoint.

Good luck and please keep us informed.

Jim

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