highest psa yet

i posted last week under name D. i am 62 yrs. old and have had four ultrasound rectal biopsy's over the last five years and all were negative. My psa has been as low as 4 in 2009, and then between 6 and 9 for the past four years. i just got total psa of 11.4 and free psa of 2.8 and the nurse told me the doctor left her a message stating i could get another biopsy or give another urine test to see if a bacteria could be identified. i have taken all kinds of anitbiotics over the last 2 yrs. and sometimes the psa responded but this time it did not. The last time my doctor sent a letter telling me we could do a saturation biopsy which i think is where they put me out and get more samples. i guess this is what i need to do. any suggestions would be greatly appreciated. Thanks.

D., a lot of prostatitis just doesn't respond to antibiotics. Did they notice signs of inflammation on any of your previous biopsies? Is your neutrophil count elevated? I think I read somewhere that they can culture the biopsy core for bacteria, and that might be productive even when it doesn't show up in your urine.

A saturation biopsy is the gold standard. They use a template and go through the perineum taking 30 or more cores. I thought they used a spinal nerve block rather than general anesthesia, but I may be wrong. Some of the cores sample from places in your prostate that a normal TRUS-guided biopsy can't reach. Another option available in a few places is using a 3T MRI with an endorectal coil to take multiparametric MRIs and fuse the image with a real-time ultrasound to do a guided biopsy. I know Drs. Bahn, Lee & Ukimura do a color doppler ultrasound-guided biopsy.

All my previous biopsies were negative. On my last biopsy, the pathologist stated he saw moderate chronic inflammation in four areas sampled. (i started getting copies of my pathology report for my file after the 4th biopsy) I don't know what neutrophil count is, could you please tell me what it is? I am going to ask the uro to culture the samples of my next biopsy, that is the first time i have heard about doing that but it makes sense. I have taken about five different types of antibiotics-Cipro, Bactrim, Doxyclcline, Sulfamethoxazole/tmp (only one psa responded to but not this last time).

Thank you for the replies, it is very helpful and appreciated.

That's a tough one for sure. The saturation biopsy isn't fun but not that bad - you're not awake for the procedure. The real question is, what do they hope to find? It might be worth it to give it a try - maybe they'll get better information.

The earlier PSA numbers seem like just normal PSA bouncing around but the rise between March and April is concerning.

Still, it's very possible to be a stubborn infection that's resistant to antibiotics. If they could culture it and see what it is that would be great. Does you Uro think they can do that?

Hang in there and keep us updated,
Andrew

Neutrophils are the major kinds of white blood cells. Neutrophil count is part of the standard white blood cell (WBC) count done in routine bloodwork. They get elevated in response to infection and may be a clue that that is what is going on. Here's a reference to show your doctor:

Low serum neutrophil count predicts a positive prostate biopsy.

They can also culture your prostatic secretions and look at the white blood cells there pre and post a prostate massage.There is a diagnostic test called a Meares-Stamey 4-glass test, where they collect urine pre and post a prostate massage. Maybe you can ask for that before you get another biopsy.

The chronic inflammation means chronic prostatitis (which may coexist in the same prostate with BPH and PC), so you seem to have a diagnosis of that. It's not unusual to have prostatitis that is unresponsive to antibiotics. It's been estimated that about a third of men have chronic prostatitis that is asymptomatic and unresponsive to antibiotics. However, it makes interpreting your PSA a nightmare. %fPSA cannot distinguish well between chronic prostatitis and PC. PCA3 can, but not everyone with PC expresses it. The new PHI test, when available, should do a better job of distinguishing them.

I think that all those transrectal biopsies you've had may have made matters worse. Each time a core is taken, fecal bacteria are injected into the prostate. Also, you've taken a course of antibiotics each time, which increases the probability of bacterial resistance. One good thing about a saturation biopsy is that it is transperineal rather than transrectal, so it is less likely to cause infection even though it is filling your prostate with holes and scar tissue.

I tend to think that you should consider the saturation biopsy. You are kind of in a situation similar to mine, although my PSA was not all that far out of the norm.

I had a horrible case of BPH which, naturally, tended to push my PSA number up a bit. But, as one urologist told me, that does not mean it cannot also be masking the presence of PC. Think of it as a "sleeper" pin while bowling. You think there is only one pin there when there actually is another one hiding behind it.

Anyway, that is my thought. For peace of mind -- and to guarantee your health -- you should give it some thought. If you go for it, be sure the urologist has performed hundreds of saturation biopsies.

Good luck!
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.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.

After reading more about the PCa3 blood test, i am asking myself why my doctor has not told me about this test or has not done this test. It sounds like this test is pca specific, that is it is a gene produced only by P
Ca cells. But i also read if the PCa3 score is low it indicates the probability of a negative biopsy. Is this farily new and maybe that is why my doctor has not mentioned it?

D,
It's fairly new - maybe about 3 years. The process is very similar as for the "4-glass test" for prostatitis -- they both require a thorough prostate massage followed by urine collection. I may be wrong, but I would think they can collect for both tests simultaneously.

D,
What a quandary!! I can't offer you any advise but I wish you well
Bill

I have an appointment this coming thursday with my uro and i believe he will massage my prostrate and then get a urine sample to obtain my pca3 count. i am going to tell uro i want a saturation biopsy done asap. i am going to ask uro if he approaches prostrate through rectum or perinea. i have read where there is no difference in the pca detection abilities of either approach. any comments on rectal vrs. perinea approach? I am also going to ask him about mri or doppler guided saturation biopsy. I have never heard him talk about these type biopsies and think he will tell me he uses ultrasound guided rectal even with the saturation.

D.

Put "free psa" in search; My husband's was 7, which is considered low and low free psa can be indicator of pc.  Free psa of over 20 is generally considered good as it is usually infection.  Not saying it means you have pc, but you definately need more of a look.

Good luck!