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Posted 4/6/2018 1:04 PM (GMT 0)
My PSA level keeps rising even though I have had a negative biopsy. Here are my numbers and any advice or information is greatly appreciated. I am a 49 year old with strong family history of prostate cancer (paternal grandfather and father). My Dad's cancer was aggressive but contained to prostate. He had surgery to remove.

1/7/17: PSA 4.3
4/5/17: PSA 5.2
4/5/18: PSA 7.0

4/14/17: Prostate Biopsy
A. Prostate, right apex, needle core biopsy- benign prostatic parenchyma.
B. Prostate, right mid, needle core biopsy - benign prostatic parenchyma.
C. Prostate, right base, needle core biopsy - benign prostatic parenchyma.
D. Prostate, left apex, needle core biopsy - benign prostatic parenchyma.
E. Prostate, left mid, needle core biopsy - benign prostatic parenchyma.
F. Prostate, left base, needle core biopsy - benign prostatic parenchyma.
Posted 4/6/2018 1:13 PM (GMT 0)
I would get an mpMRI done. Biopsy can be a hit or miss.
Posted 4/6/2018 1:18 PM (GMT 0)
Thanks, ddss. I meet with my Urologist on the 19th and will ask about that. Last year my gastro located a Neuroendocrine Tumor (NET) in my small intestine. Was malignant for carcinoid cancer. Had bowel resection where they found another malignant NET on my appendix with 3 lymph nodes also testing positive. Ever since, I have had either a CT or MRI done every six months. Would normal MRI with contrast detect prostate cancer?
Posted 4/6/2018 1:42 PM (GMT 0)
Sorry Taylor, you are treading through some really rough times.
Normal MRI even with contrast won’t detect cancer. You need to have the specific mpMRI where they dye specifically to detect cancer in th prostrate.
MULTIPARAMETRIC MRI SEQUENCES
Radiologists can use multiparametric MRI to measure the extent of a tumor, identify the location or locations of a tumor, estimate the Gleason score of a tumor and determine whether a tumor has spread beyond the prostate gland. A multiparametric MRI exam consists of three separate imaging techniques (‘parameters’): T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced imaging.
T2-WEIGHTED IMAGING
A T2-weighted imaging sequence provides anatomic information about the prostate gland. It offers detailed visualizations of the prostate gland and its distinct zones. T2-weighted imaging has applications in the detection,
localization and staging of prostate cancers.
On T2-weighted images, cancers in the peripheral zone of the prostate typically appear as areas of enhancement or bright spots against a dark background. Cancers in the transition zone are more difficult to detect. They appear as smudged charcoal against a grey background.
T2-weighted imaging also provides opportunity to evaluate seminal vesicles and the bladder wall to determine if a tumor has spread beyond the prostate. Other prostate conditions can be mistaken for cancer on T2-weighted images.
DIFFUSION-WEIGHTED IMAGING
Diffusion-weighted imaging (DWI) measures the motion of water molecules within the prostate to provide useful functional data about cancers. This sequence produces an ADC value for different areas of the prostate gland. ADC values measure the degree of motion through different tissues. Lower ADC values appear in cancerous tissue than healthy tissue. ADC values also correlate with Gleason scores, with lower ADC values indicating a higher Gleason score.
DYNAMIC CONTRAST-ENHANCED IMAGING
During dynamic contrast-enhanced (DCE) imaging, a contrast agent (gandolinium) is used to evaluate blood flow through the prostate. Cancerous tissue absorbs the contrast agent more quickly than healthy tissue, which is apparent on DCE images. The role of DCE imaging is secondary to T2-Weighted Imaging and DWI, but it can help to detect small, yet significant cancers missed by the other two sequences.

MULTIPARAMETRIC MRI INTERPRETATION
Multiparametric MRI exams are interpreted according to the Prostate Imaging Reporting and Data System (PI-RADS). This is a classification system that uses a 5-point scale to standardize assessment of exams. A PI-RADS assessment indicates the likelihood of intermediate- and high-risk cancers based on findings from the three multiparametric MRI sequences.
PI-RADS 1 – Highly unlikely that clinically signifi cant cancer is present.
PI-RADS 2 – Unlikely that clinically signifi cant cancer is present.
PI-RADS 3 – Uncertain whether clinically signifi cant cancer is present.
PI-RADS 4 – Likely that clinically signifi cant cancer is present.
PI-RADS 5 – Highly likely that clinically signifi cant cancer is present.
Posted 4/6/2018 2:00 PM (GMT 0)
thanks for the great info. Dr. just called and wants to repeat PSA next week right before I meet with him. I am definitely going to discuss this with him.
Posted 4/6/2018 2:11 PM (GMT 0)
With your gradual increase of PSA, I agree you need a mpMRI, as perfectly described by ddyss. However, they are expensive and some urologists are reluctant to recommend them.
A biopsy is the only way to diagnose PCa. Ironically, randomly directed biopsies cannot detect many significant tumors (false negatives) that can be detected by MRI with a 80% true positive probability. But PSA sometimes gives unrealiable results as well. Or the increase may be caused by a not significant G6 tumor that will not probably be detected by MRI. I hope you are reassured about your previous negative biopsy results after the new tests.
Posted 4/6/2018 2:17 PM (GMT 0)
Sir- I am sorry you are dealing with increasing PSA, especially at your age and with significant family history of disease. The mpMRI, as stated in earlier post, can identify regions in the prostate as potentially cancer- that MRI can be used to guide biopsy pins to regions of the prostate that are suspicious in appearance, removing some of the randomness of the sampling process.

I got my first biopsy in 2013 at PSA ~7, 12 pins, all negative-

One year later, a second biopsy on PSA of 14- mpMRI was not then in practice- and after 19 pins, another negative biopsy- went on finasteride for some BPH, that pushed PSA down to 6, but after 18 mos, up to 20 on the PSA- time for another biopsy, but NOW mpMRI was in practice, so that was used to help guide sample sites

there were 4 zones (3 x PIRADS 5, 1 x PIRADS 4)- so on this biopsy I had 12 random cores and 18 guided cores taken in biopsy- even then, the URO was confident we would snip this thing out and I would have a long runway- I was Gleason 10 in most of the cores and scans showed metastasis to nodes outside the pelvis-

I only relate this story to emphasize that yes, biopsies can easily miss cancer and that mpMRI can help reduce that possibility- timing is everything, I expect I might be on a different treatment pathway now had the mpMRI been available on my second biopsy.

I believe there are computer-guided biopsy processes now that correlate the mpMRI with live imaging to place the pins, but it can be done by standard biopsy as well if the PIRADS zones are large enough- the URO uses ultrasound to place pins while looking at the MRI scan for guidance- that is how mine went down-

best of luck to you- in my opinion, you need this now not later- but I ain't a doc and hindsight is near 20/20, isn't it?

rf
Posted 4/6/2018 2:40 PM (GMT 0)
thanks for the great info and guidance. Dr. just called and wants to repeat PSA next week. I will do that and them meet with him to discuss results.
Posted 4/6/2018 4:46 PM (GMT 0)
to my knowledge the only thing that can detect cancer in the fullness of that word...at this point is a pathological exam of the tissue{biopsy}..
Posted 4/6/2018 7:03 PM (GMT 0)
Hi Taylor. I had a similar situation with a rising PSA but a negative biopsy. As my PSA continued to rise, my urologist decided to perform a second biopsy a few months later. That is when it came back positive but with a low Gleason score of 6. We determined watchful waiting was prudent along with continued PSA results. This past Nov it jumped and then jumped again in January when we decided on IMRT/Calypso treatment which I am undergoing currently. It is unsettling to have a rising score but nothing definitive. I see there are some good suggestions in this thread for additional testing. I wish you the very best of luck and hope you receive an actionable diagnosis so you know how to proceed.
Posted 4/6/2018 7:28 PM (GMT 0)
thanks Steve for the response. I was diagnosed last year when a neuroendocrine tumor was located in my small intestine and another on my appendix with lymph node involvement for Carcinoid Cancer. It has been a crazy year and now dealing with this. I will be anxious to get the repeat blood test done next week to see if this week's was a anomaly. Most likely wishful thinking but I will take things as they come. I appreciate your well wishes. Thanks again.
Posted 4/6/2018 9:06 PM (GMT 0)
I think a few biochemical tests would be more useful than an MRI right away. The best/cheapest tests are:

1. Prostate Health Index (PHI). This test includes PSA but also other indicators that are more specific for prostate cancer. It is less subject to errors due to prostatitis or BPH.

2. Confirm MDx. They do a genetic test on your biopsy tissue to identify markers linked to aggressive PC. If this test is negative, you can be sure with about 90% certainty that you do not have prostate cancer. If it's positive, you can go ahead with an mpMRI and another biopsy.

3. PCA3. It is a urine test after a prostate massage. It is specific for prostate cancer, but not every kind of prostate cancer is PCA3 positive.

Did the pathologist note any chronic or acute inflammation on your biopsy report?
Posted 4/6/2018 9:56 PM (GMT 0)
Taylor, Give some thought to switching doctors if yours is not affiliated with a major university. I regretted staying with my local dr as long as I did, through 2 negative biopsies and fortunately switched to another where knowledge of and access to latest techniques is available (in my case 5 years ago MP MRI).

My dr did not even suggest MPMRI and just wanted to keep waiting and doing biopsies every 6 months, perhaps, in part, because he did not want to lose me as a patient, or perhaps because he was unaware of the latest advances in diagnostics. At the end of the day I lost perhaps up to a year in delayed treatment because of this.

This comment is not meant to say all non-university affiliated doctors fall under this umbrella, and most I am sure are responsible and would refer you to another facility if required, and if they were aware of the latest techniques. Just keep this in mind.
Posted 4/7/2018 8:50 PM (GMT 0)
Diagnosis of PCA is an inexact science.

Like others here, I had a rising PSA and multiple negative biopsies. Had a PCA3 test that was favorable. Finally, had an mpMRI that was then used for a 21 core Fusion biopsy (had PIRADS 2s and a 3). Was diagnosed as a G6 - but the 2 positive cores were not from areas identified as of interest by the MRI - which were called high grade PIN. Decided to pursue AS. Had another mpMRI in December as a follow up and the Rads are still discussing whether I have PIRADS 2, 3 or 4 called - and this is from a major teaching and referral oncology service. Reading prostate MRIs is difficult. I am scheduled for a confirmatory biopsy next month (14 months after original DX), so I suppose we shall see.

The upshot is that, unfortunately, PCA diagnosis is a difficult and inexact process. As long as you are experiencing a rising PSA, you should continue to pursue a diagnosis.
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