LOW PSA prostate cancer? Anyone else?

Hi Everyone! I want to start out by saying this forum has been so very informative. Thank you for all of your contributions...
Here is our story; my husband is 46 years old. No PC family history except for an uncle . He has had some minor LUTS for a couple of years... mostly just a slow flow in the am. Don't know if that is from prostatitis or from the cancer.
I was a bit concerned by these symptoms and had him get his first PSA test back in May 2018 at age 43. It came back as 2.3 with a free psa of 17%. Urologist said it was normal... don't worry. I wasn't totally convinced... but hey he is the proffesional. What do i know?
For the next 7 months, I could not shake this nagging feeling that something was wrong... earlier this month I encouraged him to go back to get his PSA checked... I actually found you can order a PSA test yourself from a website called Accessa labs- they send you to the local quest diagnostis to draw blood and then you get the PSA results in your inbox a couple of days later. This time his PSA was lower- 1.9 but the free psa was 11%. We decided to get him checked again but by a different urologist. At this point my husband is super irritated with me and thinks I have built this whole thing up in my head... but he goes along with it as he wants me to relax. We go to a UCLA urologist, show him the PSA results, he shrugs and says it's normal. I then embelish on family history and ask him if there are any additional tests that can be done to prove he is ok. Dr agrees to order a 3TmpMRI.... Hubby is not happy as we are paying out of pocket, but again he just wants me to relax so he goes ahead with it.
Well my intuition was correct. The MRI comes back with a 1.2cm lesion that is a Pirads 5/5. The mri shows no capsular involvment, seminal vesicles, lymph nodes, etc are all clear. The characteristics of the lesion suggest it is aggresive.
We now have a biopsy scheduled for next week.
I am so scared that he will be one of the unlucky guys to have the LOW PSA agressive variety of prostate cancer...
Any other guys with low PSA that had a pirads 5 mri?

Post Edited (Beena77) : 1/31/2019 3:08:40 PM (GMT-7)

I would have posted something similar, but Andrew covered the issue quite nicely.
Good luck with the biopsy; I hope your husband has a urologist with a lot of experience in needling prostates. Some of them are better than others. The anesthesia may also vary. Inquire ahead of time if your husband has concerns.

Leah, I'm new to this forum as well. It's a great place and there are many knowledgeable people here. That said, I too am a low PSA cancer positive guy, in my case 1.2 - even down a bit from a few years ago - with 3 positive cores. So your husband is not alone.

I wish him and you best of luck. I consider myself extremely fortunate to have a wonderful wife, and I'm sure your husband would say the same!

A very important part of the biopsy procedure is that the patients takes an anti-biotic in advance. Do not skip this crucial step, since a bad infection is a risk of the prostate biopsy! For most people the biopsy is weird but not horrible.

2019Guy said...
Leah, I'm new to this forum as well. It's a great place and there are many knowledgeable people here. That said, I too am a low PSA cancer positive guy, in my case 1.2 - even down a bit from a few years ago - with 3 positive cores. So your husband is not alone.

I wish him and you best of luck. I consider myself extremely fortunate to have a wonderful wife, and I'm sure your husband would say the same!

It is encouraging to see you can have a G6 and low PSA. Do you know what your MRI overall pirads score was?

Leah,
You husband is lucky to have such a good nagging wife.
Biopsy experience is not pleasant but critical step as others have pointed out. I just want to add that there is no correlation between a pirads score and a Gleason score - so don’t worry too much about it. Pirads 5 means that there is high level of confidence that it is a cancerous lision.
Make sure you read up on what to expect after biopsy. There are many threads on this forum on that subject. It’s mostly inconvenience of some order ( for lack of better words).

Leah, welcome to the club--there are other wives here as well who post about their husband's stories. You'll know a lot more in a week or so--and the docs at UCLA are highly regarded, so he's in good hands.

It might be a good plan to learn what Gleason scores mean, and how they fit the risk levels. A common event is for someone to have a biopsy, and have it come back with a small amount of G6--and then at the next consult the patient schedules surgery for the next week. Unless he comes back with significant G8 or G9 cancer (which is possible but very unlikely), you will have weeks or even months to make a treatment decision IF he comes back positive after the biopsy--which he may not.

When you get the report, ask for a paper copy, and post the results here. We'll help you interpret it and work through the next steps--which may include: "go home and don't worry about it".

Hey guys, thanks for calming me down. I have been researching everything PC for the last few weeks. I am pretty familiar with what the different gleason scores mean, etc.
The MRI is what had me worried- In case you are curious, here is what it says

CLINICAL HISTORY: prostate cancer focus/family hx
PSA 1.9 ng/mL

COMPARISON: None.

TECHNIQUE: MRI of the pelvis was performed on a 3 Tesla Siemens Skyra scanner. A transabdominal phased array was used. Small field of view sagittal, axial oblique and coronal oblique T2W TSE high resolution images and diffusion weighted images with
apparent diffusion coefficient map were obtained. Pre- and post-contrast axial dynamic view-sharing time-resolved gradient recalled echo T1-weighted images are acquired with intravenous administration of gadolinium contrast. Offline post-processing on a
dedicated InVivo DynaCAD 3 workstation was performed for generation of time-intensity curves and pharmacokinetic maps and 3D contouring of the prostate gland and any target lesions using combined automated and manual segmentation techniques Full field of
view axial T1- and T2-weighted images through the pelvis were also acquired

CONTRAST: gadobutrol (Gadavist) 1 mmol/mL inj 10 mL.

GLUCAGON: No

FINDINGS:

Quality: Motion artifact mildly degrades the examination.

The prostate measures 32 g based on contour, (4.4 cm x 3.9 cm x 4.6 cm).
PSA Density: 0.06 ng/mL/cc

The background transition zone is normal. The background peripheral zone is heterogeneous with linear and wedge-shaped areas of T2 hypointensity likely reflecting prostatitis or sequela thereof.

The following appears suspicious (> PI-RADS 3):

Target #1 / ROI #1 (3D T2 slice #41)
location: left anterior transition base
Clock-face axial location: 1-2 o'clock
Cranio-caudal location: 70-80% of distance from apex to base
Longest diameter: 1.2 cm
Capsular involvement: may abut the capsule
T2 signal: oval moderately hypointense signal with obscured margins, 4/5 suspicion
Diffusion-weighted imaging: focal very markedly hyperintense high B-value DWI and very markedly hypointense ADC, 714 square microns/second, 5/5 suspicion
Dynamic contrast-enhanced perfusion: early, non-intense (< 200% increase) positive
Enhancement kinetics: Ktrans 0.110, Kep 0.698, iAUC 3.020
Suspicion for extracapsular extension: 1 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
Suspicion for neurovascular bundle involvement: 1 (1 = none, 2 = possible, 3 = highly likely)
Suspicion for seminal vesicle invasion: 1 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
Overall PI-RADSv2 Score: 4/5 (1=very low suspicion, 5=very highly suspicious).
Overall UCLA Score: 4/5 (1 = very low suspicion, 5 = very highly suspicious).

There is no lymphadenopathy. Heterogeneous marrow signal. No focal bone lesions are present. Sigmoid diverticulosis.


IMPRESSION:

1. Focal findings suspicious for neoplasia as above.

2. Capsular margin: intact - no suspicion for involvement.

Standardized reporting guidelines follow recommendations by ACR-ESUR PI-RADS v2

I, Haatal Dave, M.D., have reviewed this radiological study personally and I am in full agreement with the findings of the report presented here.

Appendix (based on UCLA data/publications)

Overall MRI sensitivity for prostate cancer detection = 47%
Sensitivity for tumors > 1 cm or for Gleason > 3 + 4 = 72%

Biopsy yield for prostate cancer based on overall level of suspicion:
3/5 = 16 - 24%
4/5 = 37 - 78%
5/5 = 80 - 96%

I concur with some of your early intuitions.
Best of luck.

Thanks for sharing the details of the report. These are always interesting to read...

Some prostatitis (benign prostate infection) observed in the peripheral zone. This projects like cancer, but the "wedge-shape" of the pattern is the indicator; cancer would be more rounded. Nothing specific to worry about here.

The finding of interest (target #1) was in the left anterior transition base...cancers in this area are rarely palpable (cannot typically be felt by DRE). location description is provided; the finding may "abut the capsule," but there is an abundance of "fibromuscular stroma" which protects that area. The most significant MRI test for PCs in the transition zone is the T2 imaging signal...keeping in mind that the "multi-parametric" MRI is several different tests which all look for different things. So, once it was determined that the transition zone was of interest, your husband's "Overall" score of 4/5 is based on the T2 score of 4/5. It was very favorable (perhaps obviously) that NVB and SVI were very low suspicion.

You must of course keep in mind that the PI-RADS score is NOT an indicator of aggressiveness; only an indicator that clinically significant cancer is likely present, which means something more than 3+3. 3+4 is still the most common biopsy finding for PI-RADS 4/5 mp-MRIs. Only the Gleason score coming from a prostate biopsy tells the aggressiveness. The likelihood of a clinically significant tumor being found for the 4/5 case is listed at the bottom as between 37% and 78%...I've seen it listed elsewhere squarely at 60%.

Expect the biopsy to find something which will be "clinically significant," and will likely require treatment.

A high Gleason finding in biopsy may be troubling; high Gleason with low PSA often is troubling...as was your prior intuition.

Best wishes...

My PSA was around 2.4-2.5 not moving for a few years and what triggered the biopsy was positive DRE and family history. You can look my signature for more details, findings, and treatment.

Hi Michael, I am encouraged by your stats! Right now the urologist is Dr. Stuart Holden. He has been around forever, I believe he is in his late 70's. Thursday hubby is getting a biopsy done by Dr. Pantuck.
Please let me know who you reccomend. Thanks

My PSA was 0.7 and I was diagnosed by biopsy with 4+3 and 3+3.
I was incidentally diagnosed with prostate Ca after TURP which was 3+3.
Had RALP in November of 2016. Thankfully, I was downgraded to 3+4 post surgery.
MK