High PSA of 35 I would like an opinion

Ralphtoo

I'm 51 with no family prostate history.  I recently started to feel sick one night.  Then I started to feel the need to urgently pee but when I did I almost had to force it out.  It was quite painful too.  

So I went to my GP who did a urine test that showed no UTI.  So I got a blood test and my PSA was 35.  My two previous PSA's in 2016 was 2 & December 2018 1.6.  The doctor wanted me to wait 5 weeks and repeat the PSA test.  I wasn't entirely happy with this so I went to a 2nd GP.  He said the result was interesting and had treated high PSA levels simlar to this before.  He did a DRE and said my prostate was enlarged & firm.  Not sure if that's good or not?.  So he put me on 4 weeks of Nufloxib.  And also wants to do a repeat PSA test in 5 weeks as well.  He has also referred me to a urologist if the PSA is still high by then.  

Anyway the symptoms have gone away but it does still feel tight and uncomfortable in my bladder pelvic region.  I also had some lower back pain but that appears to be going away now as well.

These symptoms that lead to the high PSA level came on all of sudden.  I have had over the last couple of months (not recently though) some mornings where I wake up with some nausea until I pee but apart from that I've had no other symptoms,  I only have to pee once a night (not always) and my stream is full on.  So no issues really until recently.

So with no UTI and such a sudden rise in PSA from low to pretty high what could cause this?. Of course I'm fearing cancer but I've read that prostate cancer usually comes on slow with no symptoms.  So what do you think?. 

Thanks

VascodaGama

You are right. PCa usually comes on slow with no symptoms

Ralph,

Welcome to the board. I think that both doctors you have consulted followed the proper and typical steps to diagnose your situation. Both address the possibility in existing UTI and the later put on antibiotics (Nufloxib), which seems that have already alleviated the symptoms.

The positive DRE could be a cause of inflammation or BPH (benign prostatic hyperplasia) that can be the reason for the high PSA. In one month you will know what is happening. In any case, at 51 years old and with no inflammation or BPH issues the PSA shouldn’t be higher than 2.8 ng/dl if one wants to rule out existing cancer. A higher value could imply the need for a biopsy to clarify the situation, in particular due to the positive DRE.

The level in the PSA test is sensitive to any massage of the prostate. One shouldn’t have sex the night before drawing blood for the test, ride a bike or tractor, or masturbate, as the movements could lead to high PSA results.

I hope it all resolves in your favor.

VG

Ralphtoo

VascodaGama said:

You are right. PCa usually comes on slow with no symptoms

Ralph,

Welcome to the board. I think that both doctors you have consulted followed the proper and typical steps to diagnose your situation. Both address the possibility in existing UTI and the later put on antibiotics (Nufloxib), which seems that have already alleviated the symptoms.

The positive DRE could be a cause of inflammation or BPH (benign prostatic hyperplasia) that can be the reason for the high PSA. In one month you will know what is happening. In any case, at 51 years old and with no inflammation or BPH issues the PSA shouldn’t be higher than 2.8 ng/dl if one wants to rule out existing cancer. A higher value could imply the need for a biopsy to clarify the situation, in particular due to the positive DRE.

The level in the PSA test is sensitive to any massage of the prostate. One shouldn’t have sex the night before drawing blood for the test, ride a bike or tractor, or masturbate, as the movements could lead to high PSA results.

I hope it all resolves in your favor.

VG

PSA velocity

Thanks for that.

I've been extensively going down the Dr Google route.  There's a lot of very confusing and conflictiong information and opinions about this.  I'm hoping it's just prostatitus or BPH, but most things I've read say 35 is pretty high and also reading about PSA velocity has really freaked me out!!!!.  This thing came on pretty suddenly and normally I wouldn't be concerned but the combination of symptoms and the sudden rise in PSA has got me worried about Advanced Pca.  Can it come on that quick (19 months or so) though ????.  

ASAdvocate

35 is High. but

I have read accounts where men had PSA spikes up to 60, and it then returned to normal and no cancer was ever found. I think the world record for non-cancerous PSA was over 200. But, those inflammation spikes don't last long.

There are other tests, like free PSA, PHI, 4K score, that would add more data points. An MRI could determine if possibly cancerous lesions exist. All of those are reasonable next steps if the next PSA test does not show a dramatic drop.

Max Former Hodgkins Stage 3

Ralphtoo said:

PSA velocity

Thanks for that.

I've been extensively going down the Dr Google route.  There's a lot of very confusing and conflictiong information and opinions about this.  I'm hoping it's just prostatitus or BPH, but most things I've read say 35 is pretty high and also reading about PSA velocity has really freaked me out!!!!.  This thing came on pretty suddenly and normally I wouldn't be concerned but the combination of symptoms and the sudden rise in PSA has got me worried about Advanced Pca.  Can it come on that quick (19 months or so) though ????.  

Use your gut

Ralph,

There are medical certitudes, and then there are subjective/impressionistic views and 'wisdom' that doctors acquire over time.  The 'certitudes' regarding PCa diagnosis come only from biopsy, but even biopsies are fairly given to false negatives (showing no disease when it is in fact present).

A PSA of 35 by itself proves nothing, but it damn strongly suggests aggressive PCa.  Hope for the best and assume the worst.  My urologist teaches PCa surgery all over the country via seminars and in our own medical school, and did his own residency at MD Anderson, Houston.   I have asked him personally what he thinks of the notion that a PSA test after sex or strenuous activity might be falsely high, and he said he does not believe it, and has never seen such a scenario in his own practice.   I had chronic prostatitis for 30 years (yes, years), and it never caused a high PSA result for me.  A grossly enlarged prostate prior to removal never caused a PSA increase in my one, ancedotal case either.  (Most prostatitis is non-bacterial/non-viral, and hence antibiotics have no effect on it.)

It is best to assume nothing but use due diligence and request an MRI-guided biopsy now.  Please update us, as your scenario is a clinical outlier.  And avoid Google 'research.'   If you want to read in the mean time, use the Harvard Medical School site, or Johns Hopkins, or Sloan, or MD Anderson, or the Cleveland Clinic.  All are free and offer only professional assessments of diseases.   

Avoid the hemp oil/yoga crowds, of which there are many.

Ralphtoo

Been a year was supposedly OK but another MR has me concerned

Hi Again,

You can all read my history above but essentially last year I had a worrying PSA reading of 35 related to a probably infection.  I say probably because antibiotics appeared to  reduced it from 35 back to 4 and I have had several PSA tests since and they have all been below 3.  My last one was 2.36 with free PSA 26.  I also had a MRI that showed a lesion - left mid to lower third 2 to 6 o'clock peripheral zone some low T2 signal intensity changes T2 3 DWI 3.  DCE No focal enhancements. Overall PI-RADS 3. Everything else was normal.  The Urologist felt that the lesion was most likely scarring left over from the infection.  He said it would probably clear up and told me to repeat the MRI in a year's time.  So we now come to today.

As previously state no indicators since then that anything was wrong.  PSA generally good, DRE's felt normal.  Had another MRI and there was an issue noted and I thought someone might have some ideas. On the Peripheal Zone. There are diffuse low T2 signal changes noted with the peripheal zone from base to apex.  There is associated low grade resricted diffusion demonstrated.  Diffuse enhancement is noted within the peripheal zone.  Overall PI-RADS 3.  Central Gland. There is mild glandular and stromal hyperplasia of the transition zone in keeping with mild prostatic hypertrophy.  There are no concerning regions of restricted diffusion or altered architecture. PI-RADS 2.  Everything else is normal.  In the comments they noted.  There are diffuse low T2 signal changes noted with in the peripheal zone, slightly more pronounced than previously and diffuse low grade restricted difusion. The changes appear more pronounced than previously in the right peripheal zone as well.  As I previously said my PSA is 2.36.

The Urologist told me that 80% of this time it's just inflammation but he's sent my for a transpirneal biopsy nonetheless.  I recently had a melanoma removed and that specialist assured me that it was probably nothing as well so my confidence is a bit shaky at the moment.  Any thoughts would be appreciated.

VascodaGama

MRI only predicts, biopsy diagnosis

I agree with your doctor. The biopsy is the next step and that should have extra needles directional to the lesion found on the MRI. If negative I would follow the PSA tests periodically and continue with an extra MRI in one year for peace of mind. 

Let's hope for a negative biopsy. 

Best

VG 

Ralphtoo

Thanks

Hi there,

Thanks for your reply. 

From my limited knowledge on this whole subject this MRI report seemed to me to be very vague as it did not appear to report anything specific. The diffuse low T2 signal changes appeared to be over the entire prostate (base to apex). Have I got this wrong?. PI-RADS 3 is a very vague "one way or the other" score (it was 3 last year as well).

While he gave me the impression that it was more likely to be inflammation he did also mention that if it was cancer that he would recommend removing the prostate all together.  I guess that this all depends on how advanced it turns out to be but I have heard a lot about Active Survellance for low grade (Gleason 6) cancers. I know that this is highly debatable so my question is at what point (ie: Gleason score) is AS no longer an option?. I have also read that a negative biopsy result does not necesarily mean that there is no cancer, just that this particular biopsy didn't find it.  So how long and how many biopsies woould you have to do to be certain that it wasn't cancer if these same indicators showed up on subsequent MRI's?.

As I said I'm very shaky about this. I have only just gotten over the melanoma which required a rather large skin graft on my head.  So not the best timing all round.

Thanks

Clevelandguy

Targeted biopsy

Hi,

Your right, a non targeted biopsy is just taking a random sample which may or may not show any cancer.  As stated above only the biopsy will determine if you have cancer.  If it was me I would not let them poke my Prostate full of holes unless they knew where to take the sample.  Glad to see your PSA has lowered back to a much lower value.  I have always said you need to find it to kill it so I would do PET or MRI scans untill something showed up and not random biopsys.  But I am not a doctor nor do I play one on TV...................

 

DAVE 3+4

VascodaGama

You are not yet a member of this club

Please note that at the moment you have not been diagnosed with prostate cancer. Surely the comment: "diffuse low T2 signal changes noted with in the peripheal zone, slightly more pronounced than previously ..." is for concern. However the urologist will take this into consideration when planning and delivering the needles. The typical biopsy template of 12 needles usually do not miss difused findings (continuos T2 signal).

In any case you can request for two extra needles directional to the lesion.

A 12 needle biopsy investigates about 0.7% of a normal size prostate (24cc) of a 51 years old, but it aims 3 or 4 areas at each lobe. Missing is possible but rare.

AS is the intervention we all aspire to have once diagnosed. This is not "doing nothing" but a regimen of tests and exams done every year (including biannual biopsy) to certify that the bandit doesn't become over aggressive. 

The conditions leading to recommend AS, are low PSA, Gleason score of 6 or 7 in two to three cores of a 12 template, where the rate 4 is less than 10% of rate 3 in one of the needles. Different institutions may use different parameters. 

Best,

VGama 

 

Old Salt

Active Surveillance

Different institutions have different protocols for Active Surveillance (AS); you might inquire what an institution that your are comfortable with, does with respect to AS.

I agree that the MRI did not identify a specific locus that should be investigated further; in a way, that's good news.

Finally, I concur with Vasco that a negative biopsy doesn't prove that there's no cancer in a prostate.

I do NOT concur with your specialist that surgery would be best for someone in your situation. Perhaps. but we need to know a lot more to decide among the various options in case cancer is found.