Work up complete - headed for surgery

I had a PSA done in June which was 15 (outpatient Quest lab drawn on a Friday, sample run on Monday in a different state. I followed up at a close by regional cancer center who repeated the test 1 month later (24) - different lab in house.

MRI, followed by fusion biopsy - showed 2 lesions 1.9 CM ( rt. peripheral) and 0.7 CM (lt.transitional). Path sowed gleason 7 (3+4), < 20% grade 4 in 3/14 cores, 2 being the target lesions.

MRI was negative for extra prostatic spread.

PSMA scan was negative for prostate mets - there was some low areas signal in the region of centralized hyper metabolic bronchiectasis in the thorax. Follow up CT chest and pulmonary consult demonstrated sarcoid and central/upper lobe bronchiectasis in the setting of upper lobe pulmonary fibrosis and traction on healthy structures - this dates back to 2016 asymptomatic with no significant pulmonary impairment. Fine for surgery.

I chose surgery because because of previous radiation therapy to my retropertonial nodes in abdomen and left pelvic lymph nodes in 1982 when I was treated for testicular cancer. Radiation therapy back then wasn't as precise as it is today and it's likely my prostate got a lot of scatter - so I wasn't comfortable leaving it in and then blasting it with more radation - particularly since there is disease in both lobes.

I will be at high risk for bio chemical recurrence - may need salvage radiation +/- meds down the road.

Bad news is I can't get scheduled until late October, best surgeon in town booked until then (he has done about 1,000 cases).

Every professional I have seen is perplexed by the PSA, doesn't quite fit the picture:

• biopsy missed a higher grade lesion?
• pathology error? (will likely get upgraded on final path after surgery?
• lab error on 2nd reading (15 to 24 in 1 month)
• my prostate in small 27 grams, 1 of the tumors is big in a small prostate?
• PSMA scan is only 90% accurate, missed mets? certainly possible, existing tumors had avid uptake for sure

Navigation of the medical system has proven to be very frustrating - you really have to be your own advocate.