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Medical Forum / Diseases and Disorders / Prostate BPH / March 2005Radical surgery w/out positive biopsy ?
Over the last 8 years my dad (67 yo) had PSA going up and down, between 12 and 24, now around 15. 3 8-core biopsies were negative, but they were performed by the same doctor. Free PSA was measured twice (7% in 1999, 15% in 2003), but both times with PSA > 10, so I'm not sure how indicative it was. Prostate is markedly enlarged, 7cm x 6cm x 5.5cm based on a CATscan. At this point we don't feel like doing more biopsies because there are rumors they may actually speed up spreading of metastasis (is it true, BTW) ? My dad is open to a radical surgery, though (he is fully aware of potential side effects). So I have a few questions: 1. If a tumor has spread, could it become more aggessive after a radical surgery ? 2. If a tumor has not spread, could a radical surgery cause it to spread ? 3. Are there cases when a radical surgery has been performed without a positive biopsy, but just based on the PSA history ? As always, different doctors have different opinions, so I would really appreciate any kind of advice, especially if somebody had similar experience. > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they [quoted text clipped - 6 lines] > rumors they may actually speed up spreading of metastasis (is it true, > BTW) ? I haven't seen any convincing evidence that this happens. > My dad is open to a radical surgery, though (he is fully aware > of potential side effects). I would be very surprised if he could find a surgeon willing to do a radical prostatectomy without a biopsy showing prostate cancer. > So I have a few questions: > > 1. If a tumor has spread, could it become more aggessive after a > radical surgery ? That has been suggested for various cancers, but there doesn't seem to be any convincing evidence that it happens for prostate cancer. > 2. If a tumor has not spread, could a radical surgery cause it to > spread ? Ditto. > 3. Are there cases when a radical surgery has been performed without a > positive biopsy, but just based on the PSA history ? I've never heard of it, but I suppose it is possible that it is done in very special circumstances. You should ask your doctor about it. > As always, different doctors have different opinions, so I would really > appreciate any kind of advice, especially if somebody had similar > experience. I would be surprised if there were substantial disagreement among doctors about the points you raise. >> rumors that biopsies may actually speed up spreading of metastasis > I haven't seen any convincing evidence that this happens. Leonard, thanks a lot for all your crystal-clear points. But the knowledge about PC is changing so rapidly, that we always feel uneasy about any intrusive procedure in the place that is, obviously, not well in some respect. Just an example - it was always assumed that fatter people have more aggressive PC; but now it's been proven false - it's just that their PSA is more diluted, so it crosses the biopsy-triggering level later. Ikon wrote...snip... > it was always assumed that fatter > people have more aggressive PC; but now it's been proven false - it's > just that their PSA is more diluted, so it crosses the > biopsy-triggering level later. Don't think it has been proven false. It's just that the more aggressive the PCa (e.g. higher GS), the lower the PSA output from the tumor. Hence, many men with high BMI have high GS, but relatively low PSA. So I think the point was that because men with high BMI can have higher GS tumors with what appears to be "normal" PSA readings, they need to be especially vigilant...Ron I'd do at least three other things first: 1. Get a TRUS-guided 12(maybe more?)-core biopsy, 2. Look elsewhere for the cancer, via CT, bone scan, etc., and 3. Try a different urologist, one who might have suggested more samples at least by the second biopsy. PC is PC, and pumps out PSA, whether it's in the prostate or in our shoe. Biopsies, even surgery, are shown not to spread PC, from what I've read. I.P. > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they [quoted text clipped - 18 lines] > appreciate any kind of advice, especially if somebody had similar > experience. > I'd do at least three other things first: > 1. Get a TRUS-guided 12(maybe more?)-core biopsy, [quoted text clipped - 7 lines] > > I.P. For other cancers, it has been known for years that when a primary tumor is cut out, secondary tumors quickly spread. It just happened to a family friend with kidney cancer. The primary tumor suppresses the others. It may well be one reason why so far the tests on PC have shown no great benefit (about 10 years) over doing nothing. But who knows. Science certainly does not. Do those other cancers continually pump cancer cells directly into the blood stream as PC does? If not, surgery may be their first access to the rest of the body. PC has had access to our whole bodies for years, maybe decades, so Bx or surgery doesn't add a whole lot to our exposure, as I understand it. I.P. "George Conklin" <georgeconklin1@earthlink.net> wrote > > > For other cancers, it has been known for years that when a primary tumor > is cut out, secondary tumors quickly spread. It just happened to a family > friend with kidney cancer. The primary tumor suppresses the others. It may > well be one reason why so far the tests on PC have shown no great benefit > (about 10 years) over doing nothing. But who knows. Science certainly does > not. > "George Conklin" <georgeconklin1@earthlink.net> wrote > > > > For other cancers, it has been known for years that when a primary tumor [quoted text clipped - 7 lines] > > > > Do those other cancers continually pump cancer cells directly into the blood > stream as PC does? If not, surgery may be their first access to the rest of > the body. PC has had access to our whole bodies for years, maybe decades, so > Bx or surgery doesn't add a whole lot to our exposure, as I understand it. > > I.P. Most cancers have good blood supplies. But do they specifically eject cancer cells into the bloodstream as PC does? I.P. > Most cancers have good blood supplies. > But do they specifically eject cancer cells into the bloodstream as PC does? > > I.P. > >> Most cancers have good blood supplies. I think this is misleading. PSA is a natural product of the prostate; it is what makes semen "thin" just after ejaculation. Where it SHOULD NOT be is in the blood. PSA in the blood is a good indication of PC, but not definitive. The PC actually spreads to the lymph system and generally goes to the bones/lungs. The high PSA level can mean that the PSA is actually being produced in the bones as well as the prostate. Once this spread has occurred, no surgery will stop it. You are left with hormone therapy, which eventually fails as the cancer mutates. Unfortunately, nobody seems to have devised any drug that attacks PC directly; all they can do is indirectly try to shut off your testosterone level, as in its early stages PC needs this hormone. I hope that has helped. >> But do they specifically eject cancer cells into the bloodstream as PC >> does? [quoted text clipped - 7 lines] > NOT be is in the blood. PSA in the blood is a good indication of PC, > but not definitive. It is perfectly normal for men without prostate cancer to have significant levels of PSA in the blood. I'm not sure of the mechanism, but some of the PSA produced in the prostate does normally get into the blood. Only men without prostates should have PSA levels which are essentially zero. (Minute amounts are created elsewhere, so exactly zero levels may never be attained.) In addition, the great majority of men whose PSAs are considered elevated above normal by current standards do not have prostate cancer. Moreover, the overwhelming majority of men whose prostate cancer is detected early by PSA testing do not have spread of the disease to distant sites. A PSA significantly higher than 10 does suggest that spread is more likely, but large numbers of men with such levels either do not have prostate cancer or have prostate cancer confined to the prostate gland. > The PC actually spreads to the lymph system and generally goes to the > bones/lungs. The high PSA level can mean that the PSA is actually being > produced in the bones as well as the prostate. It is a bit complicated because not all prostate cancer cells produce PSA. But generally, by the time prostate cancer has spread to the bones, the PSA levels will be very high, much higher than any cutoff points currently being used to diagnose early prostate cancer. > Once this spread has occurred, no surgery will stop it. You are left > with hormone therapy, which eventually fails as the cancer mutates. > Unfortunately, nobody seems to have devised any drug that attacks PC > directly; all they can do is indirectly try to shut off your > testosterone level, as in its early stages PC needs this hormone. I agree with that, but I think the preceding statements were misleading. > I hope that has helped. > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they > were performed by the same doctor. Free PSA was measured twice (7% in > 1999, 15% in 2003), but both times with PSA > 10, so I'm not sure how > indicative it was. Prostate is markedly enlarged, 7cm x 6cm x 5.5cm > based on a CATscan. You're a good son helping your dad out with this. Since the PSA fluctuates and the proststate is enlarged, it sounds like your dad probably has some level of prostatitis. However the consistently elevated PSA and the borderline to low free PSA would concern me. It could all be explained by the large gland but I wonder. > At this point we don't feel like doing more biopsies because there are > rumors they may actually speed up spreading of metastasis (is it true, > BTW) ? My dad is open to a radical surgery, though (he is fully aware > of potential side effects). So I have a few questions: There is no evidence that I am aware of that biopsy may spread prostate cancer outside of the prostate. Cancerous cells are continually released into our body through a variety of mechanisms (a biopsy is one). However, it is difficult for prostate cancer cells to survive outside of the prostate. As the cancerous cells grow within the prostate, eventually they do acquire the ability to survive outside the prostate. When this happens they don't need a biopsy to release them. There is evidence that in a small percentage of biopsies, cancerous cells do appear along the needle tracks, but still contained within the prostate. > 1. If a tumor has spread, could it become more aggessive after a > radical surgery ? This is Folkman's hypothesis and I am not aware of any studies that support it for PCa. There are studies that appear to argue against it for PCa. > 2. If a tumor has not spread, could a radical surgery cause it to > spread ? See above > 3. Are there cases when a radical surgery has been performed without a > positive biopsy, but just based on the PSA history ? > > As always, different doctors have different opinions, so I would really > appreciate any kind of advice, especially if somebody had similar > experience. Most PCa tumors originate in the peripheral zone and so this region is (usually) preferentially sampled during biopsy. However, about 20% of PCa tumors are located in the transition zone. They tend to grow large and put out a lot of PSA, but are often detected late because of the lower sampling rate in this region. You might want to discuss this possibility with a urologist and see if using more than 8 sticks and taking a good look at the transition zone would make sense...Best wishes and good health, Ron Contrary to some suggestions, an RP may be performed to deal with an enlarged prostate even though biopsies are negative. A retired personal friend who was a board certified internist had serious concerns with repeat PSA tests over 20, an enlarged prostate over 120 grams, and no PCa. Medical treatment to shrink the gland did not do the job, an attempt to deal with urinary problems by a TRUS did not work, and he and his urologist decided to deal with the discomfort by taking it out. The pathology was all negative. He is now in excellent condition, plays tennis every day, and drinks more than his share of beer. > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they [quoted text clipped - 18 lines] > appreciate any kind of advice, especially if somebody had similar > experience. >Contrary to some suggestions, an RP may be performed to deal with an >enlarged prostate even though biopsies are negative. [quoted text clipped - 7 lines] >excellent condition, plays tennis every day, and drinks more than his >share of beer. Thanks for the post. After sitting at about 10 for around 5 years, my PSA has risen to over 20 in a year. So I'm heading for a biopsy. Your info and that of others gives me encouragement that it might not be cancer. Just curious... after a radical prostatectomy, how is incontinence handled? Ed > After sitting at about 10 for around 5 years, my PSA has risen to over > 20 in a year. So I'm heading for a biopsy. Your info and that of [quoted text clipped - 4 lines] > > Ed Prior to having a TURP in 98, my PSA went from 4 to 17 over a period of several years. Had two negative biopsies. Dr. attributed high PSA to enlarged prostate. After TURP, PSA dropped back to 4 and has been there ever since. Don [quote]Just curious... after a radical prostatectomy, how is incontinence handled? [/quote] Most men have little control for the first few days when standing or walking. Sitting down or laying down is fine usually. After a week or two of doing a few kedgels, you will gain some control of dribbling when standing. You will find a slow improvement in a couple of months and find that walking or standing is fine ,too. You will then have 'Stress incontinence", caused by sneezing, coughing, farting, getting down under a table to pick up something, or carrying a heavy load. 4 months post op. I am getting a handle on 'Stress incontinence" and wear only one pad a day which only catches the very occaisional dribble. I am optomistic that I will be continent in 12 months............or less! Ronaldo I could cough, sneeze, laugh, cry, fart (that was the toughie), pick things up from the floor, stop midstream, etc. the day my catheter came out. None of that has changed except farting without peeing is easier. But here I am going on four months and I'm still squirting most of my standing moments unless I'm concentrating 95% on Kegels. If actually DOING anything distracting, especially involving exertion, I'll fill a diaper in an hour. It is improving, but only lately and only slightly. The "average" recovery is primarily a mathematical entity; we each have our own pattern. I.P. > [quote]Just curious... after a radical prostatectomy, how is > incontinence [quoted text clipped - 17 lines] > > Ronaldo > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they > were performed by the same doctor. Free PSA was measured twice (7% in > 1999, 15% in 2003), but both times with PSA > 10, so I'm not sure how > indicative it was. Prostate is markedly enlarged, 7cm x 6cm x 5.5cm > based on a CATscan. You're a good son helping your dad out with this. Since the PSA fluctuates and the proststate is enlarged, it sounds like your dad probably has some level of prostatitis. However the consistently elevated PSA and the borderline to low free PSA would concern me. It could all be explained by the large gland but I wonder. > At this point we don't feel like doing more biopsies because there are > rumors they may actually speed up spreading of metastasis (is it true, > BTW) ? My dad is open to a radical surgery, though (he is fully aware > of potential side effects). So I have a few questions: There is no evidence that I am aware of that biopsy may spread prostate cancer outside of the prostate. Cancerous cells are continually released into our body through a variety of mechanisms (a biopsy is one). However, it is difficult for prostate cancer cells to survive outside of the prostate. As the cancerous cells grow within the prostate, eventually they do acquire the ability to survive outside the prostate. When this happens they don't need a biopsy to release them. There is evidence that in a small percentage of biopsies, cancerous cells do appear along the needle tracks, but still contained within the prostate. > 1. If a tumor has spread, could it become more aggessive after a > radical surgery ? This is Folkman's hypothesis and I am not aware of any studies that support it for PCa. There are studies that appear to argue against it for PCa. > 2. If a tumor has not spread, could a radical surgery cause it to > spread ? See above > 3. Are there cases when a radical surgery has been performed without a > positive biopsy, but just based on the PSA history ? > > As always, different doctors have different opinions, so I would really > appreciate any kind of advice, especially if somebody had similar > experience. Most PCa tumors originate in the peripheral zone and so this region is (usually) preferentially sampled during biopsy. However, about 20% of PCa tumors are located in the transition zone. They tend to grow large and put out a lot of PSA, but are often detected late because of the lower sampling rate in this region. You might want to discuss this possibility with a urologist and see if using more than 8 sticks and taking a good look at the transition zone would make sense...Best wishes and good health, Ron "This is Folkman's hypothesis" 3 gold stars for you, Ron! He made so much sense; I really thought he was onto something. But, as you implied, angiogensis inhibitors for PCa did not pan out. Bill Denton RP 2/12/02 Memphis Besides, we NEED angiogenesis, for everything from exercise recovery to heart attacks. Angiogenesis is our FRIEND . . . unless it's killing us. I.P. > angiogensis inhibitors for PCa did not pan out. > "This is Folkman's hypothesis" > [quoted text clipped - 6 lines] > RP 2/12/02 > Memphis They certainly did for rat PCa and there seems to be an additional factor in human PCa. Recently angiogensis inhibitors have shown some promise in other cancers. Attention Posters: There is a "cancer" newsgroup and a "BPH" newsgroup. Please don't confuse them when you decide where to post. There is a reason that they're separate. Thanks, Ron > From: "George Conklin" <georgeconklin1@earthlink.net> > Organization: EarthLink Inc. -- http://www.EarthLink.net [quoted text clipped - 17 lines] > in human PCa. Recently angiogensis inhibitors have shown some promise in > other cancers. Ikon, Assuming his doctor feels no nodes and his PSA vacillates without an upward trend, considering his negative biopsies, it is very possible that he has BHP, a benign problem with his prostate. However, if your doc suggests another biopsy, or if you get another opinion and he suggests another biopsy, then I'd get the biopsy. I've never heard anything suggesting that biopsies aggravate cancer. They aggravate PSA, but not PCa.  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3bN0M0 Seminal Vesicle involvement, Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05 PSA .07 .05 .06 .05 non Illegitimi carborundum > Over the last 8 years my dad (67 yo) had PSA going up and down, between > 12 and 24, now around 15. 3 8-core biopsies were negative, but they [quoted text clipped - 18 lines] > appreciate any kind of advice, especially if somebody had similar > experience. |
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