-
MRI for elevated PSA
My husband is almost 2 years since diagnosis (High grade T1), has had several rounds of BCG. This last round went fine but the blood work showed an elevated PSA (6.49). His previous BCG was 5 months ago, it was interrupted by the shortage and corona. They want to do a pelvic MRI this week. I thought an elevated PSA was a side effect of BCG?
January 2018 it was 1. 68, dx in August 2018, had surgery and started BCG. Next PSA was January 2019 and it was 6.18, then in October 2019 it was 5.53 and now this one from last week is 6.49.
-
13 Replies
-
I forgot to mention about incidental prostate cancer. The incidental prostate cancer is when the prostate cancer is found by accident when they were examining a patient for non prostate cancer related diseases. University of Southern California and University of Iowa did such studies based upon the patients who had radical cystectomy.
University of Southern California checked 1,476 patients who underwent RCP (radical prostatectomy) between 1970 and 2008 for urothelial carcinoma of the bladder (without prior known history of prostate cancer), 559 patients (38%) were identified to have incidental prostate adenocarcinoma. Please note is seems that the procedure to remove the prostate including during radical cystectomy for bladder cancer is called RCP(radical prostectomy). Anyway, 38% of bladder cancer patients who had removed the bladder happened to have prostate adenocarcinoma.
University of Iowa found that 34% of the bladder cancer patients who had radical cystectomy was found to have prostate cancer (adenocarcinoma).
A study looking at autopsy of general public who were not known to have prostate cancer before they died found prostate cancer from 5% at age of 30 and under and 59% at age greater than 79 years old. So the data from USC and University of Iowa make sense because 1 in 9 males will have prostate cancer according to American Cancer Society website and 90% of bladder cancer patients are over 60 years old at the time of the initial diagnosis.
So, though they found a lesion by MRI which was done because of the rise in the PSA value of your husband, high percentage of males – seniors have prostate cancer anyway regardless of the status of other disease, including bladder cancer. Please note that many prostate cancers are slow growth and will not affect much the patients. It is known that many men die with other causes without knowing that they had prostae cancer.
This is another reason I think the lesion found is prostate originated.
Link to the paper by Univesity of Iowa regarding incidental prostate cancer of bladder cancer patients who removed the bladder.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5031900/
Link to the paper which investigated the incidental prostate cancer of those who died for other reasons.
-
First of all, I do not have any medical background. So, I was hesitant to post my reply as the information I have is limited to my own experience and “Googling”. So, please read with a big grain of salt.
I am sorry to hear that your husband feels tired. In my case, when the first CT scan was done, not only they found a mass in my bladder and the enlarge prostate pushing my bladder. My urologist had a challenge time to put a scope as the prostatic urethra (the portion of urethra going through the prostate) was squeezed by the enlarged prostate. So, about six months after my bladder cancer was diagnosed with non-muscle-invasive and intermediate grade, I had a surgery to scrape out much gland. Luckily the biopsy of the gland was benign. Before the surgery, I had problem of holding pee. Perhaps, because of the anxiety of always thinking about it and going through the initial stage of being a bladder cancer patient, my blood pressure went up high. So, I was put on blood pressure pills.
When I was attending a local prostate cancer support group, I did not met anyone who had developed prostate cancer from bladder cancer but I became aware of cases prostate cancer patients developed bladder cancer from the treatments. A guest urologist mentioned that he had recently seen patients who had a radiation therapy in the past for the prostate cancer developed the bladder cancer. There is also a treatment called prostate brachytherapy or internal radiation therapy which places many radioactive seeds into the prostate. I know a patient who developed bladder cancer because a seed got into the bladder.
In terms of bladder cancer progressing into the prostate, the study I listed showed that if the bladder cancer is stage 4a, which means the cancer also penetrated through the muscle layer and the fat layer, it could go to the prostate. This would not apply to non-muscle-invasive bladder cancer. But, the same study reported that some T2,T3 muscle invasive bladder cancer patients and including non-muscle-invasive patients showed the cancer in the prostatic urethra (the portion of urethra going through the prostate) or prostate duct. Please note that the study was based on those patients who had radical cystectomy. Please note that the study does not say how many patients out of 1400 patients who had radical cystectomy were non-muscle-invasive patients or why non-muscle-invasive patients decided to have radical cystectomy though I suspect that intravesical BCG did not work to them. Anyway, I would expect that the number of non-muscle-invasive bladder cancer patients who had successful BCG treatments or in the treatment will have prostate involvement only in rare cases.
So, I think it is likely a prostate related lesion. Because the prostate consists of many mucous glands that secretes fluid to carry semen at ejaculation, the healthy prostate look white in MRI. A lesion is usually a darker spot in the MRI image. Incidentally, adenocarcinoma (adeno means gland in Greek) is the most common cancer in the prostate. Often, it can be controlled by stopping the external stimulus, the male hormone testosterone. But bladder cancer ( urothral carcinoma ) grows without external stimulus. They are different even in genomic analysis.
I have watched a few videos in which pathologists explain how to distinguish adenocarcinoma from the area which looks abnormal but not adenocarcinoma, caused by inflammation, infection and other reasons. So, it is possible
the lesion in the MRI image could be something else than adenocarcinoma.Incidentally, it is good that MRI was done first. They know the location where they get biopsy from. In the past, they sometime pissed the spot. I have read that now a days, they use MRI assisted biopsy so they do not miss the spot. Also I expect that they would get samples from different spots of the prostate.
I hope the biopsy on 18th goes smooth. It is noted that according to cancer.net the 5-year survival rate for most men with local or regional prostate cancer is nearly 100% compared to 77% of bladder cancers. So, the odds is in your husband’s favor.
Best wishes
-
Interesting. So the lesion could be unrelated prostate cancer or still could be nothing but not likely metastatic bladder? My only red flag that could also be nothing is that in the last few months, he seems more frail, slower.
The biopsy is scheduled for 8/18, if his Covid-19 test is negative.
-
1. Bladder cancer and prostate cancer
Below is the link to Mayo click study on prostatic involvement of bladder cancer.
– They had 1404 radical cystectomy between 1980 to 2006.
– Of 1404 patients, 201 patients had prostatic involvement (prostate cancer).
– Of 201, 75 patients were non-muscle-invasive bladder cancer patients.
– Most of non-muscle-invasive bladder cancer patients did have BCG treatment, but the report did not say
if they were BCG non-responsive patients or not.https://bjui-journals.onlinelibrary.wiley.com/doi/pdf/10.1111/bju.12486
2. Metastasis
Interestingly, several studies I read excluded prostate cancer as metastasis by bladder cancer. They include distant organs, including lymph nodes. MRI should be able to tell if lymph nodes were affected.
-
Sorry, the lesion is on the prostate. He originally was diagnosed with bladder cancer in August 2018.
-
Very unlikely to be prostate cancer if it was in the bladder. Unlikely to be mets since it is in the bladder. You will just need to wait and discuss this with the doctor. It is probable that he will want to do a TURB.
Good luck to you both
Sara Anne
Diagnosis 2-08 Small papillary TCC; CIS
BCG; BCG maintenance
Vice-President, American Bladder Cancer Society
Forum Moderator -
My husband is almost 73, so that might be a factor. We will see the doctor on Tuesday and ask for clarification. Thank you.
Finally got an MRI. It showed a 1 cm “suspicious lesion”. He’ll have a biopsy on the 18th. How likely is it to be prostate cancer or would it be metastatic bladder cancer? Could also be nothing?
-
First of all, it is great that you are being an advocate for your husband.
I am sorry to hear about the delay of MRI, but I would not worry much because your husband is already on BCG treatment. CT scan and MRI are used to check to see if BCa has spread outside of bladder. In my case, it was CT scan. Columbia University Urology website says MRI is preferred over CT scanning for some patients with reduced kidney. Only your urologist knows why he or she had chosen MRI. MRI takes longer and it costs more than CT scan.
PSA
I would not think PSA value is the only reason for MRI or even if it is a reason. Your urologist can answer the question. PSA testing has become controversial. Even when PSA level is low, the patient can have prostate cancer. Even when PSA level is high, the patient does not have prostate cancer. Also, even the patient may have prostate cancer, but it can be very very slow-growing cancer and can live without a problem. I used to go to a local prostate cancer support group. Anyway, the evidence, the study paper says, 75% (27 out of 36 patients) of Intravesical BCG treatment developed higher PSA level. 40% developed to 6.97 and above. Yes, the paper says
those 40% came down to 3.86 but does not say if it is average. Also none of 36 patients had prostate cancer.American Cancer Society’s site says only 1 of 4 men with PSA level between 4-10 may have prostate cancer. Most of those men are not under BCG treatment. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/how-diagnosed.html
Also, the pathology report says your husband is T1Hg. It has not gone to the muscle layer. So, it has little chance that BCa has spread to the prostate.
Dizziness :
BCG is live bacteria in liquid form. When it is instilled into the bladder, bacteria infect the inner wall of the bladder, which invokes our immune system and attacks bacteria and bacteria-infected cells. This causes inflammation and sometimes bleeding. Consequently, the side effect includes bleeding, frequency in urination, fever, fatigue, etc. So, I know from the forum that several people experience dizziness also. The good news is that he is able to go through BCG treatment as there are some patients who give up BCG treatment because of severe side effects.
About the fall.
I am sorry to hear your husband’ fall. But I am also glad that it was just a bruise on his rib. I had a fall from a bike just a year before they found my cancer in my bladder. I cracked 4 ribs and developed hemothorax / pneumothorax. I had to stay in the hospital for 2 weeks. No more mountain biking, so my family said. I am 73 years old, so now I am just riding a bike on the flat surface with my dog in the dog trailer these days.
Take care. I have a hunch that everything is going to be okay with your husband.
-
We still don’t have insurance clearance for the MRI, not sure why it’s taken this long.
His PSA has been elevated since January 2019 and the last PSA was 5 months after his last BCG, so I’m guess that’s why they are investigating?
A side question-has anyone experienced dizziness with BCG? He did on the last day of treatment last week and had a bad fall in the middle of the night, bruised a rib.
-
The study done in 2000 says that they have observed 75% of Intravesical BCG patients saw the elevated PSA level. The report says it will go back to normal level after 3 months. Consequently, the report recommends NOT to perform prostate biopsy which is quite invasive procedure when PSA level goes up during Intravesical BCG treatment.
Its great that your husband will get MRI done anyway as it can clarify your concerns.
pubmed.ncbi.nlm.nih.gov/11025701/#:~:text=Conclusions%3A%20Intravesical%20BCG%20therapy%20is,such%20patients%20and%20PSA%20monitored.
Best wishes
-
Let us know what they say. Knowledge is power and understanding! Thanks,
DX 5/6/2008 TAG3 papillary tumor .5 CM in size. 2 TURBS followed by 6 instillations of BCG weekly with a second round of 6 after a 6 week wait. -
My husband is almost 73, so that might be a factor. We will see the doctor on Tuesday and ask for clarification. Thank you.
-
I have not heard nor read about PSA elevation being a side effect of BCG. From what little I remember from my docs, it is somewhat normal as men age to have a slow increase in the PSA number. 1.68 to a 5 is a quick increase. Also, from what I remember (I haven’t really discussed these with them in 3-4 years, 65-70 year olds have readings from what I recall is at 4.5 to 6.0) a 6 is border elevated but, your numbers appear to have stabilized. At the same time, none of us are doctors so I’d ask for clarification next time you meet. The pelvic MRI sounds reasonable to me.
DX 5/6/2008 TAG3 papillary tumor .5 CM in size. 2 TURBS followed by 6 instillations of BCG weekly with a second round of 6 after a 6 week wait.
Log in to reply.