Archive - Miscellaneous

Questions & Answers

You performed a radical prostatectomy for me 13 years ago. My pre-operative PSA was 4.6, and my Gleason score was 7. The cancer was contained within the prostate. Since my radical prostatectomy, my PSA has always been less than 0.1. Over the past few years, my moods, energy, and lust for life have significantly diminished. Recently during my annual checkup, my GP recommended testosterone replacement therapy. Could this be a good treatment for moods, energy, etc., and do you think it is safe?

You should have your blood testosterone level measured. If it is low, testosterone replacement would almost certainly be safe. However, you should also monitor your blood testosterone levels, your blood counts, your liver function tests, as well as your PSA levels to ensure that it is not causing any harmful side effects.

Should men in their thirties be worried about prostate cancer?

Men in their 30’s usually needn’t worry unless they have a very strong family history of prostate cancer such as a father and brother, two brothers, or multiple family members with prostate cancer or if they have a family history of prostate cancer that occurred at an early age.

ACCURACY OF TRANSRECTAL ULTRASONOGRAPHY IN DETECTING NEUROVASCULAR BUNDLE INVOLVEMENT: How accurate is the TRUS in diagnosing possible neurovascular bundle involvement?

The short answer is “not very accurate.” No imaging scan, such as transrectal ultrasound, CT, magnetic resonance imaging or even magnetic resonance spectroscopyis very accurate in detecting microscopic neurovascular bundle involvement, even under the best of circumstances. Also, prior needle biopsy of the prostate with bleeding, swelling, and scarring can produce artifacts that may make it appear that the neurovascular bundle is involved. Only gross involvement can be detected by scans, and usually such extensive involvement is also apparent on the digital rectal examination of the prostate gland.

Can veterans get medicines through the VA at reduced or no cost?

This is correct, but for some medicines, they may have to apply.

Does a bruise on your penis have anything to do with prostate cancer if you do not know what caused it?

Almost never. Bruising occurs because a blood vessel has ruptured. This can occur because of trauma to the penis itself, or to an adjacent area of the body with the blood tracking through the tissues into the penis.

How long does it take to recover form a vasectomy with a testicular biopsy?

Usually about 1 to 3 weeks, unless there are complications.

What will a PAP test show about mestastases? Is this an old test? How long after a digital exam should a patient wait to take further free PSA or PAP test?

PAP stands for prostatic acid phosphatase. It is an old test. Usually, when it is elevated, it indicates bone metastases. It is seldom used since PSA is available and more accurate. Neither test is perfect for metastases. You should wait at least 48 hours after a rectal exam to have a PAP or PSA test. I use the PAP test in men with prostate cancer that is at very high risk to have metastasized, i.e., men with a very high Gleason grade (8-10), those with very high PSA (>10), and those with very extensive involvement of the biopsy specimens with cancer.

Regarding the Proscar research on the possibility that it may mask the more aggressive prostate cancers, would it be the same for Avodart?

It is not known for certain. Studies are currently underway. If they are appropriately designed, executed, and analyzed, I believe they will show that it would be the same.

My husband finished 40 IMRT radiation therapy treatments. He had very little fatigue and even worked a full time physical job while going through treatment. He is now experiencing extreme fatigue. His last blood test in October showed that everything was in normal range and PSA at 0.04. Is there such a thing as a “delayed reaction” to the radiation treatment as far as fatigue is concerned?

In my experience, fatigue is not uncommon during radiotherpy, but delayed fatigue is uncommon. He should be checked for anemia or other possible causes of fatigue, in my opinion.

I am 25 and I have a vesicle/bulla that is about 1 cm in diameter and located 2mm anterior to my anus. It has been present in that location for almost a year now. It always contains some pus and blood and usually never itches. I dont have any trouble urinating or with any other bodily functions. Could I take antibiotics to get rid of it? Could it be a pre-cursor to rectal, colon or prostate cancer? Due to its location I feel embarassed to go to a doctor and that’s why I am asking you for your advice. Thank you.

Antibiotics might help, but it might require surgical drainage or removal to get rid of it completely. You should go ahead and have this done, in my opinion. It is probably not a precursor of cancer.

My PSA has been running in the 6’s. I’ve been having BCG treatments following post op resection of a grade 3 stage 1 bladder tumor. I had a PSA done last week (2 weeks after a BCG treatment) which was 10. How high does it get after BCG and how long does it stay elevated.

The PSA can certainly get in the 10 ng/ml range after BCG treatment, and it can take more than one year for it to return to normal.

What is more reliable in detecting metastatic lesions from prostate ca, bone scan or trans-rectal MRI? My father’s bone scan was negative, but MRI shows a lesion of some kind. Could it be a cyst or arthritis rather than metastasis?

If the bone scan is negative, it is very unlikely that it is a metastasis.

UPM3 TEST: Do you know of it and do you recommend it?

I have heard about this test, but I do not use it myself. I have not seen sufficient information to lead me to recommend it to others at this time. It is a urine test that checks for cells expressed from the prostate gland that overexpress a gene (PPM3) that is frequently overexpressed in prostate cancer cells. Further study is needed to determine its clinical value.

Please explain the prostascinct scan to me. My father who is 73 had his prostate removed 7 weeks ago and the cancer was also found in a lymph node. His doctors want to put him on hormone therapy. But my concern is that I don’t think that hormones cure lymph cancer. Yesterday his PSA was 2.77

The prostascint scan is based upon radioactive antibodies to prostate-specific membrane antigen that are supposed to indicate whether there are prostate cancer cells in the lymph nodes. I do not believe that it is very accurate, and I do not use it in my personal patients. If there are lymph node metastases, it is called metastatic prostate cancer. Lymphoma is a primary cancer arising in the lymph nodes. Metastatic prostate cancer is usually treated with hormonal therapy, whereas lymphoma is treated with radiotherapy or chemotherapy. The fact that his PSA is detectable after surgery suggests that he has cancer cells remaining and should consider at least intermittent hormonal therapy. Please see Quest article on hormonal therapy posted on this website.

My husband had a radical prostatectomy by you 5 years ago (PSA 7.4 and Gleason 4+3) and has tested at 0.00 since surgery. Our son is 35 and took Propecia for baldness from age 18 to 30. Should he have a baseline PSA now or wait until age 40?

Because drugs like Propecia may be associated with a higher probability of developing aggressive prostate cancer, it may be safest to begin testing at age 35. This would be especially important if your husband or other family members were diagnosed with prostate cancer before the age of 45.

I have heard that immunotherapy with CAR-T cells is the “holy grail of medical research” for cancer. What do you think about this?

This is one of the new approaches to cancer immunotherapy that is currently generating a lot of interest and some excitement. CAR-T cell immunotherapy has been effective in inducing remissions in a high percentage of patients with blood cancers (leukemia and lymphoma) but not so much with solid tumors (prostate, breast, colon). The “universal” approach that is being emphasized includes adding antibodies to a variety of different tumor antigens that may be helpful in improving the effectiveness with solid tumors. This type of treatment can also be relatively toxic with possibly life-threatening side effects. My guess is that clinical trials may show a high initial tumor response rate with substantial side effects in patients who have exhausted all other treatment options. The durability of the responses will be an important issue.

What does it mean if there is microscopic blood? in the urine?

Normally, there can be up to 3- 5 red blood cells per high-power microscopic field in the urine. If there are more, it raises concern that there may be a problem in the urinary tract, such as infection; a stone; a tumor of the kidney, ureter, bladder, prostate, or urethra; a stricture (scar tissue); damage from previous radiation therapy to the uro-genital tract; intrinsic kidney disease, etc. The “proper” evaluation consists of obtaining another “clean- catch” urine sample for repeat urinalysis, culture, and cytology (looking for tumor cells). If there is still an increased number of red blood cells, a tri-phasic CT scan of the abdomen and pelvis with intravenous contrast should be obtained to image the entire urinary tract from top to bottom and the patient should undergo cystoscopy (a look into the bladder with a soft, flexible cystoscope under local anesthesia).

After having a prostate biopsy giving a Gleason score of 3+4 and having an orgasm that was somewhat bloody, I was concerned that the semen might then be carrying the cancer to the sperm ducts, and some cancer cells may stay in them afterwards. So if the ducts are not removed or treated subsequently, can this become the source of later problems?
in the urine?

It is possible that semen might carry cancer to the sperm ducts, but recurrence of prostate cancer in the sperm ducts (vas deferens and epididymis) is extremely rare. However, some patients can have bacterial infections or inflammation after biopsy and even after treatment.

I received radiation treatments for prostate cancer four years ago and have had no significant side effects. Last weekend I had bright red blood in my urine. What could be causing the bleeding?

In patients who have undergone radiation therapy, blood in the urine is usually caused by fragile blood vessels in the bladder. The proper evaluation includes a tri-phasic CT scan of the abdomen to visualize the entire urinary tract, as well as looking into the bladder by passing a small flexible scope through the urethra under local anesthesia produced by a lidocaine jelly. It also includes collecting urine samples to look for infection and malignant cells.

Usually the results are negative. Then, we feel reassured that radiation(called “radiation cystitis”) was the cause and we do not need to pursue further follow-up unless it occurs again several years later.

My blood tests indicate a low testosterone level. What is involved in getting testosterone-replacement therapy to bring it back to normal values?

Testosterone-replacement therapy can be given by injection, patch, gel, or underarm liquid (in increasing order of cost). While patients are receiving the therapy, they should be monitored at least annually—and often more frequently—for blood counts, liver function tests, cholesterol and lipid measurements, testosterone measurements, and PSA levels. Also, body weight should be monitored for fluid retention.

Patients on testosterone- replacement therapy become dependent upon it, because if the patient is receiving “external” testosterone, the pituitary gland does not normally stimulate the testicles to produce it. In such cases, the testicles often decrease in size.

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