Question Title: CT/MRI diagnosis?

My husband had an initial PSA of 7.9. His urologist diagnosed
prostatitis and prescribed Trimethoprim, yet did not rule out the
possibility of cancer. After a month and another PSA which
showed 7.3 this time, he still has not ruled out cancer because
he can feel a "ridge" on one side of the prostate. The doctor
wanted to do a biopsy, but my husband does not like this idea
because if it is cancer, he feels the cells would be split and
multiply more. His doctor offered to do an ultrasound but would
need to use anesthesia due to prostate tenderness still. My
husband elected to take the prescription another two months and
then have another PSA and go from there. He is due to go back
to the doctor the end of this month. However, he has heard of
having the prostate checked by CT scan and MRI and has made
arrangements to have this done. How accurate is this type of
detection tool in this situation? Also, if he gets a negative
from this, should that ease his mind from the possibility of
cancer? His father had prostate cancer but did not die from it.
Thank you for your help and time.

---

Dear Deb,

Prostate cancer screening is performed with a digital rectal exam (DRE) and a serum prostate specific antigen (PSA). Annual screening begins at age fifty in whites and age forty in blacks and high risks groups. An abnormal DRE (asymmetric, nodular or indurated) and/or elevated PSA warrants further evaluation with a prostate biopsy. However, there are other conditions which cause an elevated PSA. Benign prostatic hyperplasia (BPH), prostate biopsy, infection and cancer are some of the causes of an elevated PSA.

In this instance, your husband has two reasons to proceed with prostate biopsy--elevated PSA and abnormal DRE. In addition, he has a family history of the disease. The gold standard for prostate biopsy is the trans-rectal ultrasound guided approach (TRUS). This allows imaging of the gland. Invasion of surrounding structures can also be evaluated with ultrasound. Also, TRUS is convenient because the prostate gland lies anterior to the rectum. This makes the prostate easily accessible for biopsy. It is performed on an outpatient basis. Antibiotics are given for three days starting the day before the procedure. Risks include blood in the urine, stool and ejaculate, infection, rectal and urethral injury and urinary retention.

While theoretically there is a risk of seeding the rectum with cancer while doing the biopsy, clinically this has not been the case. CT or MRI are not the ideal imaging studies. Also, they are not practical with respect to prostate biopsy compared to TRUS. If CT or MRI is used to biopsy the prostate, there is still the theoretical risk of seeding the tumor along the biopsy tract. Once his infection clears, your husband should have a TRUS guided prostate biopsy. If the prostate biopsy is negative, then the next step would be to follow the PSA. If it remains elevated, a repeat biopsy with transitional zone specimens would be indicated. If not, your husband should continue annual prostate cancer screening. The treatment of prostate cancer consists of watchful waiting, radiation therapy, cryotherapy, hormonal therapy and surgery. This would depend on how aggressive the cancer is and the patient’s wishes.

More individualized care is available at the Henry Ford Hospital and its urban campuses by calling (1 800 653 6568). We can also arrange local accommodations through this number if this is your need. Please bring any physicians' notes and lab test results that you may be able to obtain. These will help us greatly.

HFHS M.D.-JL
*Keyword: Prostate cancer, PSA, DRE, TRUS, ultrasound, biopsy, digital rectal examination

---