Can you imagine having a PSA higher than 100—four prostate biopsies don’t find cancer? This is the true story of a 73-year old man who came to Duke University Medical Center early in 2021. When he was examined, his prostate gland was enlarged (60 grams) and his digital rectal exam (DRE) found no abnormalities. He had minimal urinary tract symptoms. However, his PSA was 110 ng/mL and rising. He was there for suspicion of prostate cancer (PCa).

His PCa history begins with four conventional TRUS biopsies (2004, 2007, 2009, 2011), all of which proved negative. Undergoing four biopsies is a rather chilling thought, given the risks of pain and infection. All the while, his PSA continued to rise from 3 ng/mL in 2002 to a whopping 100 ng/mL by 2019. He must have been desperate but at the same time fed up with needle biopsies. The authors of a published case study note, “The patient was understandably hesitant about more invasive testing and I believe it may have been challenging to convince him to do more testing, given that he felt perfectly fine.”^[i]

It should also be said that he had an additional history of four negative MRI scans at other centers (2012, 2014, 2017, 2019). The MRI in 2017 found abnormal nodules in the transition zone (TZ), but none of the scans detected lesions suspicious for PCa. One of the authors, Dr. Rajan Gupta, is an Associate Professor of Radiology at Duke. In explaining that prostate MRI can be challenging to interpret, especially in the TZ, he points out that “…it is critical to ensure high-quality MRI, with interpretation performed by radiologists with significant experience in prostate MRI.”^[ii] Perhaps the patient did not have earlier access to the high caliber of prostate MRI as performed at Duke.

In any case, while the patient’s high PSA could have been due to other conditions, it was a strong indication of PCa, including possible metastasis. They therefore performed two secondary screening tests, the Prostate Health Index (PHI) and the ESO Dx Prostate Test. The results were persuasive that PCa was present, and the patient agreed to another MRI, and possibly another biopsy based on MRI results.

Indeed, this time the multiparametric MRI (mpMRI) at last revealed a PI-RADS 5 lesion in the left anterior TZ. Based on this visual evidence of tumor, the patient agreed to undergo a 5th biopsy for accurate tissue diagnosis.

The result? The biopsy identified two cores of Gleason 3+4=7, Gleason grade group (GG) 2 disease. Further body imaging (CT and nuclear medicine bone scan) ruled out metastatic disease. Amazingly— given his PSA—his disease turned out to be contained in the gland, so a decision was made to perform an open radical prostatectomy for his localized PCa. “Final pathology revealed a 66-gram prostate, Gleason 4 + 3 = 7, GG3, organ-confined disease with negative lymph nodes…”^[iii] His PCa was gone.

Duke’s clinical team brought together key elements in diagnosing and treating a patient whose PCa had gone undetected for 17 years, from 2004-2021. The novel secondary tests (PHI and ESO Dx) are an example of a growing trend in diagnosis that utilizes genomic information to fill in PSA gaps. In addition, Duke’s prostate mpMRI’s are done under a 3T magnet similar to ours, and their experienced radiologist was able to recognize features of anterior TZ lesions that may be unfamiliar to radiologic readers with less interpretive skill. Also, since TRUS biopsies miss up to nearly 50% of anterior lesions, thanks to the high-quality MRI the Duke team had the benefit of knowing where to direct needles.

It was the combination of the secondary tests that led to the mpMRI, and it was the mpMRI that located the disease that had stayed hidden for 17 years! Still, this 73-year old man might have gone on to live out his full life if his PCa had never been found. According to the authors,

Ultimately, he had organ-confined disease that may have never seriously harmed him. In retrospect, this patient could have possibly lived his allotted life expectancy based on the fact that his disease was organ confined. However, we contend that the management was appropriate and justified and could have been a medicolegal risk if not addressed.^[iv]

The important word is “possibly.” I personally join other experts who believe that Gleason 4+3 PCa cannot be counted on to act like insignificant (Gleason 3+3) disease. The fact of Gleason 4 places a patient in a higher risk category because it’s more aggressive and therefore more likely to progress. Since this patient was in otherwise good health, he had more than 10 years’ life expectancy. Harboring a potentially dangerous disease is not to be taken likely. We will never know if this patient would have died from his PCa if it hadn’t been treated, or from some other cause. But why take chances? I congratulate the team at Duke. I believe there’s a good likelihood that finding and treating his cancer saved his life.

At our Center, we are committed to saving life, as well as quality of life, through our expert 3T MRI guided detection, diagnostic and focal laser ablation services. Our experience, AI-assisted imaging technology, and staff are second to none when it comes to excellence in clinical services. For more information, contact us.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] JMorris KE, Grimberg DC, Gupta RT, Pendse AA, Moul JW. Successful Diagnosis and Treatment of Occult Prostate Cancer Despite Multiple Negative Prostate Biopsies and Negative Prostate MRIs. Oncology (Williston Park). 2022 Mar 8;36(3):178-183.
[ii] Ibid.
[iii] Ibid.
[iv] Ibid.