Our patient today had a PSA of 7.4. He is a 67 year old Caucasion male with no other medical issues other than episodic high blood pressure. He does report some mild urinary symptoms mostly involving going to the bathroom frequently but his urine stream is normal and he has no incontinence or dribbling.
He has had PSA testing in the past. At one point it was 7.1 but after he saw a holistic practitioner it decreased to 4.5. Approximately 6 months later it was 7 again and his primary care doctor thought it was worth evaluating further. He did not want a biopsy and so had a prostate ultrasound performed and an examination by a Urologist. His prostate was smooth and the ultrasound was benign so it was considered appropriate to just watch him.
The new PSA was 7.4 which does represent an increase from previous. In addition, his urinary symptoms has worsened but not drastically so. He still had a normal stream but had increased frequency in compared to before.
For a better risk assessment, we performed a Total and Free PSA. Many physicians are not familiar with the Free PSA.
In men over 50 with an elevated Total PSA, the %Free PSA gives an estimate of the probability of prostate cancer
Our patient had a Total PSA = 7.4 and a %Free PSA – 22%. In this case, the ideal %Free PSA should be over 25%. The lower the %Free PSA the greater the greater the probability of cancer. Here is a table that shows the Estimated Probability of prostate cancer.
PSA(ng/mL) Free PSA(%) Estimated(x) Probability of Cancer(as%) 0-2.5 (*) Approx. 1 2.6-4.0(1) 0-27(2) 24(3) 4.1-10(4) 0-10 56 11-15 28 16-20 20 21-25 16 >or =26 8 >10(+) N/A >50 Given that our patient's Total was in the 7 range and the high Free PSA, the probability of cancer is low but still significant at 16%
Here is a nice graph from Quest: showing our possible decision tree.
This patient had a normal rectal examination so the liklihood of cancer based on the testing is still low but significant. The next options are to refer for a biopsy, which he did not want, wait to re-test in 3-6 months to see how the numbers may change or to see if we can’t further risk stratify.
If we want to further risk stratify then we can consider using the Prostate Health Index (PHI).
This patient, like many, fall into that category that often result in a biopsy but don’t have cancer. See our image above. Of course, one never knows and that is why the biopsy is performed because who want to be the statistic that ends up with prostate cancer.
To help with this decision, researchers looked for an alternative biomarker which led to the discovery of the PHI. PHI offers greater specificity in identifying patients that truly need a biopsy.
Phi is the only FDA approved blood test that is 3 X more specific than PSA alone.
The phi combines the use of another biomarker called p2PSA which is an isoform of free PSA that is the most prostate cancer specific biomarker found. When p2PSA is used with the total PSA, and free PSA, the diagnostic accuracy improves to 71%
If you are like our patient who falls into this gray zone area and are concerned about getting a biopsy. Please call us at 352-235-9636 or Toll Free at 855-474-8522
or Schedule an Online Diagnostic Consultation
Say it isn’t so. But yes it is. Men can and do get breast cancer. There were about 2500 cases of breast cancer in the US last year.
In men, breast cancer is usually a PAINLESS lump. Usually it is hard and does not move and is in the area just around the nipple. The lump can be deep and does not need to be on the surface of the skin. Since men don’t usually check their breast or chest area, breast cancer is usually advanced in men by the time of diagnosis. Most men have advanced stage III or IV disease by the time they get diagnosed.
You may be at risk for breast cancer if there are other family members with breast cancer. If you have two or more members of your family with breast or ovarian cancer or breast cancer at a young age, it would be advisable to first test the affected family members for the BRCA1 or BRCA2 genes before getting tested first.
Why Unexplained and Persistent Rash may need further evaluation – The Signof Lesar-Trelat
Today I saw a 64 year old woman who had a persistent rash on her legs, arms and back. The rash was small raised bumps that were red or blanched. The rash itched tremendously and she had only minor relief with topical cortisone.
She went to an Urgent Care center and was prescribed prednisone a steroid to take. After taking the first dose, she felt dizzy and so stopped this medication. She then made an appointment with a Dermatologist. The first dermatologist prescribed a stronger topical steroid and did a skin biopsy since the rash was persistent. The steroid cream was too expensive and the patient was unable to fill it. The biopsy results showed inflammatory dermatitis. She then went to a second dermatologist who then performed a shave biopsy on a different lesion on her back. The pathology results showed eosinophilic infiltration and non-specific dermatitis.
She came to our clinic for further evaluation. A complete physical examination did not reveal any significant findings. A more thorough medical history was obtained. She then reported that at one point, she had unexplained abdominal pain that was transient but lasted a few months and as part of the evaluation, a CT-abdomen was performed which showed a small lesion over her kidney. The recommendation was to follow-up with a repeat CT scan in 6 months which due to travel and other circumstances she was unable to do.
A follow-up CT scan showed a mass above the left pole of the kidney.
The Sign of Lesar Trelat – is defined as the sudden appearance of skin lesions caused by an associated cancer. The more typical skin lesions are seborrheic keratosis but other skin findings can also be found. The sign was first described by Dr. Leser and Dr. Trelat who noted skin angiomatosis in patients with intra-abdominal cancer. The cause of the various skin findings is a consequence of growth factors secreted by the cancer. It is usually associated with a type of cancer called an adenocarcinoma.