Color Doppler Ultrasound and other questions.

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nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/6/2009 9:18 AM (GMT -6)   
Hello again.  I'm back with more questions -- this time about Color Doppler and where it can be done.  Following is what I wrote about my husband back in December (I cut and pasted from my original post the pertinent parts).   He did not get his PSA and free PSA checked at the 6 month mark because we had travel plans this summer.  However, he did get everthing done at 7 months.  I will give you the results after this history so it is consistent.
 
 At age 50 he had his first PSA test for a workman's comp physical.  It was fine. 1.9 or somewhere in that range.  The next year it was very slightly higher but nothing the doctor worried about.  DRE's totally normal. 

The third year it jumped to 4.3 and he was sent to a urologist.  Normal protocol -- antibiotics and a free PSA was done.  Normal DRE.  The PSA came down to 3.8 after the antibiotic therapy, but the free PSA was only 17%.  To make a long story short, over the course of the last year and a half his PSA went up after the antibiotics were discontinued, his free PSA continued to be very low.  He's had a half dozen -- results have been 17%, 12%, 10%, 7% 9%.  All tests were run at the Mayo Clinic as that is the lab used by our clinic.   His PSA's have fluctuated from 3.8, 5.6, 10.3, 7.9, and the last one was 5.6.  All DRE's normal.

His first 12 core biopsy was done this past August and it was completely benign.  No cancer, no pre-cancer, no inflammation, no prostatitis.  Nothing!  It was noted that his prostate was 52cc.  The only physical symptoms my husband has noted was a weaker stream and a bit of trouble starting in the morning, but during the day everything is fine.  He does not get up at night, and has no urge to go.  All other plumbing works just fine.

A cystoscopy was done and everything look fine in the bladder but it was obvious his prostate was a bit large and pushing into the bladder which probably causes some uriniation difficulties he has, although minor.  The doctor suggested Avodart but didn't really push it since he wasn't really having that much problem.  He also said he could try Saw Palmetto which he ended up doing. 

When his PSA came back at 10.3% (a jump from 5.6% in three months) and the free PSA was 7% we decided right then and there to go to the Mayo Clinic.  We were fortunate to get in with an excellent urologist who confirmed that he was NOT comfortable with this history.  He got my husband in for a biopsy the next day.  They also ran a PSA and free PSA during the visit and those values were 5.6 and 9%  which were down (and up, depending on which one) from only two weeks prior.  DRE at Mayo normal.  The biopsy done was an 18 core biopsy with state of the art equipment and something called 'end fire probe'.  He was completely sedated which was different from the first biopsy which he tolerated with no problems whatsoever.  He was assured he did not want to be awake for this particular biopsy though.
 
Has anyone heard of these types of values and no cancer?  We have been preparing ourselves for months and had even discussed and accepted various treatment options should cancer have been found.  Let's just say that we were in a good place had the news been otherwise and were ready to act.  Now we are just more confused and although we have been to Mayo still not sure there isn't cancer there that has been missed.  Is anyone ever comforted by negative prostate biopsies??

Ok, the results of his latest tests were that interestingly he PSA went DOWN to 4.5% but that dang percent free PSA is at 7%.  Last week he had another saturated 24 core biopsy and we are still waiting the results.  The ultrasound photo looked perfectly normal, and there are no lumps or ridges on the prostate.  We won't be surprised if the biopsies are negative and we won't be surprised if they are positive.  (neither gives us comfort, and this is getting to be a real drag).
 
So, my question is:  Where is the closest place to let's say Fargo, North Dakota to get a color doppler ultrasound?  Is this something insurance would cover or is it considered experimental (my husband's urologist says it's still experimental), and they don't do it or recommend it at Mayo as far as we can tell.  How much would the test run if we pay for it out of pocket?  And why in the heck is something that can detect cancer experimental?  grrr.
 
Frustrated, but thankful for all of the help and advice here! :-)
 
deb
P.S.  is there any other reason in the world, other than cancer that the percent free PSA would be so low? 

Post Edited (nodaker) : 9/6/2009 10:04:17 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 9/6/2009 10:11 AM (GMT -6)   
Thanks for the update, be intersesting to see the results of that latest biopsy. I am hoping JohnT comes along and sees your post, he seems to know a lot about the color dopler testing process.

Hoping for the best for your husband.

David in SC

AKRoamer
New Member


Date Joined Nov 2008
Total Posts : 15
   Posted 9/6/2009 8:54 PM (GMT -6)   

Hello Nodaker,

Been wondering how things were going for your husband.  I'm still in the same boat- 2 biopsies, both neg.  Low % free PSA, 7 to 8 %. about all my urologist has been able to tell me is that much research is being done on what makes up free PSA and breaking it down into which part of it is the actual marker for PCa.  Not much help.  I'm sched for another PSA test & appt in Dec. 

Dan 


Age 49
PSA 6/2003 1.5
PSA 7/2/2008 4.8, % free PSA 8
PSA 7/14/2008 5.2, % free PSA 8
3 weeks Levaquin
PSA 9/2008 5.8, % free PSA 7
Biopsy 10/08 10-core all neg, no sign of PCa, told prostate was enlarged
PSA 12/2008 5.2, % free PSA 7
PSA 2/2009 4.7, % free PSA 8
PSA 5/2009 5.2, % free PSA 8
Biopsy 6/2009 12-core all neg, no sign of PCa, prostate "slightly enlarged".


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 9/6/2009 11:23 PM (GMT -6)   
Nodoker,
I was in the same position for 10 years. 12 biopsies and and MRIS all negative. The 13th biopsy picked up indolant PC cells and that almost led me to surgery.
I finally had a color doppler and it found a large tumor that everything else had missed. Dr Bahn, who did the color doppler explained how urologists do biopsies and showed me the tracks of the last biopsy which had missed the tumor. He then said there were only two Drs in the world that could hit that spot and he was one of them. He also said that if I had had 12 more biopsies they still wouldn't have found it. I later had an MRI (Combidex) with a Telsa 3 MRI and it also saw the tumor. A Telsa 1.5 MRIS, which most institutions use couldn't see it.
The skill of the Dr doing the color doppler is more important than the technology. Dr Bahn in Ventura CA and Fred Lee in Rochester MI are by far the best. If they can't find it it probably isn't there. Both have done over 15,000 biopsies each. Color doppler uses blood flow to locate tumors as tumors need blood to grow.
My Insurance covered it with no questions. One thing this experience taught me is that if it looks like a duck and acts like a duck then it probably is a duck. I would assume that it is PC unless it is proved otherwise. Don't be satisfied until someone can rationally explain the free psa and psa.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 9/6/2009 11:30 PM (GMT -6)   
I think my color doppler biopsy cost about $2100 and insurance paid way less and it was accepted as full payment. I know Ohio State had a color doppler biopsy by Fred Lee I think he paid about $1700.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/8/2009 11:19 AM (GMT -6)   
Thank you David, Dan and John for your replies.
 
Dan, my husband and I can totally understand your frustration with the situation! 
 
John,  your duck analogy rings so true.  I never thought we'd be say that we hope they find cancer, but in a situation where no one can give us a logical reason for the very low percent free PSA numbers we'd rather find out sooner than later what seems to be a 'duck'.  Rochester, MI is a long way from where we live.  I wonder if there are color doppler capabilities in Minneapolis?  Chicago?  My husband's urologist said that prostate cancer can't be seen with a regular MRI.  I guess he is saving us money by not performing them.   I was wondering how Dr. Bahn had come to the conclusion that only two doctors in the world could hit that spot.  What made 'that spot' so difficult and why only the two doctors?  Please know that I'm not being argumenative -- I just think that of all of the urologists in the world it is odd that only two could have found the cancer.  You have probably talked about it before, but what was different in how they perform the biopies vs. how most urologists do? 
 
Due to the long weekend we have not heard the results yet from the biopsy.  We will know on Wednesday because my husband has a follow-up appointment, however, he did ask to be notified by phone if the results are back earlier.  This being the third time he feels he can take the news by phone now.
 
deb
 

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 9/8/2009 11:41 AM (GMT -6)   
Nodaker,
These are good questions that everyone should ask of their doctors. My Uro Oncologist also told me that color doppler wouldn't work.
Bahn and Lee are interventional radiologists, not urologists and they have different skills, especially when reading images. Urologists are not trained or have experience in reading images. Also as Dr Bahn explained to me, the urologist biopsies at an angle through the rectum, in my case the angle would have never hit the anterior of the transition zone where my tumor was located. The other difference in Dr Bahn's biopsy was that he spent about 25 minutes just looking, drawing images and taking notes before he even picked up a needle. My other biopsies would have already been over.
MRIS can see PC if it is in the perpheral zone or in the bed, but has a difficult time seeing into the interior of the prostate. Also a Telsa 3 MRI using Dye Enhanced Imaging can spot small tumors in the prostate.
Please don't stop asking good questions until you get answers that make sense. Knowing what I know now, I wouldn't hesitate to travel to get a color doppler from Bahn or Lee.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/10/2009 11:32 AM (GMT -6)   
Not surprising my husband's third biopsy results were completely negative. His radiologist said 'you know the drill', back in six months for another biopsy. His urologist is not comfortable with the 7%fPSA and as long as it is that low he wants to biopsy. We of course said 'when is enough, enough?' and he said about 4 is where he usually says it is time to do a TURP. I've been doing quite a bit of reading about TURP and whoo boy there is conflicting information about that. Also, quite alarming that the transition zone tumors found with TURP are usually of a high Gleason score.

Dan, have you been offered this procedure yet?

John, had you considered this procedure yourself? I think both my husband and I think that future TRUS guided biopsies will be futile if there is a tumor in the TZ.

On a side note, my husband's PSA had gone done from 5.6 to 4.5 in the last six months. Artifically lowered by the Saw Palmetto?

I'm off to find threads on TURP in this forum.

Needless to say -- the uneasiness continues. A fourth biopsy seems futile.
deb
P.S.  Does one have to wait 6 months to do the TURP?

Post Edited (nodaker) : 9/10/2009 10:41:51 AM (GMT-6)


AKRoamer
New Member


Date Joined Nov 2008
Total Posts : 15
   Posted 9/12/2009 7:28 PM (GMT -6)   

deb-

My urologist has not said anything about a TURP.  Me, if my doc suggested a TURP I'd be looking for a good color doppler ultrasound facility instead.  I don't know too much about the TURP procedure, but if a person does not have symptoms that require a TURP then using it to look for PCa seems pretty invasive to me, with its own chances of not too subtle side effects. 

This low free PSA stuff really stinks.  Next appt I'll try to pick my uro's brain, I saw he is the lead for a clinical trial at my hospital looking for new biomarkers for PCa.  I don't see him again til Dec.

Dan


Age 49
PSA 6/2003 1.5
PSA 7/2/2008 4.8, % free PSA 8
PSA 7/14/2008 5.2, % free PSA 8
3 weeks Levaquin
PSA 9/2008 5.8, % free PSA 7
Biopsy 10/08 10-core all neg, no sign of PCa, told prostate was enlarged
PSA 12/2008 5.2, % free PSA 7
PSA 2/2009 4.7, % free PSA 8
PSA 5/2009 5.2, % free PSA 8
Biopsy 6/2009 12-core all neg, no sign of PCa, prostate "slightly enlarged".


nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/14/2009 6:55 PM (GMT -6)   
Dan,
 
Thank you for reply and your honest opinion.  My husband and I are in serious conversation about making a trip to California to the PCRI and persuing the color doppler ultrasound.   In the coming weeks/months we'll be making some phone calls, checking with insurance, etc.  Since he just had a third biopsy two weeks ago I wonder if he'll have to wait 6 months to get another one there (if something is found on the color doppler ultrasound).   
 
This is probably old news here since I don't keep up with every topic, but the PCRI has their PCRInsights newsletter online.  What a wealth of information!
 
Deb

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 9/14/2009 8:38 PM (GMT -6)   
Deb,
I had my color doppler biopsy 6 weeks after a 25 core biopsy, so it's no problem. PCRInsights has been one of my best sources of information; its light years ahead of the typical info you get on PC.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/18/2009 8:59 AM (GMT -6)   
Just a quick update.  I have been in contact with the Urology clinic in Rochester, MI and next week we will be making an appointment for the end of October early November to see Dr. Lee.  Thank you John for all of your information regarding color doppler ultrasound.  I had faxed my husband's records to Dr. Lee and he would like to investigate the transition zone.
 
deb

Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 9/18/2009 3:45 PM (GMT -6)   
Has he had a PCA3 test?

nodaker
Regular Member


Date Joined Dec 2008
Total Posts : 22
   Posted 9/18/2009 5:08 PM (GMT -6)   
No he has not had a PCA3 test.
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