Transitional zone cancers

GH writes from Alaska,

> My diagnosis (details below) was confusing for a while: minor

symptoms

> (decreased stream) and unremarkable DRE four years ago, but suddenly a

PSA

> of 61 (first one taken). PAP also high.

Small volume prostate. Biopsy

> first looked only "atypical" but after examination at the Mayo Clinic,

was

> read as Gleason 2+2.

Although this is compatible with transitional zone, we have to worry about

a larger unsampled tumor lurking somewhere. Prostatitis may also cause

elevated PSA but isn't nearly as likely. The probability of having a sole

transitional zone tumor as a cause of elevated PSA is increased if you have

a normal DRE.

Other tests (CT, Bone Scan, pelvic lymph nodes

> (laproscopic sampling) are negative.

Good news is always welcome.

> The paradox is the ominous biochemistry (in Dr. Stamey's

characterization,

> "metastatic PSA levels") and the relatively benign (but cancerous)

> morphology. When I emailed to Dr. Stamey, he suggested that the low

> Gleason and high PSA might be caused by a transition zone cancer, perhaps

> in the anterior lobe of the prostate which is not sampled well in

standard

> biopsies. Since transition zone biopsies should be done by experienced

> hands, I am now trying to arrange a trip to Stanford to get that biopsy

> tissue for histopath. As I understand it, a demonstration by biopsy that

> my cancer is in the transition zone (coupled with no evidence that it is

in

> the peripheral zone) increases the probability that metasis is absent.

That's how I see it as well. Stamey, whose parter McNeal first identified

the transitional zone, wrote an article (J Urol, 149:510-515, 1993)

describing three men with transitional zones cancers and PSAs between 150

and 456. All were organ confined upon examination of the radical

prostatectomy specimen. I don't know about follow-up on these men.

The rigor with which you are seeking information and opinions sets a fine

example to all men possessing the wherewithall to do likewise. Your young

age is reason enough to be gung-ho about this. The paradox for me is that

you were detected at a Health Fair! Now if you can come back in ten years

an tell me (God willing) that you have no signs of recurrent cancer, I have

yet another reason for re-evaluating my thoughts on mass screening. Still

we can't base public health policy on anecdotal evidence, even though you

are by far the most important anecdote of you entire life!

Regards,

JR Oppenheimer, MD

Prostate Pathologist

Oppenheimer Urologic Reference Laboratory

Oklahoma City, OK