Prostate

[Alan-Enis]

    
      Re: Prostate
    


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Posted by HFHS M.D.-MS on February 20, 1998 at 18:06:57:

In Reply to: Prostate posted by Allan Enis on February 17, 1998 at 10:14:47:

: I have had an increasing PSA for 11/2 years. I have had three biopsies with negative results. The path report says prostatitis and atrophy all three times. I have no symptoms of prostatitis. The only symtom of anything is more frequent urination. I am 59 years of age. Coincidentally, I have trigeminal neuralgia and have restarted taking Tegretol approximately in the same time period as my PSA started to increase. The NEJM had an article about a couple with Hepatitis A who both had elevated PSA levels. When the Hepatitis was resolved the PSA dropped to normal. Since Tegretol can cause liver abnormalities is there any history of the association of this drug with elevated PSA's? If not, what could be the reason for my high PSA level? EWhat is the statistics on a cancer being missed three times on TRUS and biopsy? Thank you very much for any opinions.
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Dear Allan
Thank you for your intriguing questions.
I did a Medline search focusing on the following  keywords: Carbamazepine/ or tegretol, Prostate-Specific Antigen/ or *Prostatic Neoplasms/ or *Prostatic Hyperplasia/ or *alpha
1-Antichymotrypsin/ or *Tumor Markers, Biological/ or *Prostatectomy/ or
PSA.   I searched back to 1981 (before PSA was beginning to be used as a prostate tumor marker)  and found no articles which show a correlation.  (PSA and Hepatitis) got a few more returns but only one article which maybe of pertinence. See Below.
Tregretol is known to increase the efficiency  of the liver enzymes and only in allergic reactions causes elevations in these same liver enzymes and hepatitis.  While Tegretol and PSA are mostly bound in the serum by albumin, alpha1-antitrypsin (AAT) or alpha1-antichymotrypsin (ACT) (all of which are made in the liver) there has been no association between chronic hepatitis  and uniformly elevated PSA levels.  Please see the abstract below.  Tregretol has however been associated with an increase in urinary frequency.    
This is the article and abstract which may reference contradicting articles and might be  available in a medical library. If interested I would call first, this journal is not always easy to locate in the US.
Kadayifci A. Benekli M. Simsek H. Sencan O .
Department of Internal Medicine, Hacettepe University Medical School, Ankara,Turkey.
Prostatic acid phosphatase and prostate specific antigen in liver disease.
International Urology & Nephrology. 28(1):67-71, 1996.
Serum concentrations of prostate specific antigen (PSA) and prostatic
acid phosphatase (PAP) were measured in 51 liver cirrhosis, 37 chronic
active hepatitis (CAH) patients and 26 healthy individuals. Elevated PSA
levels have been found in 2 of cirrhotic patients while no increase has
been detected in CAH and controls. Serum PAP levels have been observed
slightly increased in 2 patients with cirrhosis, 2 patients with CAH and
1 control case. Mean PSA and mean PAP values showed no significant
difference between groups (p > 0.05). Serum PSA and PAP levels are
reliable in diagnosing and monitoring prostate cancer in chronic liver
patients and maintain their specificity in this situation.
Your rising PSA levels need to be put in perspective.   If your PSA was 2.5 and has risen by 0.1 per year this is certainly within the range of variation of the PSA assay.
Your rate of rise of your PSA also has a bearing on the risk for cancer.   If your PSA has been rising more than 0.75 ng/dl per year for a two year period this put you into a more worrisome category.  
Urologist understand that bigger prostates make more PSA and therefore divide the PSA by the estimated prostate size measurement on transrectal ultrasound. The ultrasound is often used to direct the prostate biopsies to the periphery of the gland where most cancers are found.  Knowing the PSA and the size of the gland, we can make a proportion of PSA to grams of prostate.     The PSA divided by the number of grams of the gland is called the PSA density.   A PSA density greater than 0.15 is more worrisome for cancer.  The biopsy is the most specific test of the above.  If  you have had three benign biopsies, and the middle of the gland was sampled  ( Transitional zone  were about 25% of cancers arise) the literature quotes a 10-20% chance of having cancer found on a subsequent biopsy.  The risk of the biopsy needs to be weighted heavily against the chance of finding cancer on future biopsies.  One factor may also hinder finding cancer is if you have a very large gland, (then the needle in a haystack theory applies. Having chronic prostatatis on your pathology report may help explain your elevated PSA even though you are asymptotic from the prostatitis standpoint.
This information is provided for general medical information purposes only. Please consult  your physician for diagnostic and treatment options pertaining to your specific medical condition. Drs. Menon, Keoleian, Peabody and Stricker at our institution have experience inthe problem which you describe. If you would like to make an appointment  for another opinion,  please call us at  (1-800-653-6568). We can also arrange local accommodations through this number if this is  your need. Please bring any ultrasounds and pathology slides (not just the reports) as well as any physician’s notes and lab test results that you may be able to obtain. These will help us greatly.
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Hope this has helped and Good Luck.
Sincerely;
HFHS-M.D. MS
* Keyword: PSA/ elevated, Prostate biopsy,  PSA determinations