Best biopsy methods: I am new to this... - Prostate Cancer N...

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Best biopsy methods

Stephen399b
Stephen399b

I am new to this site, live in the UK. I recently had a PSA test at 7.5 and, because for other reasons I can't have an MRI, consultant asked for a biopsy. I had a transrectal ultrasound and it has come back at a Gleason score of 4+3.. The consultant is suggesting surgery, but we will discuss after the Christmas break and a bone scan.

It has been suggested that a better diagnostic biopsy is a Transperineal biopsy? Does anyone have an opinion on this?

Also has anyone had a PSMA PET scan to back up the diagnosis?

Any help and ideas welcomed.

Many thanks

Stephen (age 70)

56 Replies
oldestnewest

You have learned enough and don't need any more biopsies. Your kind of prostate cancer is called "unfavorable intermediate risk" and the treatments with the best cure rates are certain kinds of intense radiation.

You can see for yourself the odds of surgery curing you by filling in this risk calculator:

mskcc.org/nomograms/prostat...

The types of intense radiation that are appropriate for you are SBRT or HDR brachytherapy monotherapy. You can talk to an RO about SBRT at Royal Marsden Hospital. For HDR brachytherapy monotherapy, I suggest you arrange a meeting with Peter Hoskin at Mt. Vernon Cancer Center in Northwood, Middlesex

Lezzers
Lezzers in reply to Tall_Allen

Would you mind explaining what exactly is meant by 'unfavourable intermediate risk' and what makes a risk 'unfavourable intermediate'

Thanks for your help

Tall_Allen
Tall_Allen in reply to Lezzers

A US organization of most of the top cancer hospitals called NCCN comes to a consensus about the risk categories used for prostate cancer. Their risk stratification system is accepted around the world. They look at the risk factors for prostate cancer and how they are correlated with the success of treatments for prostate cancer. "Intermediate risk" means that there is intermediate risk that the cancer will recur after treatment. A few years ago, they divided "intermediate risk" into favorable and unfavorable sub-categories. This explains it:

prostatecancer.news/2016/08...

Lezzers
Lezzers in reply to Tall_Allen

Thank you, I'll have a read of that

Thank you for your replies, I will do more homework based on this. I thought I understood the situation but am getting more confused by the different biopsies and now types of therapy, including HIFU Focal therapy. Guidance welcomed.

Stephen

Think twice about HIFU. Read this first:prostatecancer.news/2016/12...

I know the Ahmed/Emberton group at University College London are only choosing intermediate risk patients. But it is experimental and should only be done as part of a clinical trial.

Stephen399b wrote >>> " ...... I had a transrectal ultrasound and it has come back at a Gleason score of 4+3.. The consultant is suggesting surgery, but we will discuss after the Christmas break and a bone scan.

It has been suggested that a better diagnostic biopsy is a Transperineal biopsy? Does anyone have an opinion on this?

.............. "

The Saturation Transperineal 3Dimensional Prostate Mapping Biopsy utilizing Ultra Sound provides the level of information I WANT of my prostate while in situ.

Your TRUS is an "in office" SOC procedure but antiquated. The actual percentage of prostate volume sampled was negligible and simply does not yield adequate results "IMO" to determine treatment.

Did you obtain a SECOND OPINION on the samples???? Over diagnosis should be a concern since it can lead to treatment that might not be needed.

Tall_Allen wrote >>> "You have learned enough and don't need any more biopsies... "

SORRY, but if it were me in your place I would have to DISAGREE with T A. I would research then RESEARCH some more and test via scans, blood work and a superior biopsy before proceeding with treatment.

BTW, I am now 70 and 5.5 years from being diagnosed 5+5 GLEASON 10.

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I had a random biopsy that came back with Gleason 8. Wanting more info I opted for a mri guided fusion biopsy and it was more accurate and was deemed Gleason 7 mostly 3+4 and while only giving me a slight bit of relief I am still mulling over my options. I have some appointments coming up this January and so far I’m thinking since it’s all still localized within the prostate dr. Recommended a full prostate ablation. This may be my way to go. Do your research. Some are better then Others but quality of life and life expectancy are important for me being I’m only 53.

I had Cryoablation by Grandfather of PCa Cryo, Dr. Onik

Tall_Allen
Tall_Allen in reply to Jordache

In a recent trial of full prostate ablation with TULSA-PRO, a third of the men were not cured.

Anomalous
Anomalous in reply to Tall_Allen

Define “cured.” I think they based efficacy on a 75% PSA reduction. There’s so much to learn and know. But I noticed Profound, thr maker, just hit a high on the stock market and announcements are coming out almost weekly on new clinics offering its Tulsa-Pro for cancer. That tells me the medical field considers it very promising.

Tall_Allen
Tall_Allen in reply to Anomalous

A third of the men were found to have cancer in the prostate, proven by biopsy, within 5 years of TULSA-PRO. So they were not cured by anyone's definition.

That tells you that there is a lot of money to be made by selling a therapy that doesn't work to desperate patients. There is a multi-billion dollar supplement industry that feeds on that desperation too.

Anomalous
Anomalous in reply to Jordache

Most Tulsa-Pro ablation doctors won’t do 4+3. Some will. It won’t be known for 20 years how effective it is. On the other hand, its been 40 years since new prostate cancer treatments were introduced. I don’t think ablation hurts. But further treatments may be required. For your 3+4, I think its a great option

The prognostic groups are based on what is found on a biopsy, not based on what is really there if one had a prostatectomy. They work!

Hey Stephen399b!

If HIFU interests you, you might also consider FLA, Focal Laser Ablation. A tumor, not cancer in multiple areas, in the early stages, confined within the capsule has the best chance of a good outcome with focal treatments.

HIFU was approved for use in the US of A by the FDA on prostate tissue and now I believe prostate cancers as a result of the success that HIFU had in treating prostate cancer recurrence for men who had failed radiation treatments.

The TRUS biopsy is a bit archaic. So many men's cancer has been missed with TRUS biopsies. A link below--copy both lines to access it.

___________________________________________________________________________________________

Diagnostic accuracy of multi-parametric MRI and TRUS ...

pubmed.ncbi.nlm.nih.gov/281...

___________________________________________________________________________________________

A transperineal biopsy mostly eliminates the possibility of sepsis from the procedure.

It is time that the transperineal biopsy is accepted as the standard biopsy.

The link below will be of interest : ___________________________________________________________________________________________

Transperineal prostate biopsy

Image: slideshare.net

The transperineal prostate biopsy is the gold standard of biopsy. It can reach areas of the prostate transrectal can't. With an MRI image, the special grid can be referenced on that image to target the biopsy, and reduce the number of needle samples required.

Transrectal or Transperineal Prostate Biopsy | Prostate Cancer | Fo…

patient.info/forums/discuss/transrectal-or-transperineal-prostate-biopsy-541288

patient.info/forums/discuss/transrectal-or-transperineal-prostate-biopsy-541288

____________________________________________________________________________________________

Whatever you do avoid any drugs from the fluoroquinolone family. Cipro and Levaquin are two of the most frequently used. These drugs can cause damage to joints ligaments and tendons much longer than is acknowledged. I, unfortunately know about this. They are also been found to double the number of aortic aneurysms. In our age group I imagine it was thought that "Well, that can happen when 'they' get older"! Next patient!

The drugs Rocephin and Cefdinir can be used to prevent sepsis.

Not being able to have a MRI presents a bit of a challenge. Be certain that your medical team is well experienced. My very best to you.

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

HIFU has never been approved for treatment of prostate cancer in the US. In fact, it was specifically disapproved for that purpose.

Currumpaw
Currumpaw in reply to Tall_Allen

Hey T_A!

I didn't say HIFU was approved. I said I believed it was. It is being used to treat prostate cancers in the US-- a sort of work around with a wink and nod --perhaps --from the FDA. I know you don't like HIFU, FLA, or Cryo-- A link--

___________________________________________________________________________________________

HIFU as Alternative Therapy for Prostate Cancer ...

discover.vumc.org/2020/04/h......

____________________________________________________________________________________________

Another link and some info up front--

____________________________________________________________________________________________

Does HIFU Really Work for Prostate Cancer? Get the Facts.

cliffordgluckmd.com/wellnes......

Jul 17, 2019 · High Intensity Focused Ultrasound, or HIFU, is a well established and accepted method for treatment of localized prostate cancer.It has been in continuous use in Europe since 1994, and now has been employed world-wide, including the United States, where the Food and Drug Administration (FDA) approved HIFU …

Merry Christmas!

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

You are quoting "used car salesmen" who are hawking unproven therapies. Their lawyers got around the FDA-disapproval for prostate cancer by claiming it can remove prostate tissue (like a TURP). The FDA disapproved it because the trials showed it was uneffective. Canada, which previously allowed it, disallowed it.

Currumpaw
Currumpaw in reply to Tall_Allen

Hey T_A,

Why didn't you mention that HIFU is accepted in Europe, Mexico and I could go on.

Not quite "used car salesmen"--those in the link below--

___________________________________________________________________________________________

HIFU effective for treating prostate cancer

news.keckmedicine.org/hifu-......

____________________________________________________________________________________________

An excerpt:

“This positive data empowers urologists to use focal HIFU ablation to effectively address prostate cancer without the intrinsic side effects of radical treatments,” says Andre Abreu, MD, urologic surgeon with Keck Medicine and first author of the study. Abreu is also an assistant professor of clinical urology and radiology at the Keck School of Medicine of USC."

Another excerpt:

"Keck Medical Center of USC was ranked among the top 20 hospitals nationwide on U.S. News & World Report’s 2020-21 Best Hospitals Honor Roll and among the top 3 hospitals in Los Angeles and top 5 in California."

These people are very talented --clicking around on their site I found this. Rated 9th best in the US of A in urology! The aortic thing--those of us who have had a little "too much" Cipro or Levaquin might use their talents to repair aortic aneurysms!

"The annual Best Hospitals rankings and ratings assist patients and their doctors in making informed decisions about where to receive care for challenging health conditions or common elective procedures. For the 2020-21 rankings and ratings, U.S. News evaluated more than 4,500 medical centers nationwide in 16 specialties and 10 procedures or conditions. In the 16 specialty areas, only 134 hospitals (nearly 3%) were ranked in at least one specialty. Keck Medical Center and others named on the Honor Roll posted high scores across many of these areas of care.

At No. 7, geriatrics was the medical center’s highest-ranked specialty. Ten additional specialties also placed in the nation’s top 45 — urology (No. 9), pulmonology & lung surgery (No. 12), ophthalmology (No. 12), cardiology & heart surgery (No. 15), gastroenterology & GI surgery (No. 15), neurology & neurosurgery (No. 19), nephrology (No. 21), cancer (No. 26), orthopedics (No. 30) and ear, nose & throat (No. 44).

Keck Medical Center also was rated High Performing, the highest rating possible, in nine out of 10 evaluated procedures and conditions: abdominal aortic aneurysm repair, aortic valve surgery, colon cancer surgery, heart bypass surgery, heart failure, hip replacement, knee replacement, lung cancer surgery and transcatheter aortic valve replacement (TAVR).

“These impressive specialty rankings are a result of highly skilled physicians, pioneering researchers and committed staff,” Hanners says. “The results underscore our excellent outcomes caring for and treating some of the most complicated cases in the country.”

I wasn't aware of this center of excellence for learning and treatment. Thanks for getting me to click here and there!

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

There are many "used car salesman" offering it - that doesn't mean that it is proven. Results so far look poor. Klotz reported that a third of men treated with whole gland HIFU (TULSA-PRO) had a recurrence within 5 years. One can get laetrile in Mexico too - that doesn't mean it's good.

Currumpaw
Currumpaw in reply to Tall_Allen

T_A,

An excerpt from an excerpt in my last response to you--

"At No. 7, geriatrics was the medical center’s highest-ranked specialty. Ten additional specialties also placed in the nation’s top 45 — urology (No. 9),"

I am not comfortable with the comparisons you are making.

I don't advise anyone to have or not have a treatment. Just some info. Each is capable of making their own decision.

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

I am only countering your disinformation. When a patient makes a decision, he should understand all the info - not just what you pick and choose. I know of many such "used car salesmen" with practicing privileges at major hospitals - we are treated by doctors, not hospitals.

Currumpaw
Currumpaw in reply to Tall_Allen

T_A,

It is not "my" disinformation". I did not write it but posted links. These professionals are judged to be the 9th best urology specialists in the country. I am not comfortable in a written discussion where they are compared to used car salesmen.

If you feel that way fine. I want no involvement in denigrating these people or their institution.

From a previous reply:

"Keck Medical Center of USC was ranked among the top 20 hospitals nationwide on U.S. News & World Report’s 2020-21 Best Hospitals Honor Roll and among the top 3 hospitals in Los Angeles and top 5 in California."

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

As I said, one is treated by a doctor, not by a hospital. Keck hires a lot of doctors - some are good, some not. The FDA has sent out warning letters to doctors (including doctors who practice at hospitals) making unfounded claims on their internet sites that their ablation therapies cure prostate cancer. I hope long-term clinical trials will continue for this experimental therapy.

When you leave out vital info, like recurrence rates, you are engaging in disinformation.

Currumpaw
Currumpaw in reply to Tall_Allen

T_A,

I posted a link. I also didn't make any claims of my own. I do not do research. These people do. Please do not label me as one who "engages in disseminating 'disinformation'".

Unless one has names and can refer to specific, punitive actions taken against licensed professionals by licensing or governmental entities empowered to do so it is wise not to malign professionals. You are entitled to your opinion.

Currumpaw

Tall_Allen
Tall_Allen in reply to Currumpaw

Like this one?"However, no HIFU device has been approved for the treatment of localized prostate cancer in the United States"

medscape.com/viewarticle/88...

Or this one?

mqa-internet.doh.state.fl.u...

Questionable practices:

sfgate.com/health/article/D...

Patients who have been misled by unscrupulous doctors should consider a lawsuit:

kytrial.com/medical-malprac...

Currumpaw
Currumpaw in reply to Tall_Allen

T_A,

Doctor Wheeler is yesterday's news.

Good day,

Currumpaw

I have read that a review of the failed TULSA-PRO cases found calcifications were blocking the paths to the untreated lesions. Now, patients seeking TULSA-PRO who have prostate calcifications are advised to have a TURP first (Scionti uses HIFU for that), or find another treatment.

Anomalous
Anomalous in reply to ASAdvocate

Indiana’s Dr. Koch gave a great talk on that. He also suggested that movement during the procedure might hinder the ultrasound. As well as the possibility that movement of thr prostate while its being cooked could also. And the final thing is he questioned what the harm of an isolated 3+4 was stuck in necrotic prostate tissue. Time will tell on this procedure

It was a very large degree of failure (1/3)- I wouldn't trust that it was merely due to calcifications that can be cleared with a TURP - that requires a clinical trial. But more importantly, it seems silly to have an invasive procedure - why not just have SBRT or HDR brachy which we know work well and have minimal side effects?

maley2711
maley2711 in reply to Tall_Allen

not SBRT or IMRT + brachy boost for 4+3?

Tall_Allen
Tall_Allen in reply to maley2711

I did say SBRT. HDR brachy boost is certainly an option too, but Peter Hoskin is one of the world experts at both the monotherapy and the boost, so I'd just listen to him. He has used it as a monotherapy, even in high risk cases. Unlike LDR brachy, HDR brachy can treat a margin outside of the prostate.

prostatecancer.news/2016/08...

If LDR brachytherapy is all that's available, it would have to be with external beam as well.

maley2711
maley2711 in reply to Tall_Allen

Interesting re HDR and treating outside margin.....is that an advantage compared to SBRT??

Tall_Allen
Tall_Allen in reply to maley2711

SBRT is a form of external beam radiation and can be aimed anywhere. HDR brachy uses catheters (hollow tubes through which the radioactive needles are inserted and withdrawn) that can be put anywhere.

maley2711
maley2711 in reply to Tall_Allen

Allen -

sorry for my poor wording....what I meant was..... SBRT not able to safely treat outside margins, whereas HDR can?

Tall_Allen
Tall_Allen in reply to maley2711

Both SBRT and HDR-BT can treat any given margin outside of the prostate. SBRT is a kind of external beam therapy, so it can treat anywhere.

maley2711
maley2711 in reply to Tall_Allen

Thanks Allen...so any type of external beam has that advantage, and that is an advantage when compared to both LDR brachy AND surgery!!??

Tall_Allen
Tall_Allen in reply to maley2711

Yes.

Gleason score can be determined from MRI???

No. He already had a biopsy that detected GS 4+3

Thanks--I misinterpreted the information.

Jordache
Jordache in reply to Tall_Allen

Btw a focal ablation is not an option dr is saying whole gland ablation. Does that make a difference and if the whole gland is ablated and it’s still hasn’t left prostate why not?

Tall_Allen
Tall_Allen in reply to Jordache

I think you will understand the issue better if you think of "whole gland ablation" as "whole gland attempted ablation." Although whole-gland TULSA-PRO made a great attempt at ablating all the tissue in the prostate, in a third of the men, live cancer was still found in the prostate via biopsy. There are physical and biochemical reasons why the attempts are not successful, such as heat-sink effects (failure to keep tissue at high enough temperature for long enough time), protective heat shock proteins, and physical barriers caused by congealed/necrotic tissue.

Incidentally, radiation is non-ablative of healthy tissue. It inserts hydroxyl radicals (mostly) into the cell's DNA. It takes advantage of a peculiarity of cancer in that it loses the ability to self-repair its DNA. When the cancer cells try to replicate, they are killed (called "mitotic catastrophe"). Healthy cells either fix the DNA damage or self-destruct (called "apoptosis") and are replaced by new cells.

Jordache
Jordache in reply to Tall_Allen

What is your feeling about proton therapy? Interesting read on Drs and their financial investments in sonoblate.

Tall_Allen
Tall_Allen in reply to Jordache

There was a similar proton building boom a few years ago. Unlike HIFU, proton has been used for a long time. But it has never been proven in a randomized trial to be any better than photons (in spite of the Bragg peak). That's why most insurance won't pay the extra cost of it. Here's what I've seen:

prostatecancer.news/2016/08...

Now, what I would really like to see is a carbon ion treatment center. Only the government could afford to fund it, but President-elect Biden is very supportive of gov't cancer projects, so who knows?

prostatecancer.news/2016/08...

Anomalous
Anomalous in reply to Tall_Allen

Mayo is building one in Jacksonville. 2025. jacksonville.com/news/20191...

Tall_Allen
Tall_Allen in reply to Anomalous

Cool. I'm sure treatments will be super expensive. Give them another 5 years on a learning curve.

Anomalous
Anomalous in reply to Tall_Allen

According to the Hitachi site, there are a number of carbon facilities already, mostly in Japan. No discussion of cost. hitachihealthcare.com/parti...

Tall_Allen
Tall_Allen in reply to Anomalous

Yes, there are carbon ions in Japan, Germany and Italy - none in the US. They are free to citizens of those countries. I don't know if they will treat outsiders since they are govt projects. Probably for enough money they will.

Justfor_
Justfor_ in reply to Anomalous

There is also a private one in Austria with dual capability (proton and carbon ions). Cost of the order of 50k Euros.

If I were you before i would make any decision on the strength of that biopsy i would send it to Johns Hopkins Pathology Lab for a second opinion. They are the best in the USA in reading biopsies. Maybe there is an organization in England that is equally good, but either way dont make decisions on that biopsy until you confirm that it is accurate. Good luck.

Thank you all for your help and thoughts. I am on another Healthunlocked site as I have a form of blood cancer and, as with there, real people sharing real experience is the best.

Happy Christmas to all and lets hope for a better 2021.

Stephen

I was in this situation 3 years ago. I chose a transperineal biopsy, not a rectum biopsy. I researched which method has least risk of “seeding” any cancer cells liberated during the needle penetrating the prostate capsule. I chose a leading urology professor to carry out the biopsy. I was told you want the best for such a procedure. I guess that applies to any medical procedure. I found that transrectal biopsies are not the leading biopsy procedure. My professor urology surgeon told me they had not carried out any transrectal biopsies for 8 years (3 years ago). No one in the medical field will tell you which procedure outright. They tell you the pros snd cons as there is no single set solution. It’s time, cost, opportunity etc. Don’t delay but think of perineal if you have the time, money, opportunity. I’m not a physician or medically trained. I’m a prostate cancer patient who is recovering from high intensity and frequency ultrasound (HIFU) treatment in 2018 which to date is keeping the cancer at bay. As with all cancers, it is watchful surveillance for the future.

Just seen Tall-Allen’s comments. TA helped me at the time and is authoritative on the prostate cancer subject. Take his advice before mine. Dont want to cause any confusion for you. I’m still learning - we all are but some are ahead of others. My PCa was (might still be it or might again be) focal ie inside the capsule and not touching the internal sides so it was more relevant for HIFU. But even then I had thoughts about wishing I’d chosen prostate removal which removes doubts but has other risks. It’s down to your specific diagnosis.

Stephen399b
Stephen399b in reply to Adam10

Thank you Adam. I confess that I found the arguments that my original post prompted, to be progressively more confusing.

My inclination is to have the removal, but want to sure that I have have a full diagnosis.including a PSMA Pet scan.

Tall Allen clearly knows his stuff, but grateful for all opinions.

Stephen

Thanks to TA and everyone for contributing to a most enlightening thread. I suspect most urologists would learn a thing or two reading it. I sure did.

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