Missing the Target: One biopsy for de... - Prostate Cancer N...

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Missing the Target: One biopsy for deciding initial treatment

climb4blue profile image

I have not seen anyone bring this up on our forum: The topic of using one biopsy to decide on initial treatment.

Any discussion about AS includes advice to have repetitive biopsies, as was the case during my phone consult with Dr Epstein, because the odds of missing a higher-grade tumor is over 30% on the first biopsy.

Well then, if the first biopsy is used by a man for deciding on his treatment, is there not a significant risk of undertreatment for him because the one biopsy missed a higher-grade tumor?

A simplest of examples, in the context of choosing treatment and not AS, wouldn’t the SOC treatment plan materially change for a man, even if all of tumors remained confined within the prostate capsule, if one of four tumors biopsied were 4+3 rather than all being 3+3?

Does this observation suggest that a repeat biopsy be scheduled before having initial treatment when the first biopsy is categorized as low risk and intermediate risk for a man?

Does this observation suggest a repeat biopsy, even more so, when MRI reports identify a PI-RAD4 lesion but the targeted fusion biopsy tissue taken is shown to be benign, because fusion biopsies are known to miss lesions due to fusion-software misregistrations or low tumor volume?

26 Replies

climb4blue wrote --- " ...Any discussion about AS includes advice to have repetitive biopsies, as was the case during my phone consult with Dr Epstein, because the odds of missing a higher-grade tumor is over 30% on the first biopsy.... "

The Saturation Transperineal 3Dimensional Prostate MAPPING Biopsy I had in 2015 yielded 100+ core samples for pathological review covering approximately 95% of my prostate's volume. The likelihood that additional PCa would be found if an additional biopsy was perform would be minimal.

Yes, it would address my concern.

Treatment efficacy data are based on the biopsy, and not what is really there.

Right, the D’Amico scoring for risk stratification is based on actual pathology biopsies post RP, not clinical pathology from a biopsy prone to miss tumors.

Maybe this is why there is a 10% of recurrence in low risk men - due to biopsy clinical misdiagnosis.

I just think this is an overlooked topic for the newly diagnosed patient. He should not assume his clinical pathology is his actual risk because it may result in under treatment, and could result in recurrence.

Absent a saturation biopsy as suggested by addicted2cycling, why is no one advising a repeat template biopsy be performed before initial treatment to prevent under treatment?

Because the treatments based on single biopsy results are so effective. For surgery, the main risk is cancer outside of the capsule, which you can't know from any number of biopsies. For radiation, which treats a margin outside the prostate too, there is 97+% freedom from recurrence for low risk PCa. Not worth multiple biopsies.

Dividing the two-part discussion for clarity's sake:

The first part being about relying on a single biopsy (template or random) for initial treatment when it has a 30% chance of missing the worst tumor.

The second part being how treatment may change if a second biopsy were done and the worst tumor was found.

In regards to the second part, if all of tumors remained confined within the prostate capsule, is your point that on a single template biopsy pathology of low risk PCa, it is not worth multiple biopsies to determine the worst tumor because the missed tumors will get curatively treated anyway by the SOC chosen by the patient, say for example, with SBRT monotherapy?

Yes. Treatment effectiveness statistics are based on results of a single TRUS biopsy. More biopsies do not increase the benefit of treatment as much as the harm of the extra biopsies themselves. Treatment effectiveness is already excellent for favorable risk (on first biopsy) patients.

That applies to treatments, but not to AS. IMO, there should always be at least a confirmatory biopsy for men on AS. Otherwise, many urologists would not even consider them to be on AS.

The follow-up biopsy within 6 to 12 months is the "repeat biopsy".

Could not waiting "6 to 12 months" for a "repeat biopsy" be detrimental if 4's or 5's were missed because only a TRUS was performed?

Yes and I think that AS could cause significant levels of anxiety. The 4's or 5's can also be missed by the repeat biopsy. Isn't active treatment an option?

ASAdvocate profile image
ASAdvocate in reply to Gemlin_

Actually, studies have shown NO increased mortality when treatment for high risk prostate cancer was delayed for six months.


After an initial biopsy and Gleason 7(4-3), my Urologists was ready for the knife. He suggested moving forward quickly so to lesson the risk of spread.After consulting a R.O. She suggested an MRI and a genetic test. In her words “after only a biopsy, you and I don’t have the info needed to decide between surgery and radiation”. Yet, with my initial diagnosis, waiting on another biopsy while receiving Androgen therapy would not have been pleasant.

I choose 5 radiation treatments and 6 months of Firmagon. Looking forward to being done with It soon.

climb4blue profile image
climb4blue in reply to 1Ubspaine

I don’t see your PSA was at 10+ and/or a tumor was palpable, so you seemed to be Favorable intermediate risk.

Was it the genetic results that drove Dr. Garant at UT Southwestern in Dallas to put you on neoadj ADT with SBRT?

What margins (mm) were treated around your prostate?

1Ubspaine profile image
1Ubspaine in reply to climb4blue

PSA was 6.5, I was unfavorable. I got the impression she suggested Androgen Therapy as much for a higher % of success than a necessity.

climb4blue profile image
climb4blue in reply to 1Ubspaine

I misread Gleason pattern. Makes sense for neoadj ADT based on what I have studied. Hope you are getting along okay.

Do you know the margins treated, was it 4mm?

Did you get gold fiducials?

1Ubspaine profile image
1Ubspaine in reply to climb4blue

Yes to gold f.Had 6 tumors, 3 were 4-3 and one next to prostate wall.

Not sure on margins, I never heard that, need to ask Dr.

ADT sucks, but many are on it the rest of their lives, I am done in 3 months.

Genetic test showed I had intermediate growth cancer. Annoying as I had been monitoring it for 2 years, then PSA spikes and I have 7, 4-3, which requires more medical attention.

If anything greater than a 3+4 very low volume, and thus RP is elected, a followup biopsy that would show you were actually 4+3 or worse would not yield much benefit in terms of treatment, other than perhaps a decision to remove some/more lymph nodes during surgery. With radiation, a missed higher Gleason score might mean that SOC ADT for higher risk had been skipped. Also, Gleason score is not the only thing in determining treatment......see MSK's pre-RP nomogram and the definitions of low, intermediate, and high risk PCa.

Per someone else's comment re a PIRADS 4 that yield s only a benign biopsy......yes, the Doc would definitely want additional testing..... a standard 12-18 TRUS biopsy if one hadn't already been done. I'm a case in point........PIRADS 5,but 6 cores all benign.....lesion was in transition zone......BPH? But, not a repeat biopsy, because the fusion biopsy also included 12 standard core, and one was low volume 4 +5( < 10% ofcore), and another core <10% 3+3. PSA had been stable at 7.5 for 30 months. Uro with 20+ years experience at Kaiser said he had never seen another high risk case like mine?

I doubt there are any such studies..but is it possible that a man would only have 1 mm of 4+5 in his entire prostate? and if yes, would that actually require high risk management for a 73 yr old man? My Uro was actually willing to watch the PSA, but Kaiser's tumor board disagreed! The Uro obviously understands the immediate deterioation in QOL for an older man who undergoes either surgery or radiation with almost 2 years of ADT !! I do understand that almost certainly there is more or much more 4+5 than just the 1 mm from one core.

Anyway, a good question by climb4 blue IMHO. Good luck as you move forward..we all need luck!!

climb4blue profile image
climb4blue in reply to maley2711

What I find very interesting in your metrics is an elevated but stable PSA of 7.5, but diagnosed with an aggressive cancer pattern.

In contrast, My PSA is now 8.01, and was 5.97 about 6 mos ago and 4.38 a year ago, so it is rapidly rising, but diagnosed with grade group 1 cancer. I did get a template biopsy that was MRI fusion guided to hit my PI-RAD4.

maley2711 profile image
maley2711 in reply to climb4blue

Perhaps I have very little 4+5? The treatment guidelines don't distinguish, though nomograms do usually include # of cancerous cores. and % of highest grade. Without RP, never know what exactly is there!!

Before he took my case to the Kaiser tumor board, my Doc said my biopsy results were very unusual, and at my age 72, he offered me the option of watching my PSA before going full bore on a treatment. As I expected, the tumor board eliminated that option......but I'm sure my 20+years experienced Doc had a reason for initially offering that option? Meanwhile, I'm terrified of destroying my QOL with either RP or radiation with 18 mo. of ADT. I'm not feeling lucky as to the SE outcomes for either option! Folks/friends who know me don't understand why I'm not rushing to have a treatment!! Any mention of cancer!!

maley2711 WROTE --- " Perhaps I have very little 4+5? ......... Without RP, never know what exactly is there!! ... "

Referring back to my original post ----

MY initial TRUS biopsy by the urologist yielded a 5+4 core sample and his treatment plan was based on the biopsy + CT + bone scan. ADT, chemo, radiation --- blah-blah-blah

I CHOSE CASTRATION then consultation with Dr. Onik who performed his 3D Prostate MAPPING Biopsy thus finding the actual Gleason 5+5 tumor's boundary and size. A RP was not needed.

My experimental treatment for GL10 is not something I would recommend especially since I get biweekly testosterone injections but 6.5+ years later doing ok and never had ADT issues.

So you bypassed all SOC and are doing high T instead? Sounds like it, since no ADT issues....almost unheard of!

Wow, just the 18 core fusion biopsy resulted in catheter for me........how many cores was the mapping biopsy?

1st -- Testosterone mitigation CASTRATION

preferred ORGANIC instead of CHEMICAL-----simply remove---instead of---using drugs-----

2nd -- Hemi Cryoablation instead of RP/Chemo/Radiation

--Mount Everest Assault--instead of ---cut out/drugs/fry

3rd -- First time experimental single injection of a 3 drug cocktail 7 months following the Cryo

4th --- Reintroduction *T* via biweekly injections of man made Cypionate to live a much more normal life (maybe adding fuel to the fire??? as many assume)

My Saturation Biopsy used a brachytherapy grid with 5mm spacing between needles having the number of needles determined by viewing prostate size at time of procedure via ultrasound observation. Insert boundary to boundary with needle yielding 1 core sample for pathology or what ever is deemed needed --- 2 or 5 or 10. My biopsy needles yielded 100+ core samples allowing boundaries of GL10 tumor to be 3-Dimensionally seen as being encapsulated giving a Best Case Scenario of no visible ECE. The number of Cryo FREEZING needles used in the right half of prostate was enough to ablate the WHOLE PROSTATE and in doing so a more methodical freeze could be done limiting the REQUIRED FREEZE BALL SIZE thus remaining clear of nerves permitting erection/orgasm even though castrated. mind over matter IS PARAMOUNT

Procedure being a First Time OFFERED Experiment has an unknown/unproven outcome and if it proves terminal, so be it. Prior to treatment the PCa cells had plenty of time to begin a whole body journey so again WHATEVER.

Thanks for the clarification! Congrats on the good result so far!! I guess the chemical castration could have the advantage of stopping at some time and hope for natural recovery of T? So, basically you had a focal hemi-gland ablation for high risk cancer. I think the focal method with longest documented results is HIFU? Seems like I read that somewhere, and cryo also a long history. ...though you say Onik used a different cryo approach. Any idea re what the cocktail was, and since been tried with other patients?

Did you primarily decide on cryo with the greater hope of preserving sexual ability?

Yes, by the time we are diagnosed, who knows how much bad stuff already circulating? Was Onik able to rpovide you with any study data re your treatment.......something must have convinced you that it could be just as effective as SOC?

My Hemi-ablation is not considered to be a FOCAL procedure. Focal is for smaller volume SPOT AREAS. My triple freeze with passive thaw between is more time consuming and not followed by all other cryo providers. Being almost 65 at time of dx, the preservation of sexual ability took a *back seat ;0)* in my thought processing of treatment choices.

Favorable results from the combo of drugs occurred before my use but I was the first with my specific diagnosis. If you notice the date in the following link, I am a recipient of the 2 mentioned PLUS Keytruda back in 2015. Work continues with tweaking taking place to improve results.


Never had expectations of being "cured" just wanted "the best life possible" until.

Thank you !!

Before you make your treatment decision, it would be helpful to do a bone scan and a CT scan.

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