Nubbins On Your Nuts: What You Should Know About Tunica Cysts

February 9, 2019

Andrew Siegel MD    2/9/2019

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Image of testes and its tunics (covering sheaths) from Gray’s Anatomy (public domain)

The tunica albuginea is the dense fibrous sheath that surrounds, covers and protects the delicate contents of each testicle. The tunica albuginea is surrounded by a second layer, the tunica vaginalis. Benign cystic masses may arise from either tunic.

Cysts originating from the tunica albuginea are the most common benign masses that originate external to the testicle. They are small, firm, irregular, plaque-like nubbins located on the surface of the testes ranging from 2-5 mm in size.  They are often described as feeling like a “grain of rice.” They are most often found  on the upper front or upper side aspect of the testicle. In most cases they are minimally symptomatic and are discovered incidentally by the patient, who is typically around 40 years of age.

These cysts can cause a great deal of concern and worry because of the fear of testes cancer, but they are distinguished from testes cancer by being cystic (not solid) and on the outer surface of the testes as opposed to being within the testes.  Ultrasonography is the imaging study of choice for evaluating testicular masses and can differentiate cystic, benign masses from solid, malignant masses.

On ultrasound the tunica albuginea can be seen as a 2-layered echogenic (containing lots of echoes) structure surrounding the testicle and the cyst as a small, regular fluid-filled structure abutting the surface of the testicle (see below).  On occasion, a tunica cyst may calcify. Microscopically, they are seen to contain fluid and cellular debris.  Although these cysts can be surgically excised, it is only rarely necessary to do so because ultrasound can reliably confirm their benign diagnosis.

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Tunica albuginea cyst on ultrasound
       (cyst is black oval structure)

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel is the author of 5 books: FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 and hot off the press is PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Andrew Siegel MD Amazon author page 

 

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Active Surveillance of Prostate Cancer: “To do nothing, that’s something”

July 13, 2019

Andrew Siegel MD  7/13/2019

AS always bring homework

Yours truly in the operating room using my down time productively to write while waiting for a case to get into motion.  My motto is “always bring homework.”

Active Surveillance to Treat Prostate Cancer: What You Need to Know

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Torse d’homme, 1934, Jules Desbois, Musee d’Orsay, Paris (photographed by my friend Angela Fornstrom)

The challenge for those of us who treat prostate cancer is to predict the behavior of the cancer to treat it appropriately—offering curative treatment to those with aggressive cancer but sparing the potential side effects of curative treatment in those who have non-aggressive cancer. “Active surveillance” is the strategy of careful monitoring of non-life-threatening, low risk prostate cancers. The goal of active surveillance is to avoid active treatment of prostate cancers that do not have lethal or metastatic potential.

“To do nothing, that’s something.”   Samuel Shem, The House of God

If there is no difference in mortality (between active surveillance and immediate treatment), then quality of life is the defining issue.”  Mark Litwin, MD, MPH, Chairman of Urology, UCLA School of Medicine

The ratio of lifetime likelihood of diagnosis of prostate cancer (about 1 in 9 men) to death from prostate cancer (about 1 in 40 men) points to the fact that many men with prostate cancer have indolent (slow growing) cancers. On this basis, an alternative strategy to aggressive management of all men with prostate cancer is for careful follow-up, reserving curative intervention for if and when signs of progression develop.

Active surveillance involves rigorous monitoring and the willingness to have regular follow-ups. In addition to its utility for men with non-aggressive cancer, it is also appropriate management of prostate cancer in older men or those with serious health conditions. Active surveillance was introduced in the mid-1990s and has gradually gained traction to the extent that we are now in the “era of active surveillance.”

Eligibility criteria for active surveillance are the following (note that these are general guidelines and are modified in accordance with patient age, general health and other factors— certainly if one has a life expectancy of less than 10 years, he would be a good candidate for active surveillance):

  • Prostate Specific Antigen (PSA) less or equal to 10
  • Gleason score 6, although active surveillance is occasionally used for low-volume Gleason 7 (3+4) cancer (Note that although some experts do not think that the term “cancer” is appropriate for Gleason 6 disease, recent studies have shown that a small percentage of men with Gleason 6 can potentially have local extension beyond the prostate, supporting the argument for continuing to use the term cancer for these tumors.)
  • Stage T1c-T2a
  • Less than 3 cores with cancer
  • Less than 50% of any one core involved
  • Genomic testing confirming low risk for progression is an additional tool that can help guide eligibility

A general guide to the monitoring schedule is the following:

  • PSA and DRE every 6 months
  • Repeat biopsy (“confirmatory biopsy”) one year following initial diagnosis, then periodically thereafter (I prefer annual biopsies for the first 3 years)
  • Prostate MRI (not a substitute for repeat biopsy, but once serial biopsies have confirmed low risk cancer, can be used periodically in lieu of prostate biopsy)

Serial PSA levels are invaluable for men on active surveillance. PSA doubling time (PSADT)—the amount of time it takes for the PSA to double—is an excellent means of predicting prostate cancer behavior.  A short PSA doubling time is usually indicative of an aggressive, rapidly growing tumor, whereas a long PSA doubling time is indicative of an indolent, slower growing tumor. A PSADT of less than 3 years is clearly associated with the potential for progression of prostate cancer.

The repeat biopsy is the most important component of the active surveillance protocol.  There are three possible outcomes to follow-up biopsies: cancer-free, stable low risk cancer, and worsening cancer. A cancer-free pathology report is usually indicative of an excellent prognosis, insofar as the absence of cancer on repeated prostate biopsy (because the cancer is of such low volume) identifies men who are unlikely to have progressive prostate cancer.  It does not mean that cancer is no longer present but implies that the cancer is extremely low volume and that the original biopsy discovered the “needle in the haystack.” Stable low risk cancer is consistent with the original biopsy in terms of tumor volume and grade and indicates that the active surveillance protocol may be continued, sparing the patient the potential side effects of surgery, radiation or other modalities. Worsening cancer is demonstrated by a higher Gleason score or increased tumor volume as indicated by number of cores and percentage of tumor involvement per core. A higher Gleason score, increased tumor volume or a PSADT of less than 3 years will often result in a reclassification requiring a change in plan to active management with curative intent.

65-75% or so of men on active surveillance remain free of progression at five years, and definitive treatment is usually effective in the 25-35% who progress or elect active treatment for another reason.

Advantages of Active Surveillance:

  • Avoids side effects and complications of immediate treatment
  • Minimizes over-treatment of indolent prostate cancer
  • Low cost

Disadvantages of Active Surveillance:

  • Need for frequent and repeated testing and biopsies
  • Anxiety of living with untreated prostate cancer
  • Imprecise criteria for delayed intervention
  • Delayed treatment may ultimately need to be more aggressive (with more potential side effects) compared to earlier intervention
  • Delayed treatment may not be curative or as effective as earlier intervention

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

When Sex Hurts

July 6, 2019

Andrew Siegel MD  7/6/19

When Sex Hurts and Pain Replaces Pleasure

Today’s entry is a short break from the prostate theme, which will be resumed next week.

Sex should be a pleasurable and enjoyable experience, but sadly, that is not always the case. The pleasure aspect is a brilliant bait-and-switch design of nature that ensures reproduction of the species; members of the animal kingdom, “baited” by the pursuit of pleasure are actually “switched” to reproduction. 

“Dyspareunia” is doctor-speak for difficult or painful sexual intercourse, derived from “dys,” meaning “difficult” and the Greek term “pareunos,” meaning “lying with.” Although more typically a female complaint, dyspareunia does not spare men.

An Overly Mechanistic View of Sexual Intercourse

Sexual intercourse is a physical activity that involves moving parts that need to be lubricated and fit together properly for optimal function.  The “piston” component of an engine moves up and down within the “cylinder,” requiring appropriate fitting together of these component parts and sufficient lubrication to avoid excessive friction among the moving parts. “Piston clearance” is the clearance or gap between piston and cylinder.  If piston clearance is too small, the piston can “seize” inside the cylinder on expansion. If the piston fits too tightly within the cylinder, it can result in excessive friction and damage to the cylinder wall.  The bottom line is that problems can arise if the piston does not properly fit the cylinder or if there is inadequate lubrication of contact points.

Internal_combustion_engine_pistons_of_partial_cross-sectional_view

Internal combustion engine with pistons and cylinders, Attribution: Mj-bird [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D

 Causes of Female Dyspareunia

  • Size discrepancy with partner – The vagina is an incredibly accommodating organ capable of tremendous stretch and expansion—think vaginal delivery of a 10-lb. baby—so this is relatively rare, but the combo of a woman with petite anatomy  coupled with an outsized male can be a formula for pain. A lengthy penis can strike the cervix or vaginal fornix and a penis with formidable girth may prove excessive for a narrow vagina, resulting in “collision dyspareunia.”
  • Vaginal scarring – Scar tissue from pelvic or vaginal surgery, birth trauma, or poor healing of episiotomies can alter vaginal anatomy and make sexual intercourse painful and challenging.
  • Menopause – Estrogen nourishes and nurtures the genital tissues.  Declining levels of estrogen after menopause cause thinning, fragility and less suppleness of the vaginal walls as well as diminished vaginal lubrication.
  • Infection – Vaginitis (vaginal infections), bacterial cystitis (bladder infections), interstitial cystitis, pelvic inflammatory disease, and infections of the para-urethral glands (Skene’s glands) a.k.a. Skenitis that can give rise to painful intercourse.
  • Endometriosis –The lining tissue within the uterus (endometrium) can implant outside the uterus, causing painful intercourse.
  • Excessively tight pelvic floor – This is a condition—a.k.a. vaginismus– in which the pelvic floor muscles are over-tensioned and fail to relax properly, which can cause painful intercourse, if sex is even possible at all.
  • Vulvodynia – This is a condition marked by hypersensitive vulvar tissues that are extremely tender to touch.
  • Loss of vaginal lubrication – This can happen from menopause (natural or from surgery), side effects of medications, breast-feeding, as well as insufficient foreplay.
  • Disuse atrophy – Use it or lose it; if one has not been sexually active for prolonged times, there can be loss of tissue integrity and vaginal atrophy. Staying sexually active keeps one’s anatomy toned and supple.
  • Urethral diverticulum – This is an acquired out-pouching from the urethra causing a cystic mass in the vagina that can result in pain with sex.
  • Psychological/emotional – “The mind suffers…the body cries out.” Emotionally or physically traumatic sexual experiences can negatively affect future sexual experiences.

Causes of Male Dyspareunia

Urologists sometimes refer to male dysparenuia as “his-pareunia”–not a legitimate medical word, but to the point!

  • Infections —Infections of the prostate (prostatitis) and urethra (urethritis) can cause pain with ejaculation.
  • Peyronie’s disease – Scarring of the sheath of the erectile cylinders can cause an angulated and painful penis, particularly so with erections.
  • Phimosis — This is a condition is which the foreskin is tight and cannot be drawn back, leading to inflammation, pain and swelling.
  • Tethered frenulum — The frenulum is the narrow band of tissue that attaches the head of the penis to the shaft; at times it can tear during sexual intercourse, causing bleeding and pain.
  • Excessively tight pelvic floor – This condition in which the pelvic floor muscles are over-tensioned and fail to relax properly is not unique to females and can result in pelvic pain and pain with sexual activity.
  • Penile enlargement procedures – Efforts to “bulk up” the penis with injections of fat, silicone and other tissue or prosthetic grafts can result in an unsightly, lumpy, discolored, and painful penis.
  • Improperly sized penile implants – Penile prostheses can be lifesavers for the sexually non-functional or poorly functional male, but need to be sized precisely, like shoes for one’s feet.  If too large, they can result in penile pain and pain with sex.
  • Her issues causing his pain – Mesh exposure is a condition in which a mesh implant–used in females to help support dropped pelvic organs and to cure stress urinary incontinence–is “exposed” in the vagina, which feels on contact like sandpaper and can result in both female and male dyspareunia.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel’s latest book: PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

Prostate Cancer Treatment Overview: What You Need to Know

June 29, 2019

Andrew Siegel MD  6/29/19

The following is a brief overview of traditional prostate cancer treatment options based upon  risk stratification (as reviewed last week). The entries that follow in future weeks will discuss each treatment option in detail.

It is important to understand that there is no one-size-fits-all treatment approach to prostate cancer as there are “competing” options, each with benefits that must be weighed against side effects. Many patients are fearful and confused about side effects that may occur after surgery or radiation—specifically, what they are, how frequently they occur, how severe they are, and how they are managed. Nowadays, side effects occur less frequently and are less severe than many imagine because of technical progress and advances in both the treatment of prostate cancer and in the management of side effects.

Stages Of Prostate Cancer

Stages of Prostate Cancer: Goal is to identify prostate cancer early in its course and treat potentially aggressive cases

Treatment for cure is pursued in men with potentially aggressive prostate cancer when the cancer is localized to the prostate, with the goal of eliminating all prostate cancer cells from the body.  Localized cancer options are robotic-assisted laparoscopic prostatectomy and prostate radiation therapy. In general, if one is young and in good health, the option of choice is often surgical removal of the prostate as this is a highly effective means of long-term cure. Radiation therapy can be an excellent alternative to surgery with similar cure rates and less adverse effects and is often the option of choice in the older and less healthy population, as well as in men reluctant to undergo surgery.

Androgen deprivation therapy uses medication to suppress levels of the male hormone testosterone to “castrate” levels, the same levels that would be achieved if the testes were surgically removed.

Active surveillance is a means of vigilant tracking used in men with non-aggressive prostate cancer with no treatment per se aside from careful monitoring with plans for a change in strategy to active intervention if indicators worsen.

Observation is a means of monitoring with the expectation of palliative therapy (relieving pain and alleviating other problems that may arise) if symptoms develop or a change in exam or PSA suggests that symptoms are imminent.

Cryosurgery (freeze destruction of the prostate) and high intensity focused ultrasound, a.k.a. HIFU (heat destruction of the prostate) are alternative approaches and are not listed in the overview treatment option outline that follows.

TREATMENT OPTIONS BASED UPON RISK STRATIFICATION

Abbreviations:

RALP (robotic-assisted laparoscopic prostatectomy)

 RT (radiation therapy)

ADT (androgen deprivation therapy)

AS (active surveillance)

Observation

Very Low Risk

< 10-year life expectancy: observation

10-20-year life expectancy: AS

> 20-year life expectancy: AS or RALP or RT

Low Risk

< 10-year life expectancy: observation

> 10-year life expectancy: AS or RALP or RT

Certain factors increase the likelihood of progression on active surveillance and their presence may influence a low risk patient to pursue active treatment.  These include the presence of peri-neural invasion on biopsy (cancer involving the space surrounding a nerve), African American race, family history of prostate cancer or a genetic predisposition to metastatic prostate cancer. Low risk men most likely will have localized disease and have a 90-95% recurrence-free survival rate 5 years after RALP or RT. Surgery and radiation in the low risk population generally do not improve survival before 10 years of follow-up as compared to active surveillance but reduce prostate cancer progression and the occurrence of metastases thereafter.

Intermediate Risk

< 10-year life expectancy: observation or RT + ADT 4-6 months

> 10-year life expectancy: RALP or RT + ADT 4-6 months

AS may be a possibility in selected patients with favorable intermediate risk prostate cancer, but this will incur a greater chance of developing metastases as compared with definitive treatment. Intermediate risk men have a 65-75% recurrence-free survival rate 5 years after RALP or RT.  Patients with intermediate risk prostate cancer have improved survival when short-term ADT is combined with RT.

High Risk

RALP or RT + ADT 2-3 years

High risk prostate cancer is aggressive and incurs a likelihood of metastases and death. There is no place for AS, although observation is preferred in a man with a life expectancy of fewer than 5 years. Under the circumstances of symptomatic disease and limited life expectancy, ADT alone is a reasonable option.  High risk men have 50% recurrence-free survival rate 5 years after RALP or RT. Combined modality therapy is likely to be needed, such as RT plus long-term ADT, or RALP plus adjuvant RT (radiotherapy given as soon as the healing process after RALP is completed).

Very High Risk

T3b-T4: RT + ADT 2-3 years or RALP (in select patients) or ADT alone

Lymph node spread: ADT or RT + ADT 2-3 years

Metastatic disease: ADT

Treatment for palliation of cancer is used when prostate cancer advances well beyond the confines of the prostate gland, often to the bony skeleton. In palliative therapy the goal is reduction in the severity of the symptoms resulting from the cancer, but not cure. ADT is most often used in this setting.

 

PSA FOLLOWING TREATMENT

No matter what the treatment, careful follow-up is imperative. Paramount is PSA—an excellent marker for the status of the prostate cancer.  After successful RALP, the PSA should be undetectable; after successful radiation, the PSA should drop to a very low level and remain so.

After definitive treatment, a rising PSA may be the sole indication of the recurrence of prostate cancer, a condition known as “biochemical recurrence.” The important question that needs to be answered is whether the PSA elevation is due to local recurrence, systemic disease, or both, and how to distinguish the low risk from high risk patient.

A single abnormal PSA does not necessarily indicate that a biochemical failure has occurred. After RALP, biochemical failure becomes a consideration after the PSA is in the 0.2-0.4 range. In general, a low pre-treatment PSA, a lower grade, a lower stage, a longer time from definitive treatment to PSA relapse, and a longer PSA doubling time prognosticate a low likelihood for development of systemic metastases and a greater likelihood of local recurrence.

Salvage radiation therapy (RT following RALP, after a biochemical recurrence is noted) is an appropriate consideration for localized recurrence after RALP.  Cryosurgery, HIFU, or ADT are considerations for biochemical failure due to localized recurrence after RT.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

 

 

Prostate Cancer Risk Assessment: A Sensible Guide To Appropriate Treatment

June 22, 2019

Andrew Siegel MD  6/22/19

To determine the most appropriate and effective prostate cancer management strategy, newly diagnosed patients are “risk stratified” to predict the cancer’s potential for aggressiveness and severity. Today’s entry explains the means of this process.

Each case of prostate cancer is unique and has a variable biological potential for progression, spread and death. Prostate cancer can be “triaged” into low, intermediate and high risk categories.  Many cancers are “indolent” (low risk) requiring no treatment aside from careful monitoring, while some at the other end of the spectrum are so highly aggressive (high risk) that they incur the prospect of metastatic disease and cannot be cured (but can be well managed), and many lie in the middle (intermediate risk), in which there is the potential for death from prostate cancer and benefit from treatment, which is often curative.

Classification of prostate cancer into risk categories is based upon the following factors: tumor stage, Gleason score, volume of cancer on biopsy, PSA and PSA density, and at times, genomic testing. Additional factors that influence treatment choices for prostate cancer are: age, life expectancy, health status, presence or absence of urinary symptoms and personal preferences.

The extent of prostate cancer—whether localized, regionally advanced or metastatic—is an important factor that informs treatment. Extent or “staging” is determined by digital rectal exam and magnetic resonance imaging; additionally, computerized tomography and bone scan are often obtained to stage unfavorable intermediate risk and higher risk prostate cancer.

Tumor staging

The TNM (Tumor/ Lymph Nodes/ Metastases) system is used to determine the stage of prostate cancer. T refers to tumor size; N the extent of lymph node involvement; and M to the presence or absence of metastasis (spread).

Prostate cancer diagnosed because of a PSA elevation without the presence of an abnormality on digital rectal examination (DRE) is a different tumor category than one diagnosed because of an abnormality on DRE. This is because the presence of palpable cancer (one that can be felt on DRE) indicates that the cancer is already close to the capsule—perhaps beyond the capsule—whereas non-palpable cancer is typically earlier in the natural course of cancer progression.

Stages Of Prostate Cancer

Stages of prostate cancer (Image from PROSTATE CANCER 20/20:  A Practical Guide To Understanding Management Options For Patients And Their Families)

Stage T1

Tumor is microscopic and confined to the prostate and not apparent on DRE. T1a is tumor found incidentally in prostate tissue removed because of symptomatic enlargement (< 5 % of prostate tissue removed); T1b is tumor found incidentally in prostate tissue removed because of symptomatic enlargement (> 5 % of prostate tissue removed); T1c is tumor identified by biopsy because of PSA elevation or acceleration.

Stage T2

Tumor is confined to the prostate and is detected by DRE.  T2a involves less than half of one side of the prostate; T2b involves more than half of one side; T2c involves both left and right sides of the prostate.

Stage T3 or T4

T3a tumors extend beyond the prostate capsule, sparing the seminal vesicles; T3b tumors invade the seminal vesicles. Stage T4 tumors have spread to organs near the prostate, but within the pelvis, e.g., bladder, rectum or pelvic sidewall.

Stage N+ or M+

Cancer has spread to pelvic lymph nodes (N+) or to lymph nodes, bones, and/or organs distant from the prostate (M+).

Gleason Score

Dr. Gleason devised a clever system that microscopically grades prostate cancer based upon cellular architecture. He recognized that prostate cancer grade is the most reliable indicator of the potential for cancer growth and spread. The grading system that bears his name provides one of the best guides to prognosis and treatment.

To determine Gleason score, the pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells, the first number representing the grade of the primary (most predominant) pattern and the second number representing the grade of the secondary pattern. The grades range from 3 (just over the threshold for cancer) to 5 (the cells that have the most cancerous appearance). The sum of the two grades is the Gleason score. The lowest possible score is 6; the highest is 10. The Gleason score predicts the aggressiveness and behavior of the cancer, with higher scores having a worse prognosis than lower scores.

Gleason score is one of the most important factors to be considered prior to making an informed treatment choice. Whereas men with low Gleason scores are often candidates for active surveillance, a high Gleason score mandates more aggressive management.

There are 5 Gleason Grade Groups based upon Gleason score:

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8 or 3+5=8 or 5+3=8)

Grade Group 5 (Gleason score 4+5=9 or 5+4= 9 or 5+5=10)

To help understand the significance of the Gleason score, the rates of undetectable PSA five years after surgical removal of the prostate in Grade Groups 1-5 are the following: 96%, 88%, 63%, 48%, and 26%, respectively.

Number cores with cancer

Generally, at least 12 biopsy cores are obtained and the number of cores that have cancer can provide invaluable information to help guide treatment. The more cores that contain cancer, the greater the volume of cancer and the greater the risk.  A man who has 12/12 cores with cancer has a very different disease than a man with 1/12 cores with cancer.

Percent tumor involvement (PTI)

The percentage of cancer in each cancer core is also useful information. In general, the greater the PTI, the greater the risk. A man with cancer in 3/12 cores that involves 100% of each core has a very different disease than a man with cancer in 3/12 cores that involves 5% of each core.

PSA and PSA velocity

PSA is a superb tumor marker for men with prostate cancer. In general, the lower the PSA, the greater the chance of localized (organ-confined) cancer and conversely, the higher the PSA, the greater the chance of non-localized cancer.  The lower the PSA, the greater the likelihood of cure with surgery or radiation therapy.  Men with a PSA higher than 20 have a greater risk of locally advanced or metastatic disease and a higher likelihood of failing surgery or radiation therapy.

PSA velocity (rate of change over time) also provides essential prognostic information. A high PSA velocity preceding the diagnosis of prostate cancer is associated with a poorer prognosis.

PSA density (PSAD)

PSAD is the relationship of PSA to the size of the prostate, determined by dividing PSA by the prostate volume. The volume of the prostate is easily determined by ultrasound or by MRI (magnetic resonance imaging). A PSA density > 0.15 is considered to be a higher risk.

Genomic testing

Genomic biomarkers have become an increasingly popular tool for risk stratification. Oncotype DX (genomic prostate score) is one such assay that determines the expression of 17 genes. It is often used for newly diagnosed Gleason 6 (3+3) and 7 (3+4) cancers to help determine who will benefit from active surveillance vs. surgery or radiation.

Age and life expectancy

The prevailing view accepted among prostate cancer experts is that the more years one has left to live, the greater the likelihood that surgery will provide the greatest chance of achieving that potential. So, if you are 43 years old and in perfect health, the most prudent option is often a radical prostatectomy. On the other hand, if you are elderly and have a less than ten-year life expectancy, you likely will not need any treatment as other more pressing medical issues may cause your demise before the prostate cancer has a chance to.

With respect to age, I refer to “physiological” age as opposed to “chronological age.”  In other words, not how many years per se that you have lived on the planet, but at what age you are functioning and how many years you may be expected to live.  Of two men who are chronologically 65 years old, one may be functioning like a 55-year-old and the other as an 80-year-old, and treatment needs to be tailored accordingly.

As surgery and radiation have competitive 15-year results and the demands and potential side effects of surgery are greater than that of radiation, at a certain age, radiotherapy becomes a more prudent consideration.

Health status

If you are not in good health and do not have an expected ten-year life expectancy, there is usually no compelling reason to treat the prostate cancer as other health issues are likely to be of more concern than the prostate cancer.

In general, surgery should be reserved for healthy men who can tolerate an invasive surgical procedure and the general anesthesia necessary to undergo it. If your health is compromised, but you have a greater than ten-year life expectancy, radiation becomes a sensible management option.

Urinary symptoms

Benign prostate enlargement commonly accompanies aging, paralleling the increasing prevalence of prostate cancer with aging. As the prostate enlarges, it often—but not always—squeezes the urethral channel, making urination difficult and resulting in annoying symptoms and sleep disturbance.  An enlarged prostate can act like a hand squeezing a garden hose, compromising the flow through the hose. The situation can be anything from a tolerable nuisance to one that has a huge impact on one’s daily activities and quality of life.

The presence of Lower Urinary Tract Symptoms (LUTS) can be an important factor in guiding treatment options.

 Obstructive LUTS consist of the following:

hesitancy—a stream that is slow to start

weak stream—a stream that lacks force

narrow stream—a thin stream

intermittency—a stream that starts and stops

straining—the need to use abdominal muscles to urinate

prolonged emptying time—excessive time to empty the bladder

incomplete emptying—inability to empty the bladder

Irritative LUTS consist of the following:

frequency—urinating more often than normal

nocturia—awakening from sleep to urinate

urgency—the sudden and strong desire to urinate

precipitancy—the need to get to the toilet in a hurry

urgency incontinence—the sudden and strong desire to urinate with the inability to get to the toilet in time to prevent leakage

The presence or absence of LUTS can be an important factor to help guide the most appropriate treatment options. For example, if a man diagnosed with prostate cancer has significant LUTS, a prostatectomy may be the best management option to treat both the cancer and the annoying symptoms, as opposed to radiation therapy that can worsen the LUTS.

Personal preferences

Our intention as urologists is not to dictate exactly what approach to take, as there are usually several competing management options, but to provide education, direction and guidance through the options, offering sensible and pragmatic advice based upon our knowledge and experience.

I truly believe in the FBSU test (Father, Brother, Son, Uncle test)— giving patients the same advice I would give to family members. Every man has different circumstances, priorities, medical issues, life expectancies and concerns about the side effects of treatment alternatives.  Recognizing this, the opinions of the patient, family members and loved ones who have a clear understanding of the management options are of paramount importance in the ultimate choice of a treatment.  The goal of this collaborative and shared decision-making process between patient and physician is to optimize medical decisions by helping patients choose the option they feel most comfortable with.

RISK CATEGORIZATION (This strategy is based upon the National Comprehensive Cancer Network guidelines)

Integrating the factors of tumor stage, Gleason score, cancer volume, PSA and PSA density, supplemented with genomic testing, an individual case of prostate cancer can be assigned to one of five risk categories ranging from very low risk to very high risk. This risk categorization is helpful in predicting the future behavior of the prostate cancer and in the management decision-making process.

The following are the five risk groups and the criteria for membership in each:

Very Low Risk: T1-T2a; Gleason score 6; fewer than 3 cores with cancer; PTI less than 50% of cancer in each core; PSA < 10; PSA density < 0.15

Low Risk: T1-T2a; Gleason score 6; more than 3 cores with cancer; PTI greater than 50% of cancer in any core; PSA < 10

Intermediate Risk: T2b-T2c or Gleason score 7 or PSA 10-20

Within the intermediate risk category, further sub-stratification is as follows:

      Favorable Intermediate Risk:

T1-T2a, Gleason score 6, PSA 10-20

T1-T2a, Gleason score 7 (3+4), PSA < 10

      Unfavorable Intermediate Risk:

T2b, Gleason score 7 (3+4), PSA < 10

T1-T2, Gleason score 7 (3+4), PSA 10-20

T1-T2, Gleason score 7 (4+3), PSA < 20

High Risk: T3a or Gleason score 8-10 or PSA > 20

Very High Risk: T3b-T4 or Gleason grade 5 as the predominant grade (the first of the two Gleason grades in the Gleason score) or > 4 cores Gleason score 8-10

Coming next week…An overview of prostate cancer treatment options based upon risk assessment.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

 

Making Sense of the Gleason Prostate Cancer Grading System

June 15, 2019

Andrew Siegel MD  6/15/19

Each case of prostate cancer is unique and has a distinctive biological behavior.  One of the best predictors of the future behavior of any prostate cancer is the  cancer grade, a microscopic determination made by the examining pathologist.  Dr. Donald Gleason, a former chief of pathology at the Minneapolis Veterans Administration Center, devised a prostate cancer grading system many years ago that is still used today. His legacy, the system that bears his name—the Gleason score—provides one of the best and most reliable predictors for prostate cancer growth and spread.  Gleason score remains one of the most important factors guiding the individualized and nuanced treatment of the prostate cancer.

Gleason grade, Gleason score, Gleason grade group

Gleason GRADE

Gleason grade is determined by the pathologist who studies the biopsied prostate cancer with a microscope. Grade is indicative of the extent of difference in the cellular architecture of cancer cells as compared with normal cells. Low grade cancers appear almost like normal cells whereas high grade cancers bear little resemblance to normal cells. Gleason grades range from 3 (just over the threshold for cancer) to 5 (the cells that have the most cancerous appearance). Grade 3 is considered a low grade and grade 5 a high grade cancer.

Gleason

Gleason grades based upon cellular architecture: note that grades 1 and 2 are not considered to be cancer.  Thank you AUAnet.org

Gleason SCORE

The cancer from any individual biopsy site is often heterogeneous as opposed to homogeneous. In other words, cancer cells often have a variety of architectural patterns,  a predominant pattern as well as secondary and tertiary patterns. To determine Gleason score, the pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells, the first number representing the grade of the primary (most predominant) pattern and the second number representing the grade of the secondary pattern. The sum of the two grades is the Gleason score. The lowest possible score is 6; the highest is 10.

Gleason score predicts the aggressiveness and behavior of the cancer. Higher scores indicate a worse prognosis than lower scores because the more mutated cells typically grow faster than the more normal-appearing ones. Prognosis also depends on further refinements. For example, a Gleason score of 7 can occur two ways: “4+3” or “3+4”. With “4+3,” cancer cells in the most predominant category appear more aggressive than those in the secondary pattern, suggesting a more serious threat than a “3+4” score, in which cells in the most predominant group appear less aggressive.

Gleason GRADE GROUP

There are 5 Gleason grade groups based upon Gleason score:

Grade Group 1 (Gleason score 3+3=6)

Grade Group 2 (Gleason score 3+4=7)

Grade Group 3 (Gleason score 4+3=7)

Grade Group 4 (Gleason score 4+4=8 or 3+5=8 or 5+3= 8)

Grade Group 5 (Gleason score 4+5=9 or 5+4= 9 or 5+5=10)

The lower the Gleason grade group, the less aggressive the cancer; conversely, the higher the Gleason grade group, the more aggressive the prostate cancer.

Bottom Line: The Gleason grading system is an effective, reliable and time-tested means of determining the biological potential of any given prostate cancer to grow and spread, of vital importance in helping guide the appropriate treatment. 

Coming next week…Prostate Cancer Risk Assessment: A Sensible Guide to Appropriate Treatment.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Your Prostate Biopsy Report

June 8, 2019

Andrew Siegel MD   6/8/19

Today’s entry will enable you to make sense of the prostate biopsy report, which can be a source of confusion for patients.

Prostate Histology (the study of the microscopic structure of tissues) in 30-seconds   

The prostate gland is divided into anatomical subdivisions known as lobes. It is organized like a tree with a major trunk draining each lobe, each trunk served by many ducts which progressively branch out into smaller and smaller ducts. At the end of each duct is an acinus (Latin, meaning berry), analogous to a leaf at the end of a tree branch. Each acinus is lined by cells that secrete prostate fluid, a nutrient vehicle for sperm that is an important component of semen. Each acinus is surrounded by a basement membrane that is a barrier layer that separates the secretory cells from surrounding structures.

ducts and acini from AUA AUAnet.org

Microscopic view of healthy prostate ducts and acini (plural of acinus); image from AUAnet.org

 

Pathologists are the doctors that study biopsies under the microscope and make the diagnosis of cancer.  By staining tiny fragments of tissue cut in slices thinner than a hair, elements of the cell are highlighted that would not normally be apparent, identifying cancer.

What are the possible outcomes of the prostate biopsy?

There are four possibilities:

  • Benign prostate tissue
  • HGPIN (High Grade Prostate Intraepithelial Neoplasia)
  • ASAP (Atypical Small Acinar Proliferation)
  • Prostate Cancer

What is benign prostate tissue?

This is a biopsy report indicative of healthy prostate tissue, with no evidence of cancer or pre-cancer.  This is the kind of report that urologists are delighted to convey to patients.

What is HGPIN?

HGPIN is an acronym for “High Grade Prostate Intraepithelial Neoplasia.” HGPIN occurs in 0.6 – 24% of biopsies. It is a microscopic abnormality marked by an abnormal appearance and proliferation of cells within ducts and acini, but the abnormal cells do not extend beyond the basement membrane to the surrounding parts of the prostate (as occurs with prostate cancer). HGPIN is considered a pre-malignant precursor lesion to prostate cancer.

Current recommendations for men who are found to have one site of HGPIN (uni-focal HGPIN) are to follow-up as one would follow for a benign biopsy, with annual digital rectal exam and PSA.  However, if there are multiple biopsies indicating HGPIN (multifocal HGPIN), a more vigilant follow-up may be necessary, particularly if the PSA is elevated, accelerated or if there is ASAP (see below) found adjacent to the HGPIN. Repeat biopsy is a consideration, with sampling of identified HGPIN areas and adjacent sites. The more cores containing HGPIN on an initial prostate biopsy, the greater the likelihood of cancer on subsequent biopsies. The overall risk for prostate cancer following the diagnosis of multifocal HGPIN is about 25%.

What is ASAP?

ASAP is an acronym for “Atypical Small Acinar Proliferation.” ASAP occurs in 5 – 20% of biopsies. It is a microscopic abnormality marked by a collection of prostate acini that are suspicious but not diagnostic for prostate cancer, falling below the diagnostic “threshold.” The risk for cancer following the diagnosis of ASAP on re-biopsy is 40-50%. It is recommended that men with ASAP should undergo re-biopsy within 3 to 6 months, with sampling of identified areas and adjacent sites.

What is cancer?

All cancers begin with a cell that goes rogue during its replication—a cell gone wild—reproducing and proliferating endlessly and creating a mass of identical cells. This process is often caused by a single mutation.  Cancer is defined as the uncontrolled and disorganized growth of abnormal cells, as opposed to the controlled and organized means of replacing old cells after they become non-functional. Whereas normal cells grow, divide and die in an orderly fashion, cancer cells continue to grow, divide and form new abnormal cells.

Normal cells become cancer cells (malignant cells) when permanent such mutations in the DNA (deoxyribonucleic acid) sequence of a gene transform them into a growing and destructive version of their former selves. These abnormal cells can then divide and proliferate aberrantly and without control. Although damaged DNA can be inherited, it is much more common for DNA damage to occur by exposure to environmental toxins or from random cellular events.  Under normal circumstances, the body repairs damaged DNA, but with cancer cells the damaged DNA is unable to be repaired.

As cancer cells grow they form a mass of cells (1 cubic centimeter of cancer consists of about 100 million cells) and the properties of the mutated cells allow them to encroach upon, invade and damage neighboring tissues. They can also break off from their site of origin via blood and lymphatic vessels and travel to and invade remote organs including lymph glands, liver, bone and brain, a situation known as metastasis.

Prostate cancer is a microscopic abnormality marked by an abnormal appearance and proliferation of cells within prostate ducts and acini (plural of acinus) that have broken through the basement membrane barrier to involve the deeper tissues of the prostate. The appearance of prostate cancer cells and their architectural patterns of growth differ from normal cells in ways that enable the pathologist to recognize and diagnose the biopsy as cancer. The degree to which these tissues demonstrate malignancy allows the pathologist to assign a grade to the cancerous tissue. The higher the grade, the more profound the malignant changes.

If the prostate biopsy demonstrates prostate cancer, the pathologist will provide a detailed report indicating the following:

  • Number of cores showing cancer
  • Percent of cancer involvement in each core
  • Location of the cores with cancer
  • Gleason score (the pathologist’s numerical quantification of aggressiveness)
  • Biopsy map

Most prostate cancers are “adenocarcinomas” (adeno- “pertaining to a gland” and carcinoma– “a cancer that develops in epithelial cells”) — a type of malignancy that originates from glandular cells. On occasion, a prostate adenocarcinoma is found to be an “intra-ductal carcinoma,” a proliferation of malignant prostate cells that fill and distend the inside space of prostatic ducts and acini, with the cells around the basement membrane largely preserved. Intra-ductal prostate cancer is often invasive, high grade, and typically has large tumor volumes.

Rarely, a prostate cancer is found to be a “small cell carcinoma,” a type of malignancy that originates from neuro-endocrine cells. This high grade and aggressive cancer accounts for only about 1% of prostate cancers and is typically diagnosed at an advanced stage, tends to progress rapidly and has a poor prognosis with an average survival of less than one year.

Coming next week: The Gleason grading system for prostate cancer.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

 

 

 

Prostate Biopsy: What is Involved?

June 1, 2019

Andrew Siegel MD   6/1/19

Today’s entry takes you through the details of a prostate biopsy, which–although scary in concept–is a brief and simple office procedure that obtains valuable and potentially life-saving information.  

Hopefully, you will never need to undergo a biopsy of your prostate gland.  However, many men will ultimately require one if there is concern for, or suspicion of the possibility of prostate cancer—most commonly based upon an elevation in PSA, a PSA acceleration, or an abnormal digital rectal exam.  Other indications are to reevaluate pre-cancerous lesions, including high grade prostate intra-epithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP), monitoring patients on active surveillance, and in the evaluation of men who have received prior prostate cancer treatment and have rising PSAs.

Although digital rectal exam, PSA blood testing, and MRI are suggestive and helpful tests, it is the biopsy that is definitive. “The buck stops here” with prostate biopsy, the most conclusive diagnostic test. 

Diagram_showing_a_prostate_biopsy_CRUK_472_pl

Attribution of Image Above: Cancer Research UK uploader [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)%5D…Note prostate, ultrasound probe and needle biopsy, translated from Polish

Prostate ultrasound is a means of prostate imaging using sound waves (like sonar on a submarine) generated by an ultrasound probe placed in the rectum. Reflected echoes create a high-resolution image of the prostate to measure the prostate volume, check for abnormalities, and precisely guide biopsies. The ultrasound image alone is not sufficient to diagnose prostate cancer without a tissue biopsy. MRI is often used prior to the biopsy to ascertain if there are any discrete abnormalities that can be targeted by the biopsy.

Preparation for ultrasound-guided prostate biopsy involves a Fleet enema the evening before the biopsy to cleanse the rectum, discontinuing blood thinner medications for a week or so prior to the procedure and starting a short course of oral antibiotics prior to the biopsy, since the biopsies are performed via the rectum.

The prostate biopsy can be performed using a local anesthetic or, alternatively, with intravenous sedation. I prefer to do the biopsies in the office setting using intravenous sedation provided by an anesthesiologist, which makes the experience much more pleasant for the patient and avoids the need for local anesthetic injections into the prostate, which can increase the risk of infection. Two antibiotics are administered intravenously immediately prior to the biopsy.

The ultrasound/biopsy is about a 10-15-minute procedure, although one needs to arrive 30 minutes prior to and remain for about 30 minutes or so after the procedure. In the knee-chest position while lying on one’s side, the ultrasound probe is gently placed into the rectum.  After obtaining imaging and volume measurements, prostate biopsies are obtained with a spring-driven needle device that is passed through the needle guide attached to the ultrasound probe. The biopsies are tiny, about the size of eyelashes.  Generally, a minimum of 12 biopsies are obtained—six from each side with two biopsies each from the apex, mid-gland and base, providing a pathological “map” of the prostate. Each biopsy is placed in a separate specimen container noting the site of the biopsy and is carefully examined by a pathologist to make a diagnosis.

If an abnormality is visualized on ultrasound—classically a hypo-echoic region (an area with less echoes than adjacent prostate tissue)— this specific area will be biopsied as well. Often, MRI is performed prior to the biopsy and any specific area of suspicion identified on MRI is matched with the ultrasound, and targeted biopsies are obtained of these areas, as well as the standard 12 mapping biopsies. MRI/ultrasound fusion-guided biopsy is a means of fusing pre-biopsy MRI prostate imaging with ultrasound-guided prostate biopsy images in real time, so that the suspicious regions seen on MRI can be precisely targeted. Fusion-guided biopsies require sophisticated hardware and software technology and the combined efforts of the radiologist, technician and urologist. Alternatively, cognitive-guided biopsies are ultrasound-guided biopsies performed while simultaneously viewing the pre-biopsy MRI images to target the regions of concern.

After the biopsy, it is important to stay well hydrated, complete the prescribed antibiotics, and to take it easy for a day or so. Urinary and/or rectal bleeding following a biopsy is common and typically resolves within a few days or so.  However, it is not uncommon to experience some blood in the semen for up to 6 weeks after the biopsy. It generally takes 7-10 days or so to receive the biopsy results.

Trans-perineal (via the anatomical region between scrotum and anus) mapping prostate biopsies are sometimes done as an alternative to the trans-rectal biopsy described above. Ultrasound is used to image the prostate and numerous mapping biopsies—typically at 5 mm intervals—are done via a perineal template. This provides a pathological map of the entire prostate, sometimes used to obtain a primary biopsy but more often used as a confirmatory biopsy that improves staging because of the number of biopsies obtained at precise anatomical locations.

Coming next week…What you will learn from the prostate biopsy report.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

Prostate Cancer Screening Biomarkers: What You Need To Know

May 25, 2019

Andrew Siegel MD  5/25/19

Before we get to the main course, let’s begin with a little appetizer—some trivia about urology, the occupation of yours truly.  There are not many of us around; there are currently 12,700 practicing urologists in the USA, 1 for every 25,000 Americans.  90% of  are male and 10% are female. 57% of urologists are in private practice and the remainder are employed by hospitals or academic medical centers. 40% of urologists have a primary subspecialty, oncology (cancer) being the most common.

Although I have subspecialty training and board certification in female pelvic medicine and reconstructive surgery, I enjoy general urology, treating both male and female adults with a variety of conditions (voiding and sexual dysfunction, incontinence, pelvic organ relaxation, urological cancers, infections, kidney stones, bleeding, vasectomy, etc.), the balance between office and surgical practice and—most importantly– the fact that as urologists, we can help most patients improve their quality and quantity of life.  

 

Bi·o·mark·er

/ˈbīōˌmärkər/
noun
plural noun: biomarkers
  1. a measurable substance in an organism whose presence is indicative of some phenomenon such as disease, infection, or environmental exposure.

Prostate specific antigen (PSA) was the first prostate cancer biomarker, singularly responsible for revolutionizing the diagnosis and follow-up of prostate cancer. There are several new biomarkers that can help with the decision of whether or not to biopsy the prostate as well as to inform and support prostate cancer management decisions (active surveillance vs. active treatment, the specific means of treatment for early and localized cancer, and when to pursue androgen deprivation therapy).

Prostate health index (PHI): This is a compilation of several different PSA sub-types, including pro-PSA, free PSA and total PSA, into a single score. It can help discriminate between higher and lower grade disease. PHI score coupled with other factors including age, prostate volume, digital rectal examination (DRE) {abnormal DRE vs. normal DRE} and biopsy history (prior prostate biopsy vs. no prior prostate biopsy) are used to help determine the need for biopsy in a patient with suspected prostate cancer.

Prostate cancer antigen (PCA3) urine test: PCA3 is a specific type of RNA (ribonucleic acid) that is released in high levels by prostate cancer cells. Its expression is 60-100 times greater in prostate cancer cells than benign prostate cells, which makes this test much more specific for prostate cancer than PSA. The first ounce of urine voided immediately after prostate massage (a vigorous DRE with the intent of milking the prostate) is rich in prostatic fluid and cells and is collected and tested for the quantity of PCA3 genetic material present. Urinary levels of PCA3 are not affected by prostate enlargement or inflammation, as opposed to PSA levels. PCA3 > 25 is suspicious for prostate cancer.

4Kscore test:  4Kscore test measures blood levels of four different prostate-derived proteins: total PSA, free PSA, intact PSA and human kallikrein 2. Levels of these biomarkers are combined with the patient’s age, DRE, and history of prior biopsy. These factors are processed using an algorithm to calculate the risk of finding an aggressive prostate cancer (Gleason score 7 or higher) if a prostate biopsy were to be performed. The test can increase the accuracy of prostate cancer diagnosis, particularly in its most aggressive forms.  It cannot be used if a patient has had a DRE in the previous 4 days, nor can it be used if one has taken finasteride (Proscar) or dutasteride (Avodart) within the previous six months. Additionally, it cannot be used in patients who have undergone any procedure to treat symptomatic prostate enlargement or any invasive urologic procedure in the prior 6 months.

Apifiny test:  This test measures the immune response to prostate cancer, detecting autoantibody proteins in the blood that are produced against prostate cancer cells. It is a risk assessment tool that does not rely on PSA. A score of 1-100 is given: the higher the score, the greater the chance for the presence of prostate cancer.

Biomarker to confirm a negative (benign) biopsy:

ConfirmMDx:  Since a biopsy of the prostate samples only a small volume of the total prostate, it is possible to have benign biopsy results when in fact an underlying cancer was missed.  This particular assay is done on prostate tissue derived from a negative biopsy to help determine its accuracy. It quantitates the chemical status of certain genes to detect abnormal changes associated with the presence of prostate cancer. ConfirmMDx detects a “halo” associated with the presence of cancer at the DNA level, which may be detected in prostate cancer tissue despite a normal microscopic appearance. This test helps identify low risk men who may forego a repeat biopsy and high risk men who would benefit from a repeat biopsy.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

4 small

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

Prostate MRI: What You Should Know

May 18, 2019

Andrew Siegel MD  5/18/2019

MRI (magnetic resonance imaging) is a high-resolution test that is an important tool for prostate cancer diagnosis, targeting of biopsies, clinical staging, surgical planning, follow-up of prostate cancer patients managed with active surveillance and in the evaluation of recurrent prostate cancer following treatment. A shout-out to Dr. Robert Waxman, who provided the MRI images seen below. 

MRI uses a powerful magnet to enable viewing of the prostate gland and surrounding tissues in multiple planes of view with the advantage of not requiring radiation. The planes are axial (cross section), sagittal (the plane that divides the body into left and right) and coronal (a plane dividing the body into dorsal and ventral parts). The axial images are by far the most important images of the study. MRI identifies areas suspicious for cancer and enables “targeted” biopsies as opposed tosystematic” biopsies. Although useful in the diagnostic evaluation of any man who has a suspicion of prostate cancer, it is particularly beneficial in men who have had previous benign prostate biopsies who have persistent PSA elevations or accelerations.

MRI is a valuable part of the diagnostic armamentarium, increasing the detection rate of clinically significant (Gleason score 7 or higher) prostate cancers, while reducing the detection rate of clinically insignificant (Gleason score 6) cancers. MRI provides anatomical details about the neuro-vascular (nerve and blood vessel) bundles, urinary bladder, seminal vesicles, pelvic lymph nodes, bowel and pelvic bones and beneficial staging information on tumor extension beyond the prostate capsule, pelvic lymph node enlargement and seminal vesicle involvement.

Prostate MRI is performed at specialty imaging centers.  Preparation involves a Fleet enema to clear gas from the rectum that can generate artifacts on the MRI images making interpretation suboptimal.  A coil placed in the rectum (endo-rectal coil) is no longer necessary as it was in prior versions of MRI. The study is done before and after the injection of about 20 cc of intravenous contrast to optimize the results.

Note: MRI cannot be performed under the following circumstances: pacemaker, recent coronary artery stent placement, ferromagnetic brain aneurysm clips and the presence of metal near the spinal cord, e.g., bullet fragments.

Refinements in MRI involve diffusion and perfusion studies. Diffusion is the movement of water into tissues; because prostate cancer cells are more tightly packed than normal cells, diffusion is often restricted with prostate cancers. Perfusion is the circulation of blood to tissues; because prostate cancers are hyper-vascular (increased blood supply), with the injection of the intravenous contrast there is increased perfusion with prostate cancers.

The value of prostate MRI is highly operator-dependent and requires both a quality study and interpretation by a skilled and experienced radiologist. Sophisticated software performs image analysis, assisting radiologists in interpreting and scoring MRI results. A validated scoring system known as PI-RADS (Prostate Imaging Reporting and Data System) is used. This scoring system helps urologists make decisions about whether to biopsy the prostate and, if so, how to optimize the biopsy.

PI-RADS      

I     most probably benign (clinically significant cancer highly unlikely)

II    probably benign (clinically significant cancer unlikely)

III   indeterminate (clinically significant cancer equivocal) — 20% chance

IV   probably cancer (clinically significant cancer likely) — 50% chance

V   most probably cancer (clinically significant cancer highly likely) —75% chance

Of note, the IV and V groups are the same, differentiated only by the size of the suspicious region. In the IV group the abnormality is < 1.5 cm; in the V group the abnormality is > than 1.5 cm in diameter.

Now let’s play radiologist.  Can you identify the suspicious regions in the following two images?  There is a magnified view of the abnormal sites at the end of this entry.  Radiology clue: when you view images, always be on the look out for asymmetries between the left and right.

MRI1

Patient 1 with a PIRADS-5 lesion

 

MRI2

Patient 2 with a PIRADS-5 lesion with mass effect on the rectum and likely extra-capsular extension

MRI is by no means a perfect test, as clinically significant cancers (particularly small ones) are not always apparent on MRI, and PIRADS-4 and PIRADS-5 lesions when biopsied are not always found to contain clinically significant cancers. An additional concern is its expense.  Some urologists believe in obtaining a prostate MRI on all patients prior to performing a prostate biopsy, whereas others reserve MRI for patients with a previous negative biopsy in the face of a rising PSA. In the former setting, a biopsy remains the only definitive means of assessment regardless of the PIRADS score, one of the key utilities of the MRI being to help precisely target the biopsy.  However, in the latter setting, when the MRI reading is PIRADS-1 or PIRADS-2, a repeat biopsy can often be avoided.

Fact: PSA, DRE and MRI are all useful and informative tests, but the prostate biopsy (tissue sampling) is the only way to know for sure if one has prostate cancer.  In other words, whereas PSA, DRE and MRI are “suggestive,” the biopsy is “definitive.” “The buck stops here” applies to the biopsy.

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Magnified view of lesion of figure 1

 

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Magnified view of lesion of figure 2

Final note: Most insurance companies will readily cover the cost of a MRI study prior to doing a prostate biopsy.  The exception is CIGNA, which apparently cares more about its bottom line than the welfare of its insured patients.  I am constantly fighting with CIGNA-employed physicians in “peer-to-peer” conversations in an effort to get the company to pay for a pre-biopsy MRI.  My last such conversation was two days ago and sadly, I have never prevailed.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 

Laser Vaginal Therapy: Hope or Hype?

May 11, 2019

Andrew Siegel MD 5/11/2019

HAPPY MOTHER’S DAY!

For better or for worse, we are living in the era of “vaginal rejuvenation.”  Procedures referred to as “designer vaginoplasty,” “re-virgination,” “reduction labioplasty,” “G-spot amplification,” “platelet-rich plasma (PRP) injections,” “vaginal bleaching,” etc., have come into vogue as expensive plastic procedures advertised by some entrepreneurial physicians for cash-paying patients. Within the domain of “vaginal rejuvenation,” the last few years have also witnessed an explosion in the availability of office-based vaginal laser therapies for a variety of conditions, including vaginal dryness and other symptoms of menopause, vaginal (laxity) looseness, and stress urinary incontinence.

Vagina collage public domain

Vaginal Collage (public domain)

LASER = light amplification and stimulated emission of radiation

The theorized mechanism of action of laser therapy is collagen and elastin fiber remodeling, growth of new collagen, blood vessel ingrowth and growth factor infiltration.  The goal is the restoration of vaginal elasticity, suppleness and moistness that often decline after menopause with the cessation of estrogen production, a hormone that contributes vitally to female genital health.

In the USA, these procedures are costly and not covered by insurance. They are most commonly performed by gynecologists, but any MD with a license or their nurse practitioners or physician assistants can legally perform these laser procedures.  Lasers are expensive to purchase or lease and private physicians charge an “arm and a leg” to treat the vagina, since these procedures are outside the domain of health insurance.

The problem is the lack of scientific evidence regarding effectiveness of laser procedures as well as the possibility of serious adverse effects (including itching, burning, redness, scarring, swelling, pain during intercourse and chronic pain). In July of 2018, the FDA issued a warning against the use of energy-based devices– including lasers and radio-frequency devices– for vaginal rejuvenation and vaginal cosmetic procedures.

The bottom line is that although there is some evidence of effectiveness based upon observational studies, there exists a strong need for long-term, large, randomized and placebo-controlled clinical trials to evaluate the safety and effectiveness of these vaginal laser procedures before they can be recommended.

As a urologist, I often use lasers for fragmenting stones in the urinary tract (bladder, ureters and kidneys) and for creating a channel through an obstructed prostate gland. These are legitimate and bonafide uses of lasers in medicine. My urology group does not utilize vaginal laser therapy (although its use was considered, but voted down after considerable research).  I do have some patients who have had vaginal laser procedures outside of my practice to manage symptoms of menopause, vaginal laxity and stress urinary incontinence. Anecdotally, I have one patient who speaks very highly of the fractional laser therapy she received for post-menopausal dryness, which seemed to improve her situation.

With respect to vaginal laxity and stress urinary incontinence, my feeling is that as fabulous and high-tech as lasers are, in these two cases lasers are a solution in search of a problem and are ineffective options for the management of these problems. If a woman truly has vaginal laxity–often accompanied by pelvic organ prolapse–or significant stress urinary incontinence she will often benefit from surgical therapy if unresponsive to conservative treatments.  Furthermore, my advice is to stay away from vaginal bleaching, G-spot amplification, PRP injections, and re-virgination insanity.  Labiaplasty is a reasonable consideration if a woman has outsized labia that get in the way of life’s activities, but otherwise my advice is to maintain a healthy lifestyle and pursue pelvic floor exercises as a means of vaginal fitness.

Bottom Line:  Laser Vaginal Therapy: Mostly hype with a bit of hope.  As always, caveat emptor (buyer beware)!

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel’s newest book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

one-sheet-poster