Archive for June, 2019

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

 

 

 

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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