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Best Prostate Biopsy – Live at the AUA

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The Best Prostate Biopsy – Live at the AUA 2014

MRUS

A Transrectal Ultrasound prostate biopsy (TRUS Bx) is performed using a probe inserted into the rectum.  The probe transmits sound waves through the rectal wall toward the prostate gland. The waves bounce off of different kinds of tissue, and register as black-and-white images on a computer monitor. Although abnormal prostate tissue may show up differently than normal tissue, information about the true nature of the abnormality is limited.
According to Dr. Peter Pinto (NCI), speaking here at the American Urology Association meeting, up to 60% of “suspicious lesions,” meaning areas that look like cancer in an ultrasound, are negative and not cancerous.
Thus, a TRUS Bx is considered a “blind” biopsy – meaning physicians must randomly sample the prostate. This is an approach that has been in use since the 1980s and is still the standard form of performing this procedure.
TRUS Bx lacks precision and often misses ‘bad cancers,’ leading to under-diagnosis. In the newer Magnetic Resonance Imaging-Ultrasound Fusion method (MR/US) the patient undergoes an MRI exam before undergoing a biopsy. The MRI is much better at detecting cancerous lesions than an ultrasound. During the biopsy, the MR image is fused with ultrasound (US) imaging.
The MR/US combination guides the biopsy needle to the lesions that detected by the MRI – leading to significantly higher accuracy in finding bad cancer of the prostate.
In their presentations at the American Urology Association (AUA) meeting, Dr. Pinto and Dr Samir Taneja (NYU) presented compelling evidence suggesting significant improvement in cancer detection rates with targeted MR/US fusion prostate biopsies compared to blind biopsies.
They highlighted a study published in the European Journal of Urology, which showed that among 172 prostate biopsies, targeted biopsy detected 75.0% of all clinically significant cancers and 86.4% of Gleason sum ≥7 cancers compared to the standard (blind) biopsy.  (Wysock et al 2013).

 

Challenges with MR/US fusion prostate biopies

It may be a challenge to find physician’s performing targeted biopsies across the U.S and the world at large. Community physicians are particularly unlikely to use this newer technique for collecting prostate tissue since there is a relatively steep learning curve and higher cost associated with MR/US fusion biopsies. Lastly, targeted biopsies require a team effort among urologist, radiologist and pathologist.

In order to perform these MRIs and interpret the resulting images correctly, radiologists need a specialized skill set specific to the prostate. In other words, a radiologist who typically looks for cancerous lesions on the breast may be under-qualified to adequately find lesions of the prostate.

My Take On This

I attract many patients who are (understandably) reluctant to undergo biopsies despite their high PSA score. Prostate biopsies are no fun, to put it lightly.

However, at this time, the gold standard way of diagnosing a man with prostate cancer is by obtaining prostate tissue. And that’s it. So when there is suspicion of prostate cancer and a biopsy is required, it makes sense to undergo the best biopsy possible. As of now, the best type of prostate biopsy is the MR /US fusion method.

Current medical institutions performing targeted MR/US fusion biopsies include:

NYU Smilow Comprehensive Prostate Cancer Center – main urologist performing this technique, Dr. Samir Taneja

National Cancer Institute department of Urology – main urologist performing this technique, Dr. Peter Pinto

UCLA Urology – main urologist performing this technique, Dr. Leonard Marks

This list is incomplete as I am still learning about groups performing MR/US fusion prostate biopsies.

Stay tuned for more Prostate Cancer AUA updates.

 

Reference:

AUA convention 2014, Orlando, Florida

Wysock JS1, Rosenkrantz AB2, Huang WC1, Stifelman MD1, Lepor H1, Deng FM3, Melamed J3, Taneja SS4. A Prospective, Blinded Comparison of Magnetic Resonance (MR) Imaging-Ultrasound Fusion and Visual Estimation in the Performance of MR-targeted Prostate Biopsy: The PROFUS Trial. Eur Urol. 2013 Nov 8.

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by Dr. Geo

10 comments… add one

  • While i understand your take on this within your blog, — given the fact that the body has cancerous cells coming n going throughout ones life, – then the higher levels leading to biopsy are simply to determine a higher concentrated group of cancer cells yes?

    So regardless of the biopsy – the treatment

    Naturally, should be of a different origin that needles samples n all thst.. Correct?

    There must be a more natural way of dealing with this… From japan to india to china etc…

    Getting probed n cut up just seems wrong. The body has clues of imbalance

    Reply
    • While I don’t disagree with everything you said Eric, especially since I am ultra conservative with regards to prostate cancer screening, if someone is fearful or suspicious of having prostate cancer a biopsy is the only way to really find out. Thanks for you comment. GE

      Reply
  • Alan Gelband ,

    Do you think that if a patient has an MRI and the urologist studies the MRI without linking it with the ultrasound, the results would be better than just a plain random biopsy?

    Reply
    • Good question Alan. Theoretically, yes, it’s better as the practitioner has a better ‘map’ to target. However, that is assuming the practitioner is good at reading prostate MRI’s. Not all of them are. Even radiologists who read general MRI’s may not be versed in reading prostate MRI’s. Again, theoretically, it is marginally better I think. GE

      Reply
  • Artemis MRI guided fusion biopsy has better ability to detect cancer in the prostate and to more accurately characterize the cancer… identify the most aggressive component , or highest Gleason score. This allows for better personalized recommendations for treatment.
    I had the opportunity to work with the MRI fusion technology and Artemis when I was on the full time faculty at NYU and now Artemis MRI guided fusion biopsy is part of the diagnostic approach used at the Scionti Prostate Center in Sarasota, FL.

    Reply
    • Thank you for your comment Dr. Scionti. Yes, I would consider you a pioneer with this technology. Good luck in Sarasota.

      Reply
  • Margaret Ellis MD ,

    TRUS is archaic, although standard of care. If 60% of suspicious lesions on US are benign, how many non- suspicious lesions are malignant? The medical establishment actually promotes CME which ‘ educates’ the reader that if the lesion doesn’t look malignant on US then you don’t biopsy despite the velocity of increase of the PSA. I have been aware of the MRI guided diagnosis and treatment for a couple of years. Unfortunately insurance won’t cover and it is expensive. When are we going to quit sacrificing men to this malicious disease? 60% of prostate cancers will be slow growing. Why don’t we develop techniques to find it and eradicate ( like an adenomatous polyp of the colon) rather than subjecting middle aged men to reduced quality of life for the rest of their lives! Thanks for the opportunity for me to express my passion.

    Reply
    • Margaret, I concur with your position on TRUS Biopsies. The good news is that more insurances, even medicare, are now covering MRI guided biopsies.
      The other good news is there are multiple focal ablative techniques being studied to erradicate the tumor while leaving the prostate in tact. High Intensive Frequency Ultrasound (HIFU), approved as a treatment in most countries except the US, is one such approach. There are others as well, but they need to be further studied as there are some imperfections with such therapies. Thank you for your comment.

      Reply
  • DANIEL OTAJELE,MD ,

    Dr Geo,Hi.
    Thanks for this update. It is now real technology will always be with us and developing by the day.
    I do not agree with the notion the TRUS/US is achaich and of no use: If you do a DRE and fellt nodularity with corresponding deragement of the PSA regardless of the velocity,ratios,etc and do a TRUS, six seven cores and out of which, 4 cores are architecturally characterised as GL 7, does the mode of further advice and treatment for the patient differ if you had 12 cores and GL 7? A mater of statstics?

    I love technology but it apperas to me we are becoming overreliant on it and further down the line my be non beneficial to us and patients.Market may be to blaim?

    Consider the cost of MRI Fusion and the resultant effects versus the insignificant difference it makes with further treatment in view and we will discover that the TRUS/US is still a very validdated tool for assessment of Cap.

    Reply
    • Daniel, thank you for your comment. I agree that MRI is expensive. But your example of a 7 core TRUS biopsy often either misses important tumors while the PSA still rise or hits tumors that we should not find. As the MRI continue to evolve they will help target tumor hard to find and those that are more aggressive. How the rest of the world will respond to MRI targeted biopsies we will see as cost would make it difficult for all to access.

      Reply

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