Inaccuracy of biopsies

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John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 3/18/2010 12:42 PM (GMT -6)   
For those who are relying on biopsy data alone for thier information on a treatment are in for a surprise.
This article posted on the New Prostate Cancer Infolink show the inaccurracy of biopsies alone.
Additional staging methods such as Color doppler, MRIS, and poloidy analysis, PAP and PCA3 are other staging tools to better help in getting a clearer picture.
 
 new, detailed, correlative analysis of pathologic data from saturation biopsies as compared to the actual pathology of radical prostatectomy (RP) specimens has demonstrated that 90 percent of patients with apparent unilateral prostate cancer on biopsy really had bilateral disease.

Falzarano et al. set out to determine whether, at their institution, saturation needle biopsies (SBx) could predict prostate cancer location in RP specimens with a high degree of accuracy. Their data was based on 72 patients, all of whom received an SBx according to the following protocol: traditional sextant cores as well as 10 or more additional biopsy cores (i.e., a minimum of 16 biopsy cores in total). All 72 patients went on to have an RP, and after the RP a single pathologist mapped the tumor outlines, determined the number of prostate cancer foci, and assessed the patients’ Gleason scores, and pathologic stages.

The results of this study can be summarized as follows:

  • The median age of the patients was 60 years
  • The median PSA level of the patients was 5.6 ng/ml.
  • SBx detected bilateral disease in 33 men and unilateral disease in 39 men.
  • All cases shown to have bilateral prostate cancer by SBx also had bilateral disease at RP.
  • 35/39 patients (89.7 percent) shown to have unilateral prostate cancer by SBx were shown to have bilateral disease at RP.
  • 12 potentially clinically significant prostate cancer tumors were missed by SBx in 11/35 patients.
    • 2/12 had a Gleason scoreof 6
    • 10/12 had a Gleason score of 7
    • 11/12 were stage pT2
    • 1/12 was stage pT3.

The original objective of this study was to investigate the potential of saturation biopsy as a method to identify patients who were suitable candidates for focal therapy. And it is likely that the advocates for focal therapy willl repond to these data by saying that the investigators didn’t take enough biopsy cores. The authors concluded that, “A negative SBx does not confirm the absence of cancer in the corresponding side of the gland and cannot be used as single determinant when considering a patient for focal treatment.”

The “New” Prostate Cancer InfoLink has a larger concern, which is the accuracy of any biopsy as a means to diagnose clinically significant prostate cancer.

This study was conducted by researchers at a well-respected, major medical center by individuals with (we assume) considerable expertise in prostate biopsy and subsequent evaluation of the biopsy materials. Despite this, there were unable to find bilateral prostate cancer in 35/39 patients and the unidentified cancer was potentially clinically significant in 31 percent (11/12) of those cases.

We have long known that prostate cancer biopsy is not the most accurate diagnostic tool. Between 25 and 40 percent of patients may be upgraded after surgery as compared to their original biopsy findings. However, the current study is suggestive of the idea that a significant proportion of all potentially clinically significant prostate cancers may be being missed entirely on biopsy.

For The “New” Prostate Cancer InfoLink, this is just one more very clear indication that the current state of technology used to find and diagnose prostate cancer is inadequate. It is bad enough that we have such difficulty determining who actually needs treatment and who can be monitored by some form of expectant management. But this study suggests that we may be “missing” the chance to diagnose thousands of men each year because of inadequate technology.

We do not believe that we immediately need to start biopsying every patient under MRI guidance. (Indeed the data supporting such an idea is still less than fully convincing.) What we need is a much clearer acceptance on the part of advocates, physicians, and researchers that better tools are essential if we are to assure ourselves that we are identifying early the men who are most at risk for progressive disease and who can and should be treated with curative intent while their cancer is still potentially curable.


64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 3/18/2010 1:02 PM (GMT -6)   
I can't understand how anyone can call a 16 core biopsy a saturation biopsy. That's just 4 more cores than a normal biopsy. The lowest number of cores I know of a saturation biopsy was 30 the largest 90, I myself had 45. Primary factor for the amount is the size of the prostate mine was a relative normal 28g
Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A
 
2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study
 
4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal
 
7/30/08 - Psa: .32
11/10/08 - Psa.62 -
April 2009 12 of 12 Negative Biopsy
 
2/16/10 12 of 12 Negative Biopsy 
 
 
 


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 3/18/2010 1:20 PM (GMT -6)   
I stopped reading here:
 
This study was conducted by researchers at a well-respected, major medical center by individuals with (we assume) considerable expertise in prostate biopsy and subsequent evaluation of the biopsy materials.
Age 55   - 5'11"   215lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 3/18/2010 1:26 PM (GMT -6)   
John T said...
The original objective of this study was to investigate the potential of saturation biopsy as a method to identify patients who were suitable candidates for focal therapy.
I was under the impression (not something I had looked into thoroughly, though) that focal treatments (HIFU or cyrotherapy, for example) would always have a color doppler or the advanced MRI (forgot what it's called) procedure after the biopsy as standard procedure prior to treatment.

Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 3/18/2010 1:33 PM (GMT -6)   
Casey59 said...
John T said...

The original objective of this study was to investigate the potential of saturation biopsy as a method to identify patients who were suitable candidates for focal therapy.

I was under the impression (not something I had looked into thoroughly, though) that focal treatments (HIFU or cyrotherapy, for example) would always have a color doppler or the advanced MRI (forgot what it's called) procedure after the biopsy as standard procedure prior to treatment.


I can only speak for my TFT and no all that was called for prior was a 3D mapping saturation biopsy to best determine the area for cryosurgery.
 
 
Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A
 
2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study
 
4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal
 
7/30/08 - Psa: .32
11/10/08 - Psa.62 -
April 2009 12 of 12 Negative Biopsy
 
2/16/10 12 of 12 Negative Biopsy 
 
 
 


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 3/18/2010 4:45 PM (GMT -6)   
Surgery may be barnyard medicine in many peoples book, using a radical treatment for many cases that don't require radical treatment, but, at the end of the day, even if the biopsy did miss bilateral disease, the surgeon gets it all, and the pathologist lays the walnut on the table and we know all we need to know about it. Hard to argue its effectiveness.

For the guys doing alternative therapies, it underscores the importance of multiple testing procedures to confirm what the biopsy suggested. Unfortunately, some of these tests such as color doppler, are not readily accessible to everyone.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01

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