Do not get biopsy without it !!!!

Totally agree.  Well said Cooper!

Greg

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PSA 1/06 at age 40 = 1.0
PSA 4/09 at age 43 = 2.9

PSA 4/10 at age 44 = 4.6

FPSA 4/10 = 4.7 and 6%
10/10 = 4.7 and 9%

Biopsy 5/11/10 12 out of 12 negative
2nd Biopsy 7/13/10 12 out of 12 negative

CDU is a value-added step for anyone starting an Active Surveillance program.

For most guys planning surgery (for example, which is the most common treatment mode), not so important.

I believe the doctor reading the CDU has alot [most] to do with how reliable this technology is. There are only a handful of doctors that have the equipment and the expertise to accurately sort out where to biopsy or even if to biopsy [in my husbands case] My husband experienced it and I sat right next to him and saw exactly what was on the screen the Dr saw calcification,prostatitis but no areas that needed further examination. If he had, then biopsy would have been done.   Cooper

Sadly, my prostate was so rotten he would have needed CDU to find a spot that was normal!
I didn't have the CDU but my biopsy was still 7 out of 12. Lucky me.
Jeff

Had to look that one up - STPB.

Looks like (from the summaries on PubMed.gov) it is expected as a tool for re-biopsy, to get to the areas that a normal trans-rectal can not get to, when there are other indications that they missed something in the first biopsy.

The downside is that it is described as a general anesthetic procedure.

Hate to think the fight that would result with the insurance company -

My "normal", non CDU biopsy found more than I wanted to know about, so that was enough for me.

 

Tony,

I can understand why the CDU detects cancer in 27% of the cases where TRUS biopsies did not detect (the needles missed the cancer).

What I do not understand is why the Trus biopsy detects cancer in 15% of the cases where the CDU did not detect cancer. Were the cancer tumors too small for the CDU to detect? What is the lower resolution of a CDU (1 mm?).

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PSA 2007 - 2.8; 11/24/2008 - 7.6; PCa Dx 2/11/09; age at Dx 62; RLP 4/20/09

Biopsy - Invasive moderately differentiated prostatic andenocarconoma; G 3+3=6; PT2C; No evidence of Seminal Vesicle or Extraprostatic Involvement; Margins clear; Tumor identified in sections from prostatic apex. 70 gram prostate. Continent after removal of cath.

ED - Trimix works well; levitra @ 90%
PSA - 7/31/09 <0.06; 12/1/09 <0.06; 3/29/10 <0.06; 8/4/10 <0.06

First off, Cooper thanks for the interesting topic...
When I had my biopsy the physician used a “TargetScan” proprietary system. Its a 3D thing. I only know this as I am interested in such stuff and noted the name on the equipment while I was awaiting the team to do my biopsy. Then when I had the time I googled it. In my case, I had 10 of 12 positive, my brother with the same physician and technique, had 6 of 12 positive. This correlated nicely with the post-op path results as my brother had less cancer volume.
IMO…not having a biopsy based on the results of any type of imaging study is flawed. CT,MR, Ultrasound, CDU, or the human eye…the assumption that cancer, (prostate, can use other types of tissue here) is always a local or focal event in genesis is again in my opinion flawed. And think about this...If a physician postoperative can cut a prostate in half and actually look at the tissue, and touch the tissue and smell the tissue, can she or he say with absolute authority that the tissue is or is not cancerous? I know of a person that had a ugly looking tumor come out of his colon, the physician said as much ( this is probably going to be problem ,however we need to get the pathology report back before we know for sure). Just in the past few days a friend had the same conversation regarding a breast tumor that she had removed. However, an intra-operative “frozen section” provided a conclusive diagnosis. But the story is the same… You can’t tell by just looking at the tissue… the only way to make or exclude the diagnosis of cancer is with appropriate pathology examination. In some cases noted on this forum, even the microscopy observations vary between pathologist (is it cancer, is it not cancer) It’s biopsy for my family…I’m just saying….

Hero

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Age 51 PSA 6.8
Bxy 10 of 12 Cores positive for Gleason 6. up to 75%
Robotic surg 11-02-09
Post op path. 20% neoplasm;4+3=7 Gleason
All nodes (14) and other related tissue negative for cancer
No EPE
Post op PSA x 3, all <0.01

I would readily agree that color doppler is a great tool. I think we have seen where it is particlularly useful in finding PC where the TRUS doesn't, when the tumor is transitional or in a place where the needles may not hit it.

On the other hand, being a "garden variety" PC case, it really wasn't needed or useful in my case. Once the old needle hits some Gleason 7, 8, or 9, you most likely are going to the next step, particularly with a low PSA. In higher PSA's, it may be useful in determining if it has escaped the capsule yet, but most likely even the CDU woun't see a few cells outside the capsule.

I proceeded directly to the next step, no more diagnosis required, so why waste the time and money ? Seemed pointless in my case.

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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

1 year psa (364 days) .01

15 month PSA <.01

A couple of things about Color Doppler.
Yes it does miss some cancers, but the CDU experts say that these are the clinical insignificant cancers that a random biopsy will sometimes pick up. Missing these is a good thing not a bad thing. They say that a CDU will identify those cancers that will hurt you a much higher % of the time than a random biopsy because all agressive tumors need blood flow to support them.
The real impact of CDU is in staging. It can identify tumor size and location. I believe many failed surgeries are due to the fact that the tumor had already penetrated the capsul or it was a large Apex or anterior tumor, or was near the nerves or seminal vessicles. All of these locations lead to a high surgical failure rate and it would be good for patients to know this before making a life changing decision.
In my own personal situation a CDU picked up a very agressive tumor that 13 random biopsies missed and also could not see a <5% G6 that the random biopsy picked up. The spot was rebiopsied with 3 cores and negative results. In this light it could help some patients avoid a radical treatment. It also identifies the tumor location as highly likely for a positive surgical margin. I recieved three important pieces of information from a CDU that were never available with a standard biopsy and contributed to my treatment decision making. I think its value is consistantly understated and everyone that I have talked to that has had a CDU was more than pleased they had done it.
JT

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65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

John T., et. al.:

I got a question about CDU. I keep reading what a great thing this is. Yet, when I brought it up to my doctor about 15 months ago, I was told that it is way overhyped and not generally accepted as a big improvement.

This still seems to be the case. ie: it is not yet in the mainstream. As evidence, I keep hearing about the same 2-3-4 physicians who are using it. Why is that? If it is such a major improvement, why isn't this commonplace and considered state of the art?

Mel

Mel,

this is the way it has been explained to me: CDU is very old technology even though it has had some recent improvements such as increased power range. It takes quite a bit of time and skill in order to learn how to accurrately read it. Most new radiadiology doctors are interested in the sexier newer technology and just don't want to put in the time learning an old technology. Most of the CDU doctors are old school.

The color doppler machines cost over $120,000 and urologists are not willing to invest in specialized equipment.

There is also a very vicious inside fight in that urologists think that the practice of giving biopsies should only be done by urologists and don't feel that radiologists should be giving biopsies. Dr Barantsz in Holland explained that every time he has attempted to develop a scan that would improve the accurracy of biopsies, he has be fought tooth and nail by the urologists. If the current gate keepers (urologists) of prostate cancer lose this position it's billions of dollars in revenue. Prostate Cancer is still the only cancer that has surgeons as the main diagnosticians.

Currently CDU is used only by interventional radiologists, and this is a very limited field. Even though I was a very special diagonostic case, none of my "expert" urologists ever mentioned CDU and when I finally said something they said it wouldn't work. Even when I did it against their recommendations and was discussing the results with my surgeon he was insisting that I should get an MRIS, which I already had that was negative. This is when the light went on and I realized that he was more interested in defending his position than in my welfare so I dropped him.

All I know is that I had 13 biopsies and an MRIS that were negative. I had two color dopplers that clearly showed a large tumor that was confirmed by biopsy and a Combidex scan. To me this was compelling evidence that two scans not supported by the urological community were much better than what they were using. The only way you would ever hear of the CDU is in forums such as this one or if you go to a private practice oncologist or a radiology center like Dattoli.

I know of about 5 doctors that use it regularly and they are all radiologists. My doctor, who is an oncologists uses it daily, but if he sees something suspicious always send his patients to Dr Bahn. He said that flatly Dr Bahn is much better than he is and that he just doesn't want to get involved in giving biopsies and taking flack from the urological community. When it comes to PC there are a lot of turf wars that we patients are not aware of and are not doing us any good. If I ever had a reoccurrance I would get another CDU in order to attempt to define if it is a local reoccurrance.

I would never start a program of Active Surviellance without getting a CDU as a baseline to monitor tumor growth. If I were considering surgery I would get a CDU in order to identify the tumor location to evaluate the probability of a successful outcome. I would never get a biopsy unless it was CDU guided. All this I learned on my own with quite a bit of resistance from by urologists. I think there is compelling evidence that CDU, in the hands of a skilled radiologist, is a useful tool in helping identify and stage PC.

JT

 

Mel,
I have seen about 5 or 6 studies on CDU and they are mixed. Some showing a significant difference and others showing no difference. I don't think any skill or experience was factored in and I would expect that the true masters would have gotten much better results.
I saw a presentation by Dr Bahn in which he identified a localized reoccurrance after a failed surgery. You might want to contact him or Dr Lee in your neck of the woods to see if this is of any value. If you are going to have SRT anyway it may be of little value, but if one was considering a choice between SRT and HT it would be a good thing to know if it is localized. For SRT it would also be valuable to know whether to radiate just the bed or the pelvic lymphnodes along with the bed.
JT

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65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.