Do not get biopsy without it !!!!

I'm going to post this once a month for any new guys! I believe from the bottom of my heart no man should have a biopsy without it being color doppler guided. If you have to travel so be it,if you have to pay the difference between reg. & color pay it,for that matter if you have to pay period, pay it! This is speaking from a middle class, steel working family. There are a few areas in the country where there are excellent Dr's who can provide this kind of guided biopsy. You have the assurance of the doctor and yourself [you watch the ultrasound yourself w/wife or partner]. I cannot imagine starting down this path [with all its pitfalls] without it. Its one of those things when you experience it you know its right,not just for yourself but for all. For all who will say that's a broad statement, I say why not!!!!!...........That's my public service announcement......Cooper

Totally agree.  Well said Cooper!

Be that as it may, 95% of the biopsies will be performed without the extra guidance provided by the Color Doppler machine..

The end result is pretty much the same..They will find cancer or they won't..

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Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

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.

CDU is an enhancement and not a replacement for core biopsies. It is not a perfect method by any means. Attached is a comparative study posted at the InfoLink on CDU:

prostatecancerinfolink.net/2010/07/09/color-doppler-ultrasound-and-prostate-cancer-biopsy/

The study does show a failure rate of the technology to discover cancer that a TRUS biopsy detected of about 15%. Conversely, it detected prostate cancer in 27% of cases that a TRUS biopsy only detected 24%.

What I believe is missing in the study is whether has any ability to detect if the cancer has left the prostate. It is certainly possible with both technologies but we don't know if CDU improves that ability. Some say it does but there is no hard proof of it.

Is this the needed replacement for detecting prostate cancer? I don't think so. But it may be helpful for those who have had multiple TRUS biopsies come up negative. But again, a 15% failure rate to detect what a TRUS biopsy could leaves much to be desired. Hopefully further advances will improve this technology.

Tony

---

Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 11/13/2010 5:57:55 PM (GMT-7)

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

I agree with that cooper.
The doctor does indeed matter for anything specialized. But we don't know the quality of the doctors in the study. Lee and Bahn claim to be the best and I think they probably are in the US, but we don't have much to compare with them. Both treat prostate cancer in a way that does not verify actual extensiveness of prostate cancer. And I don't know of many cases that saw them for CDU and had surgery. They will typically recommend cryo or radiation. PCRI, for which both are Scientific Advisory Board Members, tends to be radiation centric. Radiation will never provide actual comparative data on the performance of CDU or TRUS biopsy that removing the prostate and examining it will. But certainly if we can get a stronger imaging diagnostic, it will be helpful for all treated for prostate cancer. CDU is not new but there are a few places to get one done. There is a role for it for sure in prostate cancer.

Tony

---

Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

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

I have been told that the rectal biopsies regardless of color doppler or whatever can miss sampling 40% of the prostate. If you want a true analysis get an STPB.

Had to look that one up - STPB.

I find it also interesting the Dr. Bob B. (Michigan uro-surgeon and a great overall doc and person), will occassionally send his patients to get the nearby services from Dr. Fred Lee using CDU for biopsies or rebiopsies or comparisons. He is righteous enough, that it isn't all about his profit line for motivation purposes, more about what might serve the patient best. (that is why it is interesting).

So, CDU being used by the few whom devoted themselves to using it as artists are probably worthwhile for ones consideration. Plus you get to see the photo images.....horray.....'the colors'...(well Timothy Leary would have been impressed-LOL).

---

Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

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?).

---

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

RCS,
I can't answer that question. The study does not touch on that. It could be that not all cancers are going to show up on the screen, and logically we know that no imaging that we have today can detect prostate cancer when it's too small to see. CDU does give us a better approach but it's not strong enough to rely on it solely. I think the benefits outweigh the limitations, however. Cooper posted that all should use the technology however I don't think all will benefit from the use of it. I've seen where some members have used it here and their doctor saw what he thought was cancer only to have a negative biopsy. I would tell that patient that he still needs to be monitoring his PSA closely. Since CDU misses 15% that was detected by TRUS biopsy in the linked study, then it would be reasonable to suggest that it's possible that this is a missed detection case.

BTW I misinterpreted the study a bit. The CDU detected cancer in 27% of the cases while TRUS biopsy detected it in 24% of the cases. This is a very narrow gap.

Tony

---

Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 11/13/2010 5:59:58 PM (GMT-7)

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

There's a video about STPB at:
http://chicagoprostate.wordpress.com/

Scroll down. It's near the bottom.

I have never had any problem with general anesthetic procedures. Insurance has covered all of them in the past.

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

I see some new guys on here looking for what kind of biopsy to get IMO... Color Doppler guided seems best to me & a few others on here [JohnT being one]! Just bumping it up for Nov........................Cooper 

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.

As always, very well said..................Cooper

John T., et. al.:

CDU can not identify cancer...It can, in expert hands, provide an assessment of risk of whether cancer might be lurking and point out where if might be..Many men are very gun-shy of biopsies and this instrument can help avoid needless ones by pretty much ruling out the presents of increased blood-flow aggressive tumors need.. If nothing else, they provide the patient some reassurance that a biopsy is really necessary and the urologist is not simply going on a fishing expedition...

Since doing biopsies is a profit center for Urologists, and they can lead to bigger things, they are not highly motivated to buy an expensive machine so they can do fewer biopsies..But with all the controversy boiling up now about excessive testing and unnecessary treatment, they may become more motivated when the U-doc down the street buys one..Back-stage, Medicare payments play an important part, as they always do..

Mel,

John T:

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.

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.