CDU & New Guys

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cooper360
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   Posted 3/19/2011 9:01 AM (GMT -6)   
Any new guys......... If you need a biopsy make sure its color doppler guided,by one the experts.........Cooper wink

compiler
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   Posted 3/19/2011 1:43 PM (GMT -6)   
You mean Dr. Samadi doesn't do color doppler?
 
Mel

cooper360
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   Posted 3/19/2011 5:46 PM (GMT -6)   
I don't know  Dr. Samadi ! But I do know Dr Fred Lee in Mi........& you obviously do not know me.........Cooper  wink

Fairwind
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   Posted 3/19/2011 7:45 PM (GMT -6)   
cooper360 said...
Any new guys......... If you need a biopsy make sure its color doppler guided,by one the experts.........Cooper [img]/community/emoticons/wink.gif[/img]


The problem is, there are only 10 or 15 color doppler machines in the country...So 98% of the half-million biopsies performed every year will have to do without one...

cooper360
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   Posted 3/19/2011 8:19 PM (GMT -6)   
My husband was one of the 2%.........if you can get one do so......why not its added assurance that the biopsy is targeting the right area. My husband was lucky to have Dr Lee right in our own back yard [Mi]..........Cooper  wink

An38
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   Posted 3/20/2011 12:25 AM (GMT -6)   
Dr Lee is an "artist" with the CDU and he has helped many people identify exactly where the tumour in their prostate is so that the biopsy does not miss the tumour .... but the CDU is not perfect and does miss small but significant tumours. The main critisism from respected oncologists such as Dr Strum is that sometimes Dr Lee relies too much on the CDU unit and suggests to his patients that they do not need a biopsy just based on what he sees on the CDU. Dr Strum suggests insisting on a standard template biopsy in this situation.. and in fact he suggests a standard template biopsy even if the CDU unit identifies a primary tumour which can then also have a few extra cores taken.
 
An

Post Edited (An38) : 3/20/2011 12:34:57 AM (GMT-6)


Steve n Dallas
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   Posted 3/20/2011 1:46 AM (GMT -6)   
Function
The Color Doppler Ultrasound measures blood flow to the area and displays the results in full color for interpretation by your radiologist and oncologist.
 
Effects
Using the images gathered by the Color Doppler Ultrasound, your doctors have the ability to identify tumors on your prostate. The results also give information about the size, type and stage of the cancer.
 
Benefits
Color Doppler Ultrasounds are quick and cause no pain, compared to needle biopsies. These ultrasounds also pose no threat for inflammation that may exacerbate tumors in some cases.
 
Considerations
Although Color Doppler Ultrasound is effective in the majority of cases, it is possible for tumors of the prostate to not show up with the test. For example, a study by EJ Halpern at Thomas Jefferson University revealed that as many as 20 percent of Color Doppler Ultrasounds miss the presence of cancerous prostate tumors in patients.

Piano
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   Posted 3/20/2011 4:24 AM (GMT -6)   
Standard biopsies can miss tumors too, so this problem is not confined to CDUs.

If you are having a CDU, it is surely because your doctors suspect a problem. If CDU finds no problem, I think it reasonable to still proceed with a standard biopsy. And the reverse applies too -- if a standard biopsy finds nothing, go for the CDU.

And if both find nothing, then you can celebrate!
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4/12 cores
Non-nerve-sparing RRP 7 March 2008 age 63
Organ confined, neg margins. Gleason downgrade 4+4=8
Fully continent
Bimix worked well; now using just VED
PSA undetectable at first but now 0.4, doubling time 7 months
No radiation but ADT coming unless I can slow down the rise...

cooper360
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Date Joined Jul 2010
Total Posts : 161
   Posted 3/20/2011 8:38 AM (GMT -6)   
 
"The CDU is not perfect and does miss small but significant tumours."                                       
 
I believe from what I have read that in the right hands CDU does maybe sometimes miss small but INSIGNIFICANT tumors........... and in the case of Pca is a good thing Because after 50-60 most men have some degree of prostate cancer whether it be atypical cells or indolent cancer.........
 
I guess I just believe CDU is another tool in the toolbox when dealing with a elevated psa.........I do know that JohnT says it helped to find a tumor after many biopsies did not, that and all the research I did on CDU and Dr Lee told me it was the right thing to add to our investigation as to why my husbands psa was elevated...............
 
prostatitus can skew psa and fpsa and even after a course of antibiotics to rule out infection, a biopsy can make a mess of the psa number and flare up the prostatitus.........We're comfortable with Dr Lees assessment of my husbands situation..........I only post about CDU because from experiencing seeing it I believe it is an important tool.............Cooper wink

Purgatory
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Date Joined Oct 2008
Total Posts : 25364
   Posted 3/20/2011 8:59 AM (GMT -6)   
If there are but a handful in the entire country, it seems odd to keep pushing CDU as a viable test tool. For most men, it would be out of reach or rescources to include it in their dx. process, unless they had unsual circumstances to justify it.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

cooper360
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Date Joined Jul 2010
Total Posts : 161
   Posted 3/20/2011 9:54 AM (GMT -6)   
Well maybe for the guys in the states where they are more readily available [done by expert]MI,CA,FL are the ones I know of. I guess I'm going by experience it seemed easy for us being in mi,I called for an appointment and a week and half later we were seeing Dr Lee,I know our circumstances made it easier but we would have traveled if necessary...........I guess its not odd to push it for the people in the areas where they are available.........BCBS covered both scans,it didn't seem out of reach...... Hope things will get better & better for you [I know you have been having issues] Purgatory....................................Cooper

Fairwind
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Date Joined Jul 2010
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   Posted 3/20/2011 9:56 AM (GMT -6)   
Agreed Dave..If this tool offered and delivered all it's claimed benefits, every urologists office in the country would have one.. It would seem the medical professionals who actually USE this equipment don't share in the enthusiasm displayed by those who have undergone procedure..

Purgatory
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Date Joined Oct 2008
Total Posts : 25364
   Posted 3/20/2011 1:13 PM (GMT -6)   
Fairwind, tend to agree with what you just said.

The 2 largest and oldest urological practices combined in my area 3 years ago, and have formed the largest in the entire state. They triy to stay, "state of the art", and like you said, if it were that definitively useful and accurate, I would think a huge practice like this would easily purchase and use one.

My own uro, whom I trust greatly, feels that they are not accurate enough to be useful, at least not to have across the board.

Probably get slammed by the "experts" for saying that, but don't shoot the messenger.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 3/20/2011 2:17 PM (GMT -6)   
I believe JohnT has posted many times the reasoning as to why this older technology isn't used....... so enough said,as he explains it far better than I and has experienced the benefits of it,as has my husband and a few others that have posted here.....When I first posted another poster[windquest I believe] decided to travel to Ca to see Dr Bahn,& was satisfied with his assessment of his situation.........it might be an outside the box kinda thinking..........but there's room for all options....Just putting the info out there..... I was glad I knew about it when my husband and I were trying to figure out how to approach a elevated psa......Cooper .....ps lighten up guys its not like reading runes....its just the road less traveled, some of us like to be on it  scool

Post Edited (cooper360) : 3/20/2011 2:55:33 PM (GMT-6)


John T
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   Posted 3/20/2011 2:47 PM (GMT -6)   
Fairwind and David,
I have posted many times why CDU is not commonly used.
1. It is done by interventional radiologists who are trained in reading scans.
2. Urologist are very protective of the biopsy domain and will never refer anyone to a radiologist for a biopsy. There have been numerous attempts to integrate MRIs and other scan do do more accurate real time biopsies and all have met stiff resistance from the urological community. Dr Scholz uses a CDU, but won't do biopsies because of this.
3. The Equipment cost $125k to 150k and you have to do a lot of biopsies to make it up. Medicare doesn't pay anymore for a CDU than it does for an ultrasound.
4. It takes a lot of training and pactice to read the scans. To most doctors doing only a few biopsies a week it doesn't make sense.
5. The major institutions don't use it because the radiology teachers and students are into newer technology and just don't want to learn a technology that is 20 years old.
As far as I know only 6 interventional radiologists and one oncologist uses CDU. I don't know any urologist that does. There could be more that use it, but I don't know of them. Drs Bard and Sconti in NY, Dattoli in Fla. Fred Lee in MI and Duke Bahn, Doug Chen and Mark Scholz in ca. are the only ones I know.
JT
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.

GOP
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Total Posts : 657
   Posted 3/20/2011 2:56 PM (GMT -6)   
No one will ever confuse me for an expert, but it seems to me that the mapping biopsy yeilds similar results and is far more accessible.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 3/20/2011 4:58 PM (GMT -6)   
John, your 6 reasons are only further cementing why CDU isnt in much use. So the bottom line, it may be a good tool, but is in such limited use and availability, its not really part of most men's dx. process or decision.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

John T
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Total Posts : 4188
   Posted 3/20/2011 6:33 PM (GMT -6)   
A 3D mapping is a good alternative; except that it is very invasive and is just like a surgical procedure. It also costs about $17,000 vs about $600 for a CDU the last that I heard.
David,
That doesn't mean that it shouldn't be. I know that just between Dr Lee and Dr Bahn they have done close to 40,000 biopsies so a lot of patients are using it if they know about it. It is doubtful that a patient would ever know that a scan like CDU existed if it wasn't for forums like this and certain doctors like Strum, Myers, Barkin, Scholz and others who refer their patients.

It probably doesn't make sense to travel to a distant center to get a normal run of the mill biopsy. It is a valuable staging tool for those considering surgery after being Dxed or for anyone considering AS. I would absolutely recommend it for anyone having 2 or more negative biopsies with a still rising psa.
I absoulutely believe that many failed surgeries could have been identified before hand with a CDU or an MRIS.
JT
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.

Postop
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Date Joined Feb 2010
Total Posts : 385
   Posted 3/20/2011 9:03 PM (GMT -6)   
Why should it be a matter for absolute belief? Do you know of any studies that directly test whether doppler or MRI scans are effective tools for determining who should not have surgery?

An38
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Date Joined Mar 2010
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   Posted 3/21/2011 4:21 AM (GMT -6)   
Hi John,

Agree completely with your statements below:

It is a valuable staging tool for those considering surgery after being Dxed or for anyone considering AS. I would absolutely recommend it for anyone having 2 or more negative biopsies with a still rising psa.
I absoulutely believe that many failed surgeries could have been identified before hand with a CDU or an MRIS.

However the one situation where I do not agree with the use of the CDU is where the doctor doing the CDU use this as the sole reason for not doing a biopsy (especially in cases where no biopsy has been done and no Dx has been made). To me this is just irresponsible because even the color doppler has "black spots", areas it doesn't see particularly well. This is why Dr Strum refers patients to Dr Lee and Dr Bahn becuase he know the added value this provides but insists they get a full template biopsy as well because he knows that the CDU sometimes misses significant tumours.
It is not an alternative to a biopsy, it is an additional tool in the toolbox.

An

Post Edited (An38) : 3/21/2011 4:26:02 AM (GMT-6)


cooper360
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Date Joined Jul 2010
Total Posts : 161
   Posted 3/21/2011 7:48 AM (GMT -6)   
I'll direct this to any one of the "doctors" on here concerned that my husband is irresponsibly running 4 marathons last year, with undiagnosed Pca and that Dr Lee is not doing a biopsy [also irresponsible].........My husband had a full workup w/Dr Lee.prostate exam,CDU[said in pre paperwork be prepared to have a biopsy if necessary],course of antibiotics [which brought the psa down significantly] another CDU...as the irresponsible Dr Lee said.....after careful examination there were patches of prostatitus,calcification,saw no reason to do biopsy and also said do not let anyone biopsy you as we were leaving [as biopsy would flare up prostatitus].........even though most will insist [on this forum] that CDU has no value well.....I have a different opinion,backed with the experience of seeing it done by the master at it and I'm just as much a doctor as the rest of you LOL!!!!!!!!........... Cooper  wink   Sorry for the sarcasm can't help it.Gotta go probably for good,I have a ton of patients to see.I'll leave the explaining of CDU to JohnT..............................  smilewinkgrin

Purgatory
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Date Joined Oct 2008
Total Posts : 25364
   Posted 3/21/2011 8:34 AM (GMT -6)   
These remarks don't make either side right or wrong. Each patient has to do what is right for them.

Also, no one is being critical of your husband's choice of doctor, nor is anyone telling him not to be compliant in his relationship to his doctor(s)

So no reason for the sarcasm and hostility in your post. You ask for opinions, and opinions you got, that's how it works here at HW.

Leaving for good won't help you, your husband, or the remainder of the community here. But certainly your choice as well.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

John T
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Date Joined Nov 2008
Total Posts : 4188
   Posted 3/21/2011 12:45 PM (GMT -6)   
Postop,
You can start at Dr Barkin's website, pcrf.org and view the Dr Bahn video on CDU staging.
There are no studies on either MRIS or CDU in staging. How would you even set up a study as there are so many varibles on surgery. For years many of the top oncologists have referred their patient for these scans as part of the staging process. The location and volume of the tumor as well as extracapsular extensions have a direct correlation to the effectiveness of surgery. These are well known and anything that gives you more information about these, BEFORE treatment will aid in decision making. Large APEX tumors, Seminal vessicle involvement and extracapsular extensions all have a high probability for failing surgery, and both these scans are very good at identifying these. Yet doctors continue to refer low risk patients for ineffective CT and bone scans at 4X the cost. This doesn't make any sense.
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.

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 3/21/2011 1:24 PM (GMT -6)   
No hostility here, honest just a little frustration at all the naysayers that have not seen a CDU done or know little about it,because frankly the first urologist said don't bother,because he didn't know much about it..............But I gotta tell you there have been quite a few critical remarks & second guessing the Dr, made from the first time I innocently posted our experience,An even appears to know alot about my husbands case and what Dr Lee should do...I thought our experience would possibly help someone else just staring out, that's it didn't ask for advice or opinions just a informational post....I even had to stop using the term newbie because Fairwind said it was condescending,he yelled at me cry
LOL!!! There seemed to be alot of nit picking for mostly guys. 
 
I can be a little bit of a smarta#@ I don't mean any real harm,probably annoys some people............... but hey Purgatory you have kept me reading and hoping for the best for you.... I'm also a big rah! rah! fan of JohnT [he seems to be more open minded & knowledgeable than some]            Cooper wink

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 3/21/2011 1:48 PM (GMT -6)   
John,

Thank you for your response. I guess the way to show that doppler could reduce the need for unnecessary surgery would be to take a group of preoperative patients where it is uncertain if the disease is outside the prostate. Do several types of imaging, MRI, doppler, bone scan, CT, etc on each patient. Compare the results, which ones show extraprostate extension, SV involvement, suspicious lymph nodes, bone mets--whatever that test can show that would lead you to believe that the disease has spread. See what the "extra yield" of doppler would be, that is, what portion of patients have spread documented on doppler where it wasn't evident from any other tests. I bet that many patients going to Dr. Lee have already had some of these other tests before coming to see him. It would be a simple case series, not a randomized clinical trial. Has a series like this been published? It would go a long way towards clarifying this issue, so that it wouldn't be a matter of opinion or advocacy, but of evidence. If the doppler users in practice have great results, they should want to prove it to the world with a peer reviewed article in the medical literature. Hopefully they have done this.
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