Prostate Cancer (cont.)
When the findings of the physical exam, DRE, and PSA level, suggest that a cancer might be present in the prostate, the diagnosis must be confirmed by biopsy (taking a sample of the tumor). The sample of tumor tissue is then examined by a pathologist, (doctor who specializes in diagnosing diseases by microscopic evaluation) to confirm the presence of cancer.
Main indication for prostate biopsy:
- Suspicious prostate exam with DRE
- Abnormal PSA level
- Abnormal change in PSA or PSA velocity
According to AUA guidelines there is no single threshold value of PSA that should prompt biopsy. Although the decision to take a biopsy is to be based primarily on PSA and DRE, it should take into consideration other factors such as PSA velocity, family history, ethnicity, prior biopsy results, and underlying medical conditions.
- Prostate biopsy is usually performed in an office as an outpatient procedure. The biopsies are obtained using a needle inserted through the rectum using transrectal ultrasound (TRUS) guidance while the patient is under local anesthesia.
- Local anesthetic is injected around the periphery of the prostate to reduce discomfort associated with prostate biopsy.
- TRUS imaging guides collection of the tissue sample.
- Tissues samples are systematically collected by inserting a needle into the tumor and withdrawing tissue. Typically 10 to 12 pieces of tissue are extracted from different parts of the prostate gland to look for the presence of cancer in the entire prostate.
- Most commonly, in preparation for the procedure, patients are administered a fluoroquinolone antibiotic and given a cleansing enema.
- Major complications, such as bleeding and/or infection requiring hospitalization are rare; however, hematuria (blood in the urine) and hematospermia (blood in the semen) are common sequelae of the procedure.
Pathology biopsy results:
- A pathologist examines biopsy pieces under the microscope to assess the type of cancer present in the prostate and the extent of involvement of the prostate with the tumor. One can also get an idea about the areas of the prostate that are invaded with the tumor by assessing which of the pieces contain the cancer and which of them do not.
- Another very important assessment that the pathologist makes from the specimen is the grade (Gleason score) of the tumor. This indicates how different the cancer cells are from normal prostate tissue.
- Grade gives an indication of how fast a cancer is likely to grow and has very important implications on the treatment plan and the chances of cure after treatment. A Gleason score of 6 generally indicates low grade (less aggressive) disease while that of 8 to 10 suggests high grade (more aggressive) cancer. A grade of 7 is regarded as somewhere in between these two.
Pierre-Alain Hueber, MD, PhD
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