Source: Cancer seeding (spread) has frequently been observed from transurethral resections of the prostate (TURPs). Since cancer spreads through the lymphatics and blood stream, patients are concerned with the question of cancer seeding from fine needle biopsies. Needle biopsy seeding has been documented with both the core needle (14 gauge) and biopsy gun (18 gauge) needle.
Migration of tumor along a needle biopsy track is a recognized potential complication reported in the literature. In 1953 Clarke et al reported the first case of locally seeded prostate cancer resulting in a discrete perineal nodule. Clarke, B.G., Leadbetter, W.F. and Campbell, J.S.: Implantation of cancer of the prostate in site of perineal needle biopsy: report of a case. J Urol 70:937, 1953.
May 20, 2008 6:25 AM
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Accurate diagnosis is crucial to a proper treatment decision. Several diagnostic procedures are used to help the physician determine the type of cancer, where it is, and what stage it's in.
Biopsies are used to extracted a piece of tissue from a site where cancer is suspected to be. A pathologist inspects the tissue to prove the existence of cancer and determine what type of cancer may be present. But a biopsy can't tell whether the cancer has spread. The introduction of computer-assisted technology and advancements in biotechnology give physicians tools that help them refine their diagnosis and subsequent treatment recommendations.
These new technologies are known as imaging techniques.
Imaging produces various types of pictures of the inside of the body. CAT scans (computed assisted tomography) are images of cross-sections of the body that are processed by a computer to create a 3-D picture. CAT scans are used to evaluate soft tissues in organs like the liver. MRI (magnetic resonance imaging) uses electromagnets to line up cells in patterns that can be analyzed by a computer and are also generally used to create images of soft tissue.
Computer-assisted technologies like CAT scans and MRIs can and often do miss cancer that has spread to other parts of the body, especially to the lymph nodes. Although they can create images of the body's interior structures, they aren't very detailed and lead to a high percentage of false readings.
Advances in technology have lead to recent breakthroughs in cancer imaging. Cytogen Corporation has developed a monoclonal antibody imaging technology which offers the physician new information about if and/or to where the cancer has spread. Dianon Systems
Needle BIOPSY
Of the various types of biopsies that are available, the one usually used in prostate cancer is the Fine Needle Aspiration (FNA) biopsy. A needle about the size used to draw blood or administer an injection is guided by ultrasound into the prostate in the area where tumor is thought to be located. Tens to thousands of cells are extracted into the syringe. A pathologist studies the cells and classifies them based on their relationship to normal cells (see Gleason Scores).
For a detailed discussion of FNA and other types of biopsies, go toTHE BIOPSY REPORT: A PATIENT'S GUIDE by Edward O. Uthman, MD, a diplomate to the American Board of Pathology. (Oncolink)
It's possible for a biopsy to cause the spread of cancer which before the biopsy may have been confined to the prostate capsule. Even though rare, this potential should be, but often isn't, disclosed to the patient.
As with all factors in their treatment, patients should make sure they have a clear understanding of why the biopsy is recommended, what information is sought, and what action will be taken based on its result. The following message from an Internet newsgroup cites a study by Dr. Patrick Walsh of Johns Hopkins, one of the giants in prostate cancer research and treatment, and inventor of the "nerve sparing technique" for performing prostate cancer surgery. Dr. Jonathan Epstein, a co-author of the study, is the head of pathology at Johns Hopkins and also has an international reputation.
Re: fine needle biopsy?
Newsgroup: sci.med.diseases.cancerHas anyone heard that a fine needle biopsy has the potential to spread cancer cells to the rest of the body? Do you know of any research about this? Thanks Patrick
Cancer seeding (spread) has frequently been observed from transurethral resections of the prostate (TURPs). Since cancer spreads through the lymphatics and blood stream, patients are concerned with the question of cancer seeding from fine needle biopsies. Needle biopsy seeding has been documented with both the core needle (14 gauge) and biopsy gun (18 gauge) needle.
Migration of tumor along a needle biopsy track is a recognized potential complication reported in the literature. In 1953 Clarke et al reported the first case of locally seeded prostate cancer resulting in a discrete perineal nodule. Clarke, B.G., Leadbetter, W.F. and Campbell, J.S.: Implantation of cancer of the prostate in site of perineal needle biopsy: report of a case. J Urol 70:937, 1953.
>Sheldon S. Bastacky, Patrick C. Walsh, and Jonathan I. Epstein: Needle Biopsy Associated Tumor Tracking of Adenocarcinoma of the Prostate; Journal of Urology; 145:1003-1007, May 1991.
>Our data suggest that subclinical seeding is a more prevalent process than was formerly believed. In particular, tumor seeding within the needle track can occur following transrectal biopsy, a phenomenon that has never been previously recognized. Furthermore, our study also demonstrates the novel finding of seeding following the thin needle biopsy gun technique." (3 of 7 patients).
>In view of these findings, it is important for physicians to realize that they may no longer be dealing with stages A or B. It is essential to watch for this phenomenon, and if present, the patient's disease should be upstaged to pathological stage C and dealt with accordingly. This information seems not to be common knowledge among many physicians.
Further references:
Goldman, E.J. and Samelias, W. Local extension of carcinoma of the prostate following needle biopsy. J of Urol 84:575, 1960.
Burkholder, G.V. and Kaufman, J.J.: Local implantation of carcinoma of the prostate with percutaneous needle biopsy. J of Urol 95:801, 1966.
Labardini, M.M. and Nesbit, R.M.: Perineal extension of adenocarcinoma of the prostate gland after punch biopsy. J of Urol 97:891, 1967.
Blackard, C.F., Soucheray, J.A. and Gleason, D.F.: Prostate needle biopsy with perineal extension of adenocarcinoma. J of Urol 106:401, 1971.
Goldfarb, S. and Leiter, E.: Invasion of the rectum by carcinoma of the prostate. Ann Surg 189:488, 1979.
There are other references on this topic.
Return to Information for New Patients
BONE SCAN - A relatively accurate diagnostic test used to detect the spread of cancer to the bones.
COMPUTED ASSISTED TOMOGRAPHY (CAT) "Cat" SCAN - A scan which produces a 3-D image of internal organs or glands. Some doctors and hospitals think its results are to vague to be of substantial use.
DIGITAL RECTAL EXAMINATION (DRE) - An examination whereby a physician inserts his finger into the patient's rectum to feel for abnormalities of the prostate through the wall of the lower intestine.
FALSE NEGATIVE/POSITIVE - A test is false negative if its results indicate a negative finding but the true answer is positive; for example, if an MRI indicates there is no cancer outside the prostate capsule when, in fact, cancer is known, or found by a different procedure, to be present in surrounding tissue. MRIs, ultrasound, and CT scans are accurate about two-thirds of the time, bone scans about 80% of the time.
GLEASON SCORE (Differentiation) - A report of the normalcy of tissue extracted during a biopsy. When a pathologist examines a biopsy sample, she or he may see a group of cells that is different from healthy tissue. The more wayward the cells the more aggressive and dangerous the tumor is thought to be, and the more likely it is to metastasize. The pathologist picks the two samples out of the five or six that are taken that look the most bizarre, gives them each a ranking from 1 to 5, adds the two numbers together and comes up with a Gleason Score of from 2 to 10. The more abnormal the tissue is the higher the score. The lower the score, the less malignant the tissue and the more favorable the prognosis. From 2 to 4 is well-differentiated, meaning not too different from normal tissue. From 5 to 7 is moderately differentiated, and 8 to 10 is poorly differentiated. The higher the score, the more likely the physician is to prescribe an aggressive treatment.
Gleason Score of 2-4 = Well differentiated;
Gleason Score of 5-7 = Moderately differentiated;
Gleason Score of 8-10 = Poorly differentiated.NOTE: Gleason Score highlights one of the barriers to understanding between caregivers and patients-- the use of multiple terms and acronyms to describe the same procedure. Gleason is sometimes phrased in terms of a grade.
Grade I - Well Differentiated
Grade II - Well to Moderate Differentiated
Grade III - Moderately Differentiated
Grade IV - Moderatetely to Poor Differentiated
Grade V- Poorly DifferentiatedThe actual cellular structure, well-, moderate-, poorly-differentiated, is arcane to many patients, and the existence of both a Gleason "grade" and a Gleason "score" tends to confuse patients. In my opinion, the patient would be just as well informed for his purposes if he knew his Gleason Score on the basis of 1, 2, 3, with low being better than high. Better still might be a Gleason "system" (call it a grade or score, but not both) of A, B, C: A being better than B etc. as it is in school.
These scores are subjective and should be viewed as guidelines. As with other aspects of about prostate cancer, a second opinion of the biopsy should be requested because that's exactly what it is, an opinion. Opinions of Gleason Scores can easily differ by a digit or two. A patient of a radical prostatectomy recently told us that before the operation, his Gleason Score was 6, but a post-operative analysis of the tissue in his removed prostate reclassified it as 9.
It's at the extremes, i. e. the ranges of 2 to 4 and 8 to 10, that Gleason Scores are of the most use as guidelines in prognosis and choice of treatment. The distribution of Gleason Scores in newly diagnosed prostate cancer patients is roughly bell shaped. A Johns Hopkins study found that, "Unfortunately, 75 percent of the time Gleason Scores are 5 to 7 at which the prediction of pathological stage is not as good", i.e. not real helpful as an indicator.
A study of 828 men lead by a nationally known specialist, Dr. Gerald Chodak of the University of Chicago, in the January 1994 issue of the New England Journal of Medicine found that,
- "Mortality due to prostate cancer among men with well- (Scores of 2 to 4) or moderately-well differentiated (Scores of 5 to 7 ) disease was only 13 percent after ten years, compared with 66 percent among men with poorly differentiated (Scores of 8 to 10) disease. Metastatic disease developed significantly more often with increasing tumor scores. By 10 years after diagnosis, metastasis has occurred in 19 percent, 42 percent, and 74 percent of the men respectively. These results clearly demonstrate that prostate cancer is progressive when managed conservatively. (The study notes that hormonal therapy is given to patients when metastasis occurs.)
Gleason Score is an important test to understand. Buckminister Fuller once said that he may seem repetitous but what he's actually doing is saying the same thing but in different words. We strongly suggest that you visit Comed's discussion of Gleason which will enrichen your understanding, and also has some excellent diagrams.
MAGNETIC RESONANCE IMAGING (MRI) - A diagnostic scan in which a magnetic field applied to the body creates patterns of cells which can help distinguish healthy tissue from disease. The MRI is used to help determine if the cancer is confined to the prostate capsule.
Loren Buhle, founder of Oncolink and a PhD in radiation physics from Johns Hopkins described MRI in response to a Prostate Problems Listserv question this way:
"MRI -- magnetic resonance imaging -- is a method of looking at soft tissue. It works by changing the magnetic moment of the atoms (usually the hydrogen atom) and then watching how these atoms relax back to their resting state...sort of like spinning a top and timing how long it takes for the top to stop. To change the magnetic moment...the MRI machine has to give a signal...and then switch to the listening state. This signal + listening is done by a probe...the closer the probe is to the structures to be imaged (to the atoms that are spun), the better the signal. Thus...if the probe is placed into the rectum (since it is a body cavity), the better it can image the structures near the rectum.
The same idea for MRI of the knees is employed...there isn't a handy orfice to place the probe...so the MRI collar is placed around the knee to get a good signal. The same is true for the head...the probe is placed around the head to get a good signal. This is also why the body MRI image isn't as good as the head MRI...the probes are farther away.
So...to image the prostate...get the probe as close as possible.
DNA/PLOIDY ANALYSIS Ploidy analysis is test that uses flow cytometry to determine DNA content (ploidy) of CaP. Studies show that patients with diploid cancers have longer disease free intervals and survival times than those with more aggressive non-diploid tumors. Diploid tumors are more responsive to hormonal therapy (Zinke, 1992), and may be useful in patients with T3 or node-positive disease. Ploidy is not usually done on patients with T1, T2, or node-negative disease because it can give conflicting results.
The lack of mutually accepted standards limits the usefulness of ploidy analysis. It appears premature to place too much emphasis on DNA ploidy analysis. While groups of diploid patients have better prognoses than groups of non-diploid patients, ploidy status may have uncertain prognostic value in individual patients. A small biopsy demonstrating diploid tumor may be missing a significant underlying non-diploid component. Published studies have reached different conclusions concerning prognostic value. Technical standards and methodologies differ from lab to lab. Correlation with histologic criteria remains essential.
PROSTATE SPECIFIC ANTIGEN (PSA) - A blood test that measures a substance produced only by (specific to) prostate tissue. An elevated or rapidly rising PSA level often signals the existence of prostate cancer. Controversy surrounds the routine use of the PSA tests for screening purposes, but it is an excellent way to monitor the effectiveness of treatment.
The PSA is measured in nanograms per milliliter of blood, or ng/ml. A PSA up to 4 ng/mls is considered normal. Between 4 and 10 is a gray area, and above 10 indicates the likelihood of cancer. New PSA norms are age related:
40-49 / 0--2.5
50-59 / 0--3.5
60-69 / 0--4.5
70-79 / 0--6.5.Prostatitis and prostate enlargement, both common with advancing age, can also elevate the PSA. Attempts should be made to rule out these conditions as a reason for an abnormal PSA. By the time prostate cancer can be detected by a digital rectal exam, or symptoms appear, the tumor is usually rather advanced, so the PSA is being used with increasing frequency in routine screenings. A PSA of below 4 is not a guarantee that no tumor exists. The velocity of a rising PSA should also be taken into account. For instance, a PSA that rises from 2 to 3 in a few months or a year may indicate trouble. A normal PSA below 4 should probably rise no faster than about 0.2 ng/mls per year.
PSA II Test A new derivation of the PSA test which measures total PSA and also "free" in order to try to distinguish whether an abnormal level of PSA is from BPH or prostate cancer. It is believed that free PSA is lower in patients with prostate cancer. In one study, researchers found no prostate cancer in patients with a 25% or higher ratio of free/total PSA.
RT-PCR (reverse transciptase-polymerase-chain reaction) -- The RT-PCR test is a refinement on the PSA test that attempts to predict whether prostate cancer cells have left the prostate capsule. Dr. Steven Strum, an oncologist and strong advocate of patient empowerment says,
"RT-PCR may prove to be helpful in evaluating whether or not PC is organ-confined. The Columbia University group used RT-PCR with new enhancements to detect blood-borne PSA synthesizing cells. In 18 patients with metastatic disease documented by abnormal bone scans, 14 of 18 or 77.8% had RT-PCR testing that was positive. In a patient population of 65 patients with apparently clinically organ-confined disease, the RT-PCR assay detected 19 of 28 patients who were surgically shown to have capsular penetration. This means that 28 of 65 patients did not have organ-confined disease and that the RT-PCR assay could detect 19 of those 28 for a sensitivity of 68% (9 false negatives).
The bottom line is that this test should be further evaluated as a tool to help select patients for radical prostatectomy, seed implant, cryotherapy or any local form of treatment. This should be done within clinical trials at multiple centers. The data from Partin et al using PSA + Gleason's score + clinical stage to predict pathological stage should also be compared with the results of the RT-PCR assay.
Sensitivity is true positives divided by true positives plus false negatives. The higher the sensitivity, the fewer the false negatives. Specificity is true negatives divided by true negatives + false positives. Information about this test is fluid. Check with Dianon Systems 1-800 328-2666 for up-to-date information.
STAGING - Evaluation of tests such as DRE, MRI, bone and CAT scans, ultrasound, Gleason Score, and PSA which enables a physician to form an opinion of the size, extent and location of a tumor. It's important to realize that most of these tests are not wholly accurate or objective. The physician's determination of the stage of the cancer is based on his opinion of the size and extent of the tumor based on what his finger feels during a DRE, and the interpretation of MRI, CT and bone scans, and ultrasound. A second interpretation of these tests should be sought to supplement and confirm the physician's unavoidably subjective conclusions.
STAGES - The most commonly used staging system classifies prostate cancer into four categories: A, B, C and D. Stage A is very early and undetectable by the usual screening process. Stage B is confined to the prostate, but the tumor is palpable during the DRE and/or produces an abnormally high PSA reading. B1 is in one lobe of the prostate and smaller than 2 centimeters. B2 is in both lobes and larger than 2 centimeters. Stage C cancer has left the prostate capsule but is still in its proximity. Stage D cancer is in the regional lymph nodes or bones, liver, lungs and/or other tissue.
Stages are classified into A, B, C and D.
- Stage A cancer is confined to the prostate and undetectable by the usual screening process. Stage A tumors are found during a surgery that's done for some non-cancer related reason, usually to treat a urinary obstruction caused by an enlarged prostate, a condition that comes naturally with age known as benign prostatic hyperplasia (BPH). A Stage A1 tumor is well-differentiated and confined to one lobe of the prostate. Stage A2 is moderately or poorly differentiated and in multiple areas of the prostate.
Stage B is confined to the prostate, but the tumor is palpable during the DRE and/or produces an abnormal PSA reading. Stage B1 is in one lobe of the prostate and smaller than 2 centimeters. STAGE B2 is in both lobes and larger than 2 centimeters.
A and B cancers are considered curable, i.e., if the cancer is located entirely within the prostate capsule and the capsule is removed entirely, the patient will be cured. The problem is the tests and scans used to determine whether the cancer is indeed confined aren't 100% accurate. As a result, staging is imprecise (usually on the side of understaging), so before the surgeon makes the incision to remove the prostate, he takes a sample of the lymph nodes. While the patient is on the operating table, the sample is rushed to the pathology lab to see if there is cancer that was undetected by earlier tests. If so the surgeon aborts the operation, reclassifies the patient to Stage C or D, and recommends a different treatment (usually watchful waiting or hormone therapy.)
Stage C cancer has left the prostate capsule but is still in the surrounding area, and/or the seminal vesicles. Stage C is occasionally treated with surgery and/or radiation, but hormone (anti-testosterone) therapy is more likely. Some proponents of cryosurgery say it has the potential to treat Stage C prostate cancer.
In Stage D the cancer has left the vicinity of the prostate and may be in the regional lymph nodes or beyond in the bones, liver, lungs or other tissue. Hormonal therapy is the "gold standard" treatment for Stage D cancer.
Prostate Cancer Center
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