When is it necessary to do a prostate biopsy?

You’ve may have experienced or at least heard this scenario. Urologist to the patient, “Well it looks like your PSA is elevated, let’s schedule you for a prostate biopsy.” Really, just that quick?

It wasn’t too long ago, biopsy seemed like the only option to tell if a man’s PSA was elevated because of a prostate cancer. After all PSA, although a very good diagnostic blood test, is not cancer specific. In other words PSA elevation may be due to an enlarged prostate, a prostate infection or stimulation to the prostate gland or it could be a malignancy. And come to think of it, what if we do a prostate biopsy and the needle misses the cancer?

We’ve come a long way in the understanding how to diagnose and treat this potentially deadly disease, prostate cancer. Yes, prostate biopsy is important, but let’s takes a step back for a moment. What if we had a biomarker (like PCA3) for the urine, that if it is was elevated then we could take the next step.

What if we could look a prostate by imaging it, just like we do with other glands and organs in the body? By using a high magnet, 3T MRI, which provides us with a road map of the prostate we could see if an area that looks suspicious and then we can take the next step.

If we reduce the number of prostate biopsies, and improve the information that we get when we do biopsy, then we have made progress and yes we have all this technology available to us right now.

Dr. Herb was interviewed by Ken Gordon of the Columbus Dispatch about the rise of vasectomies during March Madness.

Read the full article here.Columbus Dispatch article

Why do Men Get Vasectomies?

The following was from Dr. Turek’s blog. View his blog at http://theturekclinic.com/blog/

Why do Men Get Vasectomies?

I ask most patients why they are considering a vasectomy. The responses vary, but can be very amusing. Here are a dozen of the funniest answers I’ve heard in my practice:

1.    My wife said: “the factory is closed,” so I’m here.

2.    I was told that they broke the mold after they made me, but I want to make sure of it.

3.    My wife said: “It’s your turn now.”

4.    After this, I won’t ever have to say I’m sorry again.

5.    I’m married! Condoms are sooo high school!

6.    Have you seen the movie ‘One Fine Day?’ That’s why I’m here!

7.    Every time I look at my wife, she gets pregnant.

8.    Apparently, sacrificing some limbs just isn’t the same…

9.    She told me: “Enough, get your wings clipped already!”

10.  I was told that I can shoot the gun all I want and no one will get hit.

11.  I heard that it’s easier than getting your teeth pulled out…

12.  My wife told me that it’s time for juice without seeds.

So, here’s to the most effective contraceptive ever developed and hats off to those men who chose the “emission impossible” way to an unburdened and unbridled sex life.

Prostate Cancer the Answers Are Here Focal Therapy HIFU, 3TMRI and PCA3

There are rapid changes that are related to the diagnosis and treatment of prostate cancer. In the United States in 2011 there were 241,000 new cases diagnosed and 34,000 deaths, this is second only to the death rate of lung cancer. Tumor markers or blood tests that are used to diagnose this disease at times create significant controversy. The most in the news is PSA. This test is very sensitive but it's not specific. However there is a new FDA approved marker PCA 3 which is much more specific. If we combine these two there is a good opportunity of identifying significant prostate cancers. In other words the two used together give us meaningful information about who should have additional testing.

We gain information about prostate cancer that we can find by doing a mapping biopsy. What we learn in these cases is that patients can have more than one grade of cancer within the prostate, some very low-grade and called insignificant cancer. Some cancers are much higher grade and these can lead to wide spread disease. This aggressive cancer usually is larger than insignificant cancer and can be identified. Early diagnosis means identifying the cancer before it spreads and makes it possible to destroy it within the prostate

High quality imaging of prostate today means an MRI image when done with a high-powered magnet known as 3 Tesla, this image can demonstrate the anatomy of the prostate we can see within the prostate. 3T MRI has a very good opportunity of identifying aggressive cancer within the prostate where it can be cured. This then leads to the concept of early diagnosis of aggressive cancer. With this information we now have the opportunity to focus our attention and develop a target of the bad prostate tissue. This is done precisely and the MRI images done previously can be coordinated with a new treatment technique and we can achieve cure by only treating the targeted aggressive tumor cells within the prostate.

High intensity focused ultrasound (HIFU) is one of the treatment tools that is rapidly developing to give us to have focal therapy of prostate cancer, much like focal treatment of breast cancer, known as lumpectomy.

Although HIFU is not currently approved within the United States, it will be in the near future. It is currently being used in clinical trials in the US and is currently available outside the US. Our goal is early detection of significant prostate cancer. We can do this with PCA 3, PSA and very sophisticated imaging. The objective is for the urologists to characterize the individual patient with this diagnosis and tailor an approach for that individual patient. In cases these can treat specific areas that represent the bad tissue (malignancy) within the prostate using HIFU

HIFU utilizes an ultrasound probe... In this case however the probe produces ultrasound energy and then focuses it so that it can pass through adjacent tissue without creating harm and produce a very small but precisely focused amount of energy at the target. Almost everyone can remember in childhood when we used a magnifying glass and focused the sun's rays  so we could set a piece of paper on fire or possibly etch our name in a piece of wood. You'll also remember that unless you were at the point where the sun's rays had converged into a small pinpoint you could pass your hand through the rays and it would not even be warm.

This is the same principle; the ultrasound probe uses to provide the energy that is used in HIFU. The energy however is ultrasound. This therapy is controlled in the same as the sun is with the magnifying glass. It then enters the prostate then converges to produce high heat at the target. Using this with computer guidance allows us to target the bad tissues and destroy it. This leaves the majority of the prostate untouched. We combine this level of selective application of energy with the marvelous images that we're getting from the 3Tesla MRI and we can now produce focal therapy that has the potential to cure prostate cancer without treating the whole organ. In other words the prostate no longer will have to be totally radiated or totality frozen or removed.

In February 2013 Riverside Urology held an Educational Seminar in Columbus, Ohio with multiple expert lecturers discussing these topics. That presentation was recorded, condensed and posted to YouTube. Please take a moment to view the video, HIFU909 http://youtu.be/r4sf9YX7cYg  Thank you.

Point counter point for prostate cancer treatment

Presentation of the Con position for Focal Therapy

The goal is to bring about cure without causing significant side effects. Focal therapy has the potential to reshape treatment of prostate cancer; however a significant group of appropriately credentialed professionals believe that the efficiency of focal therapy has yet to be proven. These professionals believe that the multifocal nature of prostate cancer makes treatment using the focal approach inadequate.

It is clear that the majority of prostate cancers are the result of a mixture of low grade, low volume disease. However, some of these cases have larger deposits of high grade large aggressive cancer in a localized area. This is known as an index lesion. On the other hand, prostate cancer that is purely low grade and low stage does not progress and has led to the concept of active surveillance. This means patients who have tumors, with these characteristics, are being treated with “surveillance” rather than aggressive therapy such as radical prostatectomy or high density radiation therapy.

It is also clear however, in this surveillance group some patients will demonstrate evidence of progressive disease.  They are then treated differently and taken out of the surveillance group. When they are studied with the new techniques of imaging in some cases there is an identification of a grouping of more aggressive cells known as the index lesion. This lesion is most likely to be causing the PSA elevation.

Regardless, in many cases prostate cancer is multi focal. The question that needs to be answered simply is; what type of cancer are we dealing with? Low volume and low grade the kind that people can live out their normal lives, or is it high grade and aggressive cancer which unless appropriately treated can be life ending?

Knowing the answers to this question opens the opportunity for a number of well established prostate cancer treatments to be considered. These include aggressive therapy such as radical prostatectomy, or total gland therapy with techniques such as high density radiation, total gland treatment with cryoablation or with HIFU which is high intensity focused ultrasound. 

We have entered into a new era in the treatment of prostate cancer. We have a wide variety of options which include radical surgical removal, total gland therapy with either cryoablation or radiation and although not yet completely accepted by the medical community focal treatment with either cryoablation or HIFU.

A fully informed patient working with a urological oncologist, radiation oncologist and/or medical oncologist will have the opportunity to be treated with a therapy customized to their particular problem which will minimize or eliminate the risk that most of us associate with the diagnosis of prostate cancer. 

Point counter point for prostate cancer treatment

Presentation of the pro position for focal therapy

Focal therapy for prostate cancer is controversial. It is believed that prostate cancer occurs in more than one area within the prostate at the time of diagnosis. Focal therapy is designed however to treat a very precise area within a gland.

An example of focal therapy that clearly has been established as a prime treatment is that of renal cancer and techniques such as partial nephrectomy which is removal of a portion of the organ and small cancer within the kidney can be destroyed by using a freezing technique known as cryo ablation.

Dr. Mark Emberton and his colleagues at University College London are the world leaders in applying the principles of focal therapy for the cure of prostate cancer. There is a concept in defining prostate cancer that is referred to as an index lesion. This is the largest deposit of cancer in the prostate and is usually greater than 5 mm in diameter. This size lesion can be diagnosed by an imaging study known as the 3Tmri.

Using the information provided by the MRI, the technique of targeted biopsy results in early diagnosis of low volume disease.

It is known that there are prostate cancers that people can live with and they have no significant affects from this. These lesions when studied are low grade, small volume and less than 2 mm in diameter. This type of cancer is frequently found on autopsy and never creates a problem during the patient’s life. The index lesion is the problem and with our ability to identify this and make early diagnosis it is possible to provide curative therapy to many people without removing the prostate gland by using focal treatment. With careful selection of low grade, low volume tumor that make up an index lesion that occupies only one side of the prostate, it can be cured by using a freezing technique known as cryo ablation. This does destroy the part of the prostate that contains the tumor. The opposite side of the prostate does not demonstrate cancer. Therefore this is a method of curative focal therapy. Here are 3 educational videos from our website: Focal Cryotherapy Hemiablation Part 1 , Focal Cryotherapy Hemiablation Part 2 , Focal Cryoablation Minimally Invasive Treatment of Prostate Cancer

There currently are ongoing studies with High Intensity Focused Ultrasound (HIFU). We will discuss this in a forthcoming blog, however there is an educational video, HIFU The Latest Trend for the Management of Prostate Cancer , on our website www.riversideurolgy.com where you can learn much more about this effective treatment.

Our next blog will deal with the other side of this controversy explaining why focal therapy is felt by some experts not to be ready to be considered for treatment of prostate cancer currently.

Cryoablation is a procedure that is used to cure recurrent prostate cancer after failed radiation therapy.

Each year approximately 50,000 men in the U.S. are treated with radiation therapy for curative treatment for prostate cancer. Sixty percent of this group will have what is known as PSA failure. This means the PSA rises above acceptable limits usually thought to be 2 ng/ml. Not all patients in this group will be diagnosed with recurrent cancer, but a significant number will. This number can be as high as 15-30,000 patients. It is clearly troublesome. However, good answers for this problem exist.

As soon as the PSA failure is recognized, a timely workup is indicated. This will include new methods of imaging known as multi parametric MRI. In addition there are new tumor markers, the most important beyond PSA is known as PCA3.

The good news is that if this workup is done early many times it is possible to see the problem that has developed within the prostate. It may be a single area of cancer that has reoccurred. Using the advanced MRI this can be detected then biopsies can be guided to the specific target representing recurrent disease.

Unfortunately today, this type of workup is not common. Many times the patient is put on LHRH inhibitors (androgen deprivation therapy). The reason for this is that many believe that failure following radiation has no good answer; clearly this is not the case! Additionally, the androgen deprivation therapy has side effects; adverse affects on the heart, blood, in the sense of increased cholesterol, and depression of testosterone which results in thinning of the bone otherwise known as osteoporosis.

With current imaging cryoablation can be targeted to the area of recurrence and result in cure.

This may sound familiar. Twenty five years ago when women were diagnosed with breast cancer the answer was radical mastectomy, today that term is rarely heard. What has replaced it is lumpectomy and many women treated in this way live very full and productive lives. 

Likewise when cryoablation is used to eliminate the area of recurrent prostate cancer after radiation failure, the PSA rapidly falls to undetectable levels. Studies done in 2010 at Columbia University in New York City have demonstrated in a group of 900 patients that the 10 year cure rate is approximately 90 percent.

The key to achieving this level of cure is early diagnosis, early workup is indicated, and appropriate treatment based on today’s technology is required. Today many doctors immediately administer androgen deprivation therapy, this needs to be replaced by early diagnosis of the recurrence with the contemporary technologies that are available.  

We have produced a short video that overviews the current and evolving treatment utilizing Cryo as Salvage Treatment for Failed Radiation Therapy of Prostate Cancer Please take a few minutes to review this very useful information.