If there is concern or suspicion for prostate cancer—i.e., an abnormal digital rectal exam, an elevation in PSA, or an accelerated PSA velocity, the definitive diagnostic test is a procedure known as an ultrasound-guided prostate biopsy. Prostate ultrasound is an effective means of imaging using sound waves (like a sonar on a submarine) that are generated by an ultrasound probe placed in the rectum. Reflected echoes create a high-resolution image of the prostate to check for abnormalities, measure the volume of the prostate, and guide the prostate biopsies. The ultrasound image alone is not sufficient to diagnose prostate cancer without a tissue biopsy.
Preparation for the prostate ultrasound and biopsy involves discontinuing anti-coagulant medications and blood thinners for a week or so prior to the procedure. It is imperative that a Fleets enema be performed the night before the biopsy in order to cleanse the rectum. It is also vital that antibiotics be taken prior to and after the biopsy since the biopsies are performed via the rectum.
The procedure is done under intravenous sedation and monitoring by an anesthesiologist. After being positioned in the knee-chest position while lying on your side, the ultrasound probe is placed gently into the rectum. After obtaining careful imaging in two planes and volume measurements, prostate biopsies are taken. The biopsy cores are obtained with a spring-driven needle device that is passed through the needle guide attached to the ultrasound probe. Generally, a dozen biopsies are obtained—six from each side with two biopsies each from the apex, mid-gland and base, providing a pathological “map” of the prostate. If any abnormality is visualized on ultrasound—classically a hypo-echoic region (an area with less echoes than adjacent prostate tissue)— this specific area will be biopsied as well. Each biopsy is placed in a separate specimen container noting the site of the biopsy and is carefully examined by a skilled pathologist in order to make a diagnosis.
After the biopsy, it is important to stay well hydrated and to take it easy for a day or so. Blood in the urine, stool, or semen is common after the biopsy and should not be a reason for concern.
What Will My Biopsy Report Tell Me?
There are four possible outcomes of the prostate biopsy:
What is HGPIN?
HGPIN is an acronym for High Grade Prostate Intra-epithelial Neoplasia. The incidence of HGPIN on needle biopsy is between 5% and 8%. Essentially, HGPIN is an abnormality seen under the microscope that is considered to be a pre-malignant precursor lesion to prostate cancer. The risk for cancer following the diagnosis of HGPIN on needle biopsy is 24%. The more cores containing HGPIN on the initial prostate biopsy, the greater the likelihood of cancer on subsequent biopsies.
What is ASAP?
ASAP is an acronym for Atypical Small Acinar Proliferation. About 5% of needle biopsy pathology reports are diagnosed with this, an abnormality seen under the microscope that is suspicious for prostate cancer, but falls below the diagnostic threshold. The risk for cancer following the diagnosis of ASAP on needle biopsy is approximately 40%. All men with an atypical diagnosis should undergo re-biopsy within 3 to 6 months.
What is Prostate Cancer?
In general terms, cancer infers out-of-control growth of abnormal cells. Whereas normal cells grow, divide and die in an orderly fashion, cancer cells continue to grow, divide and form new abnormal cells. Cancer cells develop because of damage to DNA, which provides the blueprint for activities in all cells. Under usual circumstances, the body is able to repair damaged DNA, but with cancer cells, the damaged DNA is not repaired.
Prostate cancer is usually an adenocarcinoma—a type of malignancy that originates from glandular cells. Cancer happens with the occurrence of a mutation—a permanent change in the DNA sequence of a gene—allowing abnormal cells to divide and proliferate abnormally and without control. This unregulated cellular growth has the potential for invasion of adjacent tissues and spread to other areas of the body. Damaged DNA can be inherited, although it is much more common for DNA to be damaged by exposure to an environmental toxin or on the basis of random cellular events.
If your biopsy demonstrates prostate cancer, the pathologist will provide a detailed report indicating the following:
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