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Repeat Biopsies

User
Posted 14 Jul 2022 at 17:17

Hi All. Thanks you so much for the forums and information. It is really helpful and people are so kind. I am currious as to what people think about repeat biopsies in my case. So I am 60, went to GP since weeing isn't as strong as when I was a boy. (I thought prostate would be part of  the NHS health check but it is not- why not?). Had a DRE, PSA 4.7, which then put me on a path for mpMRI. This lead to 3 lesions decected. 1 M5 12mm left base/apex PZ, 1 M4 5mm right mid PZ and 1 M3 14mm right apex/mid TZ, with 37cm3 sized prostate. So given the M5 and M4s I had target TRUSP biopsies. 23 needles, all cores came back benign, only one had some PIN. I am now being told that they probably missed the tumours because of their location and I now need a trans perineal biopsy under general anaesthetic with another 20-30 needles. It has only been four weeks. I am quite worried about the procedure and the possibility that so many insults to the prostate could stimulate cancer cell growth. I am also quite sad that they didn't do the trans perineal version first (which I did ask about at the time- but apparently nice guidelines are inflexible and need to be followed). I am also confused as to how they could miss the target so badly with 3 different needles per target, especially as it was guided by ultrasound  and the MRI images in the first place. Am I being overdiagnosed, is the MRI wrong, apparently it is easy to mis-interprete it etc? I am also scared as to the future if I have radiation or surgery as I hope to live for 20 or more years and to think that a quarter of my life could become rather compromised is upsetting. It seems at my age the risk of secondary cancer from radiation is too high so surgery is most probable. I am so sorry if I sound weak with my case being so much less severe than others. I am not really a very strong person.

User
Posted 14 Jul 2022 at 19:20

The mpMRI could be wrong (we have had a couple of men on here recently with a PIRADS 5 mpMRI who subsequently got the all clear) or it could just be unfortunate that the needles didn't quite hit the spot. I think sometimes people imagine that the cancer is like a solid lump of something but that's not the case - it is an area where tiny clusters of cells look a bit different and it can be missed. It seems to me reasonable that they declined the TP biopsy first time round as it did seem they had a pretty big target to go at. If you get the all clear you will soon forget the inconvenience of having two biopsies.


I don't know where this recent stuff is coming from about RT causing cancer in the future - there must be something on Dr Google. Just to set it in context for you, as a man you have a 7% chance of getting bowel cancer. Pelvic radiotherapy can increase your risk by up to 4% which means that your risk would rise from 7% to 7.3% A man your age has a 60% chance of getting prostate cancer and your odds are worse since your mpMRI is concerning .... a treatment that stops you dying of cancer is probably worth the 0.3% chance of developing another cancer!

Edited by member 14 Jul 2022 at 19:21  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 14 Jul 2022 at 19:23
It's pretty common to have both types of biopsy - I did myself. Biopsies don't make the cancer spread - don't worry about that!

Worrying is completely normal, but treatment is highly effective. You get it sorted out and you get on with your life.

Best wishes,

Chris
User
Posted 14 Jul 2022 at 19:33

Hi Lynn, when OH saw the onco he was told that there was a small possibility of RT causing bladder or lower bowel cancer in 10 or 20 years but that they would keep an eye on it

User
Posted 14 Jul 2022 at 20:52

Nice guidelines are changing, and the transperiniel biopsy is now the preferred choice. They probably had some old TRUS biopsy equipment they wanted to use up before it's sell by date.


Anyway as Lyn says we nave had some pirads 5 MRIs which turned out all clear, so you may not have a problem. I think with the elevated PSA the fact the MRI is suspicious and the fact you are 60 you have more chance of having cancer than not, but it may be very low grade and not need treating. Has anyone shoved a finger up your bum (DRE) and said it feels wrong, that would tip the scales in favour of a biopsy. The only problem with having another biopsy is that it is another day or two of work. If you really wanted to avoid another biopsy you could consider three or six month PSA tests. If that isn't going up fast then you could possibly postpone the biopsy until the PSA does start going up, obviously only in consultation with the medics.

Dave

User
Posted 14 Jul 2022 at 21:13

Originally Posted by: Online Community Member


Hi Lynn, when OH saw the onco he was told that there was a small possibility of RT causing bladder or lower bowel cancer in 10 or 20 years but that they would keep an eye on it



Yes - as I said above, it is thought to increase the risk by about 4% 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 15 Jul 2022 at 00:55
TDavid, Interpretation of scans can be difficult and suspicious areas may be found that might or might not be cancerous and then cancer cells are not always seen anyway. when there may in fact be some there. So sometimes a second biopsy is required and very occasionally a third if it is believed there is some cancer that has not been found.

You pose a rhetorical question about why a check for PCa is not part of an NH check and then partially answer it when you raise the question of possibly being over diagnosed. If all men of let's say aged 50 had their PSA tested, this would mean many more men with insignificant tumours would demand treatment adding to those that already have what is considered to be overtreatment. The UK is by no means the only country that considered but rejected general PSA testing at 50 (usually the prelude to treatment) because of unnecessary harms to many men whose PCa would not have needed treating. Then from a practical aspect it would not be possible for Urologists, Oncologists, Radiologists etc to cope with the extra throughput, they struggle to cope as it is now, often exceeding NICE guide line times. This does of course mean that some men who would benefit from earlier diagnosis are not seen early enough.

I don't know where you saw that NICE guide required the first biopsy to be a TRUS; my London Hospital went over to Transperineal years ago and a top doctor at the Royal Marsden also said how poor the TRUS biopsy was plus there is a greater risk of infection with it.
Barry
User
Posted 15 Jul 2022 at 07:41

Originally Posted by: Online Community Member
I don't know where you saw that NICE guide required the first biopsy to be a TRUS; my London Hospital went over to Transperineal years ago and a top doctor at the Royal Marsden also said how poor the TRUSbiopsy was plus there is a greater risk of infection with it.


I think some of this confusion is because there are different types of transperineal biopsies.


Originally there was the template biopsy where a template grid is used to aim biopsy needles in a parallel path into the prostate. These are done under general or regional anesthetic (such as spinal block) and typically take 30-50 samples. (Before mpMRI scans, a variant on this called a mapping biopsy would usually take 100 or more samples.)


Then there came the need to stop doing TRUS biopsies due to increasing infection risk, and the LATP (Local Anesthetic Transperineal) biopsy was developed and started rolling out before COVID, but COVID forced most hospitals to switch as they couldn't cope with the 3-4% infection risk of TRUS. LATP doesn't use a template but usually just does 2-4 needle punctures in the perineum, which are re-angled to aim at the different parts of the prostate. Another advantage is LATP biopsies can reach the whole prostate, whereas TRUS can't reach the anterior, and sometimes misses the apex. LATP have also replaced a good number of template biopsies because of this. LATP style biopsies are sometimes done under general anesthetic instead, which allows more samples to be taken (but without a template), and reduced stress for some patients.

User
Posted 15 Jul 2022 at 10:35

Many thanks for the answers and information.  So mnay things to consider. Just a few thoughts.


1) My concern about multiple biopsies in quick succession is about wound healing and inflammation. Wound healing is a process that stimulates cell division and tissue remodelling through cytokine and growth factor signalling. At least in the lab, it seems that these are some of the factors that can promote cancer cell growth. My question really was about whether this is anything to be concerned about not (e.g. a PIN cell could get promoted to an adenocarcinoma cell with the relevant signals). I understand from the answers that in practical terms this is nothing to worry about.


2) My comment about radiation therapy in younger people leading to increased cancer risk later was not from google but from a specialist nurse. I do know that radiation is difficult to contain and the possibiity of harm from aberrant DNA damage repair is a possibility. I guess what I was asking was what were people's experience in real terms. It feels very much that different clinicians have their different treatment preferences, often based on extensive experience rather than latest scientific appraoches. Mnay thanks for giving some %s of risk that is very helpful to put things into perspective.


3) It was the nurse that told me that the NICE guidelines said to do TRUS first (I didn't read them before). I guess that I was dissappointed to have to do it twice now when I originally raised the issue of what was the best way considering the location and size of the lesions.


4) Yes I had a DRE, in which GP felt asymmtery which the trigger the subsequent MRI and biopsies.


5) I do understand that while prostate cancer is regarded as a solid tumour (unlike leukemia), it isn't solid as in a hard lump, it is more that the cells are more tightly packed (hence restricted diffusion under MRI). I am just surprised that given the size of the lesion and having a relatively small prostate that all 9 needles targeted to the lesions (2 of which are in the peripheral zone) completely missed as this was done guided by the MRI and ultrasound. Not sure why they want to do the TP under general when I beleive where I am  the clicnic  helped to establish a way of doing it under local. Probably, it is to do with who is free to do it.


6) I guess I was asking about at 60 you have an NHS heath check, so I would have expected a DRE and PSA at a minimum. While the risk obviously is lower between the ages of 60-65 of aggressive cancer it is still a possibility. It would also give a base line for future tests. At 60 (50 in scotland) you get a test for bowel cancer. Sure, I understand that there are resource limitations, possibility of diagnosis leading to uneccessary  treatments etc. Looking at it a different way (I speculate here), I could have not gone to the GP and carried on as I am with sub-optimal weeing (I am sure that many men do this). If I then went in 5 years time, I could well have been in a different situation with poorer outcome. Indeed I know someone who did exactly this, went to the GP for hip pain, which turned out to metastasis. If he had gone 5 years earlier, or had a regular check, then maybe this would not have been the case if he head early treatment. I suppose that there is a balance between mass testing and individual need which aren't the same things?

User
Posted 15 Jul 2022 at 14:54
I think the difference between prostate and other types of cancer is that prostate cancer is an inevitable part of male ageing. Every man has prostate cancer if he reaches his 80s, but the overwhelming majority will not require treatment and will die with it, not from it. Population testing would result in massive over-treatment. Not only does the NHS simply not have the resources for that, but it would cause huge anxiety for millions of men who really don't need to know that they have prostate cancer.

Best wishes,

Chris
User
Posted 15 Jul 2022 at 22:21

"Not sure why they want to do the TP under general when I beleive where I am the clicnic helped to establish a way of doing it under local. Probably, it is to do with who is free to do it."


More likely to be due to them needing to take samples from the area wgich is most difficult to get to.


"While the risk obviously is lower between the ages of 60-65 of aggressive cancer it is still a possibility." 


Aggressiveness tends not to be age related. If anything, the younger a man is at diagnosis, the more aggressive his cancer can be. We have had men on here with incurable PCa in their 30s and 40s - I know a young man who died of PCa at the age of 27.


"am just surprised that given the size of the lesion and having a relatively small prostate that all 9 needles targeted to the lesions (2 of which are in the peripheral zone) completely missed as this was done guided by the MRI and ultrasound"


As stated above, mri can be wrong. The fact that your TRUS was image guided means that you could still get the all clear from the TP. Fingers crossed for good results for you.

Edited by member 15 Jul 2022 at 22:31  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 02 Aug 2022 at 16:37

I have had a transpereneal biopsy by local AND a second and third using general light anaesthetic. 

Assuming no contra indicating issues and extra risk to a GA - I can tell you the local was much a more challenging pain experience as a patient than the GA! But perhaps that was the surgeon?! 

User
Posted 04 Aug 2022 at 12:06

Thanks for the info.... Mine's got delay as I had covid- need to wait 7 weeks before GA... Could have gone with spinal but that is a bit more risky, needs catheter etc...


 

User
Posted 05 Aug 2022 at 09:20

I had a template biopsy with GA. 2 month gap till the RALP operation with nerve sparing on one side only. I was in some discomfort during this time - aches, pains, awkward sitting positions etc etc. I tried to get through to the Urology Dept on many occasions but failed to speak to anyone. I told the surgeon just before my OP.


The surgeon told me after the OP that one side of the prostate bed was "mushy/sticky" and that I was lucky that it was on the side that the nerves were to be removed. Otherwise it would have been 100% nerve removal.

User
Posted 22 Sep 2022 at 15:02

So just an update with good news!


The second biopsy was done under GA, unfortuately I got urinary retention needed to have a catheter for a week. This was actually very unpleasent and walking and sleeping was painful, so I could not go to work. So got the path results now all cores were benign (every section in the core is looked at). So over the 2 biopsies of 50-60 cores only 1 had some evidence of high grade PIN.  So the MRI was just discordant from the pathology- there can be many reasons for this and I suspect that the structre of my prostate is a bit odd. So I basically have an enlarged prostate with BHP and now PSA will be monitored every 6 months. I also now take a alpha-blocker to releive some of the symptoms- I definitely wee much stronger now.


Thank you all for the support, discussion and information. They have been very helpful over the difficult summer.

Edited by member 22 Sep 2022 at 16:38  | Reason: slight mistake

User
Posted 22 Sep 2022 at 16:33
That’s excellent news. Glad you’ve had a good outcome!

All the best,

Chris
User
Posted 22 Sep 2022 at 16:39

Thank you


 


PS made slight mistake in post, I meant to say that I could not go to work- autocorrect got it wrong...

User
Posted 23 Sep 2022 at 05:43

Hi


I had my 1st biopsy with 12 core that were all negative. But because MRI showed T3a  stage, I had 2nd biopsy which showed G7 (3+4).


From my 1st biopsy experience that I felt lots of discomfort  and pain, in my 2nd biopsy I tried to keep away my mind from surgery. I kept talking to one of the nurse next to my bed about gardening while samples were taken. It helped a lot not to feel most of pain and discomfort.

User
Posted 23 Sep 2022 at 10:09

At my biopsy I lay on my side whilst a nurse made small talk. The problem is I find trying to make small talk more painful than having a needle shoved up my ass.

Dave

User
Posted 23 Sep 2022 at 11:13
For those of you with some scientific interest, Nature Cancer has just published a set ou outlook commentaries on prostate cancer. See https://www.nature.com/nature/articles?type=outlook

There is one on how to improve diganosis https://www.nature.com/articles/d41586-022-02858-7

and one on better biposies https://www.nature.com/articles/d41586-022-02866-7

it seems that TRUS is now disfavoured compared to perineal
 
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