Medical History And Physical Exam
If your doctor suspects you might have prostate cancer, you will be asked about symptoms you are having, such as any urinary or sexual problems, and how long you have had them. You might also be asked about possible risk factors, including your family history.
Your doctor will also examine you. This might include a digital rectal exam , during which the doctor inserts a gloved, lubricated finger into your rectum to feel for any bumps or hard areas on the prostate that might be cancer. If you do have cancer, the DRE can sometimes help tell if its only on one side of the prostate, if its on both sides, or if its likely to have spread beyond the prostate to nearby tissues. Your doctor may also examine other areas of your body.
After the exam, your doctor might then order some tests.
Further Testing For Advanced Cancer
If there’s a significant chance the cancer has spread from your prostate to other parts of the body, further tests may be recommended.
These include:
- an MRI scan, CT scan or PET scan these scans build a detailed picture of the inside of your body
- an isotope bone scan, which can tell if the cancer has spread to your bones a small amount of radiation dye is injected into the vein and then collects in parts of the bone where there are any abnormalities
What Happens After A Prostate Ultrasound And Biopsy
When the procedure is finished, you may resume your normal meals and daily activities, unless otherwise instructed. Some urologists may prescribe an antibiotic after the biopsy to prevent any infections, but given antibiotics only prior to the biopsy. Some men may have soreness for a few days after the procedure, which is normal. Your provider will contact you when your results are available
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How Is A Prostate Ultrasound Done
When you get to the facility for the test, an ultrasound technician may ask you to take off your clothes and change into a gown. Then, the technician will ask you to lie down on your back or side on an examination table and bend your knees.
To perform a transrectal ultrasound , the technician covers a small imaging tool called a transducer with ultrasound gel to help the tool broadcast good images. Then, the technician slowly inserts the transducer into your rectum and moves it around gently to get images of your prostate from various angles. For a biopsy, the technician will slowly insert a needle alongside the transducer into your prostate to remove the tissue.
Your rectum might feel like its swelling while the transducers inside, and the gel can feel damp and cold. Let the technician know if youre uncomfortable during the procedure. Your technician may use local anesthesia or a sedative to help you feel you more comfortable.
Use In Men Who Might Have Prostate Cancer
The PSA blood test is used mainly to screen for prostate cancer in men without symptoms. Its also one of the first tests done in men who have symptoms that might be caused by prostate cancer.
PSA in the blood is measured in units called nanograms per milliliter . The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that can tell for sure if a man does or doesnt have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing, while others might recommend it starting at a lower level, such as 2.5 or 3.
- Most men without prostate cancer have PSA levels under 4 ng/mL of blood. Still, a level below 4 is not a guarantee that a man doesnt have cancer.
- Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer.
- If the PSA is more than 10, the chance of having prostate cancer is over 50%.
If your PSA level is high, you might need further tests to look for prostate cancer.
To learn more about how the PSA test is used to look for cancer, including factors that can affect PSA levels, special types of PSA tests, and what the next steps might be if you have an abnormal PSA level, see Screening Tests for Prostate Cancer.
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How Do I Get Ready For A Prostate/rectal Ultrasound
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Your healthcare provider will explain the procedure and you can ask questions. Make a list of questions and any concerns with your healthcare provider before the procedure. Consider bringing a family member or trusted friend to the medical appointment to help you remember your questions and concerns.
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You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
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You may be asked to stop taking blood-thinning medicines, such as aspirin, for a week or so before the test if it is being done as part of a biopsy.
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You usually do not need to stop eating or drinking before the test. You also usually will not need medicine to help you relax .
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You may be given a small enema before the test.
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Follow any other instructions your provider gives you to get ready.
Mpmri Combined With Trus In Fusion
mpMRI has also shown significant promise when combined with TRUS through fusion biopsy. Fusion biopsy combines mpMRI imaging with ultrasound during the biopsy procedure, enabling live visualization of suspicious lesions. The additional imaging provided by mpMRI enables targeted biopsies, which refer to intentionally sampling a suspicious lesion suspected to contain csPCa, to be conducted.
Substantial research indicates that fusion biopsies have higher rates of csPCa detection compared to standard TRUS biopsy. Siddiqui et al report that fusion-targeted biopsy increases detection of higher grade tumors by as much as 67% while reducing detection of lower grade tumors by 36% compared to traditional systematic sampling.70 Son et al report that fusion-targeted biopsy detects 3 times more cancer than systematic biopsy without fusion guidance.71 Borkowetz et al compared systematic TRUS biopsy with transperineal fusion biopsy and found fusion biopsy has a significantly higher overall cancer detection rate and detected 44% more csPCa than systematic biopsy alone.72
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How Does The Procedure Work
Ultrasound imaging uses the same principles as the sonar that bats, ships, and fishermen use. When a sound wave strikes an object, it bounces back or echoes. By measuring these echo waves, it is possible to determine how far away the object is as well as its size, shape, and consistency. This includes whether the object is solid or filled with fluid.
Doctors use ultrasound to detect changes in the appearance of organs, tissues, and vessels and to detect abnormal masses, such as tumors.
In an ultrasound exam, a transducer both sends the sound waves and records the echoing waves. When the transducer is pressed against the skin, it sends small pulses of inaudible, high-frequency sound waves into the body. As the sound waves bounce off internal organs, fluids and tissues, the sensitive receiver in the transducer records tiny changes in the sound’s pitch and direction. A computer instantly measures these signature waves and displays them as real-time pictures on a monitor. The technologist typically captures one or more frames of the moving pictures as still images. They may also save short video loops of the images.
The same principles apply to ultrasound procedures such as transrectal ultrasound which require insertion of a special imaging probe or transducer into the body.
How Prostate Cancer Is Diagnosed
There are many tests used for diagnosing prostate cancer. Not all tests described here are commonly used for every person. Your doctor may consider these factors when choosing a diagnostic test:
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The type of cancer suspected
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Your signs and symptoms
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Your age and general health
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The results of earlier medical tests
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How Should You Prepare For A Prostate Ultrasound And Biopsy
Preparation for a prostate ultrasound and biopsy is simple. You shouldnt take any blood-thinning medications such as warfarin , clopidogrel , aspirin or ibuprofen before a prostate biopsy because blood thinner increase the risk of bleeding. If you are already taking blood thinners, your doctor will discuss with you how many days prior to the biopsy they should be held.
Most healthcare providers dont ask you to follow any type of special diet before a biopsy. However, they suggest eating lightly before the procedure and drinking only clear liquids. Check with your providers office to see if you need to do anything additional to prepare for the test.
Determining Whether Prostate Cancer Is Aggressive
If a biopsy sample is found to contain cancer, the pathologist analyzing the specimen takes a deeper look at the cancer cells to determine how aggressive the disease is likely to be.
If the cancer cells appear significantly abnormal and dissimilar from healthy cells under a microscope, the cancer is considered more aggressive and expected to advance quickly. Conversely, cancer cells that look relatively similar to healthy cells indicate that its less aggressive and may not spread as fast.
Prostate cancers are assigned a Gleason score depending on how abnormal the cells look.
Gleason score: Gleason scores range from 2 to 10, going from least to most aggressive prostate cancers.
There are different types of cancer cells in a prostate tumor, so the final Gleason score is determined by adding the scores of the two main areas of the tumor.
First, the primary part of the tumor is assigned a number between 1 and 5. Lower numbers indicate that the cells appear relatively similar to healthy cells, while higher numbers show that the cells are abnormal-looking. Then, another number between 1 and 5 is assigned to describe the second most prevalent area of the tumor.
Finally, the two numbers assigned to the different parts of the prostate tumor are added. So, if most of the tumor is given a 4, and some of the tumor is more aggressive and given a 5, the final Gleason score would be 9.
There are many biomarker tests, including:
- Oncotype DX® Genomic Prostate Score
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How Does Ultrasound Work
An ultrasound machine has 3 key parts: a control panel, a display screen, and a transducer, which usually looks a lot like a microphone or a computer mouse. The transducer sends out sound waves and picks up the echoes. The doctor or ultrasound technologist moves the transducer over the part of the body being studied. The computer inside the main part of the machine analyzes the signals and puts an image on the display screen.
The shape and intensity of the echoes depend on how dense the tissue is. For example, most of the sound waves pass right through a fluid-filled cyst and send back very few or faint echoes, which makes them look black on the display screen. But the waves will bounce off a solid tumor, creating a pattern of echoes that the computer will show as a lighter-colored image.
What Happens During A Prostate/rectal Ultrasound
You may have a prostate/rectal ultrasound done as an outpatient or during ahospital stay. The way the test is done may vary depending on yourcondition and your healthcare provider’s practices.
Generally, a prostate/rectal ultrasound follows this process:
You will need to remove any clothing, jewelry, or other objects that may get in the way of the procedure.
If asked to remove clothing, you will be given a gown to wear.
You will lie on an exam table on your left side with your knees bent up to your chest.
The healthcare provider may do a digital rectal exam before the ultrasound.
The provider puts a clear gel on the transducer and puts the probe into the rectum. You may feel a fullness of the rectum at this time.
The provider will turn the transducer slightly several times to see different parts of the prostate gland and other structures.
If blood flow is being looked at, you may hear a whoosh, whoosh sound when the Doppler probe is used.
Once the test is done, the provider will wipe off the gel.
A prostate/rectal ultrasound may be uncomfortable and you will need toremain still during the test. The gel will also feel cool and wet. Thetechnologist will use all possible comfort measures and do the scan asquickly as possible to minimize any discomfort.
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What Is A Prostate Ultrasound Used For
A prostate ultrasound is used to check your prostate gland using ultrasound imagery. The procedure provides your doctor with black-and-white images of your prostate and the surrounding tissues. Your doctor usually wont do this as part of a physical examination, but they may recommend it if:
A prostate ultrasound can also be used to help your doctor take a tissue sample, or biopsy, from your prostate.
Trus For Focal Therapy Of Prostate Cancer
Focal therapy of prostate cancer is still an investigational modality being studied with various available techniques. Although controversial and not currently considered a standard of care, the hypothetical advantages of focal therapy compared to the definitive treatment of prostate cancer, considered standard of care, are quite numerous. The standard definitive treatment of csPCa to date includes radical prostatectomy or radiotherapy with or without the addition of androgen deprivation therapy.107 Although these treatments have been shown to be oncologically effective for localized prostate cancer, they do entail significant potential adverse effects, including bleeding, intestinal and rectal injury, infection, incontinence, erectile dysfunction and others.113,114
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Table 4 Summary of Studies Assessing Clinical Outcomes Following HIFU Focal Therapy for Prostate Cancer |
While the limited supply of long-term follow-ups for HIFU therapy make a direct comparison to traditional treatments difficult, these findings show promise and should be further investigated for the appropriately selected patients. The precise nature of HIFU focal therapy and avoidance of damage to surrounding tissue could also make it effective in repeated treatments,120 potentially avoiding or delaying the need for more invasive procedures. Additionally, literature has shown that HIFU can be utilized as an effective form of salvage therapy for local relapses following other forms of treatment.121
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What Does The Equipment Look Like
Ultrasound machines consist of a computer console, video monitor and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers during a single exam. The transducer sends out inaudible, high-frequency sound waves into the body and listens for the returning echoes. The same principles apply to sonar used by boats and submarines.
The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination. The ultrasound image is immediately visible on a video monitor. The computer creates the image based on the loudness , pitch , and time it takes for the ultrasound signal to return to the transducer. It also considers what type of body structure and/or tissue the sound is traveling through.
For ultrasound procedures such as transrectal exams that require insertion of an imaging probe, also called a transducer, the device is covered and lubricated with a gel.
What Happens After A Prostate Ultrasound
Once the test is done, you can take off the gown and put your clothes back on. Your rectum may feel tender for a few days, but you wont need to follow any specific aftercare instructions. Your doctor may prescribe an antibiotic to prevent infection.
In some cases, your doctor or technician may ask you to wait in the facility until your results are available. Youll usually need to wait a few days for a radiologist to look at the images and diagnose any conditions, however. Depending on where the test was done, you may wait up to two weeks for results.
Your doctor will schedule a follow-up appointment to discuss your test results. If you have any abnormalities or conditions that are visible on the images, your doctor will point out these areas. Excess tissue, prostate enlargement, or cancerous tumors will appear on the ultrasound images as bright white areas that represent the dense tissue.
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Genetic Testing For Some Men With Prostate Cancer
Some doctors now recommend that some men with prostate cancer be tested to look for certain inherited gene changes. This includes men in whom a family cancer syndrome is suspected, as well as men with prostate cancer that has certain high-risk features or that has spread to other parts of the body. Talk to your doctor about the possible pros, cons, and limitations of such testing.
Trus For Assessing Prostate Size And Anatomy
TRUS is also useful for assessing prostate size and anatomy. Research has shown that TRUS measurements of prostate volume are highly accurate, showing no significant difference from the actual volume of the removed specimen.48 The accuracy of TRUS in estimating prostatic volume has been shown to be comparable to that of MRI,48 and superior to that of digital rectal exams, which often underestimate prostate size, especially if the volume is greater than 30 milliliters.49 The ability to accurately assess prostate volume make TRUS a useful tool in the diagnosis and treatment planning of benign prostatic hyperplasia. The degree of prostate enlargement can affect the severity of symptoms, response to nonsurgical therapy, need for surgical intervention and decision on the type of surgical intervention to be used.50 TRUS also enables physicians to elucidate prostate and bladder neck anatomy, including the extent and size of a prostate median lobe. While research suggests that MRI cross-sectional imaging may offer slightly greater accuracy in measuring prostate size than TRUS,51 the decreased cost and increased availability of TRUS solidify it as the preferred method of prostate size and shape mapping for many urologists.52 Current AUA guidelines recommend clinicians consider preoperative prostate size and shape assessment via either TRUS or MRI, among other imaging modalities.53
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