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Prostate cancer detection made easier—and safer

This image was generated by fusion-guided biopsy, which can be used to examine with precision the suspicious regions (shown here... This image was generated by fusion-guided biopsy, which can be used to examine with precision the suspicious regions (shown here in white) within the prostate (in red). The rods within the prostate represent cylindrical-shaped biopsy samples. Image courtesy of Gerald Andriole Jr., MD

Let’s say you’re a person with a prostate, and you’ve just had that gland checked with a prostate-specific antigen (PSA) test. Results show an elevated PSA level, which may or may not mean you have cancer. What do you do next?

If you are being cared for by a Washington University urologic surgeon at Barnes-Jewish Hospital, Barnes-Jewish West County Hospital or Siteman-South County, you can take advantage of advanced technology that offers significant improvement in detecting prostate cancer, if it is present. In fact, physicians at these institutions are among the first in the United States—and the only specialists in the central Midwest—to use magnetic resonance imaging (MRI)/ultrasound fusion, a two-step biopsy process offering greater precision.

“In the past, the next recommended step for men with an elevated PSA often was to undergo an ultrasound-guided biopsy of the prostate,” says Gerald Andriole Jr., MD, a Washington University urologist at Barnes-Jewish Hospital and chief of the Division of Urologic Surgery. “While ultrasound alone allows us to see the size and shape of the prostate gland, it does not show the vast majority of prostate cancers. And a biopsy guided only by ultrasound may miss a small tumor or just graze the edge of a large one.”

Before the new technology was available—and if a tumor wasn’t found with an initial biopsy—a man often underwent multiple biopsies to determine whether cancer was causing the elevated PSA. And, generally speaking, multiple biopsies aren’t a good thing. They can be uncomfortable, and they come with the risks of excessive bleeding and sepsis, a potentially life-threatening infection.

A better scan

The first step of the MRI/ultrasound fusion process is the MRI scan. And the kind of MRI makes a difference. “We perform an MRI scan with a 3 Tesla magnet—the strongest available—which can detect cancers 3 to 4 millimeters in diameter or larger,” says Andriole. He notes that an MRI scanner with a 1 or 1.5 Tesla magnet isn’t adequate to detect such small abnormalities. “After this test, men who have an elevated PSA but no indication of cancer have the option to choose watchful waiting rather than biopsy.” In this context, “watchful waiting” means periodic PSA tests and MRIs without intrusive biopsy or further treatment.

Andriole adds, “Years of study have shown that a majority of prostate cancers are slow-growing tumors unlikely to result in death. The sensitivity of the 3 Tesla MRI scan allows us to give men a much clearer indication of the significance of their cancer.” Though in use for several years for prostate-cancer exams, the 3 Tesla MRI is a particularly powerful tool when used as part of the MRI/ultrasound fusion process. Andriole believes that a 3 Tesla MRI exam can benefit men newly identified as having an elevated PSA, as well as those with a history of persistently elevated or rising PSA for whom repeated ultrasound-guided prostate biopsies have been negative.

“A considerable number of these men may have cancer that was missed by the biopsy,” he says. “We now have the technology to identify most of those cases and help men decide the best course of treatment.” 

A better biopsy

The “ultrasound fusion” part of the new technology comes into play for a man whose initial MRI exam reveals prostate abnormalities—a situation that may require a biopsy. Before the biopsy is performed, the information gathered during the MRI scan is uploaded to an ultrasound machine. Global positioning system (GPS) sensors attached to the ultrasound probe create a map of the prostate by fusing the MRI information with the ultrasound image. This map identifies exactly where the biopsy needle should be placed. As a result, the biopsy is much more accurately targeted compared with a biopsy performed with only ultrasound guidance.

Andriole puts it this way: “The increased specificity of the test allows us to take fewer biopsy samples and get better information. And the fewer samples taken, the less risk for complications.”

The benefit

“New technology and future improvements to it have the potential to lead us away from treatments that require removing or irradiating the whole prostate,” Andriole says. “Depending on the size and location of the cancer, we already can target specific areas of the prostate using lasers and cryoablation—applying extreme cold—to destroy tissue. And that means we may reduce debilitating side effects of treatment, such as incontinence and impotence.”