Medical Forum / Diseases and Disorders / Prostate Cancer / March 2006
biopsy and metastasis
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rosbif - 20 Mar 2006 08:57 GMT ....(still boning up my meagre knowledge!)..
This must have been aired before - is the risk of metastasis through needle biopsy fully discounted amongst the cognoscenti?
Alan Meyer - 20 Mar 2006 13:31 GMT > ....(still boning up my meagre knowledge!).. > > This must have been aired before - is the risk of metastasis through > needle biopsy fully discounted amongst the cognoscenti? Here's an old report in Pubmed from 1987. I have no idea how accurate it is, or whether current techniques are better or worse than they were then.
The authors are claiming pretty precise knowledge of how often this occurs, 1/3 of 1% of the time.
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Seeding and perineal implantation of prostatic cancer in the track of the biopsy needle: three case reports and a review of the literature.
Haddad FS, Somsin AA.
Several months (an average of 12.86 months) after perineal needling of the cancerous prostate for the purpose of obtaining tissue for biopsy, a tumor nodule becomes clinically evident in the subcutaneous tissue of the perineum, at the site of the needling in 0.34% of the cases. This nodule presents the same histological picture as the biopsy of the prostatic tumor. This is a review of 15 such cases (12 collected from the literature and an additional three unpublished cases, two of which are personal observations). At the time of needling, no metastases could be clinically detected in any of the patients; the serum acid phosphatase was normal in 73% of them. The average age of the patients was 65.66 years. The perineal nodule was tender in 40% of the cases; its average size was 2.5 cm. Excision of the nodule was the most frequently employed form of management. At the time of reporting, 60% of the patients were living and well, for an average of 18.56 months after excision. In order to prevent perineal implantation, especially in patients who are at risk, it is suggested that a fine needle be employed to obtain prostatic tissue for biopsy, and that every possible therapeutic effort be made.
ron - 20 Mar 2006 16:46 GMT Here's a similarly low number from the Hopkins' team...Ron
J Urol. 1991 May;145(5):1003-7
Needle biopsy associated tumor tracking of adenocarcinoma of the prostate.
Bastacky SS, Walsh PC, Epstein JI.
Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
We reviewed 350 previously biopsied completely submitted clinical stage B radical prostatectomy specimens resected between January 1, 1987 and December 31, 1988 in an attempt to identify the incidence of needle biopsy associated tumor tracking into periprostatic soft tissue. We identified 7 cases (2.0%) of needle biopsy associated tumor tracking, 3 in which the only tumor penetration in the gland was limited to the needle track. The maximal soft tissue extension from the biopsy site ranged from 0.1 to 1.2 cm. and approached the nearest soft tissue margin to within 0.5 mm. in 4 cases. In contrast to prior reports showing clinically evident tracking only with transperineal biopsies from high grade tumors, 6 of our 7 cases were of intermediate grade (in the glandular and tracking components) and 6 had transrectal biopsies. Needle biopsy associated tumor tracking occurred with core (14 gauge) and biopsy gun needles (18 gauge). An additional 13 cases (3.7%) showed some features of needle biopsy associated tumor tracking but they were equivocal. These findings have significant implications in light of recent proposals advocating serial mapping of prostate cancer using the biopsy gun with potential conservative observation of smaller tumors.
Leonard Evens - 20 Mar 2006 15:48 GMT > ....(still boning up my meagre knowledge!).. > > This must have been aired before - is the risk of metastasis through > needle biopsy fully discounted amongst the cognoscenti? According to Walsh in Guide to Surviving Prostate Cancer, prostate cancer cells escape the prostate all the time. The issue is whether or not such cells have the capability to survive distant from their point of origin. That is called metastatic capability, and it is what we all fear since in that case early treatment won't cure the disease. Some recent research confirms that cancer cells are found in the blood of men with prostate cancer, and at least for early cancers the incidence drops significantly after treatment. Also note Alan's answer. It seems to me that having the biopsy probably doesn't significantly change the risk of recurrence after treatment, and that the risk of metastasis is much much greater if the cancer is undiagnosed and untreated than from any cells which may escape during biopsy. Of course, whether that risk is high enough to merit treatment depends on a variety of factors such as the life expectancy of the patient and the degree of aggressiveness of the cancer. There are those who argue that for many men treatment or even screening is not generally helpful, but I think the issue of whether or not the biopsy is a significant factor in metastasis, is a red herring.
rosbif - 21 Mar 2006 13:42 GMT thanks Alan, Leonard, ron for illuminating that.
My fear about this was aroused initially in reading Scardino's book where he counsels patients not to even bother with a biopsy unless they intend to undertake treatment soon after. As a gleason6 (2 years ago, now GL7) I opted for WW. Just wondered what those loosened cancer cells might have been up to in the meantime.
Leonard Evens - 21 Mar 2006 17:00 GMT > thanks Alan, Leonard, ron for illuminating that. > [quoted text clipped - 3 lines] > ago, now GL7) I opted for WW. Just wondered what those loosened > cancer cells might have been up to in the meantime. I read Scardino's bnook a while back, so I'm not sure I remember the details of his argument. But I believe he was concerned with the other possible side effects of biopsy. First, it costs something. Second, there is a small but definite risk of infection. Third, some men find it very uncomfortable. I don't think he was concerned about the risk of spreading the tumor. If I'm wrong about that, let us know.
rosbif - 21 Mar 2006 20:58 GMT >> thanks Alan, Leonard, ron for illuminating that. >> [quoted text clipped - 10 lines] >it very uncomfortable. I don't think he was concerned about the risk of >spreading the tumor. If I'm wrong about that, let us know. No you're right - he's careful to quell such fears. In fact he says:- "Though some people worry that a biopsy might spread cancer, there is no evidence that this is true with modern biopsy techniques".
...which bodes well of course. But as a conscientious worrier I read into this:- <there is no evidence> = <well, give us another 10 years and we'll find some>
That aside, the quote I was referring to above was:-
"A biopsy is only appropriate if you would take action as a result of a cancer diagnosis."
I think I'd have treated that with some alarm had I read it after my first biopsy and after which I chose WW.
Leonard Evens - 22 Mar 2006 17:40 GMT > That aside, the quote I was referring to above was:- > [quoted text clipped - 3 lines] > I think I'd have treated that with some alarm had I read it after my > first biopsy and after which I chose WW. You raised the appropriate point that you might be interested in the Gleason score if you did indeed have cancer since you might decide to choose WW for a Gleason 6 but immediate aggressive treatment for a Gleason 7. Indeed, Scardino discusses this possibility elsewhere in his book, so he recognizes the distinction. His statement, quoted above, could be read to be inconsistent with that, but I think if you look at it carefully it isn't. The only circumstances in which it would apply is where your actions would be the same whatever the result of the biopsy. Then, of course, there would be no point in having the biopsy. There are men for whom this might be appropriate. For example, a man with a life expectancy of less than five years and no clinical symptoms of prostate cancer might easily conclude that he wouldn't do any better if he discovered he had prostate cancer later rather than earlier. Also, there are men who have become convinced for one reason or another that early treatment for prostate cancer is fruitless. Such men might easily believe that waiting until the development of more obvious clinical symptoms would make no difference in their life expectancy or quality of life. For such men a biopsy or even PSA screening doesn't make sense.
I.P. Freely - 21 Mar 2006 20:38 GMT > thanks Alan, Leonard, ron for illuminating that. > [quoted text clipped - 3 lines] > ago, now GL7) I opted for WW. Just wondered what those loosened > cancer cells might have been up to in the meantime. The key word is "bother". Even if biopsies were PROVEN and ALWAYS imperceptible, risk-free, free of cost, and 100% definitive, they still consume an hour or two of time we'll never get back and offer no reward if we don't use (i.e., act on) the information, so why BOTHER? We may as well spend the same time contemplating our navel and scuffing a toe in the dirt; at least they don't require consuming gasoline and dropping trou in front of a bunch of strangers.
Similarly, it doesn't matter what those loosened cancer cells have been up to if one isn't going to do anything about it. Spend the same time in an activity that's useful or productive or fun and you'll be ahead of the game. One good use of that same amount of time would be researching the literature and this forum to decide at what point you WILL act against your cancer (because the best answer may anything from tomorrow to never).
I.P.
rosbif - 21 Mar 2006 20:58 GMT >> thanks Alan, Leonard, ron for illuminating that. >> [quoted text clipped - 11 lines] >the dirt; at least they don't require consuming gasoline and dropping >trou in front of a bunch of strangers. This is my fault, the 'key' word as you put it is just poor paraphrasing on my part. He said:-
"A biopsy is only appropriate if you would take action as a result of a cancer diagnosis."
...and yet there are probably quite a few whose biopsy shows gleason6 who are happy to go along with WW.
>Similarly, it doesn't matter what those loosened cancer cells have been >up to if one isn't going to do anything about it. Spend the same time in [quoted text clipped - 3 lines] >against your cancer (because the best answer may anything from tomorrow >to never). My question was borne of a curiosity-rich mix of academic interest and fear.
>I.P. I.P. Freely - 22 Mar 2006 00:35 GMT > I.P. wrote >> A biopsy is only appropriate if you would take action as a result of >> a cancer diagnosis, [so why bother if one has already chosen WW?]
> This is my fault, the 'key' word as you put it is just poor > paraphrasing on my part. [Scardino] said: "A biopsy is only > appropriate if you would take action as a result of > a cancer diagnosis."
> My question was borne of a curiosity-rich mix of academic interest and> fear. My "bother" comment still applies, IMO. Whether it's Scardino's "is appropriate" or your "bother", the point remains that any test is a waste of time if its results benefit no one (benefit can include satisfying an academic interest). Wondering and asking about what what cancer cells are up to strikes me as even more fraught with risks, from losing sleep over it to developing psychoses over it. Only one's PSA, then scans, then symptoms, can even begin to answer that question.
> ...and yet there are probably quite a few whose biopsy shows gleason6 > who are happy to go along with WW. Sure, and justifiably so. But if they made that decision before bx and will not change anything despite bx findings, a bx is still a waste of everyone's time, medical resources, and insurance money, so Scardino's advice still stands no matter how it is phrased.
I'm not trying to criticize you, so don't take it personally. I'm just trying to motivate you to lay aside your worry, accept your tx choice, pursue your choice actively and diligently, keep that academic curiosity productively focused on studying USEFUL PCa issues and averted from alarming but unproductive distractions like wondering what your cancer is doing, and put some thought and curiosity into your threshold and path for changing your tx modality. I suspect that last phrase may relieve some pointless worry, give you a greater sense of control over the beast, and even become useful if and when your situation worsens.
I.P.
juniper - 22 Mar 2006 03:22 GMT > Sure, and justifiably so. But if they made that decision before bx and > will not change anything despite bx findings, a bx is still a waste of > everyone's time, medical resources, and insurance money, so Scardino's > advice still stands no matter how it is phrased. IP, you don't know until the biopsy what your Gleason is going to be. The only time this argument holds is if someone says they are not going to change any behavior no matter what the biopsy says. Most people would use the information some how. If their Gleason turns out to be a six and they want to wait, fine, and if it turns out to be an 8 and they are going to do something else, then still the biopsy was useful if a 6 came back and they did not do local treatment.
I.P. Freely - 22 Mar 2006 07:10 GMT >> Sure, and justifiably so. But if they made that decision before bx and >> will not change anything despite bx findings, a bx is still a waste of [quoted text clipped - 4 lines] > The only time this argument holds is if someone says they are not going > to change any behavior no matter what the biopsy says. That was how I interpreted the direction of this thread.
I.P.
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