Medical Past and Physical Test
If your physician believes you could be a prostate cancer victim, he/she would like to know more about any tangible symptoms. Such as sexual or urinary issues, and for how long you’ve been experiencing them. The doctor may also want to know about any pain in the bone, which may indicate the cancer has enveloped your bones.
Your physician will thoroughly assess your physical state to be completely aware of the situation. This includes a DRE exam, where a lubricated gloved finger is placed inside your rectum to note down any cancer-related hard spots or bumps on your prostate. If the cancer test turns out to be positive, the DRE exam can help determine whether the spot is on one side of the prostate or on both its sides, or if it has spread to the surrounding tissues.
Your doctor may also want to know more about your overall medical condition. As a result, a few more tests could be prescribed.
PSA Blood Test
Prostate-specific antigen tests are primarily used for detecting cancer signs in men before the symptoms surface (Read Preventing Prostate Cancer and Detecting the Disease Early). But, it is also among the preliminary tests that are carried out in males exhibiting prostate cancer symptoms.
A majority of healthy males show PSA levels below four nanograms/ milliliter of blood. As the PSA levels increase, the chances of an impending prostate cancer also go up.
Post full-fledged development of prostate cancer, the PSA levels typically go beyond 4. Even then, anything below 4 is in no way assuring complete absence of cancer – close to 15 percent males with a less than 4 PSA level can exhibit cancer signs during a biopsy.
Males with PSA levels in the 4-10 range have 25 percent probabilities of the disease. If the level goes beyond 10, the chances accelerate and reach the 50 percent mark.
Generally, physicians across the globe do not use PSA levels as standard yardsticks to determine the relevance or necessity of a prostate biopsy. Some recommend the test only if PSA levels are above 4 – and there are a few others could recommend a biopsy even when the PSA number is at 2.5. Other components, such as your ethnicity, age, family background, etc. could also be taken into consideration.
The PSA exam may also turn out useful if prostate cancer diagnosis has been done already.
For men who’ve recently been diagnosed with the particular cancer, the PSA exam could be used in conjunction with tumor grade (a biopsy constituent) and physical exam results to help ascertain if other medical tests, such as bone scans or CT scans are required.
The PSA exam is an aspect of staging and may indicate if the cancerous cells are likely to stretch beyond the prostate gland or not. If the PSA levels are on the higher side, the cancer has apparently spread past the prostate region. This could influence your treatment, since some kinds of therapy (like radiation and surgery) won’t offer any benefits if the bones, lymph nodes, etc. have been affected by the cancer.
PSA exams are also a critical aspect of overseeing prostate cancer post and during treatment (read Following PSA levels after and during treatment).
Transrectal Ultrasound (TRUS)
For this exam, a minor probe equivalent to a finger’s width is lubricated and inserted inside the rectum. The probe emits sound waves, which go inside the prostate and make echoes. The examination notices the echoes, which is then made into a black-and-white prostate image with the help of a computer.
The medical procedure doesn’t take longer than 10 minutes and is usually conducted in an outpatient clinic or doctor’s office. Some pressure can be felt when the probe enters the prostate, but it’s nothing painful. The spot could be numbed prior to the procedure.
TRUS is typically utilized for viewing the prostate during high PSA level scenarios or when a man’s DRE results are abnormal. It’s also employed during prostate biopsies to ensure the needles make it to the correct prostate area.
TRUS is helpful in other scenarios too. It could be used for measuring the prostate gland’s size, which may help ascertain the density of PSA (illustrated in Prostate Cancer Prevention and Early Detection) and also determine the multiple treatment alternatives available. TRUS gets also employed to guide some kinds of treatment, like cryosurgery or brachytherapy, also called internal radiation therapy.
Prostate Biopsy
If specific symptoms or early detection test results – a DRE or/and PSA blood exam – indicate you have the cancer, your physician will then carry out a prostate biopsy to confirm things.
The biopsy procedure entails removal of a body tissue sample for later examination under a microscope. Core needle biopsy is the primary technique used for diagnosing prostate cancer. It’s usually conducted by urologists, physicians who treat cancers relating to the urinary and genital tract, including the prostate gland.
With the transrectal ultrasound for seeing the prostate gland, the physician immediately pushes in a hollow, thin needle via the rectum wall inside the prostate. After the needle is removed, it pulls out a small cylindrical portion of the prostate tissue. This process is carried out for eight to 18 times, with the average sample count being 12.
Though the medical procedure doesn’t sound pleasing, every biopsy usually causes a minor inconvenient sensation as the process is carried out with a spring-loaded special biopsy instrument. The tool pushes in and pulls out the needle in less than a second. Most physicians administering the biopsy first numb the spot with a local anesthetic injection aimed close to the prostate. You can very well ask your physician whether he will be using such an injection or not.
The biopsy is an office procedure, which takes close to 10 minutes. Antibiotics would be prescribed to you prior to the biopsy, and perhaps for a couple of days after the test to bring down infection risks.
For some days post the procedure, you’d experience soreness in the region and may be some blood in your urine. Your rectum could also slightly bleed, particularly if you are a hemorrhoids, patient. Several males also see a rusty hue or blood during ejaculation, which could continue for many weeks post the biopsy, based on your ejaculation frequency.
Your biopsy specimens would be forwarded to a pathologist (a doctor specializing in tissue sample diagnosis), who’ll observe the samples via a microscope to determine a presence of cancer. If cancer cells are confirmed, the doctor would also grade the samples (read the following section). The results usually take a day or three – at times, it could take longer.
Even with examining multiple samples, biopsies could at times not detect cancer if the biopsy needles don’t get through them. This is called a false-negative outcome. If your physician is still sure about the chances of prostate cancer, due to your higher PSA levels, another biopsy would be carried out for confirmation.
Prostate Cancer Grading
Prostate cancers are graded by pathologists as per the Gleason system. The system calls for a Gleason grade, utilizing the 1-5 number range, depending on the extent to which the cancerous tissue cells come across as regular prostate tissue.
If the infected tissue looks normal, grade 1 is allotted.
If the cells and their development patterns come across abnormal, it’s assigned grade 5. Grades 2, 3 and four fall between the extremes. If there’s cancer, the biopsies are typically grade 3 or beyond – grades 1 and two not being used often.
As prostate cancers comprise spots with diverse grades, grades are assigned to both the spots that make up the majority of the cancer. Both the grades are attached for yielding the Gleason sum or Gleason score. The higher the score, the likelier are the chances of the cancer blossoming and spreading quickly.
The Gleason sum could fall in the 2-10 range, but a majority of the biopsies are at a minimum of 6.
This rule has some exceptions, however. If the maximum grade accounts for most parts of the biopsy (95 percent or higher), the area’s grade is counted two times as Gleason sum. Moreover, if there are 3 grades in the core of a biopsy, the maximum grade is typically accounted for in the Gleason sum, despite the majority of the cores being taken up by cancer areas with minimum grades.
A cancer with a Gleason sum of 6 or less is referred to as low or well-differentiated grade.
Gleason sums of 7 can be called intermediate or moderately-differentiated grade.
Gleason sums falling between 8 and 10 are called high or poorly-differentiate grade.
Other Biopsy Report Information
Along with cancer grade (if the cancer is present), the doctor’s report also typically entails other kinds of data that throw much better light on the cancer’s overall state. These could include:
- Biopsy core samples containing cancer (for instance, “6 out of 12”)
- The cores and their cancer percentage
- Whether the prostate cancer is on single side (right or left) or both sides (bilateral) of the prostate
Suspicious Results
At times, when the pathologist observes the prostate cells via the microscope, they may not look cancerous, but that doesn’t confirm their normalcy, either. Such results are often considered suspicious.
Prostatic Intraepithelial Neoplasia (PIN): In case of PIN, there are alterations in the way the cells come across below the microscope; however, the irregular prostate cells do not look like having grown inside other portions of the prostate (similar to cancer cells). PIN is typically classified as a high and low grade.
Most males may start developing the low-grade PIN variety early on in their lives, but do not get affected by prostate cancer. Low-grade PIN’s importance concerning prostate cancer still isn’t clear. If a low-grade PIN finding shows up on a prostate biopsy, the future procedures are typically similar to a scenario when things are normal.
If the biopsy shows high-grade PIN, there is close to 20 percent chances of the presence of cancer elsewhere in the prostate region. This is the reason doctors continually observe males with high-grade PINs and could recommend another prostate biopsy, particularly if the first biopsy didn’t take specimens from all prostate regions.
Atypical Small Acinar Proliferation (ASAP): This is, at times, referred to as atypia. In case of ASAP, the prostate cells appear to be cancerous when looked at through the microscope, but the number is too little to arrive at a concrete conclusion. If there is no ASAP presence, the chances of prostate cancer become much higher – perhaps the reason most doctors advise patients to go through another biopsy after a few months.
Proliferative Inflammatory Atrophy (PIA): With PIA, the cells appear smaller than usual, with the area exhibiting inflammation signs. PIA isn’t cancer, but medical researchers opine PIA could at times result in prostate cancer or high-grade PIN.
For further information on the reporting procedure of biopsy results, take a look at our site’s Prostate Pathology section.
Imaging exams to determine prostate cancer reach
If you have prostate cancer, your physician will use your DRE results, PSA levels, and the biopsy Gleason sum to determine the probabilities of the cancer having spread beyond your prostate. This data helps decide if imaging examinations are needed to investigate further cancer spread. Imaging exams use magnetic fields, X-rays, radioactive or sound waves substances for creating images of the internals of your body.
Men with a low PSA level, normal DRE result, and low Gleason sum need not undergo further tests as the chances of the cancer having spread any further are fairly minimal.
The imaging examinations used quite often for determining the spread of prostate cancer comprise:
Bone Scan
If the cancer moves to distant parts of your body, bone is often the first casualty. Bone scans help determine whether the bones have been infected by the cancer.
For this exam, the vein is injected with a low-level radioactive substance – either IV or intravenously. The radioactive material rests in the damaged bone portions all across the body within a couple of hours. You are then asked to lay down flat on a table for some 30 minutes, so that a special camera simultaneously picks up the radioactivity and develops an image of your skeleton.
The bone damage areas show up as ‘hot spots’ on the image – meaning, they’ve attracted the radioactivity. Hot spots could indicate bone cancer, but other bone ailments such as arthritis could also trigger hot spots. For an impeccable diagnosis, other examinations like MRI or CT scans, plain x-rays, or also a bone biopsy could be required.
Administering the IV line may also bring about momentary pain, but the actual scan isn’t painful. The radioactive substance exits the body in a few days as urine. The radioactivity levels employed is extremely low, so the chances of side effects are close to none. However, it’s always safe to ask the doctor if additional precautions need to be taken after the test.
Computed Tomography (CT) Scan
This scan is not usually required for fresh prostate cancer cases, especially if the PSA level, DRE result, and Gleason sum have proved the cancer cells won’t spread to other surrounding tissues. Still, it could, at times, help determine if the nearby lymph nodes have been infected by the cancer. If the prostate cancer resurfaces post treatment, CT scans often state if the cancer is spreading to other structures or organs in the pelvis.
CT scans utilize x-rays for making cross-sectional, detailed body images. Instead of capturing a single image, like standard X-rays, CT scanners take multiple pictures while rotating around your body that’s resting on the table. A computer is then used for combining these images into image slices of the body part under study.
CT scanners have been described as large donuts, with a straitened table sliding out and in of the mid opening. When the scan is in progress, you must stay still. CT scans are longer than traditional x-rays, and you could feel a bit claustrophobic inside the ring when the images are being captured.
For a few scans, you could be requested to consume one or a couple of oral contrast pints prior to the first image set is captured. These assist in profiling the intestine so that it doesn’t resemble any tumors. You could also require an intravenous (IV) line via which a varied type of contrast gets injected. This assists with outlining the structures inside your body.
Contrast IV could make you feel slightly flushed (a warmth feeling coupled with some skin redness). Some allergy-prone people may develop hives. It’s rare to see major reactions, such as low blood pressure or troubled breathing, occurring. Medicines could be provided to treat and prevent allergic reactions. Therefore, ensure you inform your physician everything about your allergies or any possible adverse reactions to x-ray contrast materials.
You must also consume sufficient fluids to completely satisfy your bladder. This would ensure the bowel stays away from the prostate gland region.
CT scans may not be as beneficial as MRI or magnetic resonance imaging scans to view just the prostate gland.
Magnetic Resonance Imaging (MRI)
As aforementioned, MRI scans help with viewing prostate cancer. They could conjure a crystal clear prostate image and exhibit if the prostate cancer has branched outside the prostate gland into nearby structures, such as the seminal vesicles. This data can be extremely critical for your physicians phasing out your treatment. However, similar to CT scans, MRI scans are not typically required for freshly diagnosed cancers in the prostate gland, which are likely to not spread beyond the gland depending on specific factors.
MRI scans employ strong magnets and radio waves in place of x-rays for creating images. Similar to a CT scan, a contrast substance could be injected, but that is not the norm. As there are magnets in use, patients with pacemakers, medical implants such as specific heart valves could not then be able to advantage from an MRI.
MRI scans are longer in duration than CT scans, and could take even close to an hour. The scan procedure would require you to lay down motionless within a straightened tube, which could feel restrictive and bother people who do not fancy enclosed areas. The equipment also makes buzzing and clicking noises. Some centers offer music headphones to cut out the noise.
To enhance an MRI’s accuracy, you could get a probe, known as endorectal coil, positioned within your rectum to facilitate the scan. This should stay still for half an hour to 45 minutes and could make you feel uneasy. If required, you may take sedative drugs prior to the scan.
ProstaScintTM Scan
Similar to the bone scan, ProstaScint scans employ a low-intensity radioactive substance injection to detect cancer, which has branched out to areas other than the prostate. Both the scans scout for body portions where the radioactive substance gets collected. However, these tests don’t work in a similar manner.
While the radioactive substance put into use for bone scans get attracted to the bone, the ProstaScint scan material gets attracted to the body’s prostate cells. It comprises a monoclonal antibody – a kind of synthetic protein that acknowledges and attaches to a specific material. In this scenario, the antibody gets attracted to PSMA or prostate-specific membrane antigen – a component that is found in abundance in cancerous and normal prostate cells.
Post material injection, you would have to lay down on a table and a special camera captures body images. This is typically carried out close to 30 minutes post an injection and also after three to five days.
This medical test could locate cancer cells within lymph nodes and other non-bone (soft) organs, despite it not being particularly useful in observing the area surrounding the prostate. The antibody gets attracted only to the prostate cells; so that other benign issues or cancers do not create abnormal outcomes. However, the medical test isn’t always correct, and the outcomes could be confusing, at times.
Most physicians advise against this test for males who’ve had a recent prostate cancer diagnosis. However, it could be beneficial post treatment if the PSA levels of your blood start rising, and other medical tests fail to find the actual spot of the cancer. Doctors won’t order this exam if they feel the patient won’t benefit from it.
Lymph Node Biopsy
With lymph node biopsies, also called lymphadenectomy or lymph node dissections, one or multiple lymph nodes are taken out to determine if they have cancer cells. This is not done too often in case of prostate cancer, but could be carried out to determine if the cancer has reached out to the surrounding lymph nodes from the prostate. Lymph node biopsies could be conducted multiple times.
Biopsy at the time of surgery to remedy prostate cancer.
The doctor could operate out the pelvis lymph nodes during radical prostatectomy. (Look at the “Surgery for Prostate Cancer” section for getting to know radical prostatectomy better.)
If the chances of the cancer spreading are more than minimal (based on aspects like a high Gleason sum or high PSA levels), the doctor may operate out a few lymph nodes prior to uprooting the prostate gland.
In certain scenarios, the pathologist would view the nodes instantly, while you still being under anesthesia, to assist the surgeon determine if it’s right to go ahead with radical prostatectomy. This is referred to as the frozen section test, as the tissue specimen is iced before getting subjected to a microscopic inspection. If the lymph nodes are found to be infected with cancer, the surgery is terminated (putting the prostate in position). This happens if the doctor believes taking the prostate out won’t result in a cure for the cancer, but only lead to serious side effects or complications.
However, quite often (particularly if the probabilities of cancer growth are low), an iced section test isn’t carried out. Instead, the prostate and lymph nodes are removed and forwarded to the lab for inspection. The laboratory test results usually come some days post surgery.
Biopsy as an isolated procedure
Lymph node biopsies aren’t done as isolated procedures. It is, at times, utilized when radical prostatectomies aren’t planned (like for particular males who opt for radiation therapy treatments), but knowing cancer signs in lymph nodes is still important.
Laparoscopic Biopsy: Laparoscopes are slender, long tubes with a barely noticeable camouflaged camera fixed at the end that enters the abdomen via a small incision. It allows the doctor view the abdomen and pelvis’ internals without having to do a major cut. Other minor cuts are done for inserting lengthy instruments that help remove the lymph nodes surrounding the prostate area. These later get sent to the laboratory.
Since there aren’t any major incisions, most individuals completely recover in a day or two, with the operation leaving back minor scars.
Fine Needle Aspiration (FNA): If the imaging test (MRI or CT scan) shows enlarged lymph nodes, the physician could use a few enlarged node cell samples via the FNA technique.
For this, the physician should use an image from a CT scan to direct a hollow, long needle via the skin inside the bottom abdomen part and the expanded node. A local anesthesia is used to numb down the skin so that you can not feel the needle insertion. A needle attached syringe allows the doctor to remove a small sample of tissue from the lymph node, which later gets sent to the laboratory to determine the presence of cancer cells.
Once the procedure is over, you may return home, but only after a couple of hours.
