Prostate Exams: Diagnostic Testing

Pelvic Lymph Node Dissection

Considered to be the “final check” to determine if cancer has spread, this procedure can be completed through normal open surgery but more often is conducted using a fiber optic probe that is inserted through a small incision in your abdomen.

All of these diagnostic tests are tools to determine whether there is a possibility of cancer present in the prostate and if so, just how invasive it may be.

However, there is only one way certain method to determine the presence of cancer cells and that is by examining the tissue itself.

Based on the findings of the tests we have discussed if a physician determines that there may be cancer cells he will recommend a biopsy.

A biopsy is conducted by a urologist and the procedure is normally done right in his office. Here is where the ultrasound we discussed previously comes into play. Using a transrectal ultrasound (TRUS), the doctor will image the prostate by using sound waves by inserting an instrument into your rectum. This allows the doctor to “image” the prostate. He will use biopsy needles that are hollow into any area of the prostate that looks or feels suspicious. Small bits of tissue are extracted through the needle. You may feel a stinging sensation.

Depending on the reasons for the biopsy, the doctor may take samples randomly. For instance, if the biopsy is conducted due to elevated PSA instead of a suspected abnormality in the prostate gland, as many as a half dozen or more samples may be taken. This is considered a “pattern biopsy” and is done to help determine the size and invasiveness of any cancer. Even though you may have multiple samples, a biopsy can still miss some cancers.

Once the biopsy is complete, the tissue samples are taken to a pathologist to determine the presence of cancer cells.

Normal prostate cells are usually uniform in size and are neatly patterned when viewed under a microscope. They appear similar to one another in an orderly manner.

Abnormal cells change their appearance and are not well defined. They will usually appear as misshapen and irregular.

As they deteriorate a tumor can appear. Tumors can be benign (non-cancerous) or malignant (cancerous).

If the pathologist determines the presence of prostate cancer he will “grade” each of the tissue samples. This will determine how advanced beyond normal the cancerous tissue has developed. This grading system gives the physician a good idea as to how the tumor is behaving. Tumors with a low grade are most likely to be slow-growing. Tumors with a high grade are more apt to spread aggressively or may have already spread outside of the prostate. If the latter is true, it is said to be “metastasized.”

The actual grading system most widely used by pathologists is the Gleason Grading System, developed in 1977 by Pathologist Donald Gleason. You will find the Gleason Scores in numerous places on and off the internet as it is a standard method, but we have provided them for you here.

Gleason Scores

The Gleason grading system assigns a grade to each of the two largest areas of cancer in the tissue samples. Grades range from 1 to 5, with 1 being the least aggressive and 5 the most aggressive. Grade 3 tumors, for example, seldom have metastases, but metastases are common with grade 4 or grade 5.

The two grades are then added together to produce a Gleason score. A score of 2 to 4 is considered low grade; 5 through 7, intermediate grade; and 8 through 10, high grade. A tumor with a low Gleason score typically grows slowly enough that it may not pose a significant threat to the patient in his lifetime.

Once the grade is established, your physician will need to have additional information before determining a course of treatment. He will need to “stage” your tumor which is dependent upon the size and how far it has spread.

There are two systems used for “staging” the tumor. One of them is TNM and the other is ABCD Rating. They both evaluate the size of the tumor and the spread in reference to nearby lymph nodes and if the cancer has spread beyond those parameters.

The staging system determines whether the tumor is “Localized,” “Regional” or Metastatic. Within each of these categories are divided into categories that are more precise.

Localized

Using the TNM method, you have Stage I (could also be referred to as T1.) These are tumors that cannot be felt. Using the ABCD method the staging is considered “A.”

TNM Stage II or B or T2 are tumors that you can feel but are still confined to the prostate gland.

Regional

In Stage III or C or T3 tumors have broken through the prostate capsule. They may have invaded the seminal vesicles.

T4 indicates that tumors are growing into muscles and organs that are nearby.

Metastatic

Stage IV, D or N+ or M+. This staging refers to tumors that have invaded either the pelvic lymph nodes (N+) or into other distant areas of the body (M+).

If you receive a diagnosis of cancer and different treatment options from your doctor, it would be prudent to get a second opinion. This is a normal practice and one which can help you make intelligent decisions about the most important step you may take in your life.

Getting that second opinion may confirm the diagnosis but help you to adjust the staging and your treatment options. A second opinion may also lead you to a special clinical trial of new cancer treatments that your current physician is not aware of.

Try and locate a prostate cancer support group in your area. Speaking to other men who have experienced prostate disease can do wonders in learning how to deal with your diagnosis and treatment options.

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