If the doctor is concerned that it may be prostate cancer, they will arrange for the man to have a prostate biopsy at the hospital. Biopsy means that tiny samples of prostate tissue are taken to be examined in a laboratory. There are 3 types of biopsy and it’s important to be aware that you may not be offered or are suitable for all 3 types of biopsy and some types of biopsy may not be available in your area:
- Trans rectal ultrasound (TRUS) and biopsy
- Trans-perineal or template guided biopsy
- MRI fusion guided biopsy
Trans rectal ultrasound (TRUS) and biopsy, what happens
An ultrasound probe is gently placed into the back passage using some lubricating jelly. This is gently moved around whilst the urologist or clinical nurse specialist (CNS) scans through to see your prostate on a screen. This gives a better idea of the condition of the prostate and the urologist or CNS can identify any areas of concern which they can then target with the special biopsy needle.
Local anaesthetic is injected around the gland – this doesn’t hurt, but might give the sensation that you want to pass water.
Then the biopsies (tiny samples of tissue) are taken through the wall of the back passage with a spring-loaded instrument. The whole procedure takes about 15 minutes and usually 10 – 12 tiny samples are taken from targeted areas. Taking the samples only takes a matter of seconds. There will be a ‘clicking’ noise as samples are taken which can sometimes be a little frightening and there might be a short, sharp pain or stinging as the samples are taken, although the anaesthetic usually stops you feeling any pain.
After the biopsy and before going home, you will be asked to pass urine to make sure it is not too blood stained. As the biopsy samples are taken through the wall of the back passage some antibiotic tablets will most likely be provided to prevent infection. The full course of tablets should be taken.
Trans-perineal or template guided biopsy, what happens
Again, this is to take tiny samples of prostate tissue. Instead of going through the wall of the back passage the samples are taken through the skin of the perineum. (The perineum is the area between the scrotum and the back passage). As this is a surgical operation, it will involve having a general or spinal anaesthetic.
The procedure uses the ultrasound scan as described above and a special grid or template that has holes every 5 mm through which the special needles are inserted to accurately target the area(s) that the urologist or CNS wants to take samples from. Usually about 30 – 50 samples are taken unless the prostate is very large when more samples may be taken. Occasionally it may be necessary to have a catheter put into the bladder during the procedure then removed later.
This type of biopsy may be undertaken if the cancer is thought to be at the front of the prostate and cannot be easily reached from the back passage, if there has been previous surgery to the back passage or if the back passage has previously been removed.
For most men it will be done as a day case or as an out-patient procedure but occasionally it may be necessary to stay in hospital overnight.
MRI fusion guided biopsy, what happens
This can be done either as a TRUS biopsy or Trans-perineal biopsy. The difference being that a recently taken MRI high definition picture is overlaid or fused onto the current or live images of the prostate from the ultrasound scan on the screen. Once these 2 types (ultrasound scan and MRI scan) of specialist diagnostic techniques are fused together using special computer software, they provide a detailed 360°, 3D picture of the prostate. The biopsy needle can very accurately be targeted to specific areas in the prostate.
After any type of biopsy, it’s quite common to see:
- blood in your urine (this is quite common and should clear up in a week
- blood in your semen (this is quite common and usually lasts for about 4-6 weeks)
- blood when you pass a motion
- a dull ache in the area between your scrotum ad your back passage
After a biopsy, a small number of men may be at risk of developing an infection. To try to prevent this, antibiotics will most likely be given; it’s important to finish all the tablets. However, if a large number of blood clots are passed, there is a problem passing urine, a fever with a high temperature this could be the sign of an infection. Contact should be made with the GP or NHS 24 (dial 111) or hospital if they provided a contact number.
What happens to the biopsy samples
The biopsy samples are sent to a laboratory to be examined in great detail for any signs of prostate cancer so the results won’t be available straight away. The results are generally sent to the urologist or GP in about 2-3 weeks’ time, although this time frame can vary. After getting the results an appointment will most likely be made to see the consultant urologist and CNS at the hospital.
For more information, please see the booklet Spotlight on Prostate Biopsy
Test results and what they mean
A doctor, called a pathologist, will be sent the biopsy samples taken from your prostate. The samples are examined under a microscope to look at the cells. Normal healthy prostate cells are roughly the same size and shape. As cancer grows, the cells change and become unusual in shape and size. The more unusual or abnormal the cancer cells are, the more likely the cancer is to be aggressive or spread outside the prostate.
The doctor looking at the cells decides which type of cell is most common and which is second most common. Each of these two cell types is then given a grade from 1 to 5. A grade of 1 means these cells are the most normal looking or least aggressive, whilst cells given a grade of 5 are the most abnormal looking or most aggressive. These numbers are added together to give a final score out of 10. This is your Gleason score and it describes the grade of your cancer.
Because of modern biopsy techniques, grades of 1 and 2 are rarely used, so the lowest Gleason score likely to be reported is Gleason 6.
The Gleason Score reporting system will be phased out over the next few years as a newer prognostic grade group system is introduced. For further information about Gleason score see page 26 of the booklet Early prostate cancer explained
Prognostic Grade Group
The pathologist will still be sent the samples taken from your prostate and these will be examined under a microscope to look at the cell pattern. Using the new grading system guidelines, the pathologist will grade the prostate cancer by simply numbering the prostate cancer from Grade 1 to Grade 5 with each of the grades having a likely outcome. Grade 1 will be the least aggressive and least likely to spread out-with the prostate while Grade 5 will be the most aggressive grade of prostate cancer. This system has been designed to be a simpler, more accurate and understandable way of reporting, making it easier for men and their families to understand the likely aggressiveness of their cancer.
However, until this becomes widely accepted it is likely that Gleason score and prognostic grade group will be reported together.
In practical terms this means:
|Prognostic grade group||Compares with a Gleason Score of|
|Grade 1||Gleason score 6|
|Grade 2||Gleason score (3+4) =7|
|Grade 3||Gleason score (4+3) =7|
|Grade 4||Gleason score 4+4, 5+3 or 3+5 =8|
|Grade 5||Gleason score 9 and 10|
For further information about Prognostic Grade Group score see page 27 of the booklet Early prostate cancer explained
What do all these mean in terms of prostate cancer risk?
|Result||Low Risk||Medium Risk||High Risk|
Prognostic grade group
The cancer is likely to remain in the prostate and grow slowly (be less aggressive)
There is an increased chance of the cancer breaking out of the prostate
There is a greater risk that the cancer will grow quickly (more aggressive) and may possibly have already spread outside the prostate
|PSA level ng/ml||10 or lower||10-20||More than 20|
For more information, please see the booklet Early prostate cancer explained, page 27.