Prof. Dr. Ercan Kocakoç

What is the prostate cancer? 

Prostate cancer is a malignant tumor originating mostly from the outer part (peripheral zone) of the prostate gland. Cancer occurs with the uncontrolled growth and increase in the number of malignant tumor cells.

What are the symptoms of prostate cancer? 

There may be no symptoms in the early stages of prostate cancer. The level of prostate-specific antigen in the blood called PSA may be high. For screening purposes, PSA control is recommended for all men over the age of 50 and for individuals with a family history of prostate cancer over the age of 40. As cancer progresses and grows, depending on the enlargement of the prostate, complaints such as difficulty urinating, intermittent urination, and night urination can also be seen in benign prostate enlargement. There may be blood in the urine. When it spreads to the bone in the future, there may be complaints such as bone pain and weakness.

Who is at risk for prostate cancer? Is it genetic? 

The cause of prostate cancer, as in all other cancers, does not depend on a certain factor. It is seen in men over 40 years of age and its incidence increases with increasing age. Genetic factors are important and prostate cancer in relatives such as father and uncle increases the risk. Black people also have a higher risk of prostate cancer. The contribution of smoking and viral factors in the formation of cancer is not clear. Fatty and animal-based diets can also increase the risk.
The risk starts after the age of 50 and increases with age. The risk begins after the age of 40 in those with a family history of prostate cancer.

What is the frequency of occurrence? 

Prostate cancer is the most common type of cancer in men worldwide. One out of every 7 men in the United States has prostate cancer, and 27,500 men die from this cancer each year. It is the second most common type of cancer after lung cancer in men in our country.

What is the importance of early diagnosis in prostate cancer? 

Although prostate cancer is a very common type of cancer, it is a type of cancer that can be treated if detected early. Long-term survival is possible in cases treated with focal therapy, surgery, or radiotherapy in the early period. In the absence of an early diagnosis, it may spread to distant organs such as lymph nodes, bone tissue, lung, and liver, and when there is distant metastasis, it is very difficult to completely treat the disease.

What is the importance of personal habits in the development of prostate cancer? 

The contribution of smoking to the formation of cancer is not clear. Fatty and animal-based diets may increase the risk.

TARGET DIAGNOSIS OF PROSTATE CANCER WITH MULTIPARAMETRIC MRI (TARGETED BIOPSY) ! NEW ERA IN PROSTATE CANCER DIAGNOSIS 

With multiparametric MRI, the prostate tumor is detected when it is 3-4 mm in diameter, and the suspicious area is precisely targeted with Prostate Fusion Biopsy. Thus, the necessity of taking samples from different points, again and again, is eliminated.

Prostate cancers are detected 2 times more accurately than a random biopsy.

Early diagnosis is lifesaving in prostate cancer, which usually starts after the age of 40 in men and whose risk factors increase after the age of 50. Especially with newly developed diagnostic methods, very successful results can be obtained in prostate cancer. Altınbaş University Hospital Medical Park Bahçelievler Interventional Radiology Specialist Prof.Dr. Ercan Kocakoç said, “Especially if you have prostate cancer on your father's side, you should have your scans done in the early period.” and gave information about new techniques.

A BIOPSY IS TAKEN FROM THE SUSPICIOUS AREA

Multiparametric prostate MRI; is a specially developed MRI technique for the examination of the prostate. Prostate fusion biopsy, on the other hand, is a method in which biopsy is taken directly from suspicious areas by combining both images after areas that are suspected of cancer in MRI and ultrasound are seen.

A random biopsy is taken from 12 different parts of the prostate without seeing anything in a standard prostate biopsy. Multiparametric MRI identifies the area of the prostate where a tumor is suspected. With Prostate Fusion Biopsy, directly targeted biopsy is taken. In other words, a biopsy is taken only from the area where cancer is suspected, not from all parts of the prostate, thus increasing the possibility of early diagnosis of cancer. When a random biopsy is taken, only half of the prostate cancers can be detected. 1 in 4 prostate cancers cannot be detected by a normal biopsy. In patients who have undergone fusion biopsy, 90% of the cancer is detected at once.

SMALL TUMORS CAN BE DETECTED 

In a normal biopsy, the image is taken by ultrasound and the tumor has to be very large for it to be reflected in the image. However, even a very small tumor, 3-4 mm in size, can be seen in multiparametric MRI, and since we combine the image in the MRI with the image in the ultrasound, we have the chance to take a sample from even a small tumor tissue. When taking a normal biopsy, if by chance it coincides with the tumor area, the diagnosis can be made, but since we see the suspicious area in MRI in fusion biopsy, we take the sample directly from the target. In addition, nodules of tumor and benign prostate enlargement cannot be distinguished from each other on ultrasound.

NOT DETECT NON-HARMFUL TUMORS

The most important advantage of Prostate Fusion Biopsy is that it can see where the needle is entered in real-time. Tumor areas that we suspect are predetermined in color. For example, from which side the tumor was taken you can see; from above, below, right, or left. Some prostate tumors do not kill the patient, do not harm the patient, we call this a clinically insignificant prostate tumor. In other words, in such cases, the patient does not die due to prostate cancer, and the tumor does not harm the patient. In multiparametric prostate MRI, tumors that will not harm the patient are not detected. It is one of the most important advantages of the method that it can only detect cancers that may harm the patient. When a biopsy is performed on older men, many of them may have small prostate cancer foci that do not affect their life at all. It doesn't do him any harm. Therefore, there is no point in detecting or catching them.

FOCAL TREATMENT (FREEZING, IRE etc) CAN ALSO BE APPLIED

Since we can see very small lesions with advanced MRI methods, we can take biopsies from those small lesions. When we encounter malignant tumors, the biopsy gives the patient the chance to be treated with methods such as irradiation, burning, and freezing, which we call 'focal treatment', only for the tumor area, without the need for surgery. Even if the person has to undergo surgery, he can continue his life by removing only the prostate.

IT HAS BEEN IN TURKEY FOR 8 YEARS!

Prostate fusion biopsy was first developed in 2008 in the USA. It has been used in rare centers in the public and private sectors in our country for the last 8 years. Prostate fusion biopsy is performed under anesthesia. The patient does not feel any pain during the procedure. The transfer of ultrasound images from the computer with MRI and the fusion biopsy process are performed one after the other, taking a total of 35-40 minutes. Since this method is used for the diagnosis of prostate cancer, it is mostly applied to men over the age of 40. However, due to family history, multiparametric prostate MRI and then fusion biopsy can be performed from an earlier age, such as the 30s.

What is Multiparametric Prostate MRI and Prostate fusion biopsy? How is it done?  

Multiparametric prostate MRI is an MRI examination method specially designed for prostate cancer, in which information obtained from more than one parameter is used for diagnosis. In this method, in addition to standard T1 and T2-weighted MRI images, where anatomical information is obtained, a more accurate diagnosis can be made by using diffusion MR and dynamic contrast perfusion MR techniques, where functional information is obtained. Multiparametric prostate MRI results can be evaluated with a grading system called PIRADS, which is used in common all over the world and can objectively distinguish areas with high cancer risk (PIRADS 4 and 5) from areas with low cancer risk (PIRADS 1 and 2). According to this result, while the biopsy is not needed in PIRADS 1 and 2 lesions, a targeted biopsy can be taken from PIRADS 4 and 5 lesions by fusion biopsy method. In PIRADS 3 lesions, biopsy or follow-up can be performed depending on the clinical situation.
Prostate fusion biopsy, on the other hand, is a method that provides directly targeted biopsy from the area with high suspicion of tumor in MRI by superimposing multiparametric MRI images and transrectal ultrasonography images with different devices and software. In this method, the borders of the prostate gland and the areas suspected of tumors are drawn on the MR images and a three-dimensional color map of the suspicious areas is obtained. Since the tumor suspicious areas that cannot be clearly observed on ultrasound are marked on MRI, an ultrasound-guided biopsy can be safely obtained from these areas, since ultrasonography and MR images overlap after the fusion procedure. Prostate fusion biopsy can be performed with local anesthesia, spinal anesthesia, or general anesthesia by entering through the anus, which we call transrectal, or by entering through the space between the anus and testis, which we call transperineal. During the procedure, a target detection device consisting of letters and numbers is used to directly enter the suspicious area, and the needle entry into the target is seen in real-time, and the probability of getting a biopsy from the wrong place is close to zero in a good fusion biopsy.

What are the benefits of multiparametric prostate MRI? 

The classical approach in the diagnosis of prostate cancer is to take an average of 12 random biopsies from different localizations from the entire gland under the guidance of transrectal ultrasonography. The cancer detection sensitivity of this approach is approximately 50%. In cases with normal results, when biopsy is performed again for clinical reasons such as high PSA or hard nodule, cancer is detected in approximately 15-40% of these cases. Some of these cancers are of low malignant potential, are clinically insignificant, and do not impose a risk of cancer-related death to the patient if untreated. However, when these cancers are treated for reasons such as cancer anxiety, some treatment-related problems may cause more problems for the patient.

Multiparametric prostate MRI can detect clinically significant prostate cancer with 88% sensitivity. Specificity is lower, as some pathologies, such as inflammation of the prostate, can also resemble cancer. However, when the images are evaluated with the scoring called PIRADS, the cases evaluated as PIRADS 1 and 2, which have a very low cancer risk, are prevented from going to unnecessary biopsy. Again, due to low cancer potential, an increase in the size of known lesions and other changes can be evaluated with multiparametric MRI in cases followed up with an active follow-up. In cases with high-risk factors, such as the father's prostate cancer, it can be said with MRI that there is no significant prostate cancer without the burden of biopsy. In cases that have undergone surgery for prostate cancer, recurrent cancer can be detected with multiparametric MRI, especially with the contribution of contrast-enhanced MRI.

When was prostate fusion biopsy first performed? 

Prostate fusion biopsy was first developed in the USA in 2008. For 8-10 years, the technique has been widely used as much more reliable. I have been taking biopsies with this method for 7 years in cases where it is needed. Direct biopsy without fusion in the MRI machine has been performed for a little longer; this procedure is a method that takes a little longer and provides less opportunity for multiple biopsies, and it is performed in a few centers in our country.

Is this procedure done everywhere in Turkey? 

This process has been started to be done in our country for the last 7-8 years. It is performed in some centers by interventional radiologists and urologists together who have experience in this subject. Due to the expensiveness of the devices and software used and the low number of experienced physicians, it cannot be performed everywhere. It is performed in a few centers in the public and private sectors.

From what age can it be done? 

Since this method is used for the diagnosis of prostate cancer, it is mostly performed in men over the age of 40. However, due to family history, multiparametric prostate MRI and then fusion biopsy may be needed and performed from an earlier age such as the 30s.

Who can/cannot have it done? 

It can be performed on all patients who are suspected of having a tumor in multiparametric prostate MRI and biopsy is recommended. Bleeding parameters are checked before the procedure, and it can be done after these parameters are corrected in risky cases in terms of bleeding. It can be performed in all cases with medical indications since it can also be performed with local anesthesia in cases with risk in terms of general or spinal anesthesia.

How is it different from a normal biopsy? What are the advantages of this technique? 

The most important difference from a normal biopsy is that it can be taken directly from the target lesion, which has a high probability of biopsy, not blindly, but can be taken safely. Samples can be taken more easily and quickly by coding the prostate and suspicious areas in it in 3D and in different colors. Although there is an obvious tumor in a normal biopsy, a biopsy can be easily taken from tumors located in the anterior part of the prostate and in the part called the apex, which can be overlooked. In this way, 30-35% more accurate diagnoses can be made compared to normal biopsy. Since biopsy is taken from the target lesion, the need for repeat biopsy is very, very low.  The biopsy sites can be coded in different colors and archives can be taken and comparisons can be made easily when follow-up is required. The probability of detecting cancer that is not clinically significant is very low, and the patient is protected from unnecessary treatment and treatment-related complications.

What is its role in early detection of prostate cancer? 

The most important advantage is that it allows targeted biopsy from a small suspicious area of 3-4 mm detected in multiparametric prostate MRI and detection of a very early-stage tumor that has not spread anywhere.

What is its contribution to the treatment of prostate cancer? 

Since it provides the diagnosis of limited early-stage tumors in the prostate, it enables the application of non-operative alternative focal treatment methods and total prostatectomy operations for the prostate. In addition, it can reveal whether the character of the tumor has changed by providing follow-up and, when necessary, biopsy from the same place in patients to be followed up with the method called active monitoring due to its low malignant potential.
 

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