Naveen Kella, MD, specializing in Urologic Oncology, talks about combining MRI technology with ultrasound technology and a PSA blood test to better catch and treat cases of prostate cancer.
So we interviewed your patient, who credits you and fusion biopsy for saving his life. He fell into his pool while he was building his pool and hurt his back, and kind of thought it was coincidental. He had an appointment anyway, but they discovered the PSA was elevated?
Dr. Kella: Right.
So when somebody comes to you – he seemed to indicate to us that you could miss it without this particular concept. Can you kind of go into that?
Dr. Kella: PSA is a blood test, and that’s the main thing that we’ve used for years to help detect prostate cancer. For the past 30 years, we really haven’t had too many advancements. MRI, though, is now powerful enough – it gives us high resolution images where these MRI – specifically a 3T MRI can actually show you the prostate in detail where you can pick out possible cancers, and it’s an attractive thing.
So what is the difference?
Dr. Kella: The difference between MRI and what we used to have – we used to have PSA – we still have PSA, but we also have ultrasound. And ultrasound gives us the ability to see the prostate; we’ve been using ultrasound in the office for years. But ultrasound does not give you the resolution you need to actually find a cancer. It can give us areas that look maybe like they’re cancer or not, but by no means is it accurate enough to actually predict and show cancer, and MRI gets us very close to that stage. And what patients are doing now, what I’m encouraging a lot of my patients to do, is to consider getting a fusion. This is where we get all the information from that MRI, and then we ultimately still biopsy to just verify that there is cancer. But we do that in the office, the biopsy. And it’s done using ultrasound because if you’ve ever been to an MRI, it’s a very expensive piece of equipment that’s only available in a few areas – not typically in a doctor’s office.
Describe the procedure chronologically on how this takes place. And from an outsider’s viewpoint, you look at these two tools that have been around for a long time and you think; well, how come they didn’t do that, combine them a long time ago? How does that transpire?
Dr. Kella: Right. Traditionally, or the way it works now is with MRI being available, a patient would still get a PSA; that’s an inexpensive quick test using your blood. If the PSA looks abnormal, what we previously would do is offer a biopsy. We also would do a digital exam of the prostate to feel it. Now, though, patients have the option of pursuing an MRI. They would go and get a 3-Tesla multi-parametric MRI, which is the official name. After they get this MRI done, come back, consult with the doctor and see if some hotspots are visible. If we see some areas that look suspicious, then those areas can be biopsied using fusion, using ultrasound, the tools that a doctor’s office has. We do need some special software. We have equipment that can do this; it’s called the UroNav, and there’s some others on the market. But once you have that software, you’re able to do these fusion biopsies.
And so why did it take a while to figure out that you could cross-pollinate those two?
Dr. Kella: Really there were a couple of things that have led up to this development. One is the MRI’s are getting much better for the prostate. Previously, the MRIs weren’t that good and the information you got was not enough to do a proper fusion biopsy. Then also the software and the ability to get the information from the radiology office into this machine in the doctor’s office; all those things have taken time, but fortunately it’s here now.
What does the software do exactly? Kind of walk us through that.
Dr. Kella: When the patient undergoes a fusion biopsy, the software takes those images from the MRI and it starts comparing it to images on the ultrasound, and we can create images that match. Once we have enough images that match, then when we move the ultrasound probe it knows exactly where it correlates on the MRI so it’s like a heads up display. You’re then able to move around with an ultrasound in the office, but you’re seeing it moving around like if you’re looking at the MRI; in much higher resolution with much better images.
This particular patient is very knowledgeable, he said that his cancer was in such a place that the way he described it is you might never have seen this. Can you kind of explain that?
Dr. Kella: Right. Traditionally, this has been a very frustrating thing for urologists and for patients is when a patient comes in for a biopsy, the PSA is high, we do it using ultrasound, and nothing gets picked up. The patient comes in, we run the test, we think, oh great, no cancer. Three months later, the patient comes back; their PSA has gone up even more. And what we’re finding, after using MRI, is that we’re seeing up on the topside of the prostate; we’re not sampling those areas. When we do a regular biopsy, it’s almost random. We take 12 samples, usually, in a systematic fashion, but it’s still random. With the MRI, we know where that cancer possibly is and we can focus the needle and get to areas of the prostate that we normally don’t try to sample with the older technology.
In this guy’s case he had no symptoms or anything, he didn’t even realize he had cancer, it was already aggressive … He was at stage four by the time he got to you guys. In something like that, what do I say to the doctor when I go in?
Dr. Kella: Most patients will not have symptoms. In fact, by the time you have symptoms, it’s usually too late. The cancer has already escaped. Now PSA; that blood test is actually a great tool. Also, knowing your history. If your dad or your older brothers had prostate cancer, or if you’re African-American, you should get screened earlier; starting in your 40’s with a PSA. Now a PSA’s not perfect, but if we can say hey this PSA is something to be concerned about, that’s when we can start getting into these other things like with the MRI and possibly getting into a fusion biopsy. But most people will not have symptoms, so you have to get checked with a PSA.
So either anecdotally or factually, describe to us how this fusion procedure helped save Ray’s life.
Dr. Kella: When we got the fusion biopsy, when we got the MRI images, we were able to find the area of cancer. It was lurking up higher, where it would have been missed by a regular biopsy. It would not have been visible on ultrasound. Luckily, with the MRI, it lit up, and then we were able to find it in the office using the ultrasound and the fusion. We were able to biopsy it, establish that he did have prostate cancer, and then set him up for therapy and now he’s in remission. He’s doing great.
And he had robotic surgery. So when you’re actually doing that biopsy, are you’re doing that in the hospital? In the office? What is that like?
Dr. Kella: Yeah luckily the biopsy’s in the office. The patient can be awake. I tell patients, it’s not the highlight of your day, but we can do a lot of things to keep you very comfortable. And for the information you’re getting out of it, it’s worthwhile. It’s really no more painful than a regular biopsy. And most patients, after it’s done usually tell us hey, it wasn’t as bad as I thought. But definitely, you know, it’s something that is done in the office. And then, for example our patient, he had his robotic surgery done with me in the operating room.
So how valuable has this been to you, as a physician, having this particular tool?
Dr. Kella: It’s kind of brought us out of the dark ages. It really was frustrating when we could not find cancer and I knew something was going on. The MRI has also taken a lot of fear out for patients who are scared of getting a biopsy. Now if there is an area that picks up on the MRI, the patients are a lot more agreeable to getting the biopsy done. The MRI’s can tell us a lot of times if the cancer has escaped from the prostate, which is really valuable when we’re planning treatment. Then when we combine it with the fusion technology, it’s really become something where if someone has a lesion and we’re able to biopsy it, we’re usually able to tell them for sure hey this is what’s going on. Either you do have cancer or you don’t have cancer. It really provides a lot of closure for me and for the patient.
In your office, when you were doing this biopsy on Ray, describe to us; is the MRI helping the ultrasound? Or vice versa? Or both ways?
Dr. Kella: When Ray came in for his biopsy, the MRI had already been done. He’d already had his 3T MRI, and that MRI data had already been transferred via the Internet into our system. Then we got Ray ready for the ultrasound. The ultrasound is a little probe that is able to visualize the prostate. We started matching images on the ultrasound to the MRI until we had enough images where now, anytime we move the ultrasound, we would see the exact picture, but represented by the MRI. It’s kind of like looking at a color map versus a grainy black and white image. You’re able to see so much more detail.
When you go into the operating room, describe a little bit of the operation, how you got it out. I know his was a very tricky place. Are you using those two images fused together as a mapping tool in the OR?
Dr. Kella: Once we do the biopsy, we definitely use the information from the fusion. So now I know how aggressive the cells are and I know where they are. For example, if the images show that the cancer started to creep out on one side; then I know I have to be a little more aggressive on that side of the prostate. I’ve done over 3,000 of these procedures now using the robot; we have a lot of experience. I can tell you that with the MRI, it’s made me feel a lot more confident going into surgery with all that additional information.
Now, I know, with the prostate you can go in and core it out. In this procedure, did you take out the entire gland?
Dr. Kella: When we core it out, they may not have prostate cancer yet. They may be having just problems with a big prostate. When we have a diagnosis of prostate cancer, we remove the entire prostate; so it’s done a little bit differently. What I use now and what a lot of other surgeons will do is we have little ports, they’re all dime-size type incisions, and then we dock a robot. Then I sit comfortably off in the corner and start moving and looking at a 3D image of what’s going on with the patient internally. I can move the robot and the robot doesn’t have big hands, it’s got tiny little hands that move like my hands. So it’s able to do the surgery in a much more delicate fashion in 3D and really help us achieve things with a consistency that we weren’t able to do before.
Give me a metaphor or an analogy for what you’re doing.
Dr. Kella: Yeah I have a great analogy. With robotic technology, this MRI fusion technology, metaphors really help patients understand. The robot is like a Ferrari. I tell patients, look, you want to have a Ferrari when you get your surgery done, but it’s just a tool. The Ferrari is just the car. You need to make sure you have the proper driver in that Ferrari to make sure that that Ferrari does as good of a job as possible, because chances are you’ll probably crash it if you haven’t driven it a few times. And so that’s how the robot is with surgery. With the MRI, there’s also some skill involved. You need to have a team that’s done a lot. Because there’s a lot of technology that if you’re inexperienced, you may not be getting the full benefit out of that. So luckily, though, I think most cities now have MRI fusion programs.
And last question – because Ray said he has stage four that was kind of creeping into his bladder. Where is he at now in terms of progress and prognosis?
Dr. Kella: So luckily, we were able to get the prostate out. It had not spread to the lymph nodes, fortunately. We’re checking his blood test, his PSA, and so far everything’s been really good there. There’s no prostate, there’s no cancer, there’s no PSA. So we’re going to continue monitoring that to make sure that’s the case.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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