Seeing is Believing

John Rush, M.D., returned to UT Southwestern for a checkup. That's when he learned he had prostate cancer.

Experts say one in six men is affected by prostate cancer. But the term “affected” can have drastically different ramifications depending on where and how the diagnosis is made. Ask John Rush, M.D. He knows. He’s the one in six. He’s also in a good place, in a number of ways.

Dr. Rush practiced medicine his entire career, the bulk of it at UT Southwestern. When he left UTSW in 2008 as Vice Chair of Clinical Sciences, it was to take a position as a Professor and Vice Dean at the Duke-NUS graduate medical school in Singapore. But he stayed in close contact with his UTSW doctors, and he returned to Dallas annually for his exams and care. That arrangement continued until earlier this year, when, at age 70, Dr. Rush decided to retire.

Before heading to his new home in Santa Fe, he returned once more to UT Southwestern for a checkup. That’s when he learned he has prostate cancer.

Fluctuating PSAs

The news was not entirely unexpected. Following American Urological Association guidelines, Dr. Rush had been screened using prostate-specific antigens (PSAs) for the past decade as part of his annual physical. The AUA recommends the blood test for all men ages 55 to 70. Elevated PSA numbers can indicate a variety of conditions, including prostate inflammation or a benign prostate enlargement, but they may also indicate cancer. As Claus Roehrborn, M.D., Chair of the UTSW Department of Urology and one of Dr. Rush’s doctors, explains, PSA test results can be thought of in terms of a traffic light.

“When your PSA number is below 2.5, you have a green light; when it’s from 2.5 to 4, the light is yellow, signifying caution and possibly a referral to a urologist; anything higher than 4 is a red light and means you should definitely see a urologist.” Dr. Rush’s PSA numbers fluctuated in the “green” and “yellow” zones for almost 10 years, but then, a year ago, he came to a “red light.”

Dr. Roehrborn performed a standard biopsy to determine the reason for the elevation. Results showed a pre-cancerous lesion in three places. “Men who have a precancerous lesion are at a greater risk for cancer,” Dr. Roehrborn notes. “So we continued to monitor Dr. Rush’s PSA numbers, and they continued to fluctuate, going up a little one time then down a little the next. Eventually, the number came up quite high, so we decided to have a better look, which required doing a better, more sophisticated type of biopsy.”

A Better Biopsy

The procedure UTSW specialists ordered for Dr. Rush, called MRI-TRUS (short for magnetic resonance imaging-transrectal ultrasound) fusion, is a two-step process that combines the advantages of both MRI (magnetic resonance imaging) and ultrasound and requires a high level of collaboration between a skilled radiologist and an expert urologist. In step one, the radiologist performs the MRI, marks the suspicious spot on the resulting image, and then sends that image electronically to the urologist’s ultrasound machine. In step two, the urologist uses ultrasound to view the patient’s prostate in real time on the same screen as the marked MRI image.

Using these overlaid images, the urologist is able to target the suspicious area(s) during the biopsy with unprecedented precision. “MRI-TRUS fusion is a ground breaking, still fairly unknown technique that’s making a huge difference in our abilities to detect cancer,” says Assistant Professor Daniel Costa, M.D., the radiologist involved in Dr. Rush’s MRI. “When it’s done properly, this new approach avoids the ‘hide-and-seek’ situation that can lead to repeat biopsies and the fear of possible missed cancers.”

Putting the new technique in perspective, Dr. Roehrborn says “normal” MRIs or CT scans provide a resolution “equivalent to a roadmap of the United States on a two-page foldout” while the MRI-TRUS images have a resolution that is “equivalent to a street map view of the city of Dallas.” He adds, “This new MRI enables us to, for the first time, actually ‘see’ cancer in the prostate and to therefore pinpoint it in a way not previously possible.”

Active Surveillance

Dr. Rush’s MRI-TRUS fusion biopsy revealed that one lesion, in a deep and isolated area of his prostate, registered as a Gleason 6. The Gleason scale is a grading system particular to prostate cancer that defines the aggressiveness of the cancer, with 10 being the most aggressive. According to Dr. Roehrborn, Dr. Rush’s cancer is of the low-grade, slow-growing variety that at this point can be actively monitored rather than surgically removed.

“Given the insight this new technology provides, we’re now confident that we found what has been causing the elevated PSA numbers, and that, based on the location and type of cancer it is, it’s safe to proceed with active surveillance rather than a different course of treatment,” Dr. Roehrborn says. For Dr. Rush, that surveillance means having PSA screenings four times a year, two in Santa Fe and two at UT Southwestern, on a rotating, three-month basis - a plan to which he’s amenable. “It’s having the plan that’s the important part,” Dr. Rush says.

“From a patient’s point of view, not knowing something like the reason for those fluctuating PSAs is just horrendous. If I’d not had the targeted biopsy, or what I think of as the ‘smart biopsy,’ I could still be sitting here not knowing what’s wrong and not having a plan. Instead, now I know something with certainty, and it’s very reassuring. There’s a confidence that comes with knowing.” Dr. Roehrborn notes another vital component of the MRI-TRUS fusion system is that it stores patients’ information for future use.

If, for example, in a year, Dr. Rush’s PSAs again elevate, prompting another biopsy, the system will directly guide Dr. Roehrborn to the previously pinpointed spot for checking. He says, “The MRI-TRUS fusion technique not only helps us in diagnosing cancer and in turn advising patients what treatment to choose, but even more importantly for a patient on active surveillance, it helps us manage the condition from now on, indefinitely.”

“Now we know where to go,” agrees Dr. Rush. “That’s the beauty of it.”

The Art Of Imaging

Fusion technology confirms that the target (yellow) was hit by the biopsy (red).

The science behind the latest generation of MRI machines is enabling radiologists to capture images of dazzling clarity.

Neil Rofsky, M.D., Chair of Radiology at UT Southwestern, has devoted much of his career to improving imaging technology. Techniques he helped develop are responsible for the MR visualization used in the MRI-TRUS procedure.

“It’s important that we’re able to generate unique images that reveal diseased tissue,” he says. Imaging has become a mainstay in physicians’ diagnostic toolkits, but Dr. Rofsky notes that not all imaging is created equal.

“Expertise really matters in employing the equipment and in the ability to interpret the images captured. At UT Southwestern, we have both. Our patients not only receive the best imaging but benefit from its integration into innovative patient care.”