Biopsy Schemes with the Fewest Cores for Detecting 95% of the Prostate Cancers Detected by a 24-Core Biopsy

Background

The most efficient number and location of prostate biopsies remains a matter of debate.

Objective

To identify the combination (number and location) of sampling sites that permits the detection of 95% of the prostate cancers (PCa) detected by a 24-core biopsy (24PBx).

Design, setting, and participants

Six hundred and seventeen consecutive patients with a suspicion of PCa were prospectively enrolled.

Intervention

A transrectal ultrasound-guided systematic 24PBx was prospectively performed with local anesthesia in an outpatient setting. The 24PBx was obtained by the overlapping of medial sextant, lateral sextant, octant subcapsular, and quadrant transition cores. Before fixation, each single core was individually marked and inked according to the prostatic location sampled.

Measurements

We relied on a classification and regression tree analysis to identify four subgroups of patients with different PCa detection risk at initial biopsy, according to their clinical characteristics. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the most advantageous biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup. Finally, we internally validated the tumor detection rates by using the 10-fold cross-validation method.

Results and limitations

The 24PBx detected PCa in 289 patients (46.8%). The analysis revealed that the most advantageous schemes for patients with a negative digital rectal exam (DRE), prostate volume (PV) ≤60 cm³, and age ≤65 yr was a combination of a 16-core biopsy. For patients with a negative DRE, PV ≤60 cm³, and age >65 yr or a negative DRE and PV >60 cm³, the most advantageous scheme was two different combinations of a 14-core biopsy. Finally, the sampling that permits detection of 95% of cancers in patients with a positive DRE was a combination of a 10-core biopsy.

Conclusions

The most beneficial scheme varied according to the clinical characteristics of the patients. We propose a user-friendly flowchart to identify the most advantageous set of sampling sites according to patients’ characteristics.     

Is an Initial Saturation Prostate Biopsy Scheme Better than an Extended Scheme for Detection of Prostate Cancer? A Systematic Review and Meta-analysis

Context

The optimal initial prostate biopsy core number is still an issue with many unanswered questions and significant controversy.

Objective

To compare diagnostic values of initial saturation prostate biopsy scheme and extended scheme with respect to prostate-specific antigen (PSA) levels, prostate volume (PV), and PSA density (PSAD).

Evidence acquisition

Electronic databases including Medline, Web of Knowledge, and the Cochrane Library were searched through November 1, 2012. Experts were consulted, and references from relevant articles were scanned. The meta-analysis was conducted with RevMan 5.1, according to the PRISMA guidelines. Mantel-Haenszel estimates were calculated and pooled under a fixed or random effect model, with data expressed as risk difference (RD) and 95% confidence interval (CI).

Evidence synthesis

We analyzed eight trials with a total of 11 997 participants who underwent transrectal ultrasound guided prostate biopsies for the first time and met inclusion criteria. Studies consisted of one paired design study, two randomized clinical trials, and five nonrandomized studies. Saturation biopsy scheme showed a significant advantage in prostate cancer (PCa) detection over an extended scheme (RD: 0.04; 95% CI, 0.01–0.08; p = 0.02). In addition, subgroup analyses found a saturation protocol to be superior to an extended protocol in the detection of PCa in men with PSA <10 ng/ml (RD: 0.04; 95% CI, 0.01–0.07; p = 0.002), PV >40 ml (RD: 0.05; 95%CI, 0.01–0.09; p = 0.02), or PSAD <0.25 ng/ml per gram (RD: 0.04; 95% CI, 0.00–0.09; p = 0.04).

Conclusions

The existing evidence indicates that an initial saturation biopsy scheme is more efficient than an extended scheme for PCa detection, especially for those men with lower PSA levels, higher PV, or lower PSAD, without increasing complications and the amount of insignificant cancer.     

902例超声引导下经直肠前列腺穿刺的并发症分析及处理

目的探讨经直肠前列腺穿刺并发症的发生及防治措施。 方法回顾性分析中山大学附属第一医院泌尿外科2012年1月至2016年12月共902例经直肠前列腺穿刺的患者病例资料,分析患者术后并发症发生情况及处理方法。 结果902例穿刺患者中,发生血尿者270例（29.93％）;发生血便者155例（17.18％）,其中直肠出血者19例（占血便的12.26％）;继发感染者46例（5.11％）,其中急性附睾炎者4例（占感染的8.70％）,感染者中有1例发生穿刺术后败血症导致横纹肌溶解及急性肾损伤;发生血管迷走神经反射者7例（0.78％）。 结论经直肠前列腺穿刺术技术简单易行、创伤少,但仍有发生并发症的可能,穿刺前的充分合理准备及术后预防均十分重要。     

The Effect of Prior Biopsy Scheme on Prostate Cancer Detection for Repeat Biopsy Population: Results of the 14-core Prostate Biopsy Technique

OBJECTIVES: To evaluate the diagnostic performance of 14-core repeat biopsy protocol and the impact of prior biopsy scheme on repeat prostate biopsy group. METHODS: 211 patients had repeat biopsy using 14-core protocol consisting of 10-core peripheral zone (classical sextant+4 lateral peripheral cores) and 4-core transitional zone (TZ) biopsies. The diagnostic yield was determined both in patients who had previously undergone sextant or 10-core biopsy protocol. RESULTS: Overall cancer detection rate was 25.6%. 14-core biopsy technique detected cancer in 36.1 and 18.7% of the patients who had a previous sextant biopsy and 10-core biopsy protocol, respectively (P = 0.005). Patients with and without high-grade prostatic intraepithelial neoplasia (HGPIN) in the previous sextant biopsy had 56.5 and 28.3% cancer detection rates on the subsequent extended biopsy, respectively (P = 0.017) Patients who had previous 10-core biopsy with and without HGPIN revealed 22.9 and 17.2% cancer detection rates, respectively (P = 0.465) Additional four lateral peripheral cores detected 33% (3/30) and 17% (4/24) of cancers in patients with previous sextant and 10-core biopsy, respectively. 3.7% of the patients had tumor only in the TZ and none of them had prior extended biopsy. CONCLUSIONS: The yield of extended 14-core repeat biopsy protocol was higher in patients with previous negative sextant biopsy compared to the patients with previous negative 10-core biopsy. HGPIN history found on previous sextant biopsy was a strong cancer predictor on repeat biopsy; same was not true for the patients with previous 10-core biopsy. The yield of lateral peripheral cores and TZ biopsies were lower in patients with prior negative extended biopsy.     

The potential impact of prostate volume in the planning of optimal number of cores in the systematic transperineal prostate biopsy

OBJECTIVES: We compared the detection rates of different transperineal prostate biopsy protocols with the aim to optimize the number of cores to sample according to prostate volume. MATERIAL AND METHODS: From October 2002 to October 2004 we evaluated 480 consecutive patients with PSA between 2.5 and 20 ng/ml undergoing the first set of prostate biopsy. All patients underwent a 14-core TRUS-guided transperineal prostate biopsy, including 12 cores in the peripheral and two in the transitional zone. The detection rate of the 14-core scheme was compared to the one of the other biopsy schemes obtained through the exclusion of pairs of cores. Data were stratified according to the different TRUS estimated prostate volumes. RESULTS: The detection rate of the standard sextant was 35.2%, while those of the 8-core schemes ranged from 37.1 to 38.8%. The 10-core schemes yielded detection rates of 39.6-40.8% and the protocol with 12 biopsies in the peripheral zone diagnosed prostate cancer in 42.1% of the patients. In patients with <30 cc prostate volume, the detection rate of the 14-core scheme was 43.8% and resulted statistically overlapping to the 8-peripheral cores protocol. In patients with 30.1-50 cc prostate volume a 12-peripheral core biopsy reproduced the results of the 14-core sampling. In prostates larger than 50 cc, an even more extensive procedure was mandatory, considering the low detection rate of the 14-core scheme (24.2%). CONCLUSION: Transperineal prostate biopsy is a safe procedure with a very low complication rate and high cancer detection rate. Prostate volume is the most relevant variable in the planning of the optimal number of cores in the extensive first biopsy set. A protocol with more than 8 peripheral cores) is recommended only in patients with prostate volume larger than 30 cc.     

经直肠彩色多普勒血流显像在前列腺增生症和前列腺癌中的应用

目的：探讨经直肠彩色多普勒对前列腺增生症（BPH）和前列腺癌（PCa）的应用价值。方法：应用经直肠彩色多普勒血流显像（CDFI）对53例BPH、14例PCa和18例正常对照者进行系统的检查和分析。结果：BPH和PCa的内部血流信号均有明显增加，BPH内、外腺结构清晰，CDFI以对称性内腺血流增多为主要特征，PCa则病灶及外侵部位均可见明显血流信号，低回声区血流变化多样化，晚期病例可见明显的血流分布异常。对比两者的阻力指数、收缩期血流值等重要血流参数，差异无显著性意义。结论：BPH和PCa内部CDFI的血流变化都具有各自的分布特征，在经直肠烃灰阶超声的基础上结合CDFI检测，将有利于提高超声对BPH和PCa的诊断和鉴别能力。     

经直肠多模态超声与多模态MRI检查对前列腺癌诊断价值的对照研究

目的比较经直肠多模态超声与多模态MRI检查对前列腺癌的诊断价值。方法回顾性分析2016年4月至2018年5月解放军总医院第一医学中心收治的102例可疑前列腺癌患者的临床资料。平均年龄66.1(38.0~85.0)岁,PSA平均值30.1(0.4~227.0)ng/ml,PSA密度(PSAD)平均值0.67(0.02~4.27)ng/ml^2。102例均行经直肠多模态超声(经直肠常规超声、剪切波弹性成像和超声造影)、多模态MRI(T2加权成像、弥散加权成像和动态增强)以及实验室检查。以经直肠超声引导穿刺活检或手术病理结果作为金标准,对比经直肠多模态超声与多模态MRI检查诊断前列腺癌的敏感性、特异性、阳性预测值、阴性预测值、准确性和受试者工作特征(receiver operating characteristic,ROC)曲线的曲线下面积。结果102例中,病理诊断为前列腺癌62例,良性前列腺增生(BPH)40例。并联多模态经直肠超声(即经直肠常规超声、剪切波弹性成像和超声造影检查中任一项结果阳性诊断为前列腺癌)诊断前列腺癌63例,BPH 39例;诊断前列腺癌的敏感性、特异性和准确性分别为98.4%、70.0%和87.3%。多模态MRI检查诊断前列腺癌75例,BPH 27例;诊断前列腺癌的敏感性、特异性和准确性分别为95.2%、60.0%和81.4%。并联多模态经直肠超声和多模态MRI检查诊断前列腺癌ROC曲线的曲线下面积分别为0.842和0.776,差异无统计学意义(P=0.208)。结论并联多模态经直肠超声检查诊断前列腺癌的效能不亚于多模态MRI检查。     

Optimal sampling sites for repeat prostate biopsy: a recursive partitioning analysis of three-dimensional 26-core systematic biopsy

OBJECTIVES: To explore an optimal combination of sampling sites to detect prostate cancer in a repeat biopsy setting. METHODS: A transrectal ultrasound-guided systematic three-dimensional 26-core biopsy (3D26PBx), a combination of transrectal 12 and transperineal 14 core biopsies, was performed in 235 Japanese men with prior negative biopsy. Using recursive partitioning, we evaluated cancer detection of all possible combinations of sampling sites and selected the combination that provides the highest cancer detection rate at a given number of biopsy cores. RESULTS: Prostate cancer was detected in 87 of the 235 (37%) men. The 3D26PBx improved cancer detection by 89% relative to the conventional transrectal sextant biopsy. Neither Gleason score nor percentage of Gleason 4/5 cancers differed between cancers with and without positive cores within the transrectal sextant-sampling sites. A three-dimensional combination of transrectal and transperineal approaches outperformed either transrectal or transperineal approach alone. Recursive partitioning revealed that a three-dimensional 16-core (transrectal eight cores plus transperineal eight cores) biopsy could detect all the cancers with the minimum number of cores. CONCLUSIONS: We propose a three-dimensional combination of transrectal eight cores taken from the far lateral peripheral zone and the parasagittal base, and transperineal eight cores taken from the anterior and posterior apex and the transition zone as an optimal set of sampling sites for repeat biopsy.     

Decision analysis model comparing cost of multiparametric magnetic resonance imaging vs. repeat biopsy for detection of prostate cancer in men with prior negative findings on biopsy

PurposeWe compared cost of multiparametric magnetic resonance imaging (MP-MRI) vs. repeat biopsy in detection of prostate cancer (PCa) in men with prior negative findings on biopsy.MethodsA decision tree model compared the strategy of office-based transrectal ultrasound–guided biopsy (TRUS) for men with prior negative findings on biopsy with a strategy of initial MP-MRI with TRUS performed only in cases of abnormal results on imaging. Study end points were cost, number of biopsies, and cancers detected. Cost was based on Medicare reimbursement. Cost of sepsis and minor complications were incorporated into analysis. Sensitivity analyses were performed by varying model assumptions.ResultsThe baseline model with 24% PCa found that the overall cost for 100 men was $90,400 and $87,700 for TRUS and MP-MRI arms, respectively. The MP-MRI arm resulted in 73 fewer biopsies per 100 men but detected 4 fewer cancers (16 vs. 20.4) than the TRUS arm did. A lower risk of PCa resulted in lower costs for the MP-MRI arm and a small difference in detected cancers. At lower cancer rates, MP-MRI is superior to TRUS over a wide range of sensitivity and specificity of MRI. A lower sensitivity of MP-MRI decreases the cost of the MP-MRI, as fewer biopsies are performed, but this also reduces the number of cancers detected.ConclusionsThe use of MP-MRI to select patients for repeat biopsy reduced the number of biopsies needed by 73% but resulted in a few cancers being missed at lower cost when compared with the TRUS arm. Further studies are required to determine whether cancers missed represent clinically significant tumors.     

Free-hand transperineal prostate biopsy provides acceptable cancer detection and minimizes risk of infection: evolving experience with a 10-sector template

Introduction and Objectives

Free-hand transperineal prostate (fTP-Bx) biopsy offers an alternative to transrectal prostate biopsy (TRUS-Bx) in the diagnosis of prostate cancer. Our objectives were to determine whether fTP-Bx achieves cancer detection rates comparable to historic TRUS-Bx cohorts; to determine infectious and other complications associated with fTP-B; and to propose a standardized fTP-Bx template.

Impact of early hypothalamic-pituitary-gonadal axis maturation on prostate cancer: cross-sectional analysis of a Veterans affairs cohort

BackgroundIt has been hypothesized that earlier onset of puberty, and thus a more prolonged exposure to high androgen levels, increases risk of prostate cancer development. Our objective was to determine whether earlier age of first shave and height, as surrogates of pubertal onset, were associated with risk of prostate cancer diagnosis.MethodsA prospectively collected outcomes registry of patients presenting for a prostate biopsy at the Charlie Norwood Veterans Affair Medical Center in Augusta, GA between July 1995 and June 2016 was utilized. The associations between age of first shave and height, each, and risks of a positive prostate biopsy, high grade cancer, and high volume disease were evaluated using univariable and multivariable logistic regression analysis, controlling for baseline patient demographic and oncologic characteristics.ResultsOur cohort included 2,456 patients. Biopsies were positive in 1,257 (51.2%) patients, of whom 293 (23.3%) and 407 (32.4%) had high grade and volume disease, respectively. Median age of first shave was 17.0 years (interquartile range 16.0–19.0) and height was 177.7 cm (172.8–182.9). On multivariable analysis, later of age of first shave was significantly associated with increased odds of a positive prostate biopsy (odds ratio for >18 versus <16 years: 5.34, P=0.02) and taller patients had significantly increased odds of high grade cancer (odds ratio for 175–180 versus <175 cm: 7.46, P=0.037).ConclusionsAmongst patients presenting for a prostate biopsy, those with a later age of first shave and taller height have an increased risk of a positive prostate biopsy and high grade prostate cancer, respectively.     

前列腺超声低回声区的临床意义

目的评估经直肠超声下的前列腺低回声区及其临床意义。方法1999年8月至2006年8月438例患者接受了经直肠超声引导前列腺系统穿刺活检术,活检点数为6-13点。如果经直肠超声检查发现前列腺的低回声区,亦加取该区部位的活检。将低回声区、等回声区的活检结果进行比较。结果总的癌检出率112/438（25.6%）。112例前列腺癌患者中,有低回声区者75例,占67%,无低回声区者37例,占33%。本组总共取得3504个活检点,取自低回声区者636个。636个低回声区中阳性163个,占25.6%,阴性473个,占74.4%。腺体中有和无低回声区检出前列腺癌的阳性率分别为25.2%（75/298）和26.4%（37/140）（P〉0.05）,差异无统计学意义。结论多数前列腺癌可发现低回声区,但多数低回声区并非前列腺癌。腺体中有无低回声区对前列腺癌的检出率相当。     

F/T比值在前列腺癌筛选中的应用价值

目的：评价F／T比值在前列腺癌筛选中的作用。方法：运用直肠指检、B超、PSA、PSA密度（PSAD）、F／T比值对389例行健康体检的50岁以上男性进行前列腺癌筛选，并对各项方法的准确性、特异性、敏感性进行比较。结果：共检出前列腺癌15例，其中F／T比值在敏感性不降低的情况下，其特异性明显优于PSA和PSAD，特别是在PSA的诊断灰区能很好地将良、恶性病变区分开来，使将近50％的可疑患者免受活检。结论：F／T比值是前列腺癌筛选的有效手段。     

Bleeding after transrectal ultrasonography-guided prostate biopsy: a study of 7-day morbidity after a six-, eight- and 12-core biopsy protocol

OBJECTIVE: To compare, in a prospective study, bleeding (in three categories, i.e. haematuria, haematospermia and rectal) and consultations with the general practitioner (GP), after a six-, eight- or 12-core prostate biopsy, as data on whether taking more prostate core biopsies increases bleeding complications are not conclusive. PATIENTS AND METHODS: Over a 5-year period, patients undergoing outpatient transrectal ultrasonography (TRUS)-guided prostate biopsy (six, eight or 12-core biopsy) completed a self-administered questionnaire. The prevalence and duration of the three bleeding complications and GP or hospital visits for a biopsy-related complication were assessed and compared for the 7 days after biopsy. The contribution of local anaesthetic (LA) injection to bleeding rates was also assessed. RESULTS: Of 1384 patients biopsied, 1000 were given questionnaires and 884 (88%) forms were returned. Of these, 760 were suitable for analysis (307 after six-core, 325 eight-core and 128 12-core biopsies); 351 patients were given LA before biopsy. The prevalence of bleeding complications (six-, eight- and 12-core, respectively) was: haematuria 44%, 41% and 39%; haematospermia 13%, 16% and 12%; and rectal bleeding 17%, 26% and 27%. Rectal bleeding was significantly more prevalent in the eight- and 12-core groups (P = 0.0037 and 0.019). The duration of bleeding was not significantly greater in any biopsy group. Subgroup analysis showed no significant difference in the prevalence and duration of rectal bleeding after LA. About 5% of patients in each group consulted their GP because of a complication and 2.4% consulted because of bleeding. Three men with major complications required hospitalization, of which only one was caused by bleeding. CONCLUSIONS: Only rectal bleeding was more prevalent after taking more than six cores, but the duration was no greater. Giving LA did not affect the rectal bleeding rate. With all strategies the major complication and hospitalization rate was very low.     

前列腺体积在选择穿刺活检方案中的作用探讨

目的 回顾性分析比较前列腺10点穿刺中的8点、6点及经典6点法以及10点在不同的前列腺体积中前列腺癌的检出率,寻找出合理的前列腺活检方案.方法 研究对象为直肠指检阳性和(或)前列腺特异抗原(PSA)检测在4 ng/ml的可疑病人461例.按前列腺体积分成4组:≥15ml、≥35ml、≥55ml和≥75ml.所有病例都接受10点活检法,并分析比较其中的10点、8点、6点组合穿刺方案.若声像图发现外周带边界清晰的低回声病灶再靶向穿刺1～3针.结果 148例(32.1%)患者确诊前列腺癌.前列腺癌的阳性率随前列腺体积增大而减少,从49.6%降为21.8%.在边界清晰的可疑病灶中,PCa的阳性率最低,为10.3%.在前列腺癌组中,偏外侧的6点组合系统穿刺方案癌肿检出率为84%～90%,体积最小组中,包括尖部/中部/外侧中部/外侧底部的8点穿刺的癌肿检出率为96%,仅比10点组合方案低2%;而前列腺体积在35 ml以上组中,10点组合方案比包括尖部/底部/外侧中部/外侧底部8点组合方案的检出率高3%～5%.结论 经典的6点组合系统穿刺方案不适合所有前列腺的穿刺,前列腺体积为15～35 ml者建议使用包括尖部、中部、外侧中部及外侧底部的8点组合穿刺方案,而体积＞35 ml者使用10点组合方案更合适.     

儿童甲状腺癌60例临床分析

目的 探讨儿童甲状腺癌的临床特点、诊断、治疗及预后。方法 回顾性分析我校三个医院1975～2002年收治并获随访的儿童甲状腺癌60例。结果 在60例儿童甲状腺癌中，乳头状腺癌49例，滤泡状腺癌8例，髓样癌3例，伴颈部淋巴结转移36例。全组患者均手术治疗，其中患侧甲状腺加峡部切除20例(33．3％)，患侧甲状腺全切加对侧甲状腺次全切36例(60％)，甲状腺全切除4例(6．7％)。术后均服甲状腺素片。平均随访10．5年(1～20年)，5年生存率为93％，10年生存率为87．1％。结论 儿童甲状腺癌多分化良好，极少发生未分化癌。重视其临床特点是早期诊治的关键，合理选择术式及术后综合治疗可取得满意疗效。     

Open versus robotic radical prostatectomy: a prospective analysis based on a single surgeon’s experience

The background of this study is to compare prospectively the oncological and functional results of open radical prostatectomy (OP) and robotic prostatectomy (RP) from the experience of a single surgeon. Between June 2002 and June 2007, 422 patients underwent radical prostatectomy (OP 199, RP 223). We divided OP patients into 89 early cases (OP-I) and 110 late cases (OP-II) before and after introduction of a robotic system, and RP patients into 35 early cases (RP-I) and 188 late cases (RP-II). Functional outcomes were measured by use of validated questionnaires completed by the patients. There were no significant differences in preoperative characteristics among the four groups, except that RP-I patients had lower biopsy Gleason scores. In the RP groups the mean estimated blood loss was lower and mean durations of hospital stay and bladder catheterization were shorter compared to those of the OP groups. The frequency of intraoperative complications was significantly lower in the RP-II group. The positive surgical margin rates in the RP-II group were similar to or lower than those in the OP groups when stratified by pathologic stage T2 and T3. From one month after surgery, RP-II patients had higher continence rates than OP-II patients. For patients ≥60 years old, recovery of potency was better in the RP-II group. To conclude, RP by an experienced surgeon may have a similar or lower positive surgical margin rate than OP. Additionally, RP may lead to a shorter duration of bladder catheterization and hospital stay and better recovery of continence and potency than obtainable by OP.     

The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies

Background

Guidelines advise multiparametric magnetic resonance imaging (mpMRI) before repeat biopsy in patients with negative systematic biopsy (SB) and a suspicion of prostate cancer (PCa), enabling MRI targeted biopsy (TB). No consensus exists regarding which of the three available techniques of TB should be preferred.