Ultrasound for prostate imaging and biopsy

Transrectal ultrasound guided systemic sextant needle biopsy of the prostate has been the procedure of choice for the diagnosis of prostate cancer. Several shortcomings of this procedure have been recognized and there is concern that it may represent an inadequate sampling of the prostate. Refinements include modifications of biopsy location and an increase in the number of cores obtained. Enhanced ultrasound techniques may improve the accuracy of prostate biopsy. In addition, research continues to develop prognostic factors derived from the core biopsy that may enhance the prediction of tumor biology. This paper provides a basic review of transrectal ultrasound diagnosis of prostate cancer with emphasis on advances in this area.     

对比超声引导系统穿刺活检与超声造影靶向活检诊断前列腺癌

目的比较前列腺系统穿刺活检（SB）与CEUS靶向活检对前列腺癌（PCa）的检出率。方法选取可疑PCa患者61例随机分为CEUS靶向活检组和SB组,分别进行CEUS靶向活检及11点系统活检,并进行病理学检查。结果 61例病例中,病理检查证实为PCa共19例（19/61,31.15%）,CEUS组漏诊1例,漏诊率1.64%（1/61）。SB组PCa检出率为26.67%（8/30）,CEUS靶向活检组PCa检出率为35.48%（11/31）;11点穿刺活检获得组织330条,其中癌组织21条;CEUS靶向活检获得组织257条,其中癌组织29条。两组PCa检出率差异无统计学意义（P〉0.05）,但CEUS靶向活检组每个靶点获得癌组织的概率（29/257,11.28%）较11点穿刺活检时每个穿刺点获得癌组织的概率（21/330,6.36%）明显提高（P〈0.05）。结论两组对于PCa的检出率无明显差异;CEUS靶向活检可减少穿刺点数,且每个靶点获得癌组织的概率较SB有所提高。     

Continued administration of antithrombotic agents during transperineal prostate biopsy

Purpose

To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy.

Patients and Methods

A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis.

Results

An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m², P=0.0058), but not with administration of antithrombotic agents.

Conclusions

Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy.     

Targeted dendrimer-based contrast agents for articular cartilage assessment by MR imaging

OBJECTIVE: Magnetic resonance (MR) imaging with contrast media has shown promise for articular cartilage assessment. Dendrimer-linked nitroxides, a new family of MR contrast agents targeted to glycosaminoglycan, may improve cartilage evaluation. This study is designed to determine the ability of dendrimer-linked nitroxides to enhance articular cartilage and measure the intra-articular life-time of these agents. DESIGN: Cartilage T(1) was evaluated using immature bovine patella in solutions of five different dendrimer-linked nitroxides, saline or Gd-DTPA at 1.5T. The "relaxivity per dose" (change in cartilage 1/T(1) produced by a given concentration of agent) was calculated. The half-life of joint fluid enhancement was measured at 2T after solutions of three dendrimer-linked nitroxides, Gd-DTPA, and saline were injected into rabbit stifle joints. Twenty-four hours after injection, the joints were examined grossly and by histology for toxicity. RESULTS: All but the largest dendrimer-linked nitroxide were able to intensely enhance articular cartilage on MR. Relaxivity per dose measurements were between 3.5 and 68 times greater than Gd-DTPA. The largest nitroxide appeared to be excluded from articular cartilage. Intra-articular half-lives of the dendrimer-linked nitroxides were sufficiently long (160-208 min) for in vivo MR imaging to be performed. Histological assessments of joints showed minimal synovial inflammatory and necrosis scores 1 day post-injection that were similar for all agents, including Gd-DTPA. CONCLUSION: Dendrimer-linked nitroxides strongly enhance cartilage and are promising as articular cartilage-specific MR contrast agents. The intra-articular life-time is sufficient for imaging studies and, in initial evaluation, the agents exhibit minimal toxicity in rabbit joints.     

丁卡因胶浆在经直肠前列腺穿刺活检中的临床应用价值

目的 比较患者在行经直肠前列腺穿刺活检术时,在直肠内及肛周使用丁卡因胶浆或单纯润滑剂,患者所经历的疼痛情况.方法 回顾性分析2011年1月至2013年1月120例行经直肠前列腺穿刺患者的临床资料.其中术中采用单纯性润滑剂患者60例（组Ⅰ）,采用丁卡因胶浆患者60例（组2）.采用水平视觉疼痛评分法评估患者经历的疼痛程度.结果 通过组间比较,两组患者疼痛程度与患者年龄、PSA水平、DRE是否异常、穿刺数目及术后并发症发生等均无统计学意义（P＞0.05）,当穿刺器械进入肛门时患者疼痛不适评分组1为2.8±1.8分,组2为1.3±1.6分（P=0.000＜0.05）,当行前列腺穿刺活检术时患者疼痛不适评分组1为5.5±1.7分,组2为3.3±1.5分（P=0.211 ＞0.05）.结论 麻药制剂并不能增加经直肠前列腺穿刺活检术的安全性,但采用麻药制剂（如丁卡因胶浆）后可明显减轻穿刺所带给患者的疼痛不适.     

Preoperative prostate biopsy and multiparametric magnetic resonance imaging: reliability in detecting prostate cancer

Purpose

The aim of the study was to analyse and compare the ability of multiparametric magnetic resonance imaging (mp–MRI) and prostate biopsy (PB) to correctly identify tumor foci in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa).

Materials and Methods

157 patients with clinically localised PCa with a PSA <10 ng/mL and a negative DRE diagnosed on the first (12 samples, Group A) or second (18 samples, Group B) PB were enrolled at our institution. All patients underwent mp-MRI with T2-weighted images, diffusion-weighted imaging, dynamic contrast enhanced-MRI prior to RP. A map of comparison describing each positive biopsy sample was created for each patient, with each tumor focus shown on the MRI and each lesion present on the definitive histological examination in order to compare tumor detection and location. The sensitivity of mp-MRI and PB for diagnosis was compared using Student’s t-test. The ability of the two exams to detect the prevalence of Gleason pattern 4 in the identified lesions was compared using a chi-square test.

Results

Overall sensitivity of PB and mp-MRI to identify tumor lesion was 59.4% and 78.9%, respectively (p<0.0001). PB missed 144/355 lesions, 59 of which (16.6%) were significant. mp-MRI missed 75/355 lesions, 12 of which (3.4%) were significant. No lesions with a GS≥8 were missed. Sensitivity of PB and mp-MRI to detect the prevalence of Gleason pattern 4 was 88.2% and 97.4%, respectively.

Conclusions

mp-MRI seems to identify more tumor lesions than PB and to provide more information concerning tumor characteristics.     

Optimized standards for prostate biopsy

As individual risk assessment mainly depends on the correct prediction of the tumor's biological behavior, primary diagnosis plays a key role in the clinical management of prostate cancer patients. Prostate core needle biopsy, as a primary diagnostic tool, should not only confirm clinical suspicion but also supply the urologist with information which is necessary for risk-adapted therapy. The experience and competence of both the urologist and the pathologist are crucial for the quality of prostate core needle biopsy diagnosis. Optimized handling and submission of prostate core needle biopsy specimens by the urologist to the pathologist are of outstanding importance for improving the number of cancer cases detected. Increasing availability of molecular markers leads to the necessity of developing new tissue sampling procedures which allow prostate core needle biopsy specimens to be simultaneously studied histologically and by molecular approaches.     

经会阴前列腺穿刺与经直肠前列腺穿刺活检在前列腺癌诊断的初探

目的 对比经会阴与经直肠前列腺穿刺活检在前列腺癌诊断中的阳性率及并发症。方法 回顾分析2017年1月到2019年12月行前列腺穿刺活检的病例,经直肠组187例,经会阴组68例。结果 经直肠组阳性穿刺率为34.7%,经会阴组阳性穿刺率为29.4%,两组无统计学差异（P>0.05）。穿刺后经直肠组和经会阴组的血尿发生率分别为40.1%、42.6%,尿潴留发生率分别为6.9%、7.3%,直肠出血发生率分别为1.1%、0%,差别无统计学意义（P>0.05）。穿刺后经直肠组和经会阴组的会阴肿胀的发生率分别为2.6%、13.2%,两组有统计学差异（P<0.05）。结论 超声引导下经直肠、经会阴前列腺穿刺活检均为前列腺癌诊断的有效方法。两者穿刺阳性率无明显差异,但并发症各有特点。     

Caudal analgesia for prostate biopsy

Background: Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)‐guided prostate biopsy, the best method has not yet been defined. The present prospective, double‐blind, randomized study aims to investigate the clinical efficacy of ‘walking’ caudal block compared with an intrarectal lidocaine gel for this procedure. Methods: One hundred patients were randomly assigned to two groups. In the lidocaine gel group, 10 ml of gel containing 2% lidocaine was given intrarectally. In the caudal group, 20 ml 0.1% bupivacaine with 75 μg fentanyl was injected. Pain scores, anal sphincter tone and patient satisfaction were evaluated. Results: The pain scores were significantly lower in the caudal group at all stages. Verbal rating scores (scale 1–4) during probe insertion, probe maneuver and biopsies were 1 (0–2), 1 (0–2) and 1 (0–2) vs. 3 (0–5), 2 (1–3) and 4 (2–6), respectively (P value <0.0001 at all stages). The anal sphincter was more relaxed in the caudal group than in the gel group (P value <0.0001 in all categories). Highly satisfied patients were more frequently encountered in the caudal group, 34 (68%) vs. 8 (16%), P<0.0001, and unsatisfied patients were more frequently found in the gel group 1 (2%) vs. 12 (24%); P<0.001. All patients were able to walk without any assistance immediately after the procedures. Conclusion: ‘Walking’ caudal analgesia is an efficacious method for relieving the pain during TRUS‐guided prostate biopsies in ambulatory practice.     

Lidocaine suppositories for prostate biopsy

OBJECTIVES: To evaluate, in a randomized prospective study, the efficiency of transrectal lidocaine suppositories to reduce pain during transrectal prostate biopsy, as suppositories allow longer for the agent to be effective. PATIENTS AND METHODS: In all, 100 patients were randomized to receive either a placebo suppository or 10 mL of 2% (200 mg) lidocaine gel rectally 10 min before biopsy, or a suppository containing 60 mg lidocaine 1 or 2 h before biopsy. Costs (in euros) per application were 0.82 for gel and 0.63 for suppositories. In all patients the same 10-core biopsy technique was used. Pain was evaluated using a visual linear pain scale ranging from 0 to 100 points; the patient's side of the scale did not show the number of points. RESULTS: The mean pain scores in the placebo, lidocaine gel, and lidocaine suppositories applied 1 h and 2 h before biopsy were 36.2, 40.9, 29.2 and 21.2, respectively. Thus patients with no anaesthesia reported 25% more pain than those receiving lidocaine suppositories 1 h before and 71% more pain than those receiving lidocaine suppositories 2 h before biopsy (P = 0.002). CONCLUSIONS: Lidocaine suppositories at a lower dose and with longer to take effect can be used to reduce pain significantly more effectively than the commonly used gel. As suppositories are easy to use and cheap, they are recommended in daily routine prostate biopsy.     

Ultrasound guided biopsy, a gold standard diagnostical test of the prostate cancer

The author discusses preparations for ultrasound guided prostate biopsy, its technique conditions and the process of performing a biopsy. Every author proposes the use of preoperative antibiotics based prophylaxis. Differences may be found in the type, dosage and the time span of preoperative application. For anaesthesia mostly lidocaine was proposed, which may be a gel applied in the rectum or used in the form a prostate infiltrate. The widest debate goes on in respect of defining the number of biopsies needed. Recently 8 or rather 10 samples are proposed to be taken. Twelve biopsies do offer an advantage compared to 6 although in case of 8 this isn't so. According to the site of sample taking the apex, the base and the middle part are proposed. In case of a palpable nodule or any lesion, made visible by TRUS an additional, targeted, biopsy has to be performed. Certain new techniques like the 3D Doppler, contrast, intermittent and others shall also be presented. A repeated biopsy shall be necessary in case of PIN atypia, beyond that the author also discusses other indications for a repeated biopsy. We may expect the occurrence of direct postoperative complications and it is necessary to know how to treat these.     

Comparison of contrast enhanced color Doppler targeted biopsy with conventional systematic biopsy: impact on prostate cancer detection

PURPOSE: We performed a prospective study to determine whether a limited biopsy approach with contrast enhanced color Doppler ultrasound targeted biopsy of the prostate would detect cancer as well as gray scale US guided systematic biopsy with a larger number of biopsy cores. MATERIALS AND METHODS: We examined 230 male screening volunteers with a total prostate specific antigen of 1.25 ng./ml. or greater and free-to-total prostate specific antigen less than 18%. Two independent examiners evaluated each subject and a single investigator performed 5 or fewer contrast enhanced targeted biopsies into hypervascular regions in the peripheral zone during intravenous infusion of the US contrast agent Levovist (Schering, Berlin, Germany). Subsequently another examiner performed 10 systematic prostate biopsies. The cancer detection rates of the 2 techniques were compared. RESULTS: Cancer was detected in 69 of the 230 patients (30%), including 56 (24.4%) by contrast enhanced targeted biopsy and in 52 (22.6%) by systematic biopsy. Cancer was detected by targeted biopsy alone in 17 patients (7.4%) and by systematic biopsy alone in 13 (5.6%). The overall cancer detection rate by patient was not significantly different for targeted and systematic biopsy (p = 0.58). The detection rate for targeted biopsy cores (10.4% or 118 of 1,139 cores) was significantly better than for systematic biopsy cores (5.3% or 123 of 2,300 cores, p <0.001). Contrast enhanced targeted biopsy in a patient with cancer was 2.6-fold more likely to detect prostate cancer than systematic US guided biopsy. CONCLUSIONS: Contrast enhanced color Doppler targeted biopsy detected as many cancers as systematic biopsy with fewer than half the number of biopsy cores. Although an increase in cancer detection was achieved by combining targeted and systematic techniques in this screening population, contrast enhanced targeted biopsy alone is a reasonable approach for decreasing the number of biopsy cores.     

弥散加权磁共振联合经直肠超声定位的前列腺穿刺活检诊断前列腺癌的价值

目的 探讨DWI在前列腺穿刺活检中的运用价值.方法 回顾性分析2009年1月至2010年12月在我院行常规经直肠超声(TRUS)定位下经直肠前列腺穿刺(A组)的410例患者和DWI联合TRUS定位下行前列腺穿刺(B组)的141例患者资料,按前列腺特异性抗原(PSA)＜10μg/L、10 μg/L≤PSA ＜20 μg/L、20 μg/L≤PSA ＜50 μg/L和PSA≥50 μg/L将A、B两组各分为4个亚组,分别比较DWI联合TRUS定位与单纯TRUS定位下经直肠前列腺穿刺活检的诊断率.结果 A组PSA＜ 10 μg/L、10μg/L≤PSA ＜20 μg/L、20 μg/L≤PSA＜ 50 μg/L和PSA≥50 μg/L的患者穿刺诊断率分别为12.1％、31.1％、48.0％和91.2％,B组中对应的患者穿刺诊断率分别为23.7％、35.5％、66.7％和96.3％,两种穿刺方法的诊断率在PSA＜ 10 μg/L的患者中有统计学差异(x2=4.405,P＜0.05).结论 对于PSA＜ 10 μg/L的可疑患者,建议行DWI及TRUS联合定位的可疑病灶加系统穿刺法,从而提高前列腺穿刺的诊断率.     

前列腺穿刺对前列腺癌磁共振影像分期的影响

目的　了解磁共振影像 (MRI)检查前近期行前列腺穿刺对前列腺癌MRI分期的影响。　方法　对 10例高度怀疑前列腺癌拟行穿刺检查的患者 ,穿刺前和穿刺后 1周分别行MRI检查 ,比较穿刺前后MRI临床分期结果。　结果　患者穿刺前MRI分期均为B期 ,穿刺后 6～ 8d(平均 7d)MRI分期除 1例因前列腺外周带界限不清确切分期困难外 (B～C) ,9例均为C期 ,前列腺穿刺后近期由于穿刺局部出血 ,MRI分期较穿刺前高。　结论　前列腺穿刺后 1周内行MRI ,穿刺部位的出血可影响前列腺癌手术前的临床分期 ,对临床上可疑而拟行前列腺穿刺的患者 ,应先行影像学检查 ,以免影响前列腺癌手术前的准确分期。