The role of transrectal aspiration biopsy in the diagnosis of prostatic cancer

We reviewed our experience with transrectal aspiration biopsy during an 18-month period. This procedure was the sole technique used in 75 men and prostatic cancer was diagnosed in 19. Two of these patients were not treated because a core biopsy performed at another hospital was negative for carcinoma. Aspiration and transperineal core biopsies were performed in 62 other cases. The sensitivity of aspiration to diagnose prostatic cancer was 98 per cent (45 of 46 biopsies) compared to only 81 per cent (37 of 46) for the core biopsy method. No patient suffered a complication following the aspiration biopsy. These data further support the value of transrectal aspiration biopsy as a sensitive, easy to perform method for sampling an abnormal prostate. More widespread use of this technique in the United States should be encouraged.     

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。     

超声引导下经会阴穿刺活检在前列腺癌诊断中的价值

目的：探讨超声引导下经会阴道前列腺穿刺活检诊断前列腺癌的价值。方法：对376例临床怀疑前列腺癌患者行直肠腔内超声引导下经会阴前列腺穿刺活检。分3组。A组：184例,为指检前列腺触及结节或前列腺增大、质硬怀疑前列腺癌者;B组：84例,为因前列腺增生行直肠腔内超声检查发现有异常回声区域者;C组：108例,为指检未及明显硬节而血中PSA＞10ng/ml者。结果：3组穿刺活检阳性率分别为44．5％（82／184）,29．8％（25／84）,57．4％（62／108）。结论：直肠腔内超声引导下经会阴穿刺活检取材准确,能清楚显示穿刺针的径路和深度,避免损伤邻近脏器,可重复操作,明显提高穿刺活检的阳性率。     

Prognosis and predictive factors of prostate cancer in the prostatic biopsy

This paper reviews the morphological cancer diagnosis criteria on needle biopsies, the predictive meaning of the pathological lesions of HGPIN, HAA, and P.I.A and the peculiar histopathological patterns in prostatic adenocarcinoma. We present the histological parameters that the pathologist has to informe in the diagnositic, on the routine prostate needle biopsy: Gleason histological degree, histological type, number of invaded cilindres, percentage of tumor in each cylinder, location of the biopsy and ymphovascular invasion. We also emphasize the importance of new predictive biomarkers nowadays in study and probably involved in tumor progression.     

Examination for indication of systematic biopsy for diagnosis of prostate cancer]

BACKGROUND: Systematic biopsy has been commonly used for detection of prostate cancer. Nevertheless, as this examination occasionally gives patients severe complications it is necessary to give careful consideration for application of this examination. Thus, we analyzed retrospectively 145 cases who underwent transrectal ultrasonography (TRUS) guided systematic biopsy to evaluate the application of systematic biopsy, correlating with the findings of digital rectal examination (DRE), prostate specific antigen (PSA), the findings of transrectal ultrasonography (TRUS) and the results of biopsies. METHODS: Between May, 1995 and May, 1997, 143 patients who were suspected to have prostate cancer with either of PSA and DRE, and 2 patients who received visual laser ablation of prostate (VLAP), underwent TRUS guided systematic biopsy of prostate. We evaluated diagnostic efficacy of PSA, DRE, TRUS, prostate-volume-specific PSA, and PSA density (PSAD). RESULTS: Sensitivity, specificity and positive predictive value (P.P.V.) are 78.4%, 62.8% and 53.5% for DRE, 100.0%, 4.4% and 41.8% for PSA, 88.2%, 60.0% and 52.9% for TRUS, 87.8%, 72.1% and 64.2% for prostate-volume-specific PSA, 100.0%, 30.6% and 45.4% for PSAD, respectively. Ten of 69 patients (14.5%) whose PSA levels were 4.0 to 10.0 ng/ml were diagnosed as cancer, and positive for both or either of DRE and TRUS. Twenty-seven who were negative for both of DRE and TRUS were not diagnosed as prostate cancer. Using the combination of prostate-volume-specific PSA, DRE and TRUS, we could eliminate 29 non-cancer men (21.5%) whose PSA level was greater than 4.0 ng/ml from systematic biopsy. CONCLUSION: On the diagnosis of prostate cancer, the combination of prostate-volume-specific PSA, DRE and TRUS is very useful to exclude unnecessary systematic biopsy, if an urologist could be used to and trained for DRE and TRUS.     

Indication of repeat prostate biopsy for the diagnosis of prostate cancer

There is no standard criterion for repeat prostate biopsy in cases with a negative initial biopsy. We retrospectively analyzed our experience of repeat prostate biopsy to establish its indication for the diagnosis of prostate cancer. From April 1997 to March 2005, 35 consecutive patients underwent repeat prostate biopsy at the department of Urology, Asahikawa Medical College Hospital because of clinically suspicious prostate cancer despite a negative initial biopsy. We compared patients' age, number of cores obtained during repeat biopsy, digital rectal examination findings, total prostate volume, the time from the first to the last biopsy, total prostate specific antigen (PSA) value, free PSA/total PSA ratio, PSA density and PSA velocity between cancer-positive and cancer-negative groups. Prostate cancer was detected in 17 of 35 patients (49%). Fifteen patients with prostate cancer were diagnosed by the first repeat biopsy and other 2 patients were diagnosed by the second repeat biopsy. A statistically significant difference was only noted in age and PSA density. Persistently elevated total PSA and a higher PSA density in cases with a negative initial biopsy might be a good indication of repeat prostate biopsy for the diagnosis of prostate cancer.     

前列腺小体外泄蛋白在前列腺癌诊断中的意义

目的探讨前列腺小体外泄蛋白(PSEP)指标在前列腺癌诊断中的价值。方法2015年3月至2017年3月间收集870例前列腺穿刺活检患者的穿刺前尿样及相关临床资料,采用酶联免疫法检测尿样中PSEP水平,分析尿液PSEP水平和前列腺癌的相关性。结果经病理诊断穿刺阳性370例(前列腺癌患者组),阴性500例(阴性组)。前列腺癌患者的年龄和前列腺特异抗原(PSA)水平均高于阴性组(P<0.05)。前列腺癌患者组穿刺组织中伴随炎症的比例低于阴性组(P<0.05),尿PSEP水平亦低于阴性组(P=0.013)。亚组分析显示在PSA 4~10ng/mL这一区间中,两组之间的尿PSEP水平存在差异(P=0.038)。PSEP水平与前列腺组织学炎症存在相关性(r=0.094,P=0.009)。结论伴随组织学炎症者确诊前列腺癌的风险较低,尿液PSEP水平与前列腺组织学炎症有关,前列腺癌患者尿PSEP水平显著降低,尿液PSEP检测作为辅助指标有助于减少PSA灰区患者因炎症干扰造成的不必要前列腺穿刺活检。     

The expanding role of epigenetics in the development, diagnosis and treatment of prostate cancer and benign prostatic hyperplasia

PURPOSE: Prostate cancer research has focused significant attention on the mutation, deletion or amplification of the DNA base sequence that encodes critical growth or suppressor genes. However, these changes have left significant gaps in our understanding of the development and progression of disease. It has become clear that epigenetic changes or modifications that influence phenotype without altering the genotype present a new and entirely different mechanism for gene regulation. Several interrelated epigenetic modifications that are altered in abnormal growth states are DNA methylation changes, histone modifications and genomic imprinting. We discuss the status of epigenetic alterations in prostate cancer and benign prostatic hyperplasia progression. In addition, the rationale and status of ongoing clinical trials altering epigenetic processes in urological diseases are reviewed. MATERIALS AND METHODS: An online search of current and past peer reviewed literature on DNA methylation, histone acetylation and methylation, imprinting and epigenetics in prostate cancer and benign prostatic hyperplasia was performed. Relevant articles and reviews were examined and a synopsis of reproducible data was generated with the goal of informing the practicing urologist of these advances and their implications. RESULTS: Only 20 years ago the first study was published demonstrating global changes in DNA methylation patterns in tumors. Accumulating data have now identified specific genes that are commonly hypermethylated and inactivated during prostate cancer progression, including GSTpi, APC, MDR1, GPX3 and 14-3-3sigma. Altered histone modifications, including acetylation and methylation, were also recently described that may modify gene function, including androgen receptor function. These epigenetic changes are now being used to assist in prostate cancer diagnosis and cancer outcome prediction. Epigenetic changes appear to have a role in benign prostatic hyperplasia development as well as in the susceptibility of the prostate to developing cancer. Treatments involving 5-aza-deoxycytosine and other, more selective DNA methyltransferase inhibitors remove methyl residues from silenced genes, generating re-expression, and are currently being used in therapeutic trials. Histone deacetylase inhibitors have shown promise, not only by directly reactivating silenced genes, but also as regulators of apoptosis and sensitizers to radiation therapy. CONCLUSIONS: Evolving data support a significant role for epigenetic processes in the development of prostate cancer and benign prostatic hyperplasia. Epigenetic changes can predict tumor behavior and often distinguish between genetically identical tumors. Targeted drugs that alter epigenetic modifications hold promise as a tool for curing and preventing these diseases.     

Extended and saturation prostatic biopsy in the diagnosis and characterisation of prostate cancer: a critical analysis of the literature

OBJECTIVE: To review and critically analyse all the recent literature on the detection and characterisation of prostate cancer by means of extended and saturation protocols. METHODS: A systematic review of the literature was performed by searching MedLine from January 1995 to April 2007. Electronic searches were limited to the English language, and the key words "prostate cancer," "diagnosis," "transrectal ultrasound (TRUS)," "prostate biopsy," and "prognosis" were used. RESULTS: The prostate biopsy technique has changed significantly since the original Hodge sextant biopsy protocol. Several types of local anaesthesia are now available, but periprostatic nerve block (PPNB) has proved to be the most effective method to reduce pain during TRUS biopsy. It remains controversial whether PPNB should be associated with other medications. The optimal extended protocol (sextant template with at least four additional cores) should include six standard sextant biopsies, with additional biopsies (up to 12 cores) taken more laterally (anterior horn) to the base and medially to the apex. Repeat biopsies should be based on saturation biopsies (number of cores >/= 20) and should include the transition zone, especially in a patient with an initial negative biopsy. As a means of increasing accuracy of prostatic biopsy and reducing unnecessary prostate biopsy, colour and power Doppler imaging, with or without contrast enhancement, and elastography now can be successfully adopted, but their routine use is still controversial. CONCLUSION: Extended and saturation biopsy schemes should be performed at first and repeat biopsy, respectively. The widespread use of local anaesthesia makes the procedures more comfortable.     

The value of prostatic specific antigen density in the early diagnosis of prostate cancer

In order to differentiate benign from malignant prostatic lesions, 42 patients were evaluated using the prostate specific antigen density (PSAD) test. All patients were evaluated with PSA determination, digital rectal examination (DRE), transrectal ultrasonography (TRUS) and ultrasound-guided prostatic biopsies. PSA was analyzed by the I-MX ABBOT assay. PSAD was determined by dividing the serum PSA by the volume of the prostate. Prostatic biopsies identified cancer in 3 of the 42 patients (6.38%). It is concluded that PSAD is valuable for the early diagnosis of localized prostatic carcinoma, especially when there are negative findings from DRE and/or TRUS.     

经直肠超声造影引导前列腺穿刺活检诊断前列腺癌

目的探讨经直肠超声造影(CETRUS)引导前列腺穿刺活检对前列腺癌的诊断价值。方法对79例可疑前列腺癌患者分别行常规经直肠超声(TRUS)、CETRUS及经直肠前列腺穿刺活检。以病理结果为标准,对比TRUS、CETRUS和TRUS联合CETRUS引导经直肠前列腺穿刺活检对前列腺癌的诊断效能。结果 79例中,病理诊断为前列腺腺癌36例,前列腺良性增生43例。35例CETRUS见异常征象,其中30例病理诊断恶性,诊断敏感度83.33%(30/36),特异性88.37%(38/43),准确率86.08%(68/79)。39例TRUS见异常征象,其中24例病理诊断为恶性病变,诊断敏感度66.67%(24/36),特异度65.12%(28/43),准确率65.82%(52/79)。TRUS联合CETRUS诊断前列腺癌30例,敏感度83.33%(30/36),特异度72.09%(31/43),准确率77.22%(61/79)。ROC曲线结果显示,TRUS、CETRUS、TRUS联合CETRUS引导前列腺穿刺活检对诊断前列腺癌的AUC分别为0.740、0.859及0.777,CETRUS的诊断效能高于TRUS及TRUS联合CETRUS(Z=2.371、2.858,P=0.018、0.004)。结论 CETRUS引导前列腺穿刺活检对前列腺癌的诊断效能较高。     

超声引导下经直肠10针前列腺穿刺活检对前列腺癌诊断的研究

目的 探讨超声引导下经直肠10针前列腺穿刺活检术诊断前列腺癌的临床应用价值。方法 回顾性分析104例经直肠10针穿刺活检的可疑前列腺癌患者。在标准6针系统穿刺法基础上改进确定A组穿刺点后,依据前列腺解剖分区,在经直肠B超显示的前列腺冠状切面的两侧外侧区域（B组）及中央区域（C组）增加4针穿刺点,施行前列腺活检,病例标本分别标注送病理学检查。结果 104例患者中42例确诊为前列腺癌,总阳性率为40.4%。其中所设置的A组穿刺位点阳性25例（占总检出阳性的59.5%）,B组位点阳性9例（21.4%）,C组位点阳性8例（19.0%）。假阴性率为4.7%,术后并发症总发生率为15.4%,未出现严重并发症。结论 超声引导下经直肠10针前列腺穿刺活检术安全、可靠,可以作为临床理想的初次前列腺穿刺活检术式之一。     

The role of prostate-specific antigen in the diagnosis and treatment of prostatic adenocarcinoma]

Serum prostate-specific antigen (PSA) levels were determined in four groups of patients with prostatic carcinoma: 230 untreated patients with adenocarcinoma of the prostate after careful clinical staging; in 102 patients with localized prostatic carcinoma who were treated by radical prostatectomy; in 183 patients after radiation therapy for adenocarcinoma of the prostate; and in 45 antiandrogen-treated patients with documented metastatic disease. Within each treatment modality PSA proved to be a powerful tool in predicting stage and prognosis of each patient. In the untreated group the PSA level was directly proportional to advancing clinical stage and Gleason score. The rate of increase of PSA in clinical stage A and B cancer patients suggested a doubling time of at least 2 years. In the group of patients who underwent radical prostatectomy, PSA correlated extremely well with the tumor volume and had a high predictive value for pelvic lymph node metastasis. No patient with pelvic lymph node metastasis achieved an undetectable PSA level following radical prostatectomy without adjunctive therapy. Both anti-androgen and radiation treatment were followed initially by dramatic falls in serum PSA concentrations, but the majority of patients soon experienced a reversal of this initial response, signifying early failure and again providing new information unavailable from any other source.     

The ability of systematic transrectal ultrasound guided biopsy to detect prostate cancer in men with the clinical diagnosis of benign prostatic hyperplasia.

Multiple directed and systematic ultrasound guided biopsies of the prostate were performed in 73 men with the clinical diagnosis of benign prostatic hyperplasia (BPH). Seven men (10%) had prostate cancer. Of the 67 patients with benign biopsies 40 underwent subsequent transurethral prostatectomy and 2 (5%) had prostate cancer. Multiple directed and systematic biopsies of the prostate detected 78% of the nonpalpable prostate cancers diagnosed in the study population. Radical prostatectomy was performed in all 9 men with prostate cancer: there were 3 small organ-confined tumors, 5 large organ-confined tumors and 1 stage C tumor with 1 focus of microscopic capsular penetration. Our results suggest that multiple directed and systematic ultrasound guided biopsies are capable of detecting low volume nonpalpable prostate cancer in men with BPH. However, the exact indication for pre-treatment ultrasound guided biopsy of the prostate in men with symptomatic BPH remains unclear. It may be that use of this modality is most appropriate for patients undergoing pharmacological therapy or balloon dilation of BPH rather than for those undergoing transurethral prostatectomy.