经直肠超声引导13点前列腺系统穿刺活检术160例报告

目的　探讨经直肠超声引导 13点前列腺系统穿刺活检术诊断前列腺癌的临床价值。　方法　对 160例直肠指诊阳性和 (或 )PSA >4ng/ml的患者行经直肠超声引导 13点前列腺系统穿刺活检术。即在标准的经直肠超声引导 6点前列腺系统穿刺活检术同时 ,增加前列腺中间部位及前列腺两侧旁正中线远侧的穿刺点数 ,共穿刺活检 13点。将增加的 7点活检部位病理结果与标准的 6点前列腺系统穿刺活检术进行比较。　结果　 160例患者中确诊为前列腺癌者 5 6例 ( 3 5 % )。 5 6例患者如按 6点穿刺方法 ,将有 12例患者漏诊 ,占 2 1%。 160例患者均未出现严重并发症。　结论　经直肠超声引导 13点前列腺系统穿刺活检术可明显提高前列腺癌的临床检出率     

Correlation of Transrectal Ultrasonography and Core Biopsies with Pathology Results in Radical Prostatectomy Specimens

Background: We compared preoperative tumor location, as identified by transrectal ultrasonography (TRUS), and TRUS-guided core biopsies with the final histopathological examination of radical prostatectomy specimens.
Methods: Thirty patients who had radical retropubic prostatectomy after evaluation with TRUS are included in the study. Diagnosis of prostate cancer was established with TRUS-guided systematic (3 cores from base, mid and apex of the peripheral zone, and 1 core from the transition zone of each side of the prostate) and lesion-directed core biopsies in all cases. Each prostate gland was halved for histopathological examination and results are reported in terms of "sides".
Results: Histopathological examination of the prostatectomy specimens revealed prostate cancer bilaterally in 29 glands (58 sides) and unilaterally in 1 gland. Preprostatectomy TRUS examinations missed cancer in 29 sides, and core biopsies were negative for cancer in 14 sides.
Conclusion: This study revealed that 49% of prostate cancer lesions (n=29 sides) were not recognized on TRUS and 52% of those (n = 15 sides) were diagnosed only by additional systematic biopsies. Furthermore, even with TRUS-guided systematic core biopsies, failure to detect the prostate cancer lesions may be as high as 24% (n = 14 sides).     

Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer

PURPOSE: The standard sextant protocol for obtaining transrectal ultrasound guided biopsy of the prostate has been shown to underestimate the presence of prostate cancer. Studies have demonstrated an increased cancer detection rate with additional laterally directed biopsies. We compared the sensitivity of individual biopsy cores and evaluated combinations of these cores to identify an optimal biopsy strategy. MATERIALS AND METHODS: A total of 396 consecutive patients underwent biopsy of the lateral peripheral zone in addition to standard sextant biopsy. The cancer detection rate for each biopsy core was calculated. The sensitivity of different combinations of biopsy cores was compared with those of standard sextant biopsies and with a 12 core biopsy protocol that combined the standard sextant biopsy with a complete set of laterally directed cores. RESULTS: Cancer was detected in 160 of 396 (40.3%) patients. Of the possible combinations of biopsy cores a strategy that included laterally directed cores at the base, mid gland and apex of the prostate with mid lobar base and apical cores detected 98.5% of cancers. The detection rate of this 10 core biopsy regimen was significantly better than that of the standard sextant protocol (p < or =0.001), and was equivalent to that of the 12 core regional biopsy (p > or =0.302). CONCLUSIONS: The standard sextant protocol failed to detect a large proportion of cancers located laterally in the peripheral zone. A 10 core biopsy regimen that combined laterally directed cores at the base, mid gland and apex of the prostate with mid lobar biopsy cores at the base and apex maximizes the sensitivity of transrectal ultrasound guided systematic biopsy.     

Computerized transrectal ultrasound (C-TRUS) of the prostate: detection of cancer in patients with multiple negative systematic random biopsies

This study was designed to compare the diagnostic yield of computerized transrectal ultrasound (C-TRUS) guided biopsies in the detection of prostate cancer in a group of men with a history of multiple systematic random biopsies with no prior evidence of prostate cancer. The question was asked: Can we detect cancer by C-TRUS that has been overlooked by multiple systematic biopsies? The entrance criteria for this study were prior negative systematic random biopsies regardless of number of biopsy sessions or number of individual biopsy cores. Serial static TRUS images were evaluated by C-TRUS, which assessed signal information independent of visual gray scale. Five C-TRUS algorithms were utilized to evaluate the information of the ultrasound signal. Interpretation of the results were documented and the most suspicious regions marked by C-TRUS were biopsied by guiding the needle to the marked location. Five hundred and forty men were biopsied because of an elevated PSA or abnormal digital rectal exam. 132 had a history of prior negative systematic random biopsies (1–7 sessions, median: 2 and between 6 and 72 individual prostate biopsies, median: 12 cores). Additionally, a diagnostic TUR-P of the prostate with benign result was performed in four patients. The PSA ranged from 3.1–36 ng/ml with a median of 9.01 ng/ml. The prostate volume ranged from 6–203 ml with a median of 42 ml. Of the 132 patients with prior negative systematic random biopsies, cancer was found in 66 (50%) by C-TRUS targeted biopsies. In this group the median number of negative biopsy sessions was two and a median of 12 biopsy cores were performed. From literature we would expect a cancer detection rate in this group with systematic biopsies of approximately 7%. We only found five carcinomas with a Gleason Score (GS) of 5, 25 with GS 6, 22 with GS 7, 8 with GS 8 and even 7 with GS 9. The results of this prospective clinical trail indicates that the additional use of the C-TRUS identifies clinical significant cancerous lesions that could not been visualized or detected by systematic random biopsies in a very high percentage. In addition, the results of the study support the efforts to search for strategies that utilize expertise and refinement of imaging modalities rather than elevating the number of random biopsies (f.e. 141 cores in one session) in the detection of prostate cancer.     

Clinical evaluation of transrectal power Doppler imaging in the detection of prostate cancer

To evaluate the clinical usefulness of power Doppler imaging (PDI), we compared this method to gray-scale transrectal ultrasound (TRUS) in the detection of prostate cancer. A total of 101 men with abnormally high serum prostate specific antigen (PSA) levels and/or abnormal digital rectal examination (DRE) findings were assessed using TRUS and PDI. Random systematic sextant and bilateral far lateral prostate biopsies were performed in all cases. In addition, when TRUS revealed a hypoechoic lesion or PDI revealed a hypervascular lesion (HVL), these lesions were directly biopsied. Of the 101 patients, 48 (47.5%), 42 (41.5%) and 42 (41.5%) were suspicious of having prostate cancer by DRE, TRUS and PDI, respectively. Prostate needle biopsy revealed prostate cancer in 39 patients (38.6%) and benign prostatic diseases in 62 patients (61.4%). If prostate needle biopsy was avoided when PDI was negative, then PDI eliminated the need for biopsy in 59 of the 101 patients (rate of biopsy procedures saved: 58.4%) and missed only 8 (13.6%) prostate cancers. Moreover, in 63 patients with intermediate PSA (3-10 ng/ml), the rate of biopsy procedures saved by DRE, TRUS, and PDI was 60.3%, 65.1%, and 68.3%, respectively, and the rate of cancers missed was 26.3%, 19.5%, and 14.0%, respectively. In a total of 826 specimens of TRUS-guided prostate biopsy, 126 (15.3%) specimens had adenocarcinoma. Site by site based analysis of the present series revealed 34.1% of prostate cancer sites were isoechoic and hypervascular. On a site by site basis, PDI had better sensitivity, specificity, positive predictive value and negative predictive value than TRUS. In 48 patients without abnormal DRE findings, on a site by site basis, the sensitivities of TRUS and PDI were 22.9% and 34.4%, respectively. Gleason score was associated with a positive rate of PDI on both a patient basis and site by site basis. From these results, on a patient basis, we conclude that PDI was helpful in the indication for prostate biopsy for all patients or patients with intermediate PSA level. On a site by site basis, PDI may be able to select prostate cancer sites at biopsy, in particular in patients without abnormal DRE findings.     

经直肠超声引导下经会阴前列腺穿刺315例分析

目的 探讨经直肠超声（TRUS）引导下经会阴前列腺穿刺的临床意义。方法 对315例PSA〉4ng／ml、直肠指检异常或B超发现异常回声的患者行经会阴的6点系统加异常回声处活检。年龄43～91岁，平均72岁。PSA〈4ng／ml者66例，4～10ng／ml者96例，10～20ng／ml者90例，〉20ng／ml者63例。结果 穿刺活检证实为前列腺癌111例，阳性率35．2％。PSA〉4ng／ml、指检异常、B超发现异常回声及PSAD〉0．15者穿刺阳性率分别为43．4％（108／249）、42．9％（75／175）、32．8％（63／192）及52．1％（75／144）。以PSAD〉0．15时的阳性率为最高，与其余3种标准相比差异有统计学意义。结论 TRUS引导下经会阴前列腺穿刺准确率高，并发症少而轻，是诊断前列腺癌的重要方法。     

超声引导系统活检筛查前列腺癌的临床意义

目的 探讨B超引导下前列腺穿刺筛查前列腺癌的临床意义。方法 采用6针系统活检加结节处2－4针活检,197例前列腺特异抗原（PSA）＞4ng/ml或有前列腺结节的患者行 超声引导下前列腺穿刺活检,对4例PSA持续升高者行重复穿刺。结果 有结节者107例中发现前列腺癌34例（31.8%),90例无结节者中发现前列腺癌11例（12.2％）。分析显示：PSA越高,穿刺活检阳性率越高。重复穿刺者4例中发现前列腺癌1例。结论 对有前列腺结节或PSA＞4ng/ml的前列腺增生患者应行系统活检以筛查前列腺癌,穿刺阴性后如PSA持续 增高则应重复穿刺。     

Lateral biopsies added to the traditional sextant prostate biopsy pattern increases the detection rate of prostate cancer

Urologists routinely use the systematic sextant needle biopsy technique to detect prostate cancer. However, recent evidence suggests that this technique has a significant sampling error and data based upon whole-mounted step-sectioned radical prostatectomy specimens using a three-dimensional computer-assisted prostate biopsy simulator suggests that an increased detection rate is possible using laterally placed biopsies. The simulated 10-core biopsy pattern (traditional sextant biopsy cores and four laterally placed biopsies in the right and left apex and mid portion of the prostate gland) was shown to be superior to the traditional sextant biopsy. The objective of this pilot study was to confirm the higher prostate cancer detection rate obtained using the 10-core biopsy pattern in patients. We reviewed data on 35 consecutive patients with a pathologic diagnosis of prostate cancer biopsied by a single urologist using the 10-core biopsy pattern. The frequency of positive biopsy was determined for each core. Additionally, the sextant and 10-core prostate biopsy patterns were compared with respect to prostate cancer detection rate. Of the 35 patients diagnosed with prostate cancer, 54.3%(19/35) were diagnosed by the sextant biopsy only. The 10-core pattern resulted in an additional 45.7%(16/35) of patients being diagnosed solely with the laterally placed biopsies. The laterally placed biopsies had the highest frequency of positive biopsies when compared to the sextant cores. In conclusion, biopsy protocols that use laterally placed biopsies based upon a five region anatomical model are superior to the routinely used sextant prostate biopsy pattern. Prostate Cancer and Prostatic Diseases (2000) 3, 43-46     

Computergestützter transrektaler Ultraschall (C-TRUS) in der Diagnostik des Prostatakarzinoms

In the diagnosis of prostate cancer digital rectal examination and transrectal ultrasound (TRUS) are the most utilized methods for clinical evaluation. However, both methods are not able to differentiate between benign and malignant findings with a high amount of certainty. Nevertheless, TRUS is an excellent tool to guide biopsies in practically any region of the prostate. The most significant problem of visual TRUS interpretation is the lack of specificity, especially being an inexperienced user. In order to enhance the diagnostic capabilities of TRUS we developed a computerized analysis of the TRUS signal information (C-TRUS/ANNA), which was validated by the pathohistologic findings of radical prostatectomies. The question was asked: Can C-TRUS detect cancer that has been missed by even multiple systematic biopsies? The entrance criteria was prior negative systematic random biopsies regardless of number of biopsy sessions or number of individual biopsy cores. Five C-TRUS subvisual algorithms were utilized to evaluate the information of the ultrasound signal. The most suspicious regions were marked by C-TRUS and biopsied by guiding a needle into that specific location. In this study 132 with a history of 6-72 negative systematic random biopsies (median: 12 cores) were evaluated by C-TRUS. The PSA ranged from 3.1–36 ng/ml with a median of 9.01 ng/ml. C-TRUS detected in 66 (50%) of these 132 patients cancer by targeted biopsies. In thes 66 men the median number of negative biopsy sessions were two and a median of 12 biopsy cores had been taken. From the literature, we would expect a cancer detection rate in this group with systematic sextant biopsies of about 7%. Only five of the detected carcinomas showed a Gleason Score (GS) of 5, were as 25 had a GS of 6, 22 a GS of 7 and 15 a GS above 7. The results of this prospective clinical trail indicate that C-TRUS is able to identify clinically significant cancers that were missed by even multiple systematic random biopsies. In addition, the concept of searching for strategies that utilize expertise and refinement of imaging modalities is supported rather than just elevating the number of random biopsies (i.e. 141 cores in one session).     

Effect of dimensions and volume of the prostate on cancer detection rate of 12 core prostate biopsy

Purpose To evaluate if volume or any of the three dimensions of prostate influences cancer detection rate by 12-core transrectal ultrasound (TRUS) guided prostate biopsy. Materials and methods We have searched our database for patients who underwent 12 core TRUS guided prostate biopsy with PSA values between 4.0 and 9.9 ng/ml, benign digital exam and no suspicious lesions at TRUS. The measurements of three dimensions and volume of the prostate of 99 patients were correlated with cancer detection rates of biopsy. Results There were no statistically significant differences between patients with prostate cancer or with benign histopathologic result for mean age, PSA and % PSA. Patients without cancer had a significantly higher mean prostate volume (58.88 cc) than patients with cancer (48.85 cc) (P = 0.038). A volume of 48.5 cc was determined as a cut-off value above which cancer detection rate decreases. Of the three dimensions, only the difference for the craniocaudal dimension between benign and malignant groups was marginally significant (P = 0.052). Conclusions With 12 core biopsy, cancer detection rate is lower in patients with prostates larger than 48.5 cc. Further studies comparing biopsy results with prostatectomy specimens can clarify whether these results necessitates higher number of cores for such patients.     

Impact of additional sampling in the TRUS-guided biopsy for the diagnosis of prostate cancer

AIM: To evaluate the diagnostic value of 10+ systematic sampling technique when performing transrectal ultrasound-guided (TRUS) prostate biopsy, compared with the sextant biopsy technique for patients with suspected prostate cancer. METHODS: 286 patients with suspected prostate cancer were included in the study. Patients were eligible for the study if they had serum levels of prostate-specific antigen (PSA) >4 ng/ml or ratio PSA <0.25 and/or an abnormal digital rectal examination (DRE). The population sample was divided in three groups: (1) those with positive PSA, PSA ratio and DRE (70 patients); (2) those with positive PSA and PSA ratio but normal DRE (178 patients), and (3) those with positive PSA and PSA ratio, positive PSA velocity and a negative biopsy in the previous 6-month period (38 patients). In addition to the conventional sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone (10 core biopsy protocol). Additional cores (total of 12-14) were also randomly selected in case of larger prostates (>60 ml) or from suspicious foci revealed by transrectal ultrasound. All additional biopsy cores were submitted separately to the pathological department. RESULTS: Cancer was detected in 55.7% (39/70) and 69% (48/70) of the patients (for sextant core and for the extended biopsy protocols, respectively) in the first study group, 11% (20/178) and 23% (41/178) of the patients (for the sextant and the extended biopsy protocols, respectively) in the second study group, and 42% (16/38) and 63% (24/38) of the patients (for the sextant and the extended biopsy protocols, respectively) in the third study group. The addition of the lateral peripheral zone (PZ) of the prostate to the sextant biopsy showed a 23, 105 and 50% increase in the number of cancers diagnosed in the first, second and third study groups, respectively. The improvement of cancer detection rate (sensitivity) was statistically significant for all groups evaluated. CONCLUSION: The 10+ systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer compared to the sextant biopsy technique alone, especially when performed in men with positive PSA, PSA ratio, and negative DRE.     

Ultrasound-guided transrectal extended prostate biopsy： a prospective study

AIM: To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer. Methods: One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department. Results: Cancer detection rates were 27.6% (42/152) and 19.7% (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6% (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3% (34/116). When serum PSA was 4-10 ng/mL TRUS-guided biopsy detected cancer in 20.6%, while the detection rate was 32.4% and 47.0% when serum PSA was 10-20 ng/mL and above 20 ng/mL, respectively. Conclusion: The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6% when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer.     

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.     

Significance of routine transition zone biopsies in Japanese men undergoing transrectal ultrasound-guided prostate biopsies

BACKGROUND: The objective of this study was to evaluate the clinical significance of additional routine transition zone (TZ) biopsies in Japanese men undergoing transrectal ultrasound (TRUS)-guided systematic 8-core peripheral zone (PZ) biopsies. METHODS: Between October 2002 and December 2004, a total of 788 consecutive patients underwent TRUS-guided systematic biopsy of the prostate for the fi rst time. As a rule, 10 cores were taken from each patient; that is, 8 cores from the PZ, including the standard sextant cores and 2 cores from the anterior lateral horns, and 2 additional cores from the bilateral TZ. The cancer detection rate was calculated according to several parameters. We also assessed the disease extent on radical prostatectomy specimens according to the cancer location within the biopsy specimens. RESULTS: Prostate cancer was detected by 10-core biopsies in 209 (26.5%) of the 788 patients, and 11 of these patients had positive cores only in the TZ; that is, the increase in cancer detection rate by sampling two additional cores from the TZ was 5.3%. Among 209 patients diagnosed as having prostate cancer, radical prostatectomy without any neoadjuvant therapy was performed in 59 patients with positive biopsy cores in the PZ, 7 in the TZ and 32 in both the PZ and TZ. Patients with positive cores in both zones showed significantly less favorable characteristics, indicating more advanced disease than that in those with positive cores in either zone. CONCLUSIONS: Routine TZ biopsy did not significantly increase the detection rate of prostate cancer; however, the anatomical location of positive biopsy cores could provide additional information concerning disease extension in patients undergoing radical prostatectomy.     

An extended 10-core transrectal ultrasonography guided prostate biopsy protocol improves the detection of prostate cancer

OBJECTIVE: To evaluate the efficacy of TRUS guided 10-core biopsy strategy for Turkish patients who had biopsy of the prostate for the first time. METHODS: Between February 2001 and May 2003, 303 consecutive men with suspected prostate cancer were included in the study. Indications for TRUS guided prostate biopsy were: abnormal digital rectal examination and/or a serum PSA over 2.5 ng/ml. All of the patients underwent a 10-core biopsy protocol with additional core from the each suspicious area detected by TRUS. Besides the sextant technique, 4 more biopsies were obtained from the lateral peripheral zone. We aimed to analyze whether cancer detection improved with the extended versus the standard sextant biopsy in our series overall and in each subgroup. RESULTS: Of 303 patients 94 (31%) were positive for prostate cancer. Median age and PSA of prostate cancer patients were significantly higher than of the non-cancer patients. Besides prostate volumes of the cancer patients were significantly lower than of the non-cancer ones. The cancer detection rates were 31% (94/303) and 23.1% (70/303) for the 10-core biopsy strategy and sextant biopsy strategies, respectively. Thus the 10-core biopsy technique increased cancer detection rate by 25.5% (24/94) for the whole group of patients. A statistically significant number of additional cancers were detected with 10-core biopsy strategy for all the subgroups of the patients. Furthermore 10-core biopsy protocol detected more cancers (at least 6.4%) than all the probable different combinations of 8-core biopsy protocols. Among the 94 cancer patients, biopsy from a suspicious area revealed cancer in 31.9% of them; however, in all of these patients cancer was already present in the 10-core biopsy. On the other hand, lesion biopsies revealed 5.7% additional cancers if sextant technique was used. There were only 3 (0.9%) serious complications requiring hospitalization and all 3 were infections controlled by appropriate antibiotics. CONCLUSION: Adding 4 lateral peripheral biopsies to the conventional sextant biopsy (10-core biopsy strategy) technique has increased the cancer detection rate by 25.5% without significant morbidity and without increasing the number of insignificant cancers. 10-core biopsy protocol was superior to all probable 8-core biopsy protocols in our study group. Additional biopsies from suspicious areas detected by transrectal ultrasonography revealed no further benefit if 10-core technique was used. We therefore suggest that 10-core biopsy protocol should be the preferred strategy in early detection of prostate cancer.     

Increasing prostate biopsy cores based on volume vs the sextant biopsy: a prospective randomized controlled clinical study on cancer detection rates and morbidity

OBJECTIVE: To determine if a volume-adjusted increase in the number of biopsy cores could detect more prostate cancers than the standard sextant biopsy alone, without increasing morbidity, and to determine its applicability in Malaysian patients, as a standard sextant biopsy misses 20-25% of prostate malignancies. PATIENTS AND METHODS: In a prospective randomized study of patients undergoing transrectal ultrasonography (TRUS)-guided biopsy for a prostate-specific antigen (PSA) level of 4-20 ng/mL without abnormal digital rectal examination (DRE), the men were divided into five main groups (A-E) with prostate volumes of <20, 20-40, 40-60, 60-80 and >80 mL, respectively. Patients in groups B-E were randomized into sextant (B1 to E1) and increased biopsy-core subgroups, i.e. B2 (eight cores), C2 (10 cores), D2 (12 cores) and E2 (14 cores). The morbidity profile was also evaluated during and after TRUS biopsy, assessing a pain score, rectal bleeding, haematuria, haemospermia and development of fever. In all, 132 patients were recruited (mean age 67.8 years; mean PSA 9.41 ng/mL). RESULTS: The overall cancer detection rate was 24% (32 men). Taking more cores detected 65.5% of cancers, and the sextant biopsy 34.5% (P = 0.0025), but did not increase the overall morbidity. CONCLUSIONS: The volume-adjusted, increased-core regimen significantly increased the positive biopsy rate of TRUS-guided prostate biopsies with no added morbidity.     

Documenting the location of prostate biopsies with image fusion

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Currently, systematic prostate biopsies are obtained with minimal information about their actual location. This study demonstrates that a electromagnetically tracked ultrasound probe can be used to guide biopsies into specific areas of the prostate. By registering the ultrasound to an MRI scan of the prostate, obtained prior to biopsy, it is possible to accurately map the location of biopsies. Thus, if a patient requires a repeat biopsy, or there is a question about whether a specific area of the prostate was sampled, this system can be used to more accurately guide biopsies in the future. OBJECTIVE To develop a system that documents the location of transrectal ultrasonography (TRUS)‐guided prostate biopsies by fusing them to MRI scans obtained prior to biopsy, as the actual location of prostate biopsies is rarely known. PATIENTS AND METHODS Fifty patients (median age 61) with a median prostate‐specific antigen (PSA) of 5.8 ng/ml underwent 3T endorectal coil MRI prior to biopsy. 3D TRUS images were obtained just prior to standard TRUS‐guided 12‐core sextant biopsies wherein an electromagnetic positioning device was attached to the needle guide and TRUS probe in order to track the position of each needle pass. The 3D‐TRUS image documenting the location of each biopsy was fused electronically to the T2‐weighted MRI. Each biopsy needle track was marked on the TRUS images and these were then transposed onto the MRI. Each biopsy site was classified pathologically as positive or negative for cancer and the Gleason score was determined. RESULTS The location of all (n= 605) needle biopsy tracks was successfully documented on the T2‐weighted (T2W) MRI. Among 50 patients, 20 had 56 positive cores. At the sites of biopsy, T2W signal was considered ‘positive’ for cancer (i.e. low in signal intensity) in 34 of 56 sites. CONCLUSION It is feasible to document the location of TRUS‐guided prostate biopsies on pre‐procedure MRI by fusing the pre‐procedure TRUS to an endorectal coil MRI using electromagnetic needle tracking. This procedure may be useful in documenting the location of prior biopsies, improving quality control and thereby avoiding under‐sampling of the prostate as well as directing subsequent biopsies to regions of the prostate not previously sampled.     

Improved detection rate of prostate cancer using the 10-core biopsy strategy in Singapore

OBJECTIVES: To evaluate if changing the biopsy regime to 10 cores might improve the positive predictive value (PPV) of elevated prostate-specific antigen [PSA, elevated range, 4 to 20 ng per ml, normal range, < 4 ng per ml] for the diagnosis of prostate carcinoma. METHODS: From February 2000 to April 2001, 191 patients, mean age 64 years [range, 38 to 85 yr], underwent transrectal ultrasound [TRUS] for either elevated PSA [elevated range, 4 to 20 ng per ml] and/or abnormal digital rectal examination [DRE]. A 10-core TRUS-guided biopsy of the prostate was performed. This included the standard sextant biopsy and two additional cores for each far lateral zone. RESULTS: Using this technique, 47 out of 191 patients [24.6%] had prostate cancer. The PPV for PSA levels of 4.1 to 10.0 ng per ml and 10.1 to 20.0 ng per ml were 19.3% and 35.4%, respectively. The lateral cores contributed 21.3% of the cancer cases, which would have been missed if only sextant biopsies were performed. CONCLUSIONS: With the 10-core biopsy method, the PPV for prostate cancer for patients with a PSA in the range of 4 to 20 ng per ml was in the range of 25%. This is significantly different from previous reports. The reason for this may be due to the adoption of a better, more uniform and systematic biopsy strategy for patients with elevated PSA, or it may be a true reflection of the current population incidence. Hence, this biopsy strategy is highly recommended.     

Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate

Random systematic ultrasound guided transrectal core biopsies of the prostate were compared to directed biopsies of specific hypoechoic defects in 136 men with abnormal prostates on digital rectal examination. Prostate cancer was diagnosed in 83 of 136 patients (62 per cent). In 80 of 83 individuals (94 per cent) the cancer was detected by random systematic biopsies alone. Of 57 men in whom random systematic and directed biopsies were obtained the results of biopsy agreed in 86 per cent, while in 9 per cent random systematic biopsies found cancers missed by directed biopsies and in 5 per cent directed biopsies diagnosed cancers missed by random systematic prostate biopsies. Ultrasound guided random systematic biopsy is simple and easily learned. When combined with additional directed biopsies of the rare hypoechoic areas not included in the pattern of systematic sampling, it provides a highly accurate means to diagnose prostate cancer, minimizing observer and sampling errors. This technique of prostate mapping with 6, 1.5 cm. cores provides valuable additional information on cancer volume, Gleason grade and the potential location of surgically positive margins, all without compromising the operation or the chance for a surgical cure.     

Use of serial multiparametric magnetic resonance imaging in the management of patients with prostate cancer on active surveillance

IntroductionWe evaluated the performance of multiparametric prostate magnetic resonance imaging (mp-MRI) and MRI/transrectal ultrasound (TRUS) fusion–guided biopsy (FB) for monitoring patients with prostate cancer on active surveillance (AS).Materials and methodsPatients undergoing mp-MRI and FB of target lesions identified on mp-MRI between August 2007 and August 2014 were reviewed. Patients meeting AS criteria (Clinical stage T1c, Gleason grade≤6, prostate-specific antigen density≤0.15, tumor involving≤2 cores, and≤50% involvement of any single core) based on extended sextant 12-core TRUS biopsy (systematic biopsy [SB]) were included. They were followed with subsequent 12-core biopsy as well as mp-MRI and MRI/TRUS fusion biopsy at follow-up visits until Gleason score progression (Gleason≥7 in either 12-core or MRI/TRUS fusion biopsy). We evaluated whether progression seen on mp-MRI (defined as an increase in suspicion level, largest lesion diameter, or number of lesions) was predictive of Gleason score progression.ResultsOf 152 patients meeting AS criteria on initial SB (mean age of 61.4 years and mean prostate-specific antigen level of 5.26 ng/ml), 34 (22.4%) had Gleason score≥7 on confirmatory SB/FB. Of the 118 remaining patients, 58 chose AS and had at least 1 subsequent mp-MRI with SB/FB (median follow-up = 16.1 months). Gleason progression was subsequently documented in 17 (29%) of these men, in all cases to Gleason 3+4. The positive predictive value and negative predictive value of mp-MRI for Gleason progression was 53% (95% CI: 28%–77%) and 80% (95% CI: 65%–91%), respectively. The sensitivity and specificity of mp-MRI for increase in Gleason were also 53% and 80%, respectively. The number needed to biopsy to detect 1 Gleason progression was 8.74 for SB vs. 2.9 for FB.ConclusionsStable findings on mp-MRI are associated with Gleason score stability. mp-MRI appears promising as a useful aid for reducing the number of biopsies in the management of patients on AS. A prospective evaluation of mp-MRI as a screen to reduce biopsies in the follow-up of men on AS appears warranted.