经直肠超声引导前列腺穿刺活检术诊断前列腺癌

目的　总结和评价经直肠超声引导下前列腺穿刺活检术对前列腺癌诊断的准确率。方法　222 例直肠指检阳性或 PSA>4μg/L的患者应用经直肠超声引导下前列腺6点系统穿刺活检以明确诊断。结果　222 例受检者中病理证实前列腺结节性增生41例、前列腺炎24例、前列腺肉瘤3例、前列腺癌 154 例,其中低分化癌 74 例、中分化癌 58 例、高分化癌 22 例。术后血尿15例、发热6例,其中高热1例,经抗生素治疗后体温恢复正常、尿检阴性。结论　经直肠超声引导下前列腺穿刺活检无需麻醉,患者痛苦小、安全性高,是诊断前列腺癌的可靠方法。     

Improved detection of clinically significant, curable prostate cancer with systematic 12-core biopsy

PURPOSE: While systematic 12-core (S12C) biopsy detects more cancers than sextant biopsy, to our knowledge the clinical significance of these additionally detected tumors has not been established. We studied pathological parameters of prostatectomy specimens from patients undergoing radical prostatectomy for prostate cancer detected with a S12C biopsy to determine the clinical significance of these cancers in comparison with sextant detected cancers. MATERIALS AND METHODS: A total of 179 consecutive patients undergoing radical prostatectomy for clinically localized prostate cancer detected by S12C biopsy were studied. The groups compared consisted of the sextant core subset of the S12C and the entire S12C set. Total tumor volume, Gleason score, organ confined status, surgical margin status, seminal vesicle invasion, lymph node involvement, and clinical significance of tumors detected by sextant and by S12C templates were compared. RESULTS: S12C biopsy detected a greater number of cancers scored as moderate (Gleason score 2 to 6) or high (Gleason score 7 or greater) grade, and cancers of all sizes regardless of organ confined status than the sextant cores alone (all p <0.05). S12C biopsy identified a greater number of biologically significant and insignificant tumors regardless of how they were defined. CONCLUSIONS: Compared with the sextant set S12C biopsy detects a significantly greater number of surgically curable, biologically significant tumors as well as those that might be considered clinically insignificant.     

Predictors of prostate cancer after initial negative systematic 12 core biopsy

PURPOSE: We determined the cancer detection rate at initial systematic 12 core (S12C) biopsy and identified features associated with cancer at repeat S12C biopsy after an initial negative S12C biopsy in patients with prostate specific antigen (PSA) parameters associated with a higher risk of prostate cancer. MATERIALS AND METHODS: Between February 1999 and June 2002, 841 patients underwent initial S12C biopsy. Of these patients 99 underwent repeat S12C biopsy after initial negative S12C because of a percent free-to-total PSA of 15.0 or less and/or a yearly PSA velocity of 0.75 ng/ml or greater. The association between parameters revealed by initial biopsy and cancer at repeat biopsy was assessed. RESULTS: Of the 99 patients 21 (21.2%) had cancer at repeat biopsy. Age (p = 0.01), PSA transitional zone density (p = 0.05), and high grade PIN at initial biopsy (p = 0.01) were associated with cancer at repeat biopsy. CONCLUSIONS: In this select group of patients with PSA parameters associated with a higher risk of prostate cancer the cancer detection rate after initially negative S12C biopsy was 21%. Patients with high grade PIN on initial biopsy, advanced age and higher PSA transition zone density are at increased risk for cancer at repeat biopsy. Larger prospective studies are required to confirm these results and construct a nomogram that determines the probability of finding prostate cancer at subsequent biopsy.     

Effects of systematic 12-core biopsy on the performance of percent free prostate specific antigen for prostate cancer detection

PURPOSE: The performance characteristics of percent free (f) prostate specific antigen (PSA) for differentiating between benign prostatic hyperplasia and prostate cancer were originally established using primarily sextant biopsy. We determined whether the addition of 6 laterally directed cores to the traditional sextant prostate biopsy affects the performance of percent fPSA. MATERIALS AND METHODS: We retrospectively evaluated a cohort of 350 consecutive biopsies in men with negative digital rectal examinations and PSA between 4 and 10 ng/ml who underwent systematic 12 core biopsy (S12C) biopsy at Scott Department of Urology between March 1999 and January 2003. The effects of 6 additional, laterally directed biopsies on the sensitivity, specificity and area under the ROC curve for percent fPSA was evaluated in the 277 men in whom percent fPSA was measured. RESULTS: Cancers detected exclusively in the 6 laterally directed cores were associated with percent fPSA values similar to those in patients with a benign S12C biopsy. This resulted in a modest and yet predictable decrease in the sensitivity of percent fPSA at each biopsy threshold value without affecting specificity. There was a nonstatistically significant decrease in the area under the ROC curve with the addition of 6 laterally directed cores to sextant biopsy (medial sextant cores 0.66 vs S12C 0.60). CONCLUSIONS: The 12 core biopsy strategies have a higher cancer detection rate than sextant biopsies and they are gaining widespread acceptance. The addition of 6 laterally directed cores to traditional sextant biopsy may result in a modest decrease in the sensitivity of percent fPSA at each selected biopsy threshold without affecting specificity.     

Prostate saturation biopsy in the reevaluation of microfocal prostate cancer

PURPOSE: We evaluated the ability of an extended, 32-core repeat transrectal ultrasound prostate biopsy protocol to improve the characterization of low volume, well differentiated disease in men with a diagnosis of potentially insignificant microfocal prostate cancer, as defined by 1 single focus positive core of 10 with less than 5 mm of Gleason score 6 or less tumor on primary biopsy. MATERIALS AND METHODS: A total of 35 consecutive patients, who were 62 to 75 years old, had a median serum prostate specific antigen of 8 ng/ml (range 0.5 to 14) and a diagnosis of minimal prostate cancer, and were willing to consider observation with delayed treatment at progression, were offered repeat saturation prostate biopsy with a median of 32 cores (range 18 to 36) under local anesthesia. This biopsy was to determine whether more extensive prostate sampling would confirm or disprove the initial diagnosis of microfocal, well differentiated prostate cancer. RESULTS: The procedure was aborted in 1 patient because of massive rectal hemorrhage. Another patient had acute prostatitis with gram-negative sepsis. Of 34 evaluable biopsy sets 11 (32%) were negative for cancer, suggesting that tumor detected at the primary biopsy was probably of low volume and amenable to observation with delayed treatment. Of the biopsies 23 (68%) were positive, 17 were at multiple sites and 7 were upgraded to Gleason score 7 or greater. These patients were then considered to have significant tumors and were offered active treatment. CONCLUSIONS: This study is to our knowledge the first to describe the clinical use of prostate saturation biopsies for re-evaluating potentially insignificant prostate cancer. Of patients with minimal disease on standard 10-core biopsy, results show that this technique may be helpful for distinguishing the 30% who probably have minimal disease based on negative repeat saturation biopsy from the 70% who almost certainly have a significant tumor, as characterized by multiple positive cores, with or without an increased Gleason score. The latter patients should be offered active therapy.     

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.     

Clinical value of prostate specific antigen based parameters for the detection of prostate cancer on repeat biopsy: the usefulness of complexed prostate specific antigen adjusted for transition zone volume

PURPOSE: To our knowledge the indications for repeat prostate needle biopsy in men whose previous transrectal ultrasound guided biopsy results revealed no evidence of cancer have not yet been defined. We identified the most effective method for detecting prostate cancer on repeat biopsy. MATERIALS AND METHODS: One or more systematic repeat prostate biopsies were performed in 144 consecutive patients, including 86 with prostate specific antigen (PSA) levels between 4 and 10 ng./ml. at repeat biopsy. Men in whom cancer was detected on repeat biopsies were compared with their counterparts in terms of digital rectal examination findings, PSA based parameters and an atypical prostate on initial prostate biopsy. RESULTS: Prostate cancer was detected on repeat biopsy in 39 of the 144 patients and in 19 on subset analysis of 86. Serum PSA levels at repeat biopsy did not differ significantly in patients with and without prostate cancer. According to receiver operating characteristics analysis the alpha1-antichymotrypsin-PSA complex adjusted for transition zone volume had the greatest area under the curve values, that is 0.756 for all 144 patients and 0.768 for the subset analysis of 86. Multiple logistic regression analysis of the subset of 86 patients showed that alpha1-antichymotrypsin-PSA complex adjusted for transition zone volume was the only significant independent predictor of cancer. CONCLUSIONS: alpha1-Antichymotrypsin-PSA complex adjusted for transition zone volume was the most powerful predictor of cancer in men who had undergone previous negative prostate biopsies. This parameter may be used to avoid more unnecessary repeat biopsies with an acceptable decrease in sensitivity.     

Results of the 5 region prostate biopsy method: the repeat biopsy population

PURPOSE: The decision to repeat prostate biopsy in a patient in whom the first biopsy did not detect prostate cancer poses a challenge to urologists. Many published series show a low yield on repeat biopsy using standard techniques. We reviewed our data on the 5 region prostate biopsy method to evaluate its yield in the repeat biopsy population. MATERIALS AND METHODS: A total of 125 repeat transrectal ultrasound guided prostate needle biopsy sessions were done in 110 patients for standard indications using the 5 region method. Pathological findings were reviewed and the yield of the additional regions was analyzed. RESULTS: Patients were categorized with respect to the initial biopsy technique. In those who underwent 1 and more than 1 previous sextant biopsy the relative increase in yield of the 5 region technique over the standard sextant technique was 31% and 33%, respectively. In the cohort that underwent previous 5 region biopsy the relative increase in yield of the 5 region technique over the standard sextant technique was 38%. CONCLUSIONS: In the setting of repeat biopsy the 5 region method results in an increased yield over the sextant method. It is true in patients who have previously undergone biopsies with the sextant or 5 region technique.     

B超引导10点前列腺穿刺法诊断前列腺癌的结果分析

目的探讨经直肠超声引导下10点法前列腺穿刺活检中前列腺癌阳性结果的分布情况。方法本组473例均因PSA>4ng/ml而进行经直肠超声引导下10点法宝前列腺穿刺活检,穿刺点为在标准的系统6点(前列腺旁正中线矢状切面尖部、中部、底部)的基础上,两外侧各增加2针(外侧周缘中部、底部)。本组患者年龄为41～85岁,平均65岁;PSA水平4.1～444ng/ml,平均15.05ng/ml;前列腺体积8.0～160.0ml,平均42.17ml。对穿刺各针的阳性率及各区域独立出现的阳性率进行分析。结果穿刺总阳性率为26.6%(126/473)。前列腺各穿刺部位的阳性率为:外侧底部23.7%(112/473)、外侧中部20.7%(98/473)、底部19.5%(92/473)、中部18.4%(87/473)、尖部23.9%(113/473)。只有该区域出现阳性的分布情况:外侧底部8.7%(11/126)、外侧中部5.6%(7/126)、底部2.4%(3/126)、中部3.2%(4/126)、尖部7.1%(9/126)。各穿刺部位的阳性率具有统计学差异(P<0.01)。结论经直肠超声引导下经直肠前列腺10点法穿刺活检术可明显提高前列腺癌的临床检出率。其前列腺的尖部、外侧底部和外侧中部的穿刺阳性率要比其他部位高。     

Limitations of biopsy Gleason grade: implications for counseling patients with biopsy Gleason score 6 prostate cancer

PURPOSE: We examined the implications of underestimating Gleason score by prostate biopsy in patients with biopsy Gleason 6 prostate cancer with respect to adverse pathological findings and biochemical recurrence after radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed clinical and pathological data on a cohort of 531 patients with Gleason score 6 on prostate biopsy who underwent radical retropubic prostatectomy between June 1992 and January 2002. Patients were excluded if they received neoadjuvant androgen deprivation. Concordance between biopsy and radical prostatectomy Gleason score was examined. A comparison was made with respect to final radical prostatectomy specimen pathology and the risk of biochemical recurrence between cases that remained Gleason 6 and those with a final grade of 7 or greater. RESULTS: A total of 451 patients were included in the analysis. Mean followup was 55.1 months (range 12 to 123.4). Of the patients 184 (41%) had a Gleason score of 7 or greater after a review of the entire prostate, while 37 (8%) had a score of less than 6 and 230 remained with Gleason 6. Patients who were under graded were more likely to have extraprostatic extension (22% vs 4%, p <0.01), seminal vesicle invasion (9% vs 2%, p <0.01) and biochemical recurrence (10% vs 3%, p <0.01) compared to those who remained with Gleason score 6. CONCLUSIONS: Gleason grade on needle biopsy is an inexact predictor of the final grade following radical prostatectomy. Patients with biopsy Gleason score 6 who are under graded are at significantly higher risk for adverse pathological features and biochemical recurrence than patients who remain with Gleason score 6 or less on final pathology findings.     

Transrectal ultrasound-guided transperineal 14-core systematic biopsy detects apico-anterior cancer foci of T1c prostate cancer

AIM: The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE). METHODS: In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers. RESULTS: Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers (n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers. CONCLUSIONS: TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers.     

Evidence for a biopsy derived grade artifact among larger prostate glands

PURPOSE: The PCPT has demonstrated a higher incidence of high grade (Gleason pattern 4 or greater) prostate cancers among men randomized to finasteride. One plausible explanation for this finding is that tumor grade as assigned by TRUS guided biopsy is artifactually associated with prostate volume. MATERIALS AND METHODS: We evaluated our institutional data set of TRUS guided biopsies in the last 3 years and identified 369 cases of prostate cancer that fit the criteria of PSA less than 10 ng/ml, biopsy at our center and RP at our center. We identified risk factors for Gleason pattern 4 or greater on biopsy and then on RP specimens from the same patients using univariate and multiple logistic regression analyses. Assessed covariates included patient age, PSA and TRUS volume. RESULTS: Risk factors for Gleason pattern 4 or greater in the biopsy specimens included age (p = 0.01), hypoechoic lesions on TRUS (p <0.001) and TRUS volume (p = 0.008). However, among RP specimens TRUS volume (p = 0.60) became nonsignificant of Gleason pattern 4 or greater on multivariable analysis. Although prostate volume was a predictor for biopsy derived high grade disease it was not predictive of true histological grade. CONCLUSIONS: These data suggest that simply having a larger prostate results in fewer high grade cancers diagnosed at biopsy. Prostatectomy results in the same men suggest sampling artifact, as the distribution of cancer grade is not associated with prostate volume. These findings provide evidence that the increase in higher grade tumors among men in the finasteride arm of PCPT may simply result from prostate volume reduction.     

Assessment of the enhancement in predictive accuracy provided by systematic biopsy in predicting outcome for clinically localized prostate cancer

PURPOSE: Current localized prostate cancer treatment outcome nomograms rely on prostate specific antigen (PSA), tumor stage and grade. We investigated whether the addition of prostate biopsy features may enhance the accuracy of a nomogram predicting recurrence after radical prostatectomy (RP). MATERIALS AND METHODS: Clinical data from 1,152 patients who underwent RP were used and included PSA, clinical stage, biopsy Gleason grade and systematic biopsy information that quantified the amount of cancer and high grade cancer. Predictive accuracy for freedom from recurrence after RP was assessed with and without tumor quantification in the biopsy by the area under the receiver operating characteristics curve (AUC). RESULTS: Percentage and number of cores with cancer, and percentage and number of cores with high grade cancer were predictors of outcome when added to models that included PSA, Gleason grade and clinical stage (all p <0.0001). Nomogram accuracy with 3 traditional variables (AUC 0.790) was minimally enhanced with the addition of percentage or number of positive cores (AUC 0.804 and 0.800, respectively), or percentage or number of cores with high grade cancer (AUC 0.802 and 0.800, respectively). Maximum predictive accuracy of 0.811 was achieved after supplementing the traditional 3-variable nomogram with various combinations of additional pathological predictors. CONCLUSIONS: The information provided by systematic biopsies substantially improves the ability to predict outcome following RP. However, some incremental predictive accuracy was achieved by adding systematic biopsy features.     

The incidence of prostate cancer in men with prostate specific antigen greater than 4.0 ng/ml: a randomized study of 6 versus 12 core transperineal prostate biopsy

PURPOSE: The prostate cancer detection rate in patients with elevated prostate specific antigen (PSA) increases with extended needle biopsy protocols. Transperineal biopsy under transrectal ultrasound guidance is rarely reported, although notable cancer diagnoses are obtained with this technique. We describe the results of 6 and 12 core transperineal biopsy. MATERIALS AND METHODS: A total of 214 patients with PSA greater than 4.0 ng/ml were prospectively randomized to undergo 6 or 12 core transperineal biopsy. Each group of 107 patients was comparable in terms of clinical characteristics. The procedure was performed on an outpatient basis using local anesthesia. Specimens were obtained with a fan technique with 2 puncture sites slightly above the rectum (1 per lobe) under transrectal ultrasound guidance. Cores were taken from all peripheral areas, including the far lateral aspect of the prostate. RESULTS: The overall cancer detection rate was 38% and 51% for 6 and 12 core biopsy, respectively. In patients with PSA between 4.1 and 10 ng/ml the cancer detection rate was 30% and 49% for 6 and 12 core biopsy, respectively. CONCLUSIONS: The 12 core transperineal prostate biopsy is superior to 6 core biopsy. The technique provides optimal prostate cancer diagnosis. About half of the patients with PSA greater than 4.0 ng/ml and a slightly lower percent with PSA between 4.1 and 10 ng/ml have prostate cancer.     

Comparison of endorectal magnetic resonance imaging, guided prostate biopsy and digital rectal examination in the preoperative anatomical localization of prostate cancer

PURPOSE: We compared the accuracy of endorectal magnetic resonance imaging (erMRI), transrectal ultrasound (TRUS) guided biopsy and digital rectal examination (DRE) for detecting the location of cancer in the prostate gland and seminal vesicles. MATERIALS AND METHODS: This is a retrospective study of 106 consecutive patients with prostate cancer who were referred for erMRI before radical prostatectomy. Step-section pathological data and erMRI were available in 90 patients, DRE data were available on 86 and individually labeled sextant core biopsies were available in 45. T1 and T2-weighted erMRI was interpreted by a single reader, who scored the likelihood of tumor on a 5-point scale in each seminal vesicle and in 12 locations in the prostate gland. MR spectroscopy data were not used for erMRI interpretation. One pathologist reviewed whole mount serial sections of radical prostatectomy specimens. The area under ROC curves was used to evaluate accuracy. RESULTS: The area under ROC curves for tumor localization was higher for erMRI than for DRE at the prostatic apex (0.72 vs 0.66), mid gland (0.80 vs 0.69) and base (0.83 vs 0.69). It was likewise higher for erMRI than for TRUS biopsy in the mid gland (0.75 vs 0.68) and base (0.81 vs 0.61) but not in the apex (0.67 vs 0.70). On mixed model analysis erMRI significantly increased the accuracy of prostate cancer localization by DRE or TRUS biopsy (each p <0.0001). CONCLUSIONS: For prostate cancer localization erMRI contributes significant incremental value to DRE or TRUS biopsy findings (each p <0.0001).