Value of random US-guided transrectal prostate biopsy

Cognitive Versus Magnetic Resonance-Ultrasound Fusion Prostate Biopsy: Which One Is Worthier to Perform?

The aim of our study is to compare 2 prostate fusion biopsy models in terms of accurate target sampling. One hundred patients who had Prostate Imaging-Reporting and Data System score 3, 4, or 5 lesions (lesion diameter, >5 mm in long axis) in multiparametric-magnetic resonance imaging and prostate-specific antigen levels between 3 and 10 ng/mL were enrolled in the study. All patients were biopsy naive. Two groups were composed with 50 patients each. Group 1 patients had cognitive fusion (CF) biopsy, and group 2 had magnetic resonance-ultrasound fusion platform biopsy. After fusion biopsy, standard biopsy was also performed. Outcomes of histopathologic and demographic data were evaluated statistically. There were no statistical differences between the 2 groups in terms of age, prostate-specific antigen levels, prostate volume, and lesion length (P > 0.05). There was no statistically significant difference in sampling targeted lesions (P > 0.05). Also, no difference was found between the 2 groups in terms of random biopsy cancer detection rates (P > 0.05). There was no statistically significant difference between CF and magnetic resonance-ultrasound fusion in terms of cancer detection rates. For the experienced operators, we recommend lesions that are longer than 5 mm can be sampled using CF, an inexpensive and faster technique.

Advances in prostate cancer imaging

Many exciting advances in medical imaging have been made in recent years that will alter the way we diagnose, stage, and treat patients with prostate cancer. Multiparametric magnetic resonance imaging (MRI) is emerging as the main modality for prostate cancer imaging. Contrast-enhanced ultrasound and shear wave elastography may be strong alternatives in patients who cannot undergo MRI. Prostate-specific membrane antigen-directed positron emission tomography/computed tomography has proven to be valuable in the primary staging of high-risk disease and for detecting disease in patients with biochemical recurrence. As more studies continue to emerge, it is becoming clear that the standard algorithm for diagnosing and staging prostate cancer will undergo significant changes in the near future.

A multivariable logistic regression equation to evaluate prostate cancer

BACKGROUND/PURPOSE

A possible means of decreasing prostate cancer mortality is through improved early detection. We attempted to create an equation to predict the likelihood of having prostate cancer.

METHODS

Between January 2005 and May 2008, patients who received prostate biopsies were retrospective evaluated. The relationship between the possibility of prostate cancer and the following variables were evaluated: age; serum prostate specific antigen (PSA) level, prostate volume, numbers of prostatic biopsies, digital rectal examination (DRE) findings, and the presence of hypoechoic nodule under transrectal ultrasonography.

RESULTS

A multivariate regression model was created to predict the possibility of having prostate cancer, and a receiver-operating characteristic (ROC) curve was drawn based on the predictive scoring equation. Using a predictive equation, P=1/(1-e(-x)), where X=-4.88,+1.11 (if DRE positive),+0.75 (if hypoechoic nodule of prostate present),+1.27 (when 7<PSA≤10),+2.02 (when 10<PSA≤24),+2.28 (when 24<PSA≤50),+3.93 (when 50<PSA),+1.23 (when 65<age≤75),+1.66 (when 75<age), followed by ROC curve analysis, we showed that the sensitivity was 88.5% and specificity was 79.1% in predicting the possibility of prostate cancer.

CONCLUSION

Clinicians can tailor each patient's follow-up according to the nomogram based on this equation to increase the efficacy of evaluating for prostate cancer.

Contemporary impact of transrectal ultrasound lesions for prostate cancer detection

PURPOSE

Transrectal ultrasound (TRUS) guided systematic biopsy of the prostate is the gold standard diagnostic modality for prostate cancer. Consequently, the value of discrete hypoechoic lesions on TRUS lesions considered suspicious for cancer deserves meticulous reevaluation, specifically in the prostate specific antigen era when the majority of tumors diagnosed are nonpalpable. We studied whether the predictability of a biopsy core changes if the tissue comes from an isoechoic vs hypoechoic lesion.

MATERIALS AND METHODS

Prospective data were collected on 3,912 consecutive patients referred to our medical center between 1993 and 1999 for biopsy of the prostate. A sextant technique (apex, mid gland and base) with an additional core biopsy from the transitional zone was used. If a hypoechoic lesion was identified, the biopsy was taken from the lesion. Correlation between hypoechoic lesions, isoechoic areas and cancer detection for each core was performed.

RESULTS

A total of 31,296 cores were obtained from the cohort. Overall 2,642 (68%) cores had at least 1 hypoechoic lesion ultrasonographically. Cancer was detected in 675 (25.5%) and 323 (25.4%) patients with or without hypoechoic lesions (p = 0.97). The per core cancer detection was fairly uniform and averaged 9.3% and 10.4% for hypoechoic and isoechoic areas, respectively. The difference was not statistically significant (p = 0.3). Gleason scores were less than 7, 7 and greater than 7 in 46%, 34% and 20% of cases, respectively.

CONCLUSIONS

Despite the higher prevalence of cancers discovered in prostates with hypoechoic areas, the hypoechoic lesion itself was not associated with increased cancer prevalence compared with biopsy cores from isoechoic areas. For impalpable tumors TRUS findings are not contributory for staging.

Transrectal ultrasound-guided biopsy of the prostate gland: value of 12 versus 6 cores

We investigated the effect on prostate carcinoma detection of 12 versus 6 core biopsies at transrectal ultrasound (TRUS), when all biopsies are taken from the lateral peripheral zone. This was a prospective study of 202 consecutive men, ages 51 to 81 years, referred for TRUS-guided biopsy of the prostate gland. All patients had prostate serum antigen levels higher than 4.0 ng/mL and/or abnormal digital rectal examination. In each case three biopsies were taken from the peripheral zones of the right and left lobes of the prostate. Biopsies were taken at the apex, midway between the apex and the base, and at the base. A second set of biopsies was taken from the same regions and analyzed separately. In total, twelve biopsies were taken. Note was subsequently made of additional carcinoma diagnosis increase in Gleason grade, and new diagnoses of carcinoma in the opposite side of the gland diagnosed on the second set of biopsies alone. Seventy-eight of the 202 men (38.6%) had prostatic carcinoma diagnosed on TRUS-guided biopsy. Of these 78 patients, six were diagnosed with malignancy based on the second set of biopsies alone, a 2.9% increase in the 202 patients, representing an increased yield of 8.3% (95% confidence interval, 5.3-28.6%). In nine cases (12.5%; 95% confidence interval, 6.2-22.9%), the Gleason tumor grade was increased on the second set of sextant biopsies; in an additional nine cases, carcinoma was detected in the opposite side of the gland. There were two complications (1%). A 12- versus six-core biopsy strategy for TRUS-guided biopsy of the prostate gland improves detection and histologic grading of prostate carcinoma. The added benefit of additional biopsies was lower in this series than in some prior studies using extensive biopsy protocols.

Should ultrasound criteria of the prostate be redefined to better evaluate when and where to biopsy

During the past 10 years, it has been suggested, and accepted by some, that transrectal ultrasound (TRUS) of the prostate should be used to identify a hypoechoic lesion or, if needed, guide biopsy into nonspecific areas. Retrospectively, the authors attempted to evaluate the need to identify areas that were on pathologic analysis, prostate cancer, but were not hypoechoic, but would require random/systematic biopsy to exclude prostate cancer. Six-hundred fifteen consecutive men were referred to the authors because of a concern found on digital rectal examination or because of increase in prostate-specific antigen. All patients underwent TRUS-guided biopsy of the prostate using either the four-quadrant or sextant biopsy technique. Each area undergoing biopsy was characterized as: 1) normal-appearing; 2) hypoechoic; 3) mixed echogenic (containing both hypoechoic and hyperechoic elements); 4) subtly hyperechoic (containing no calculi); or 5) isoechoic (lesion was seen because of distortion of the normal architecture). A diagnosis of carcinoma was made in 197 patients (32%). Of these, 99 (50.2%) patients had a hypoechoic lesion as the primary site, corresponding to their highest Gleason grade. Twenty-five (12.7%) had mixed echogenicity, nine (4.6%) had hyperechoic foci, and 23 (11.7%) had isoechoic biopsy-proven foci of prostate cancer. Forty-one (20.8%) patients with adenocarcinoma had normal ultrasound findings. The median Gleason grade for cancer in visible mixed echogenic and hyperechoic areas were generally higher than that for cancer in hypoechoic sites. Hypoechoic cancer sites had a Gleason grade range of 2 to 10 (median 5); mixed echogenic foci had a Gleason range of 2 to 10 (median 6); hyperechogenic cancers had a Gleason range of 2 to 8 (median 6); isoechoic cancers had a Gleason range of 2 to 7 (median 5); normal foci had a Gleason range of 2 to 8 (median 5). Results of this study suggest that 50% of clinically significant prostate cancers are not purely hypoechoic, and 37% of all diagnosed cancers contain no hypoechoic elements.

Predictors of prostate carcinoma: accuracy of gray-scale and color Doppler US and serum markers

PURPOSE

To determine the accuracy of detecting prostate cancer by using (a) gray-scale and color Doppler transrectal ultrasonography (US), (b) serum and excess prostate-specific antigen (PSA) levels, and (c) targeted and sextant transrectal US-guided biopsy. The relationship between US-detected neovascularity and tumor biologic activity was also evaluated.

MATERIALS AND METHODS

Between 1995 and 1999, 544 patients with elevated PSA levels and/or abnormal digital rectal examination underwent transrectal US-guided sextant biopsy and targeted biopsy of US abnormalities. Sensitivity, specificity, and accuracy of gray-scale US, color Doppler US, targeted biopsy, and PSA and excess PSA were calculated.

RESULTS

Gray-scale US depicted 78 (41.1%) of 190 cancers, whereas color Doppler US depicted 30 (15.8%) additional cancers. Targeted biopsy was used to detect 108 (56.8%) cancers, whereas sextant biopsy was used to detect 82 (43.2%) additional cancers. Although US-visible cancers had a higher Gleason grade than did cancers discovered at sextant biopsy (P <.05), 25 of the 66 cancers identified with sextant biopsy alone were Gleason grade 6 or higher. Color Doppler US-depicted hypervascularity correlated with biologically aggressive tumors. Excess PSA was normal in 58 (30.5%) cancers, with an accuracy of 67.3%, resulting in better prediction of prostate tumors than with serum PSA level alone.

CONCLUSION

Gray-scale transrectal US, even coupled with color Doppler US, is inadequate for prostate carcinoma screening; therefore, targeted biopsy should always be accompanied by complete sextant biopsy sampling.

Adenocarcinoma da próstata: a alteração hipoecogênica difusa da próstata é um achado ultra-sonográfico importante?

Avaliar se há associação entre a observação de alteração hipoecogênica difusa da próstata, com perda da demarcação entre a zona periférica e a glândula interna, e o diagnóstico de adenocarcinoma de próstata na biópsia prostática transretal. MATERIAIS E MÉTODOS: Avaliamos 143 homens com nível sérico de antígeno prostático específico maior do que 4 ng/ml. Todos os pacientes foram submetidos à ultra-sonografia endorretal e biópsia randomizada da próstata. RESULTADOS: Foi diagnosticado adenocarcinoma de próstata em 36,4% dos pacientes. A alteração hipoecogênica difusa da próstata, caracterizada por perda da demarcação entre a zona periférica e a glândula central, foi observada em 22 pacientes e correspondeu ao diagnóstico de adenocarcinoma de próstata em 21 deles (95,4%). CONCLUSÃO: A alteração hipoecogênica difusa da próstata constituiu um critério de suspeita ultra-sonográfica de adenocarcinoma de próstata altamente significativo, já que em 95,4% das próstatas que apresentavam essas características a biópsia foi positiva para adenocarcinoma de próstata

Correlations among prostatic biopsy results, transrectal ultrasound findings and PSA levels in diagnosing prostate adenocarcinoma

OBJECTIVE

The objective of this study was to evaluate transrectal ultrasound (TRUS) findings and prostate-specific antigen (PSA) levels in relation to prostatic biopsy results and to analyze their individual and combined performances in diagnosing prostate adenocarcinoma (PAC).

METHODS

Men (n=143) with PSA levels above 4 ng/ml underwent TRUS and randomized ultrasound-guided prostatic biopsy through the peripheral zone, including additional hypoechoic nodules biopsies, if they were noted on TRUS. Data related to TRUS, biopsy, and PSA level results were then correlated.

RESULTS

A significant correlation between TRUS images suspicious for PAC and a biopsy-confirmed diagnosis of PAC, or between the lack of such images and a negative biopsy result, was not found. However, a significant correlation was found between positive biopsy results and PSA levels greater or equal to 10 ng/ml. The sensitivity of transrectal ultrasound in making a diagnosis of PAC was 63%, whereas its specificity was 73%.

CONCLUSION

We conclude that while the separate performances of these examinations were not effective in diagnosing PAC, the integrated use of these methods was more adequate for making the diagnosis.

Endorectal color doppler sonography and endorectal MR imaging features of nonpalpable prostate cancer: correlation with radical prostatectomy findings

OBJECTIVE

The purpose of this study was to describe endorectal sonography and color Doppler sonography features of nonpalpable prostate cancer and to assess the value of endorectal MR imaging for the preoperative local staging of these tumors.

MATERIALS AND METHODS

Ninety-four patients with nonsuspicious findings on digital rectal examination and a mean prostate-specific antigen level of 16.3 +/-10 ng/mL (median, 13 ng/mL) underwent endorectal sonography, color Doppler sonography, sextant endorectal sonographically guided biopsy, and endorectal MR imaging before radical prostatectomy.

RESULTS

Tumors were visible in 48 cases and not visible in 46. The mean Gleason biopsy score, the frequency of tumors involving three sextants or more of the prostate gland at biopsies, and the frequency of stage pT3 tumors were significantly higher in patients with visible tumors (5.9+/-0.9, 42%, and 37.5%) than in those with invisible tumors (5.4+/-1.1, 17%, and 17%). The 42 hypervascular tumors were hypoechoic in every case and had a higher rate of Gleason tumor grades 4 and 5 at biopsy than did the 52 hypovascular tumors (33% versus 11.5%). Six hypovascular tumors (6/52, 11.5%, two visible) had an insignificant tumor volume. Established extraprostatic tumor spread was detected on MR imaging in six of 18 cases (sensitivity, 33%; specificity, 100%0, all of which had the following four features: hypervascularity, prostate-specific antigen level greater than 20 ng/mL, three or more sextants of the gland having positive findings at biopsy, and seminal vesicle invasion.

CONCLUSION

Endorectal sonography and color Doppler sonography are useful to differentiate low-risk invisible and hypovascular tumors from high-risk visible and hypervascular tumors. However, MR imaging has a poor sensitivity for the detection of extraprostatic spread and is accurate only in a minority of highly selected high-risk hypervascular tumors.

Stage T1c prostate cancer: defining the appropriate staging evaluation and the role for pelvic lymphadenectomy

A good staging system should be able to accurately reflect the natural history of a malignant disease, to express the extent of the disease at the time of diagnosis, and stratify patients in prognostically distinctive groups. The staging system for prostate cancer, as it is today, fails to fulfill these requirements. Approximately one third of the patients who undergo surgery for complete excision of prostate cancer in fact do not have a localize disease. The incidence of tumor at the inked margin may reach 30% for T1 stage and up to 60% for clinical T2b prostate cancer according to comparison with pathologic examination of resected specimen. Several concepts have been recently proposed as a means of improving the accuracy of the available staging system. In this paper, we review current aspects of clinical and pathological staging of prostate cancer, and the importance of these new concepts on the early stages of prostate cancer.

Update on the appropriate staging evaluation for newly diagnosed prostate cancer

PURPOSE

Prostate cancer clinical staging methods and decision support tools were reviewed to assess their accuracy to predict pathological staging results and determine what comprises an appropriate clinical staging evaluation.

MATERIALS AND METHODS

The MEDLINE data base was searched and 238 abstracts were obtained. Data were extracted from 142 articles that evaluated the preoperative accuracy of digital rectal examination, prostate specific antigen, prostatic acid phosphatase, systematic biopsy parameters (including Gleason scoring), seminal vesicle biopsy, various imaging studies and pelvic lymphadenectomy versus pathological staging results. The sensitivity, specificity and accuracy rates were calculated and tabulated from the reported data on each method or decision support tools for organ confined, nonorgan confined and lymph node metastatic tumor.

RESULTS

Decision support tools based on logistic regression analysis, which combine several statistically independent staging parameters, had greater accuracy than any single clinical staging method alone. The most accurate decision support tools for clinical staging combined digital rectal examination (T stage), systematic biopsy parameters (including Gleason scoring) and prostate specific antigen.

CONCLUSIONS

The components that comprise the most accurate decision support tools for clinical staging represent an appropriate staging evaluation for the newly diagnosed prostate cancer patient in 1997. Limited use of radiographic imaging and seminal vesicle biopsy may be indicated in select patients to detect bone metastases, and plan pelvic lymphadenectomy and surgical therapy.

Color Doppler-guided prostate biopsies in 591 patients with an elevated serum PSA level: impact on Gleason score for nonpalpable lesions

OBJECTIVES

To compare results of color Doppler-guided ultrasonography (CDUS) versus those of systematic biopsies in 591 patients with an elevated serum PSA level and to correlate them with digital rectal examination (DRE) findings.

METHODS

Biopsies were directed into hypervascularized (CDUS+) or hypovascularized (CDUS-) hypoechoic peripheral zone nodules (443 cases). When transrectal ultrasound (TRUS) was normal (148 cases), biopsies were directed into hypervascular area. Six additional posterior biopsies were also performed in every patient, together with four anterior biopsies in 117 patients with normal DRE and prostate weight above 40 g.

RESULTS

Biopsies were positive in 339 patients (57%). Positive biopsy rate (PBR) of directed biopsies was 84% in hypervascular abnormalities (264 of 316) and 17% in hypovascular nodules (23 of 134) (P < 0.001). PBR of combined biopsies was 84% in CDUS+ patients (266 of 316) and 26% in CDUS- patients (73 of 275) (P < 0.001). Comparison of TRUS and CDUS showed a sensitivity of 0.9 and 0.78, respectively, and a specificity of 0.46 and 0.8, respectively. Of the 131 patients with a PSA level between 4 and 10 ng/mL and a normal DRE, PBR was 59% (22 of 37) when CDUS was positive and 11% (10 of 94) when it was negative, regardless of TRUS abnormalities (P < 0.001). Nonpalpable cancers with a negative CDUS showed a significantly (P < 0.001) lower Gleason score (5.5 +/- 0.9) than that of CDUS+ cancer (6.5 +/- 1.1). Eleven cancers were diagnosed by only anterior positive biopsies. All of them had a negative CDUS and a PSA level above 10 ng/mL.

CONCLUSIONS

CDUS does not modify prostate biopsy policy except in patients with negative CDUS, normal DRE, and PSA level between 4 and 10 ng/mL, where deferment of biopsy can be advocated. Anterior biopsies are only useful in patients with a PSA level above 10 ng/mL and a negative CDUS.

Five year follow-up after radical prostatectomy for localized prostate cancer--a study of the impact of different tumor variables on progression

Fifty-one patients with clinically localized prostate cancer stages A and B, who underwent radical prostatectomy have been followed for a minimum of 5 years. The impact of age, stage, capsular penetration, total tumor volume, Gleason score, seminal vesicle invasion and lymph node metastases on progression has been evaluated. Progression free survival was calculated according to the Kaplan-Meier method. Uni- and multivariate analyses were performed according to the Cox proportional hazards model. During the observation period 16 patients (31%) experienced progression. Tumor volume, grade and seminal vesicle invasion emerged as statistically significant predictors of tumor progression in the survival analyses while age at surgery, preoperative stage and different levels of capsular penetration were not statistically significant. The findings in the Cox models were in accordance with those at actuarial survival analyses though tumor volume was the only variable proven to have an independent statistically significant influence on progression.

Ultrasound-guided four quadrant biopsy of the prostate: efficacy in the diagnosis of isoechoic cancer

Five hundred and eighty men underwent transrectal ultrasound-guided biopsy of the prostate using the four quadrant biopsy (4QB) technique. Four hundred and three men had focal hypoechoic lesions of the peripheral gland but the other 177 men referred because of concern for the presence of cancer had no discrete sonographic lesion. Cancer was found from 4QB in only 32 of these 177 men (18.1%) compared to 158 of the 403 men (39.2%) with focal hypoechoic lesions (P < 0.001). Additional biopsy evidence of cancer was found in contralateral isoechoic (sonographically normal) quadrants in 41 men with focal hypoechoic cancerous lesions. In 17 men with hypoechoic lesions that were biopsy-benign, cancer was found in other isoechoic quadrants. There was no difference between the average Gleason scores of hypoechoic cancers and isoechoic cancers, other than when cancers were incidentally found in men with benign focal hypoechoic lesions. These had significantly lower scores (P = 0.02). Cancer yield in the 177 men without hypoechoic lesions increased as a function of prostate-specific antigen (PSA) level; 11% if PSA < 10ng/ml, 32% if > 20ng/ml. Prostatitis was the most common abnormal biopsy finding in these men. 4QB increases the yield of prostate cancer compared to simple biopsy of hypoechoic lesions and improves knowledge of local disease extent. 4QB is recommended for men with elevated PSA levels but no peripheral gland sonographic abnormality.

The roles of fine needle aspiration and needle core biopsies in the diagnosis of primary prostatic cancer

For more than 50 years, needle core and aspiration biopsy techniques have been used to detect carcinoma of the prostate. Each has had vigorous proponents and many technical innovations have been made to improve the techniques. This report summarizes the developmental history of the techniques, examines their individual merits, reviews studies comparing the methods, and discusses the complications associated with each. Presently, in patients with abnormal rectal examinations, small-gauge transrectal core biopsy and transrectal aspiration biopsy offer similar detection and false-negative rates with very low frequencies of complications.