CT fluoroscopy-guided lung biopsy versus conventional CT-guided lung biopsy: a prospective controlled study to assess radiation doses and diagnostic performance

OBJECTIVE

We evaluated radiation doses, complication rates, and diagnostic accuracy for CT-guided percutaneous needle aspiration biopsy (NAB) procedures of pulmonary lesions performed with or without fluoroscopic guidance.

METHODS

A total of 142 patients were prospectively enrolled to receive CT-guided NAB with (Group I, n = 72) or without (Group II, n = 70) fluoroscopic guidance. Outcome measurements were patient and doctor radiation dose, and complication rate. Sensitivity, specificity and accuracy were calculated based on 123 NAB results.

RESULTS

The mean estimated effective patient radiation dose was 6.53 mSv in Group I and 2.72 mSv in Group II (p < 0.001). The mean estimated effective doctor dose was 0.054 mSv in Group I and 0.029 mSv in Group II (p < 0.001). The complication rate was significantly different between the two groups (13.4% versus 31.4%, p = 0.012). Sensitivity, specificity and accuracy for diagnosing pulmonary lesions were 97.8%, 100% and 98.4% in group I and 95.3%, 100% and 89.5% in group II (p > 0.05).

CONCLUSIONS

CT fluoroscopy-guided NAB of pulmonary lesions provides high diagnostic accuracy and can be performed with significantly fewer complications. However, radiation exposure to both patient and doctor were significantly higher than conventional CT-guided NAB.

Prostate cancer detection after one or more negative extended needle biopsy: results of a multicenter case-findings protocol

OBJECTIVES

To evaluate PCa incidence in patients with one or more negative extended prostate biopsy who underwent repeat biopsy or TURP.

MATERIAL AND METHODS

From June 2003 to February 2008, 308 patients were submitted to repeat prostate biopsy (median 20.5 cores) and 120 patients underwent TURP after one or more 12 cores prostate biopsy. Indications for biopsy were: abnormal DRE; PSA > 10 ng/mL; PSA included between 4.1-10 or 2.6-4 ng/mL with free/total PSA < or = 25% and < or = 20%, respectively 262 and 46 underwent a second and a third biopsy: 218 because for high levels of PSA, 40 and 50 patients for a previous diagnosis of HGPIN and ASAP, 28 had an abnormal DRE. PSA in patients who underwent TURP was 11.6 ng/mL (median); in all cases DRE was negative and only 76 patients referred LUTS.

RESULTS

PCa incidence at repeat biopsy was 16.9%; 96.2% of cancers were diagnosed at a second biopsy and 3.8% at a third one. PCa incidence was higher in patients with previous ASAP (43.4% and 50%) vs patients with HGPIN (25% and 0%) or benign pathology (11.9% and 0%). PCa was diagnosed in 11.1% and 19% of patients who underwent TURP previously submitted to a first and a second biopsy, respectively.

CONCLUSIONS

In case of persistent suspicion of PCa after a repeated negative saturation biopsy, TURP should be proposed as part of the diagnostic procedure aside from LUTS, especially in patients with a life expectancy greater than 10 years.

5A prospective survey of current prostate biopsy practices among oncological urologists

BACKGROUND

Needle biopsy of the prostate is a common outpatient procedure. In March 2009, the European Association of Urology (EAU) published an updated, evidence-based "Guidelines on Prostate Cancer," including recommendations for this procedure.

OBJECTIVE

To survey onco-urology specialists attending the 6th European Section of Oncological Urology (ESOU) meeting in Istanbul, Turkey in January 2009, to assess their biopsy practices and compare them with March 2009 EAU guidelines.

DESIGN, SETTING AND PARTICIPANTS

The authors designed a questionnaire and distributed it to 606 conference delegates. It was completed by 298 delegates, of whom 156 were experienced onco-urological specialists.

MEASUREMENTS

The survey results from the 156 experienced onco-urologist specialists were analyzed.

RESULTS AND LIMITATIONS

Most (59%) of the 156 respondents worked in large (> 20 bed) units, and 76% said urologists always performed the biopsies. Transrectal ultrasound (TRUS)-guided biopsy was the preferred procedure for 78% of respondents. Prostate-specific antigen (PSA) cut-off points of 4 ng/mL, 3.5 ng/mL, 3 ng/mL, and 2.5 ng/ml were used by 42%, 18%, 23%, and 8% of respondents, respectively, to determine whether a biopsy was indicated. A total of 95% of respondents gave patients prophylactic antibiotics. Another of 15% and 17% of respondents did not advise patients to stop taking warfarin or clopidogrel, respectively. A total of 23% of respondents did not give patients pre-procedure anesthesia, while others gave patients periprostatic lidocaine (31% of respondents), topical lidocaine jelly (35%), or general or spinal anesthesia (5.7%). High grade prostatic intraepithelial neoplasia (HGPIN) was considered by 71% of respondents as being a pre-malignant condition requiring a repeat biopsy. If atypical small acinar proliferation (ASAP) was reported, 62% of respondents recommended a repeat biopsy. Magnetic resonance imaging (MRI) was used to help diagnose cancer (53% of respondents), help stage cancer (83%), or help diagnose cancer recurrence (62%). Study limitations include possible difficulties with the English questionnaire.

CONCLUSIONS

Many surveyed specialists were not performing prostate biopsies according to March 2009 evidence-based EAU practice guidelines, which could have adverse consequences for patients.

Conical utility of CT-guided biopsies in orthopaedic oncology

BACKGROUND

CT-guided biopsy is a minimally invasive diagnostic method of evaluating musculoskeletal lesions. Other options include incisional and excisional biopsy with the possibility of intraoperative frozen section. The clinician's decision to order a CT-guided biopsy requires an understanding of the likelihood that this biopsy will affect treatment This requires an understanding of both diagnostic yield and accuracy. Furthermore, the clinical utility of a biopsy is affected by factors other than the yield and accuracy as the clinical setting may render a technically diagnostic biopsy unhelpful.

METHODS

A retrospective review of the electronic record at an orthopedic oncology referral center identified all patients who had undergone CT-guided percutaneous needle biopsy of musculoskeletal lesions after being evaluated by an orthopedic oncologist in clinic over a period of 5 years. 53 CT-guided biopsies of bone lesions and 16 CT-guided biopsies of soft tissue lesions were identified. The diagnostic yield (rate of obtaining tissue from which the pathologist could report a diagnosis) and clinical utility (rate at which biopsy results guided treatment decisions) were calculated and statistically compared.

RESULTS

The overall diagnostic yield of CT-guided bone biopsies was 94% (50 of 53 biopsies) and the clinical utility was 70% (37 of 53 biopsies). In the first 2 years of the study the diagnostic yield was 95% (21 of 22 biopsies) and the clinical utility was 86% (19 of 22 biopsies). In the remaining 3 years the diagnostic yield was 91% (28 of 31 biopsies) and the clinical utility was 58% (18 of 31 biopsies). This decrease in clinical utility over time was statistically significant (p = 0.01). Suspicion of metastasis resulted in a diagnostic yield of 100% (11/11) and a clinical utility of 91% (10/11). Suspicion of primary tumor resulted in a diagnostic yield and clinical utility of 93% (39/42) and 67% (28/42), respectively. This difference in clinical utility was statistically significant (p = 0.02). The diagnostic yield of CT-guided soft tissue biopsies was 75% (12 of 16 biopsies) and the clinical utility was 69% (11 of 16 biopsies). The diagnostic yield was significantly lower for soft tissue biopsy than bone biopsy (p = 0.01). There was no relationship between the rate of diagnostic biopsies and the evaluating pathologist or the location of the lesion within the body.

CONCLUSIONS

CT-guided biopsy is useful in the diagnosis of musculoskeletal lesions, however, its clinical utility is substantially lower than its diagnostic accuracy and yield due to a significant rate of diagnostic biopsies that fail to guide treatment, particularly when a primary lesion is suspected. The disparity in clinical utility based on preoperative suspicion of metastasis was even greater in our study than previously shown. CT-guided percutaneous needle biopsy is much more likely to guide treatment in the setting of suspected bone metastasis as opposed to biopsies of suspected primary bone lesions and soft tissue lesions.

Serial prostate biopsies are associated with an increased risk of erectile dysfunction in men with prostate cancer on active surveillance

PURPOSE

We determined whether serial prostate needle biopsies predispose men to erectile dysfunction and/or lower urinary tract symptoms over time.

MATERIALS AND METHODS

Men with prostate cancer on an active surveillance protocol were administered the 5-item Sexual Health Inventory for Men and International Prostate Symptom Score questionnaires on protocol entry, and at a cross-sectional point in 2008. All men had at least 1, 10 to 12-core prostate biopsy at protocol entry and yearly surveillance biopsies thereafter were recommended.

RESULTS

Of 333 men 231 returned the followup questionnaires. Correlations were found between biopsy number and erectile dysfunction, with increasing biopsy number associated with a decrease in Sexual Health Inventory for Men score (p = 0.04) and a history of 3 or more biopsies associated with a greater decrease in Sexual Health Inventory for Men score than after 2 or fewer biopsies (p = 0.02). Multivariable analysis for biopsy number, age, prostate volume and prostate specific antigen showed that only biopsy number was associated with decreasing Sexual Health Inventory for Men score (p = 0.02). When men were stratified by baseline Sexual Health Inventory for Men, those without preexisting erectile dysfunction (Sexual Health Inventory for Men score 22 to 25) trended toward steeper decreases in Sexual Health Inventory for Men score after 3 or more biopsies (p = 0.06) than did men with baseline mild to moderate erectile dysfunction (Sexual Health Inventory for Men score 8 to 21). No correlation was found between biopsy number and International Prostate Symptom Score.

CONCLUSIONS

Serial prostate biopsies appear to have an adverse effect on erectile function in men with prostate cancer on active surveillance but do not affect lower urinary tract symptoms.

Impact of stereotactic 11-g vacuum-assisted breast biopsy on cost of diagnosis in Austria

PURPOSE

To determine the frequency with which stereotactic 11-g vacuum-assisted breast biopsy (11-g SVAB) obviates an open surgical biopsy (OSB), to compare the costs of these two biopsy methods, and to estimate the potential cost savings attributable to 11-g SVAB in the diagnosis of suspicious breast lesions in patients in Austria.

MATERIALS AND METHODS

We retrospectively reviewed 318 consecutive breast lesions of BI-RADS categories IV and V (microcalcifications n=166; masses n=152) on which 11-g SVAB and OSB were performed. Cost savings were calculated using nationally allowed flat rates and patient charges. Costs were measured from a hospital and a socioeconomic perspective. Common clinical scenarios and sensitivity analyses assessed the extent of achievable cost savings.

RESULTS

11-g SVAB obviated the need for an OSB in 93 (29%) of 318 women. Overall cost savings per 11-g SVAB over OSB were € 242 per case from a hospital perspective, and € 422 per case from a socioeconomic perspective. The use of 11-g SVAB decreased the cost of diagnosis by 7% from a hospital perspective, and by 10% from a socioeconomic perspective.

CONCLUSION

In Austria, annual national savings of over 5 million Euro could be realized with the use of 11-g SVAB for the diagnosis of suspicious breast lesions. Although savings per case are modest, the national health care system realizes significant cost reduction as women benefit from a faster and less invasive approach to diagnosis.

Delays in the assessment and management of primary lung cancers in South Auckland

AIM

To determine the patient characteristics, referral patterns and delays in assessment and treatment of patients with primary lung cancer in South Auckland, New Zealand and compare with international standards.

METHODS

Retrospective review of the clinical records of 80 patients referred to a secondary care respiratory service and diagnosed with primary lung cancer in 2004.

RESULTS

Eighty-five percent of inpatient referrals and 48.5% of outpatient referrals were for advanced stage lung cancers. The median interval from receipt of outpatient referral to first chest physician assessment was 18 days, with median interval from the first chest physician assessment to bronchoscopy of 17 days and for staging CT chest of 16 days. For patients requiring a CT-guided percutaneous needle aspiration for diagnosis, there was a further median delay of 37 days after the initial CT scan. The median interval from the date of receipt of initial outpatient referral to diagnosis was 38 days, but for early stage lung cancers it was 54 days. The median interval to diagnosis for inpatient admissions was 6 days after the first respiratory assessment.

CONCLUSION

The intervals for initial assessment, diagnosis and treatment of lung cancer in South Auckland do not meet the recommendations of international guidelines, especially for early stage lung cancers. Organisational and resource changes are required at each point in the diagnostic and management pathway to reduce delays.

[The results of transbronchial needle aspiration in 164 cases with enlarged mediastinal and/or hilar lymph nodes]

OBJECTIVE

To evaluate the role of transbronchial needle aspiration (TBNA) in the diagnosis of patients with enlarged mediastinal and/or hilar lymph node.

METHODS

Patients with mediastinal and/or hilar lymphoadenopathy proven by CT scan were eligible for TBNA as reported. All specimens were directly and instantly smeared for pathological examination.

RESULTS

From June 1 2004 to December 31 2007, 164 patients were examined: including 80 lung cancers, 69 lung benign diseases, 2 other malignancy tumor, and 13 without definite diagnosis. Total 260 lymph nodes were punctured. TBNA procedures were successfully carried out in 445/463 (96.1%). Sensitivity of TBNA was 82.5% (66/80) in patients who had been proven to suffer from bronchogenic carcinoma. There were 25 patients that diagnosis of lung cancer was pathologically determined by TBNA only. A total of 122 lymph nodes in the 80 lung cancer patients were aspirated by TBNA with a positive rate of 65.6% (80/122). Severe complications were rare except small amount of bleeding at the TBNA site (100/164, 61.0%). From June 1 2006 to December 31 2007, lymph node tissues able to make histology diagnosis were yield in 73.5% (64/87) patients. Through histology pathology, the sensitivities of TBNA were 53.3% (8/15) for sarcoidosis and 78.6% (33/42) for lung cancer.

CONCLUSION

TBNA is quite safe and helpful in diagnosis and staging of bronchogenic carcinoma, and in diagnosis of benign lung diseases.

Geographic variation and physician specialization in the use of percutaneous biopsy for breast cancer diagnosis

BACKGROUND

Preoperative diagnosis of breast cancer is a standard of care. We conducted a population-based study to determine the factors associated with the use of percutaneous needle biopsy to diagnose breast cancer in Ontario.

METHODS

We identified a total of 3644 women who underwent breast tissue sampling (percutaneous needle biopsy or surgical excision) that yielded a diagnosis of cancer between Apr. 1, 2002, and Dec. 31, 2002, and for whom we were able to obtain complete data. We performed univariate and multivariate analyses to examine the association between a number of variables and the use of percutaneous biopsy or surgery for diagnosis and the performance of biopsy with or without image guidance. The variables were age, local health integration network (LHIN), income quintile, urban or rural residence, access to a primary care provider, prior mammogram, prior regular screening mammography, screen-initiated biopsy, and surgeon and radiologist specialization in breast disease.

RESULTS

A total of 2374 women (65%) underwent percutaneous biopsy to diagnose breast cancer. The use of percutaneous biopsy varied from 22% to 81% among LHINs. On multivariate analysis, no patient variables were associated with the use of percutaneous biopsy for diagnosis. Only the LHIN and surgeon and radiologist specialization were predictive of whether a woman received a percutaneous biopsy. These 2 variables, along with income quintile and screen-initiated biopsy, were associated with the use of image-guided biopsy as the method of choice.

CONCLUSION

Geographic variation in the use of percutaneous biopsy, particularly image-guided biopsy, for the diagnosis of breast cancer exists across Ontario. The frequency of such biopsies may be a useful quality indicator. Strategies to improve uptake of organized evidence-based care may increase the use of percutaneous biopsy.

EUS-guided fine needle aspiration with and without trucut biopsy of pancreatic masses

CONTEXT

Endoscopic ultrasound-guided trucut biopsy (EUS TCB) has a lower yield than fine needle aspiration (FNA) in pancreatic masses but the additional use of TCB to FNA may improve the diagnostic accuracy over FNA alone.

OBJECTIVE

To compare the yield of EUS FNA alone or combined with EUS TCB for diagnosis of pancreatic masses.

DESIGN

Single center retrospective case control study conducted at academic tertiary center. Study conducted between March 2004 and April 2007.

PARTICIPANTS

A total of 126 consecutive patients referred for EUS guided biopsy of pancreatic mass; three patients excluded from analysis, final cohort comprised 123 patients (108 malignant and 15 benign). EUS FNA was performed in 72 patients and EUS FNA+TCB was performed in 51 patients.

MAIN OUTCOME MEASURES

The diagnostic performance of EUS FNA versus EUS FNA+TCB was compared.

RESULTS

The sensitivity, specificity and frequency of cases correctly identified for malignancy of FNA alone were 87.1% (54/62), 100% (10/10) and 88.8% (64/72), while for the combination of FNA+TCB they were: 95.7% (44/46), 100% (5/5) and 96.0% (49/51), respectively (P=0.184, 1.000, and 0.193 FNA versus FNA+TCB). No major complication occurred in either group.

CONCLUSION

FNA+TCB can be safely performed in selected lesions but sensitivity is not statistically improved over FNA alone (95.7% versus 87.1%).

[Diagnostic value of core needle biopsy before neoadjuvant chemotherapy for breast cancer]

OBJECTIVE

To assess the diagnostic value of core needle biopsy (CNB) before neoadjuvant chemotherapy for breast cancer.

METHODS

One hundred and nineteen breast cancer cases underwent neoadjuvant chemotherapy in our hospital during the period from June, 2005 to January, 2007 were analyzed. CNB was carried out before starting chemotherapy. The hematoxylin and eosin-stained slides of CNB taken before and after neoadjuvant chemotherapy were reviewed independently by two pathologists, and the rate of consistency was verified.

RESULTS

Amongst the 119 cases studied, 110 cases were confirmed to be carcinoma, including 105 cases of invasive carcinoma and 5 cases of ductal carcinoma-in-situ. The rate of consistency was 97.22% (105/108).

CONCLUSION

CNB has important value in distinguishing benign from malignant lesions, as well as in confirming the diagnosis of invasive carcinoma before starting neoadjuvant chemotherapy.

Detection of prostate cancer in unselected young men: prospective cohort nested within a randomised controlled trial

OBJECTIVE

To investigate the feasibility of testing for prostate cancer and the prevalence and characteristics of the disease in unselected young men.

DESIGN

Prospective cohort nested within a randomised controlled trial, with two years of follow-up.

SETTING

Eight general practices in a UK city.

PARTICIPANTS

1299 unselected men aged 45-49.

INTERVENTION

Prostate biopsies for participants with a prostate specific antigen level of 1.5 ng/ml or more and the possibility of randomisation to three treatments for those with localised prostate cancer.

MAIN OUTCOME MEASURES

Uptake of testing for prostate specific antigen; positive predictive value of prostate specific antigen; and prevalence of prostate cancer, TNM disease stage, and histological grade (Gleason score).

RESULTS

442 of 1299 men agreed to be tested for prostate specific antigen (34%) and 54 (12%) had a raised level. The positive predictive value for prostate specific antigen was 21.3%. Ten cases of prostate cancer were detected (2.3%) with eight having at least two positive results in biopsy cores and three showing perineural invasion. One tumour was of high volume (cT2c), Gleason score 7, with a positive result on digital rectal examination; nine tumours were cT1c, Gleason score 6, and eight had a negative result on digital rectal examination. Five of the nine eligible participants (55%) agreed to be randomised. No biochemical disease progression in the form of a rising prostate specific antigen level occurred in two years of follow-up.

CONCLUSIONS

Men younger than 50 will accept testing for prostate cancer but at a much lower rate than older men. Using an age based threshold of 1.5 ng/ml, the prevalence of prostate cancer was similar to that in older men (3.0 ng/ml threshold) and some cancers of potential clinical significance were found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20141297.

Evaluation and indications of ultrasound-guided vacuum-assisted core needle breast biopsy

BACKGROUND

The Mammotome is a diagnostic tool used under stereotactic or with ultrasound guidance. A clear indication for Mammotome use under stereotactic guidance is when a non-palpable microcalcification is a target. However, the indications for the use of the Mammotome under ultrasound guidance vary among institutions, and it is difficult to find a place for the Mammotome among conventional biopsy techniques. The Mammotome biopsy has been available in our hospital since July 1999. We assessed the effectiveness and indications of ultrasound-guided Mammotome biopsy.

METHODS

We performed Mammotome biopsies in 433 cases requiring histological diagnosis from July 1999 to September 2006, using an 11-gauge articulated arm-type Mammotome under ultrasound guidance. There were 377 mass lesions including 83 non-palpable cases and 56 hypoechoic lesions.

RESULTS

The indications for Mammotome biopsy were 162 cases with inconsistent fine needle aspiration (FNA) and imaging findings, 114 cases indeterminate by FNA, 68 cases of an identified pathological type before neoadjuvant chemotherapy and confirmation of hormone receptor status, 36 inadequate cases by FNA, 20 cases of confirmation of fibroadenoma and other benign tumors, 8 removal cases of fibroadenoma, 8 microcalcification cases, and 17 others. The target lesion was obtained in 99.5% of the cases.

CONCLUSIONS

Ultrasound-guided Mammotome biopsy is an accurate and useful diagnostic method that enables sufficient amounts of tissue to be obtained with minimal invasion and few complications. The Mammotome is the first choice for obtaining a definitive pathological diagnosis in breast lesions.

Increasing the number of biopsies increases the concordance of Gleason scores of needle biopsies and prostatectomy specimens

PURPOSE

To determine the importance of increasing the number of biopsy cores to decrease the discrepancy of Gleason scores of needle biopsy and radical prostatectomy specimens.

MATERIALS AND METHODS

Between May 1998 and July 2005, 392 patients with clinically localized prostate cancer diagnosed by 18-gauge transrectal needle biopsy underwent radical prostatectomy. We categorized the cohort into 2 groups according to the number of the cores. Group 1 consisted of 206 patients diagnosed by extended biopsies (> or =10 cores, range 10-14, median 11). The remaining 186 patients who were diagnosed by sextant biopsies were categorized as being in group 2. Preoperative clinical variables, including patient age, digital rectal examination findings, serum prostate-specific antigen, and the number of cores positive for cancer the parameters, were assessed in both groups. The concordance of Gleason scores in both groups were analyzed by both individual Gleason scores and clinical subgroups of Gleason scores: 2-4 (well differentiated), 5-6 (moderately differentiated), 7 (intermediate), and 8-10 (poorly differentiated).

RESULTS

Needle biopsies revealed moderately differentiated tumors (Gleason 5-6) for the 2 groups (55.3% and 60.2%). Gleason scores of the needle biopsies were identical to that of the prostatectomy specimen in 116 (56.31%) and 76 cases (40.86%) for each group (kappa: 0.432 and 0.216 for each group, respectively). Gleason score of the needle biopsy differed by 1 grade in 56 (27.18%) and 84 cases (45.16%), and by > or =2 units in 34 (16.50%) and 26 cases (15.05%) for each group, respectively. Of the specimens, 34% were undergraded, and 10% were overgraded in group 1. These rates were 38% and 22% in group 2, respectively. A total of 70% in group 1 and 56% in group 2 remained in the same categorical group, 28% and 32% of the specimens were undergraded, and 4% and 12% were overgraded in groups 1 and 2, respectively. In group 1, the number of patients with Gleason scores of 2-4, 5-6, 7, and 8 were 9.7%, 55.3%, 21.4%, 13.6%, and 1.9%, 47.6%, 32%, 18.4%, graded by needle biopsies and radical prostatectomy specimens, respectively. However, in the sextant group, the change was the number of patients with Gleason scores of 2-4, 5-6, 7, and 8-10 was 5.4% 60.2%, 24.7%, and 9.7%, detected by needle biopsies, respectively. Radical prostatectomy specimens revealed the same Gleason categories in 4.3%, 41.9%, 38.7%, and 15.1%, respectively. There was no correlation between categorized prostate-specific antigen levels and concordance of the Gleason grade. Age and digital rectal examination results did not affect Gleason correlation.

CONCLUSIONS

We have shown that an extended biopsy scheme beyond its superior diagnostic capability also improves the concordance of Gleason scores of needle biopsies and radical prostatectomy specimens.

The impact of reducing the prostate-specific antigen threshold and including isoform reflex tests on the performance characteristics of a prostate-cancer detection programme

OBJECTIVE

To assess the effects on the performance characteristics, in a prostate-cancer detection programme using prostate-specific antigen (PSA) levels, of a lower PSA threshold and the incorporation of reflex (free or complexed PSA) tests.

METHODS

We reviewed publications and extracted data on PSA distributions and performance characteristics of the PSA test and isoform tests from population-based surveys. We estimated the rate of biopsy, cancers detected, and cancers missed that would result from lowering PSA thresholds and including reflex testing.

RESULTS

Lowering the PSA threshold for biopsy referral to 2 ng/mL would increase the number of referrals from 110 to 230 per 1000 men tested, with most of the extra biopsies being among men with no cancer, i.e. an increase from 74 to 172 per 1000 men tested. However, this increased testing would result in an increase in the cancer-detection rate from 3.6% to 5.8%. Including a reflex test for men with moderately elevated PSA levels has little effect on programme performance, with only a modest (10-15%) reduction in unnecessary biopsies and a small increase in the numbers of missed cancers.

CONCLUSIONS

Lowering PSA thresholds, with or without the concurrent introduction of reflex tests, would increase both the numbers of cancers detected and the number of patients referred for biopsy procedures, of which most would be unnecessary. As the extra cancers detected are likely to be clinically localized, and with no evidence that their treatment improves the outcome of the disease, such changes place a possibly unjustified additional burden on the healthcare provider.

Ultrasound-guided core needle biopsy of breast masses: How many cores are necessary to diagnose cancer?

PURPOSE

To investigate the number of cores required to diagnose breast cancer using ultrasound (US)-guided core needle biopsy.

METHODS

US-guided core biopsy of 150 masses was performed in 144 patients. For each mass, 6 cores were obtained and analyzed separately. The histopathologic diagnosis was classified as benign, malignant, or normal breast tissue. Each core was analyzed separately. For diagnostic purposes, the cases were grouped as follows: group G1 comprised the first core; group G2 comprised the first and second core; group G3 comprised the first 3 cores; up to group G6, which included all 6 cores. The results were also analyzed by tumor size (</=2 cm and >2 cm).

RESULTS

The sensitivity in the diagnosis of breast cancer was 90.1% in group G1 and 94.1% in the remaining groups (G2-G6). In tumors </=2 cm, the sensitivity was 88.4% for group G1 and 90.7% for the others, whereas for tumors >2 cm the sensitivity was 91.4% for group G1 and 96.6% when 2 or more cores were obtained.

CONCLUSION

It appears that 2 cores are sufficient to diagnose breast cancer in this study population assuming no technical error occurred in US guidance of the needle through the mass.

Utility of brain biopsy in patients with acquired immunodeficiency syndrome before and after introduction of highly active antiretroviral therapy

OBJECTIVE

This study investigates the changing indications, results, and practice patterns of brain biopsy in patients with acquired immunodeficiency syndrome (AIDS) as treatment evolved with the development of highly active antiretroviral therapy (HAART).

METHODS

We collected data on 246 patients with AIDS who were undergoing brain biopsy of intracranial lesions. Patients were managed in accordance with a uniform protocol. Patients were divided into two groups of those biopsied in the era before (1992-1996) or after (1997-2001) the use of HAART.

RESULTS

The introduction of HAART led to a steep decrease in the number of biopsies performed annually. The protocol functioned well. Diagnoses were obtained for 92.3% of patients. Lymphoma was the most frequent diagnosis (52.9% of patients), followed by progressive multifocal leukoencephalopathy (18.9% of patients) and toxoplasmosis (8.1% of patients). No patient who underwent lesion biopsy for reasons of negative toxoplasmosis titers or atypical radiology evaluation was diagnosed with toxoplasmosis. Nineteen patients who experienced failed toxoplasmosis treatment were diagnosed with toxoplasmosis. Toxoplasmosis titers had a high specificity and a negative predictive value. Patients with progressive multifocal leukoencephalopathy or nondiagnostic biopsies were more likely to have solitary lesions. The average Karnofsky performance score at the time of biopsy was 72.4, which is still within the range of independent functioning. Significant intracerebral hemorrhages were only observed in patients with lymphoma who also had low platelet counts.

CONCLUSION

Although the number of patients with AIDS who require brain biopsy has decreased, the procedure still has merits. The paradigm we developed was useful for selecting patients for early biopsy. Patients with AIDS who also have intracerebral lesions should have toxoplasmosis titers performed, and those whose titers are negative for toxoplasmosis should undergo early brain biopsy.

PSA and other tissue kallikreins for prostate cancer detection

Prostate cancer is the most common neoplasia of middle-aged men. Prostate specific antigen (PSA) is the first FDA-approved tumour marker for early detection of cancer and it is now in widespread clinical use. The discovery of different PSA molecular forms in serum (free PSA, PSA complexed with various protease inhibitors) in the early 1990s renewed clinical research to enhance the specificity of PSA. Also, the use of a homologous prostate-localised antigen, human glandular kallikrein 2 (KLK2) may further reduce the number of unnecessary prostate biopsies. More recently, promising data is emerging regarding molecular forms of free PSA (proPSA, BPSA, 'intact' PSA) and other members of the expanded human kallikrein family. These new findings may add substantial clinical information for early detection of prostate cancer.

Prostate biopsy in Switzerland: a representative survey on how Swiss urologists do it

OBJECTIVE

The procedure of prostate biopsy is often performed but has not been standardized. Therefore, a survey of all urologists in Switzerland was carried out to investigate indications, patient preparation and technique with regard to transrectal prostate biopsy.

MATERIAL AND METHODS

A questionnaire was mailed to all 178 urologists working in Switzerland, either as self-employed urologists (SEUs) or as employed urologists at a hospital (EUHs), i.e. a teaching centre.

RESULTS

The questionnaire was returned by 133 urologists (75%). Eighty-seven of the respondents (65%) are SEUs and 46 (35%) work as EUHs. If digital rectal examination (DRE) raises suspicion of cancer, 129 urologists perform a biopsy. A serum prostate-specific antigen (PSA) level of 4 ng/ml is used as a cut-off value by 84% of respondents (SEUs 83%, EUHs 87%). A fluoroquinolone antibiotic is prescribed by 126 of the respondents. Fifty-nine percent of respondents (SEUs 52%, EUHs 72%) are offering periprostatic injection of a local anaesthetic drug. At the initial biopsy, 24% of respondents (SEUs 30%, EUHs 13%) obtain six cores, 45% (SEUs 37%, EUHs 61%) 8-10 and 17% (SEUs 18%, EUHs 15%) > or =12. The subsequent procedure performed after two negative biopsy sessions varies considerably.

CONCLUSIONS

This survey provides an insight into the practice pattern of urologists in Switzerland concerning prostate biopsy. For almost all urologists, a positive DRE is an indication for prostate biopsy. The majority use a serum PSA level of 4 ng/ml as a cut-off value. A fluoroquinolone is the antibiotic of choice. Periprostatic nerve block is the commonest form of anaesthesia. Most urologists take 8-10 cores per biopsy.

Management of lobular neoplasia diagnosed by core needle biopsy: study of 52 biopsies with follow-up surgical excision

Lobular neoplasia (LN) is a risk factor for bilateral breast cancer without consensus as to its appropriate management. The authors report on a retrospective multi-institutional study concerning 52 patients in whom a diagnosis of LN was made after core needle biopsy (CNB) and who subsequently underwent surgical excision. The excision specimens revealed seven cases of invasive carcinoma and three cases of ductal carcinoma in situ, indicating an underestimation of lesions at CNB in 19% of cases, and in particular in those patients with pleomorphic LN, and when clinical, radiological masses were detected. This lesion is increasingly being diagnosed by CNB due to widespread screening. Follow-up surgical excision should be performed in order to examine the whole lesion in the case of masses or when the histologic specimen reveals a pleomorphic subtype. In other cases, annual mammographic surveillance should be undertaken due to the persistent long-term risk of developing bilateral breast cancer.