Immunohistochemistry increases the accuracy of diagnosis of benign papillary lesions in breast core needle biopsy specimens

AIMS

Recent studies have suggested that benign papillary lesions without atypia [benign papilloma (BP)] diagnosed on breast core needle biopsy (CNB) may not require excision. However, most have studied only small numbers of cases and scant data are available on the utility of immunohistochemistry in the categorization of papillary lesions on CNB. In the largest published series of BP identified on CNB, we studied the impact of immunohistochemistry on the accuracy of a CNB diagnosis of BP.

METHODS AND RESULTS

Breast CNBs (n = 129) with a diagnosis of papillary lesion were immunostained for calponin, p63 and cytokeratin 5/6. Haematoxylin and eosin and immunostained slides were independently reviewed by four breast pathologists. BP was the final excision diagnosis in 35 cases. With the use of immunohistochemistry, the positive predictive value (PPV) of BP diagnosis by the four individual pathologists increased from 72.7-83.3% (mean 79.2%) to 77.8-87.5% (82.1%), the negative predictive value (NPV) increased from 77.8-98.5% (88.6%) to 100% for all four participants and overall accuracy increased from 78.7-92.6% (84.7%) to 90.7-95.4% (92.8%). No case of invasive carcinoma was diagnosed as BP on CNB by any participant. The frequency of ductal carcinoma in situ following a BP diagnosis on CNB ranged from 2.5% to 4.8% (4%) but was only 0-3% (2.3%) after excluding cases that were radiologically suspicious for malignancy.

CONCLUSIONS

Immunohistochemistry increases accuracy of BP diagnosis in CNB specimens. Benign papillary lesions diagnosed on CNB do not require excision in the absence of suspicious clinical/radiological findings.

Needle core biopsy for the assessment of unilateral breast masses in men

Although unilateral male breast swelling is relatively common, a histological diagnosis is infrequently obtained. From 1998 to 2003 we routinely performed needle core biopsy on all men presenting with unilateral breast swelling in whom there was diagnostic uncertainty. Of 113 patients, 93% had gynaecomastia, two patients had primary breast cancer and one had metastatic lymphoma. One patient had chronic mastitis. Gamolenic acid treatment produced a 73% response rate amongst patients presenting with pain. Core biopsy is a safe and effective method of diagnosing unilateral male breast swelling, which allows either confident reassurance or definitive treatment of those with cancer or pain.

[Histological findings in 100 needle prostatic biopsies and original diagnosis of benignity]

INTRODUCTION

Detailed revision of prostate biopsies with benign alterations may show potentially malignant lesions limited to isolated fields, which may be overviewed in routine analysis.

AIM

To exam the morphological alterations in patients with suspicious of prostatic carcinoma and benign diagnosis in needle biopsies.

MATERIALS AND METHODS

During 2000-2001, one hundred consecutive patients with first prostate biopsy diagnosed as benign were included. Biopsies were performed by sextants or modified sextants technique. Slides were reviewed by two observers with knowledge of original diagnosis and this was accepted or modified in accordance to the findings found during the review.

RESULTS

Patients age ranged between 57 and 79 years old. Nine per cent of biopsies originally diagnosed as benign revealed different potentially malignant lesions, which should be noted due to possible association with carcinoma. In this group, there were five biopsies with atypical small acinar proliferation, three with few isolated glands with xanthomatous cytoplasm, and one with scarce atypical cells in the prostatic stroma. In contrast with Caucasian and Afro-American population, frequency of high grade intraepithelial neoplasia in needle biopsy seems to be very low and this lesion was not found in any of the 100 biopsies reviewed. Some lesions that simulate carcinoma, as atypical basal cell hyperplasia, post-atrophic hyperplasia, and adenosis were diagnosed as benign, and there was none false positive result.

CONCLUSIONS

A small but significant group of the biopsies originally diagnosed as benign lesions, showed atypical lesions in isolated fields that were overlooked in the routine analysis. It is necessary the urologist to ask for a directed review of the biopsies if clinical and laboratory data strongly suggest prostatic carcinoma. Additional histological cuts, immunohistochemical studies and more than one observer may increase the frequency of detection of potentially malignant lesions.

Nuclear abnormalities in aspirated thyroid cells and chromosome aberrations in lymphocytes of residents near the Semipalatinsk nuclear test site

Chromosomal studies in peripheral lymphocytes from 63 residents near the Semipalatinsk nuclear test site, at ages of 52-63 years old, were performed in 2001-2002. A higher rate of chromosome aberrations was observed in the two contaminated villages, Dolon and Sarjal, compared with the control village, Kokpekti. Moreover, a relationship of frequency of cells with radiation induced chromosome aberrations and the previously estimated exposure dose was observed. Furthermore, apparent nuclear abnormalities (ANA) of thyroid follicular cells were studied in 30 out of 63 residents, who were examined for chromosome aberrations. A higher rate of ANA was also found in the residents in the exposed villages compared with those in the control village. These results suggest radiation effects both on the chromosomes in peripheral lymphocytes and on the follicular cells in the thyroid.

The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules

Fine-needle aspiration biopsy (FNAB) of thyroid nodules is a safe, cost-effective procedure but the rates of inadequate cytology specimens range from approximately 1% to 15%. This study tests the hypothesis that ultrasonographically (US) guided FNAB and onsite assessment of cytology improves the adequacy rate of FNAB. A retrospective analysis was performed on 693 thyroid FNAB specimens obtained with and without ultrasound guidance and with or without onsite cytology assessment. Overall, 29 specimens (4%) were inadequate for diagnosis. Among 163 cystic nodules and 530 solid nodules, inadequacy rates were 15% (n = 24) and 1% (n = 5) respectively (p = 0.0001). An onsite assessment of cytology for adequacy was done in 550 cases (83%), which was more accurately performed by a cytopathologist (97%) than a cytotechnologist (93%, p = 0.015). With US-guided FNAB, 3% of the cytology specimens were inadequate, compared to a 7% rate when US was not done (p = 0.003). The mean number of needle punctures necessary for an adequate specimen was 3.8 +/- 0.06 (median, 3.0; range, 1-11), which was different among various types of doctors, ranging from 3.2 +/- 0.07 to 5.4 +/- 0.12 (p = 0.001 analysis of variance [ANOVA]). The fewest number of needle passes to achieve an adequate specimen were required by university endocrinologists and pathologists working together (average, 3.2 +/- 0.07; median, 3.0; range, 1-11). Sample inadequacy rate varied significantly among physician groups, ranging from 3% to 18% (p = 0.0001 ANOVA). Stepwise regression analysis showed that onsite assessment of cytology, US-guided FNAB (p = 0.16), and cystic nature of the nodule (p < 0.0001 for all) correlated with adequacy of the specimen. We conclude that US-guided FNAB with onsite evaluation of cytology specimens substantially increases the adequacy of cytology specimens and decreases the number of required needle passes, which ultimately reduces patient discomfort and diagnostic errors, thus raising the question as to whether this should eventually become the standard of care. We believe this is a goal that training programs should strive to achieve.

Incidence trends for papillary thyroid carcinoma and their correlation with thyroid surgery and thyroid fine-needle aspirate cytology

CONTEXT

Papillary thyroid carcinoma (PTC) is the most prevalent endocrine malignancy. The reported incidence of PTC has more than doubled in many countries during the past half century. In Tasmania, an island state of the Commonwealth of Australia the incidence has increased by 24.7% per annum during the last two decades.

OBJECTIVE

Using the Tasmanian population as a model, this study sought to determine the relationship between changes in PTC incidence and trends for utilization of thyroid surgery and thyroid fine-needle aspiration biopsy (FNAB) cytology.

DESIGN

Hospital and pathology services in Tasmania provided data relating to all thyroid surgical, cytologic, and histopathology procedures undertaken between 1988 and 1998. The accuracy of PTC case ascertainment by the Tasmanian Cancer Registry was validated and the relationship between thyroid procedures and PTC incidence assessed.

RESULTS

A total of 3452 individuals underwent a thyroid procedure, comprising 1968 surgical and 1756 FNAB cytologic procedures. Of these, 184 patients were diagnosed with thyroid carcinoma, of whom 121 (65.8%) had PTC. Thyroidectomy and thyroid FNAB increased by 7.0% and 49.7% per annum, respectively. The likelihood of diagnosing PTC in thyroidectomy specimens increased by 99.7% per year in those patients preoperatively assessed by FNAB, compared to 10.1% per year in those for whom a preoperative FNAB was not performed. PTC incidence increased independently of PTC tumor size, although the greatest increase occurred for PTC 1 cm or less with a history of preoperative FNAB.

CONCLUSIONS

These results suggest increasing PTC incidence is largely attributable to greater diagnosis of small PTC, many of which are likely to have been asymptomatic, identified by neck ultrasonography and subsequent FNAB. However, the incidence of PTC larger than 1 cm in patients without history of preoperative FNAB has also risen, suggesting the occurrence of clinically relevant tumors may also have increased.

Predictors of prostate cancer after initial diagnosis of atypical small acinar proliferation at 10 to 12 core biopsies

OBJECTIVES

To evaluate the factors that predict prostate cancer detection by means of 10 to 12 core repeat biopsies in patients with atypical small acinar proliferation (ASAP) results on initial biopsy.

METHODS

From 1998 to 2004, 110 of 127 patients (87%) with a diagnosis of ASAP were rebiopsied with the same technique plus additional biopsies on the ASAP site (12.6 +/- 1.1 cores [mean +/- standard deviation]). Each histologic slide was reviewed blindly by a single experienced pathologist, who also differentiated highly suspicious (ASAPH) and not highly suspicious (ASAPB) lesions for cancer.

RESULTS

On initial biopsy, a concomitant high-grade prostatic intraepithelial neoplasia (HGPIN) was present in 26 patients (23%) with ASAP. The overall cancer detection rate was significantly higher in patients who had ASAP associated with HGPIN (58%), compared with patients who had isolated ASAP (35%; P = 0.04). The cancer detection rate was not significantly higher in patients with ASAPH than in those with ASAPB (49% versus 33%, respectively; P = 0.11). In the group of patients who had isolated ASAP, the rate of cancer detection was significantly higher in patients who had a prostatic volume less than 50 mL (56%) than in patients with a prostatic volume of 50 mL or more (27%; P = 0.03).

CONCLUSIONS

The cancer detection rate was significantly higher in patients with an ASAP associated with HGPIN on initial biopsy than in patients with isolated ASAP. In ASAP patients, the detection rate was lower for patients with a larger prostate than in those with a smaller prostate.

[Computerized tomography guided percutaneous needle biopsies at Landspitali University Hospital. Indications, complications and results]

OBJECTIVE

Transthoracic needle aspiration biopsies (TNAB) are ideal for diagnosis of peripheral lung nodules. The purpose of the study is to investigate computerized tomography (CT) guided TNAB at Landspitali University Hospital (LUH) in regard to indications, complications, results and evaluate the diagnoses that were obtained with the biopsies.

MATERIAL AND METHODS

Retrospective study where information was obtained from clinical charts at LUH. A list of TNAB done over an 18 month period in 2003 to 2004 was obtained from the Department of Medical Imaging. Indications for biopsy, pathology diagnosis, complications and treatment were studied. Further studies and final diagnosis were also studied.

RESULTS

There were total of 93 patients that had TNAB. Records were available on 82 patients (46 males og 36 females). Most often the study was done because of cancer suspicion. Nodules were commonly 2-3 cm large. Most commonly there was one nodule that was peripheral. 25/82 (30%) patients developed pneumothorax after the procedure and four patients needed a chest tube. The most common diagnosis was cancer in 36/82 (44%), unspecific changes in 15/82, normal tissue in 12/82, inflammation in 9/82 and other benign causes in 10/82. The sensitivity to diagnose cancer was 61% and specificity 100%. The final diagnosis was cancer in 59/82 (72%) of the cases and benign causes in 23/82.

CONCLUSIONS

The diagnostic yield of TNAB is lower in our study than in many previous studies. The rate of complications is similar. It it necessary to do followup studies in benign diagnoses because many of them have cancer when studied further.

Extended 12-core prostate biopsy increases both the detection of prostate cancer and the accuracy of Gleason score

OBJECTIVE

To evaluate the effect of extended 12-core prostate biopsy in improving the detection rate of prostate cancer and increasing the accuracy of Gleason score.

METHODS

This study included 113 patients who underwent TRUS-guided lateral sextant biopsy (group I) and 176 patients who underwent extended 12-core biopsy (group II). Inclusion criteria for prostate biopsy were elevated serum PSA levels (>3.0 ng/ml) and/or suspicious digital rectal examination (DRE).

RESULTS

Clinical characteristics were similar in both groups. Cancer was detected in 28 (24.8%) and 64 (36.4%) patients in group I and II respectively, chi2=4.26, p=0.039. Among patients with cancer in group I, 14 were treated by radical prostatectomy (RP). The median Gleason sum was 6 (range 3-8) and 7 (range 5-9) for needle and prostatectomy specimens respectively. There was an agreement between the biopsy and prostatectomy Gleason sum in 7 (50%) patients while the biopsy Gleason sum was lower in 7 (50%) cases. Among patients with cancer in group II, 27 were treated by RP. The median and the range of Gleason sum was the same for needle and prostatectomy specimen (median 6, range 4-9). There was an agreement between the biopsy and prostatectomy specimen in 23 (85.2%) patients while the biopsy sum was lower than prostatectomy in 4 (14.8%) patients. The agreement between the biopsy and prostatectomy specimen was significantly higher in group II (82.5%) than group I (50%), Fisher's Exact Test, p=0.026.

CONCLUSION

Extended 12-core prostate biopsy significantly increases both the detection rate of prostate cancer and the accuracy of biopsy Gleason score.

PATIENT AND UROLOGIST DRIVEN SECOND OPINION OF PROSTATE NEEDLE BIOPSIES

PURPOSE

We reviewed second opinion prostate needle biopsies that were patient and urologist driven to determine how often an expert opinion resulted in a different diagnosis.

MATERIALS AND METHODS

Of 3,155 prostate needle biopsy consultations received during a 6-month interval 684 were sent at the request of the patient or urologist. A significant change in outside diagnosis was one that could potentially result in a change in therapy or prognosis.

RESULTS

The second opinion was requested by patients (21.6%), urologist (63.9%) and patients plus urologists (14.5%). The distribution of the 684 outside diagnoses was benign in 6.1%, HGPIN in 7.6%, atypical (ATYP) in 29.8% and cancer in 56.5%. In 241 cases (35.2%) a change in diagnosis was rendered upon expert review. We agreed with the majority of outside cancer, benign and HGPIN diagnoses, in contrast to only 36.8% of outside ATYP cases (p <0.0001). Uncommonly did a cancer diagnosis become a benign one or vice versa. Of changes affecting outside cancer diagnoses 73.5% were due to changes in Gleason score. The diagnosis was more likely to be changed when the consultation was requested by the urologist rather than by the patient (41.4% vs 25%, p <0.0001).

CONCLUSIONS

Cases diagnosed as ATYP have the highest likelihood of being changed upon expert review. Urologists should consider sending such cases for consultation to attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy.

Breast biopsy utilization: a population-based study

BACKGROUND

Breast biopsy, to determine the nature of a clinical or radiographic breast abnormality, was presumed to have increased in frequency with the widespread use of screening mammography. However, scant data exist regarding the utilization of breast biopsies in the community population.

METHODS

Through the resources of the Rochester Epidemiology Project, the medical records of women 18 years and older who had a breast biopsy from January 1, 1988, through December 31, 1999, were reviewed for the type of biopsy, presentation at biopsy, and tissue pathological findings. The overall and age-specific utilization rates of breast biopsies were assessed, as were changes in the breast biopsy technique after the introduction of image-guided core-needle biopsy in 1992.

RESULTS

The overall annual utilization rate of breast biopsies was 62.6 per 10 000 women per year and remained stable throughout the study. Excisional breast biopsies showed a decreasing trend and core-needle biopsies increased during the study duration. The age-adjusted incidence of benign results of breast biopsies for the study duration was 38.9 per 10 000 women. The benign-malignant ratio remained constant despite changes in the biopsy procedure.

CONCLUSIONS

This population-based study provides much-needed data regarding the frequency of breast biopsies and benign results of breast biopsies in a community population. The utilization rate of breast biopsies remained fairly constant throughout the study period despite the introduction of the image-guided, core-needle biopsy procedure in 1992. A multidisciplinary breast practice, along with established guidelines for breast biopsy, can ensure appropriate use of new technology and thereby improve patient care.

Utility of saturation biopsy to predict insignificant cancer at radical prostatectomy

OBJECTIVES

To determine whether potential candidates for watchful waiting have undersampling of more substantial cancer.

METHODS

A total of 103 men were studied, who were predicted to have insignificant cancer in their radical prostatectomy (RP) specimen. All had limited cancer on routine needle biopsy (no core with more than 50% involvement; Gleason score less than 7, and fewer than 3 cores involved) with a serum prostate-specific antigen density of 0.15 or less. Insignificant tumor at RP was considered organ-confined tumor, no Gleason pattern 4 or 5, and a tumor volume of less than 0.5 cm3. Saturation biopsy (average 44 cores) and an alternate biopsy saturation scheme with one half the number of cores using an 18-gauge Biopty gun was performed in the pathology laboratory on totally embedded and serially sectioned RP specimens.

RESULTS

Of the tumors, 97% were organ confined. The RP Gleason score was less than 7 in 84% of the cases. The RP tumor volume was 0.01 to 2.39 cm3 (median 0.14). Of the cancer specimens, 71% were insignificant and 29% had been incorrectly classified before surgery using standard biopsy schemes. Using the full saturation biopsy scheme, if we predicted significant cancer, the probability of having insignificant cancer was only 11.5% (false-positive rate). If the model predicted insignificant cancer, the probability of significant cancer was also only 11.5% (false-negative rate; sensitivity 71.9% and specificity 95.8%). Using the alternate biopsy sampling scheme, the false-positive rate was 8% and the false-negative rate was 11.4% (sensitivity 71.9% and specificity 97.1%).

CONCLUSIONS

Saturation biopsy provides accurate predictability of prostate tumor volume and grade to select suitable candidates for watchful waiting therapy.

The usefulness of the aspirate differential count in cases of nonhematologic neoplasia

A standard bone marrow examination may be done in patients with a known nonhematologic malignancy in order to evaluate the presence or absence of metastatic disease. A 300-cell-count differential of the aspirate is often performed in these cases. However, the clinical utility of the differential count has never been assessed. A retrospective review was performed on 107 bone marrow reports from 86 patients with a documented nonhematologic malignancy to determine the clinical usefulness of the differential counts in this patient population. Two cases out of 107 had clinically relevant findings from the aspirate differential. One patient had an increase in plasma cells (7%) and one had left-shifted granulopoiesis with 19% blasts. In most instances, the performance of an aspirate differential adds little clinically useful information in patients undergoing bone marrow examination for metastatic disease. There are cost savings associated with omitting the routine aspirate differential as either technologist- or pathologist-time in performing the differential is decreased.

Development and validation of a nomogram predicting the outcome of prostate biopsy based on patient age, digital rectal examination and serum prostate specific antigen

PURPOSE

We developed and validated a nomogram which predicts presence of prostate cancer (PCa) on needle biopsy.

MATERIALS AND METHODS

We used 3 cohorts of men who were evaluated with sextant biopsy of the prostate and whose presenting prostate specific antigen (PSA) was not greater than 50 ng/ml. Data from 4,193 men from Montreal, Canada were used to develop a nomogram based on age, digital rectal examination (DRE) and serum PSA. External validation was performed on 1,762 men from Hamburg, Germany. Data from these men were subsequently used to develop a second nomogram in which percent free PSA (%fPSA) was added as a predictor. External validation was performed using 514 men from Montreal. Both nomograms were based on multivariate logistic regression models. Predictive accuracy was evaluated with areas under the receiver operating characteristic curve and graphically with loess smoothing plots.

RESULTS

PCa was detected in 1,477 (35.2%) men from Montreal, 739 (41.9%) men from Hamburg and 189 (36.8%) men from Montreal. In all models all predictors were significant at 0.05. Using age, DRE and PSA external validation AUC was 0.69. Using age, DRE, PSA and %fPSA external validation AUC was 0.77.

CONCLUSIONS

A nomogram based on age, DRE, PSA and %fPSA can highly accurately predict the outcome of prostate biopsy in men at risk for PCa.

The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy

PURPOSE

Multivariate prognostic instruments aim to predict risk of recurrence among patients with localized prostate cancer. We devised a novel risk assessment tool which would be a strong predictor of outcome across various levels of risk, and which could be easily applied and intuitively understood.

MATERIALS AND METHODS

We studied 1,439 men diagnosed between 1992 and 2001 who had undergone radical prostatectomy and were followed in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database, a longitudinal, community based disease registry of patients with prostate cancer. Disease recurrence was defined as prostate specific antigen (PSA) 0.2 ng/ml or greater on 2 consecutive occasions following prostatectomy or a second cancer treatment more than 6 months after surgery. The University of California, San Francisco-Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score was developed using preoperative PSA, Gleason score, clinical T stage, biopsy results and age. The index was developed and validated using Cox proportional hazards and life table analyses.

RESULTS

A total of 210 patients (15%) had recurrence, 145 by PSA criteria and 65 by second treatment. Based on the results of the Cox analysis, points were assigned based on PSA (0 to 4 points), Gleason score (0 to 3), T stage (0 to 1), age (0 to 1) and percent of biopsy positive cores (0 to 1). The UCSF-CAPRA score range is 0 to 10, with roughly double the risk of recurrence for each 2-point increase in score. Recurrence-free survival at 5 years ranged from 85% for a UCSF-CAPRA score of 0 to 1 (95% CI 73%-92%) to 8% for a score of 7 to 10 (95% CI 0%-28%). The concordance index for the UCSF-CAPRA score was 0.66.

CONCLUSIONS

The UCSF-CAPRA score is a straightforward yet powerful preoperative risk assessment tool. It must be externally validated in future studies.

Effect of Referring Physician Specialty and Practice Type on Referral for Image-Guided Breast Biopsy

PURPOSE

To determine whether referring physician specialty and practice type affect the likelihood of referral for image-guided breast biopsy.

METHOD

We reviewed the records of every patient who received a Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 examination (mammography, ultrasound, or both) performed during the year 2000 at both our community- and hospital-based practices. We recorded the referring physician specialty and office location (academic medical center vs. community), breast-imaging facility location (hospital vs. community), patient age, patient insurance status, BI-RADS category, and palpability of the lesion. Multiple logistic regression analysis was performed to examine the relationship of these factors to the biopsy type (surgical vs. image-guided).

RESULTS

Of the 831 patients with a BI-RADS Category 4 or 5 report, 734 underwent follow-up surgical or image-guided needle biopsy. Multiple logistic regression analysis demonstrated that referral by a nonsurgeon or by a physician at the academic medical center was associated with a higher likelihood of the patient's being referred for image-guided biopsy. Patients referred by surgeons and community physicians were more likely to undergo surgical biopsy. BI-RADS Category 5 examinations and palpable lesions were also associated with a higher probability of undergoing surgical biopsy. Patient age, insurance status, and breast-imaging facility location were not related to biopsy type.

CONCLUSIONS

In our practice, patients referred for breast imaging by nonsurgeons and academic physicians were more likely to be referred for image-guided biopsy, whereas patients referred by surgeons and community physicians were more likely to undergo surgical biopsy.

[Prostatic biopsy technique in the Centre region]

Prostate cancer is the most frequent cancer and second cause of cancer mortality in men. The objective of this study was to analyse the prostatic biopsy technique and to verify its conformity with the reference technique of the Centre region.

MATERIAL AND METHOD

This study concerned first-line biopsies performed and analysed between 01/01/2001 and 31/03/2001 by all pathologists of the Centre region. We analysed the anaesthesia used to perform these biopsies, whether or not the patient was hospitalized, the needle diameter, the use of ultrasound or finger guidance, the operator's specialization and whether he/she worked in the private or public sector, the number of biopsies, the histology request form and the antibiotic prophylaxis used.

RESULTS

Six hundred and twelve reports were sent by laboratories at the request of the regional health insurance fund. There were 562 first-line biopsies, which represented 93% of all biopsies studied Biopsy was performed as an outpatient procedure, the recommended modality, in only 36% of cases; in 10% of cases, hospitalization was justified by a particular clinical context. 11% of biopsies were not ultrasound-guided, particularly in the private sector. Information about histological type, Gleason grade, tumour volume, number of cores invaded and extension to the periprostatic space was present in 46% of cases.

CONCLUSIONS

Only 40% of biopsies performed during the first quarter of 2001 complied with recognized quality criteria: ultrasound guidance, as an outpatient procedure or justified hospitalization, without anaesthesia or with local anaesthesia. Improvement of clinical practice probably requires a phase of discussions and negotiations between professionals and authorities to determine a reasonable fee allowing an objective choice adapted to the patient's state of health. The quality of the histological report is not satisfactory at the present time. A standard report was presented by the Réseau Regional de Cancérologie du Centre (Centre Regional Oncology Network) but has not been adopted by all professionals; further discussions are required to develop a simplified grid comprising essential information, especially as the quality of these reports determines treatment decisions.

PROSTATE CANCER DETECTION IN MEN WITH PROSTATE SPECIFIC ANTIGEN 4 TO 10 NG/ML USING A COMBINED APPROACH OF CONTRAST ENHANCED COLOR DOPPLER TARGETED AND SYSTEMATIC BIOPSY

PURPOSE

Transrectal gray scale ultrasound guided biopsy is the standard method for diagnosing prostate cancer (PC). Improved cancer detection with ultrasound contrast agents is related to better detection of tumor vascularity. We evaluated the impact of a combined approach of contrast enhanced, color Doppler targeted biopsy (CECD) and systematic biopsy (SB) for the PC detection rate in men with prostate specific antigen (PSA) 4.0 to 10 ng/ml.

MATERIALS AND METHODS

We examined 380 screening volunteers with a total PSA of 4.0 to 10 ng/ml (percent free PSA less than 18). CECD was always performed before SB. Another investigator blinded to contrast enhanced findings performed 10 SBs. The cancer detection rate for the CECD, SB and combined approaches was assessed.

RESULTS

PC was detected in 143 of 380 patients (37.6%, mean total PSA 6.2 ng/ml). The PC detection rate for CECD and for SB was 27.4% and 27.6%, respectively. The overall cancer detection rate with the 2 methods combined was 37.6%. For targeted biopsy cores the detection rate was significantly better than for SB cores (32.6% vs 17.9%, p <0.01). CECD in a patient with cancer was 3.1-fold more likely to detect PC than SB.

CONCLUSIONS

CECD allows for the detection of lesions that cannot be found on gray scale ultrasound or SB. CECD allows for assessment of neovascularity associated with PC. However, the combined use of CECD and SB allows for maximal detection of PC with a detection rate of 37.6% in our patients with PSA 4 to 10 ng/ml.

Significance of the Percentage of Prostate Needle Biopsy Cores with Cancer as a Predictor of Disease Extension in Radical Prostatectomy Specimens in Japanese Men

OBJECTIVES

To evaluate the significance of the percent of positive biopsy cores (PPBC) with cancer, which has been shown to be one of the most useful predictors of prostate cancer extension in patients undergoing radical prostatectomy.

MATERIALS AND METHODS

This study included 120 patients who underwent radical prostatectomy for prostate cancer without any neoadjuvant therapies. All of these patients were diagnosed by random prostate biopsy targeting 8 cores; that is, standard sextant cores and 2 additional cores from the bilateral anterior lateral horns. We evaluated the appropriate cut-off points of PPBC for predicting disease extension according to the number of biopsy cores. Based on these criteria, multivariate analysis was then performed to determine whether PPBC could be an independent factor differentiating organ-confined disease from extraprostatic disease.

RESULTS

The most suitable PPBC cut-off value using findings targeting 8 cores for predicting disease extension was 37.5%. If PPBC was calculated based on the outcome of standard sextant cores alone, it is most appropriate to use 33.3% as the cut-off point. Multivariate analysis showed that PPBC calculated based on the standard sextant cores and percent of cancer in the biopsy set could be used as independent factors predicting disease extension irrespective of other biopsy-associated factors.

CONCLUSIONS

For predicting disease extension, it may be useful to calculate PPBC based on the outcomes of standard sextant biopsy cores alone even if additional cores were taken, and that PPBC calculated in such a way may be the strongest preoperative predictor of prostate cancer extension in Japanese men scheduled for radical prostatectomy.

Prostate needle biopsy: 12 vs. 18 cores -- is it necessary?

INTRODUCTION

The aim of this study is to compare the histological results of a prostate needle biopsy scheme of 12 and 18 cores used in 372 consecutive patients submitted to an early stage diagnosis programme for prostate cancer (PCa).

MATERIALS AND METHODS

From February 2002 to July 2003 a transperineal TRUS-guided prostate needle biopsy was performed in 372 patients aged 40-73. Indications for biopsy were: suspected DRE, total PSA (PSAt) >10 ng/ml; PSAt equal to 4-10, 2.6-3.9, < or =2.5 ng/ml and PSA F/T <25%, <20% and <15%, respectively. In 256 patients, we performed 12 cores and in 116 cases 18 cores.

RESULTS

159 (42.7%) patients were diagnosed with PCa, 138 (37%) with BPH, 58 (15.7%) with chronic prostatitis, 15 (4%) with a HGPIN, 2 (0.6%) with ASAP. In patients that underwent 12 and 18 cores the incidence of PCa was 39.8 and 49%; the incidence of PCa in patients with PSA < or =10 and >10 ng/ml submitted to 12 and 18 cores was 35 vs. 47% and 57.8 vs. 52%, respectively. The preponderance of clinical stage T1c was 50% (12 cores) vs. 72% (18 cores). The median bioptic Gleason score in both groups resulted 6.6 (12 cores) and 6 (18 cores). In 110 (12 bioptic cores) and in 30 (18 bioptic cores) patients that underwent a RRP, the pTNM proved a significant clinical neoplasm (Gleason score > or =6 and/or tumoral volume >0.5 cm(3)) in the first group in all cases, while in the second group in 28/30 (94%) cases.

CONCLUSIONS

Extended schemes of prostate needle biopsy of 18 or more cores increases the PCa diagnosis in early stage and should be adopted for young patients with a PSA <10 ng/ml, negative DRE and in case of rebiopsies.

Bone marrow biopsy morbidity: review of 2003

BACKGROUND

Although some hazards are recognised, in general, bone marrow aspiration and trephine biopsy are thought to be safe procedures. Until recently, no attempt had been made to quantify any attendant risks. For this reason, documentation of adverse events was begun in 2001, under the auspices of the British Society for Haematology. Three consecutive years have now been surveyed, the results for 2003 being presented here and compared with earlier results.

METHODS

Members of the British Society of Haematology were requested to document adverse events associated with diagnostic bone marrow aspirates and trephine biopsies between 1 January and 31 December, 2003. Data were collected early in 2004.

RESULTS

In total, 19,259 procedures were reported from 63 hospitals, 13,147 being combined procedures and 6112 aspirates without a trephine biopsy. Sixteen adverse events were reported, representing 0.08% of total reported procedures. The major adverse event was haemorrhage, which comprised 11 of the 16 adverse events. Although infrequent, adverse events were associated with significant morbidity and three were judged as very serious. The major risk factors for haemorrhage, in order of frequency, were diagnosis of a myeloproliferative disorder, aspirin treatment, other putative platelet dysfunctions, and thrombocytopenia.

CONCLUSIONS

Adverse events following trephine biopsies and bone marrow aspirates are rare, but nevertheless can have considerable impact on individual patients.