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Zambon A, Nguyen TA, Fourcade A, Segalen T, Saout K, Deruelle C, Joulin V, Tissot V, Doucet L, Fournier G, Valeri A. Which protocol for prostate biopsies in patients with a positive MRI? Interest of systematic biopsies by sectors. Prostate Cancer Prostatic Dis 2024; 27:500-506. [PMID: 38114598 DOI: 10.1038/s41391-023-00770-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Current prostate biopsy (PBx) protocol for prostate cancer (PCa) diagnosis is to perform systematic biopsies (SBx) combined with targeted biopsies (TBx) in case of positive MRI (i.e. PI-RADS ≥ 3). To assess the utility of performing SBx in combination with TBx, we determined the added value of SBx brought to the diagnosis of PCa according to their sextant location and MRI target characteristics. METHODS In our local prospectively collected database, we conducted a single-center retrospective study including all patients with a suspicion of PCa, who underwent transrectal ultrasound-guided (TRUS) prostate biopsies (PBx) with a prior MRI and a single lesion classified as PI-RADS ≥ 3. We have characterized the SBx according to their location on MRI: same sextant (S-SBx), adjacent sextant (A-SBx), ipsilateral side (I-SBx) and contralateral side (C-SBx). The added value of SBx and TBx was defined as any upgrading to significant PCa (csPCa) (ISUP ≥2). RESULTS 371 patients were included in the study. The added value of SBx was 10% overall. Regarding the lesion location and the SBx sextant, the added value of SBx was: 5.1% for S-SBx, 5.4% for A-SBx, 4.9% for I-SBx and 1.9% for C-SBx. The overall added value of SBx was 6.8% for PI-RADS 3 lesions, 14% for PI-RADS 4 lesions and 6.7% for PI-RADS 5 lesions (p = 0.063). The added value of SBx for contralateral side was 1.9% (2/103), 3.1% (5/163) and 0% (0/105) for PI-RADS 3, PI-RADS 4 and PI-RADS 5 lesions, respectively (p = 0,4). The added value of SBx was lower when the number of TBx was higher (OR 0.57; CI 95% 0.37-0.85; p = 0.007). CONCLUSIONS Our results suggest that the utility of performing SBx in the contralateral lobe toward the MRI lesion was very low, supporting that they might be avoided.
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Affiliation(s)
- A Zambon
- Urology Department, Brest University Hospital, Brest, France.
| | - T-A Nguyen
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
| | - A Fourcade
- Urology Department, Brest University Hospital, Brest, France
| | - T Segalen
- Urology Department, Brest University Hospital, Brest, France
| | - K Saout
- Urology Department, Brest University Hospital, Brest, France
| | - C Deruelle
- Urology Department, Brest University Hospital, Brest, France
| | - V Joulin
- Urology Department, Brest University Hospital, Brest, France
| | - V Tissot
- Radiology Department, Brest University Hospital, Brest, France
| | - L Doucet
- Pathology Department, Brest University Hospital, Brest, France
| | - G Fournier
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
- CeRePP, Paris, France
| | - A Valeri
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
- CeRePP, Paris, France
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Zattoni F, Fasulo V, Kasivisvanathan V, Kesch C, Marra G, Martini A, Falagario U, Soeterik T, van den Bergh R, Rajwa P, Gandaglia G. Enhancing Prostate Cancer Detection Accuracy in Magnetic Resonance Imaging-targeted Prostate Biopsy: Optimizing the Number of Cores Taken. EUR UROL SUPPL 2024; 66:16-25. [PMID: 39027654 PMCID: PMC11254588 DOI: 10.1016/j.euros.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/20/2024] Open
Abstract
Background and objective The shift toward targeted biopsy (TBx) aims at enhancing prostate cancer (PCa) detection while reducing overdiagnosis of clinically insignificant disease. Despite the improved ability of TBx in identifying clinically significant PCa (csPCa), the optimal number and location of targeted cores remain unclear. This review aims to assess the optimal number of prostate biopsy magnetic resonance imaging (MRI)-targeted cores to detect csPCa. Methods A narrative literature search was conducted using PubMed, focusing on studies published between January 2014 and January 2024, addressing factors influencing targeted core numbers during prostate biopsy. The search included both retrospective and prospective studies, prioritizing those with substantial sample sizes and employing terms such as "prostate biopsy", "mpMRI", "core number", and "cancer detection". Key findings and limitations Two biopsy cores identified csPCa in 55-65% of cases. This detection rate improved to approximately 90% when the number of cores was ≥5. The inclusion of perilesional and systematic biopsies could maximize the detection of csPCa (from 10% to 45%), especially in patients under active surveillance or with prior negative biopsy results, although there is an increase in the overdiagnosis of indolent tumors (from 4% to 20%). Transperineal software-assisted target prostate biopsy may enhance cancer detection, particularly for tumors located at the apex/anterior part of the prostate. Increasing the number of TBx cores may incrementally raise the risk of complications (by 2-14% with each added core) and result in severe pain and significant discomfort for up to 17% and 25% of TBx patients, respectively. However, the overall rate and severity of these complications remain within acceptable limits. Conclusions and clinical implications The optimal number of cores for targeted prostate biopsies should balance minimizing sampling errors with effective cancer detection and should be tailored to each patient's unique prostate characteristics. Up to five cores per MRI target may be considered to enhance the detection of csPCa, with adjustments based on factors such as prostate and lesion volume, Prostate Imaging Reporting and Data System, biopsy techniques, complications, patient discomfort, and anxiety. Patient summary In this report, we found that increasing the number of biopsy cores up to ≥5 improves the detection rates of significant prostate cancer significantly to around 90%. Although inclusion of nearby and systematic biopsies enhances detection, increasing the biopsy count may lead to higher risks of complications and indolent tumors. A customized biopsy approach based on multiple variables could be helpful in determining the appropriate number of targeted biopsies on a case-by-case basis.
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Affiliation(s)
- Fabio Zattoni
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Department of Medicine - DIMED, University of Padua, Italy
| | - Vittorio Fasulo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Claudia Kesch
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Giancarlo Marra
- Department of Surgical Sciences, Division of Urology, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Alberto Martini
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Ugo Falagario
- Department of Urology, University of Foggia, Foggia, Italy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Timo Soeterik
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Giorgio Gandaglia
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - EAU-YAU Prostate Cancer Working Party (PCa-WP)
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Department of Medicine - DIMED, University of Padua, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Surgical Sciences, Division of Urology, University of Turin and Città della Salute e della Scienza, Turin, Italy
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
- Department of Urology, University of Foggia, Foggia, Italy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
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3
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Light A, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore CM, Emberton M, Punwani S, Ahmed HU, Shah TT. The Role of Multiparametric MRI and MRI-targeted Biopsy in the Diagnosis of Radiorecurrent Prostate Cancer: An Analysis from the FORECAST Trial. Eur Urol 2024; 85:35-46. [PMID: 37778954 DOI: 10.1016/j.eururo.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The role of multiparametric magnetic resonance imaging (MRI) for detecting recurrent prostate cancer after radiotherapy is unclear. OBJECTIVE To evaluate MRI and MRI-targeted biopsies for detecting intraprostatic cancer recurrence and planning for salvage focal ablation. DESIGN, SETTING, AND PARTICIPANTS FOcal RECurrent Assessment and Salvage Treatment (FORECAST; NCT01883128) was a prospective cohort diagnostic study that recruited 181 patients with suspected radiorecurrence at six UK centres (2014 to 2018); 144 were included here. INTERVENTION All patients underwent MRI with 5 mm transperineal template mapping biopsies; 84 had additional MRI-targeted biopsies. MRI scans with Likert scores of 3 to 5 were deemed suspicious. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS First, the diagnostic accuracy of MRI was calculated. Second, the pathological characteristics of MRI-detected and MRI-undetected tumours were compared using the Wilcoxon rank sum test and chi-square test for trend. Third, four biopsy strategies involving an MRI-targeted biopsy alone and with systematic biopsies of one to two other quadrants were studied. Fisher's exact test was used to compare MRI-targeted biopsy alone with the best other strategy for the number of patients with missed cancer and the number of patients with cancer harbouring additional tumours in unsampled quadrants. Analyses focused primarily on detecting cancer of any grade or length. Last, eligibility for focal therapy was evaluated for men with localised (≤T3bN0M0) radiorecurrent disease. RESULTS AND LIMITATIONS Of 144 patients, 111 (77%) had cancer detected on biopsy. MRI sensitivity and specificity at the patient level were 0.95 (95% confidence interval [CI] 0.92 to 0.99) and 0.21 (95% CI 0.07 to 0.35), respectively. At the prostate quadrant level, 258/576 (45%) quadrants had cancer detected on biopsy. Sensitivity and specificity were 0.66 (95% CI 0.59 to 0.73) and 0.54 (95% CI 0.46 to 0.62), respectively. At the quadrant level, compared with MRI-undetected tumours, MRI-detected tumours had longer maximum cancer core length (median difference 3 mm [7 vs 4 mm]; 95% CI 1 to 4 mm, p < 0.001) and a higher grade group (p = 0.002). Of the 84 men who also underwent an MRI-targeted biopsy, 73 (87%) had recurrent cancer diagnosed. Performing an MRI-targeted biopsy alone missed cancer in 5/73 patients (7%; 95% CI 3 to 15%); with additional systematic sampling of the other ipsilateral and contralateral posterior quadrants (strategy 4), 2/73 patients (3%; 95% CI 0 to 10%) would have had cancer missed (difference 4%; 95% CI -3 to 11%, p = 0.4). If an MRI-targeted biopsy alone was performed, 43/73 (59%; 95% CI 47 to 69%) patients with cancer would have harboured undetected additional tumours in unsampled quadrants. This reduced but only to 7/73 patients (10%; 95% CI 4 to 19%) with strategy 4 (difference 49%; 95% CI 36 to 62%, p < 0.0001). Of 73 patients, 43 (59%; 95% CI 47 to 69%) had localised radiorecurrent cancer suitable for a form of focal ablation. CONCLUSIONS For patients with recurrent prostate cancer after radiotherapy, MRI and MRI-targeted biopsy, with or without perilesional sampling, will diagnose cancer in the majority where present. MRI-undetected cancers, defined as Likert scores of 1 to 2, were found to be smaller and of lower grade. However, if salvage focal ablation is planned, an MRI-targeted biopsy alone is insufficient for prostate mapping; approximately three of five patients with recurrent cancer found on an MRI-targeted biopsy alone harboured further tumours in unsampled quadrants. Systematic sampling of the whole gland should be considered in addition to an MRI-targeted biopsy to capture both MRI-detected and MRI-undetected disease. PATIENT SUMMARY After radiotherapy, magnetic resonance imaging (MRI) is accurate for detecting recurrent prostate cancer, with missed cancer being smaller and of lower grade. Targeting a biopsy to suspicious areas on MRI results in a diagnosis of cancer in most patients. However, for every five men who have recurrent cancer, this targeted approach would miss cancers elsewhere in the prostate in three of these men. If further focal treatment of the prostate is planned, random biopsies covering the whole prostate in addition to targeted biopsies should be considered so that tumours are not missed.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Francesco Giganti
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, London, UK; Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.
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4
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Noujeim JP, Belahsen Y, Lefebvre Y, Lemort M, Deforche M, Sirtaine N, Martin R, Roumeguère T, Peltier A, Diamand R. Optimizing multiparametric magnetic resonance imaging-targeted biopsy and detection of clinically significant prostate cancer: the role of perilesional sampling. Prostate Cancer Prostatic Dis 2023; 26:575-580. [PMID: 36509930 DOI: 10.1038/s41391-022-00620-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The added-value of systematic biopsy (SB) in patients undergoing magnetic resonance imaging (MRI)-targeted biopsy (TB) remains unclear and the spatial distribution of positive cores relative to the MRI lesion has been poorly studied. The aim of this study was to determine the utility of perilesional biopsy in detecting clinically significant prostate cancer (csPCa). METHODS We enrolled 505 consecutive patients that underwent SB and TB for suspicious MRI lesions (PI-RADS score 3-5) at Jules Bordet Institute between June 2016 and January 2022. Patient-specific tridimensional prostate maps were reviewed to determine the distance between systematic cores containing csPCa and the MRI index lesion. Primary outcomes were the cancer detection rate (CDR) per patient and the cumulative cancer distribution rate of positive cores for each 5 mm interval from the MRI index lesion. The secondary outcome was the identification of risk groups for the presence of csPCa beyond a 10 mm margin using the chi-square automated interaction detector (CHAID) machine learning algorithm. RESULTS Overall, the CDR for csPCa of TB, SB, and combined method were 32%, 25%, and 37%, respectively. While combined method detected more csPCa compared to TB (37% vs. 32%, p < 0.001), no difference was found when TB was associated with perilesional sampling within 10 mm (37% vs. 35%, p = 0.2). The cumulative cancer distribution rate for csPCa reached 86% for the 10 mm margin. The CHAID algorithm identified three risk groups: (1) PI-RADS3 ("low-risk"), (2) PI-RADS4 or PI-RADS5 and PSA density <0.15 ng/ml ("intermediate-risk"), and (3) PI-RADS 5 and PSA density ≥0.15 ng/ml ("high-risk"). The risk of missing csPCa was 2%, 8%, and 29% for low-, intermediate- and high-risk groups, respectively. Avoiding biopsies beyond a 10 mm margin prevented the detection of 19% of non-csPCa. CONCLUSIONS Perilesional biopsy template using a 10 mm margin seems a reasonable alternative to the combined method with a comparable detection of csPCa. Our risk stratification may further enhance the selection of patients.
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Affiliation(s)
- Jean-Paul Noujeim
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Yassir Belahsen
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Yolene Lefebvre
- Department of Radiology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc Lemort
- Department of Radiology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Deforche
- Department of Radiology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Sirtaine
- Department of Pathology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Robin Martin
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Romain Diamand
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
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5
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Tomioka M, Seike K, Uno H, Asano N, Watanabe H, Tomioka-Inagawa R, Kawase M, Kato D, Takai M, Iinuma K, Tobisawa Y, Nakane K, Tsuchiya K, Ito T, Koie T. Perilesional Targeted Biopsy Combined with MRI-TRUS Image Fusion-Guided Targeted Prostate Biopsy: An Analysis According to PI-RADS Scores. Diagnostics (Basel) 2023; 13:2608. [PMID: 37568971 PMCID: PMC10417101 DOI: 10.3390/diagnostics13152608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/29/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
A prostate-targeted biopsy (TB) core is usually collected from a site where magnetic resonance imaging (MRI) indicates possible cancer. However, the extent of the lesion is difficult to accurately predict using MRI or TB alone. Therefore, we performed several biopsies around the TB site (perilesional [p] TB) and analyzed the association between the positive cores obtained using TB and pTB and the Prostate Imaging Reporting and Data System (PI-RADS) scores. This retrospective study included patients who underwent prostate biopsies. The extent of pTB was defined as the area within 10 mm of a TB site. A total of 162 eligible patients were enrolled. Prostate cancer (PCa) was diagnosed in 75.2% of patients undergoing TB, with a positivity rate of 50.7% for a PI-RADS score of 3, 95.8% for a PI-RADS score of 4, and 100% for a PI-RADS score of 5. Patients diagnosed with PCa according to both TB and pTB had significantly higher positivity rates for PI-RADS scores of 4 and 5 than for a PI-RADS score of 3 (p < 0.0001 and p = 0.0009, respectively). Additional pTB may be performed in patients with PI-RADS ≥ 4 regions of interest for assessing PCa malignancy.
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Affiliation(s)
- Masayuki Tomioka
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Kensaku Seike
- Department of Urology, Chuno Kousei Hospital, 5-1 Wakakusadori, Seki 5013802, Japan; (K.S.); (H.U.)
| | - Hiromi Uno
- Department of Urology, Chuno Kousei Hospital, 5-1 Wakakusadori, Seki 5013802, Japan; (K.S.); (H.U.)
| | - Nami Asano
- Department of Pathology, Chuno Kousei Hospital, 5-1 Wakakusadori, Seki 5013802, Japan;
| | - Haruo Watanabe
- Department of Radiology, Chuno Kousei Hospital, 5-1 Wakakusadori, Seki 5013802, Japan;
| | - Risa Tomioka-Inagawa
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Makoto Kawase
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Daiki Kato
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Manabu Takai
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Koji Iinuma
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Yuki Tobisawa
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | - Keita Nakane
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
| | | | - Takayasu Ito
- Center for Clinical Training and Career Development, Gifu University Graduate School of Medicine, Gifu 5011194, Japan;
| | - Takuya Koie
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan; (M.T.); (R.T.-I.); (M.K.); (D.K.); (M.T.); (K.I.); (Y.T.); (K.N.)
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6
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Lee AYM, Chen K, Cheng CWS, Ho HSS, Yuen JSP, Ngo NT, Law YM, Tay KJ. Intensive sampling of the umbra and penumbra improves clinically significant prostate cancer detection and reduces risk of grade group upgrading at radical prostatectomy. World J Urol 2023; 41:2265-2271. [PMID: 37395756 DOI: 10.1007/s00345-023-04499-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
PURPOSE Our objective is to evaluate the clinically significant prostate cancer detection rate of overlapping and perilesional systematic biopsy cores and its impact on grade group (GG) concordance at prostatectomy. MATERIALS AND METHODS Biopsy maps of those undergoing MRI-targeted (TB) and systematic biopsy (SB) were reviewed to reclassify systematic cores. Perilesional (PL) cores were defined as adjacent cores within 10 mm of the target lesion ("penumbra") whilst overlap (OL) cores were defined as cores within the ROI itself ("umbra"). All other cores were designated as distant cores (DC). The incremental csPCa detection rate (GG ≥ 2) and the rate of GG upgrading on prostatectomy as OL, PL and DC sequentially added to TB were determined. RESULTS Out of the 398 patients included, the median number of OL and PL cores was 5 (IQR 4-7) and 5 (IQR 3-6) respectively. OL cores detected more csPCa than PL cores (31 vs 16%, p < 0.001). OL and PL cores improved the csPCa detection rate of TB from 34 to 39% (p < 0.001) and 37% (p = 0.001) respectively. TB+OL+PL had greater csPCa detection compared to just TB+OL (41 vs 39%, p = 0.016) and TB+PL (41 vs 37%, p < 0.001). Of the 104 patients who underwent prostatectomy, GG upgrading rate for TB+OL+PL was lower compared to TB (21 vs 36%, p < 0.001) and was not significantly different compared to TB+OL+PL+DC (21 vs 19%, p = 0.500). CONCLUSION A biopsy strategy incorporating both intensive sampling of the umbra and penumbra improved csPCa detection and reduced risk of GG upgrading at prostatectomy.
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Affiliation(s)
- Alvin Y M Lee
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore.
| | - Kenneth Chen
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore
| | - Christopher W S Cheng
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore
- Department of Urology, Sengkang General Hospital, Singapore, Singapore
| | - Henry S S Ho
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore
| | - John S P Yuen
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore
| | - Nye Thane Ngo
- Department of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Yan Mee Law
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Kae Jack Tay
- Department of Urology, Singapore General Hospital, Academia, Level 5, Outram Road, Singapore, 169608, Singapore
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7
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Girometti R, Giannarini G, Peruzzi V, Amparore D, Pizzolitto S, Zuiani C. MRI-informed prostate biopsy: What the radiologist should know on quality in biopsy planning and biopsy acquisition. Eur J Radiol 2023; 164:110852. [PMID: 37167683 DOI: 10.1016/j.ejrad.2023.110852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 05/13/2023]
Abstract
Quality is currently recognized as the pre-requisite for delivering the clinical benefits expected by magnetic resonance imaging (MRI)-informed prostate biopsy (MRI-i-PB) in patients with a suspicion for clinically significant prostate cancer (csPCa). The "quality chain" underlying MRI-i-PB is multidisciplinary in nature, and depends on several factors related to the patient, imaging technique, image interpretation and biopsy procedure. This review aims at making the radiologist aware of biopsy-related factors impacting on MRI-i-PB quality, both in terms of biopsy planning (threshold for biopsy decisions, association with systematic biopsy and number of targeted cores) and biopsy acquisition (biopsy route, targeting technique, and operator's experience). While there is still space for improvement and better standardization of several biopsy-related procedures, current evidence suggests that high-quality MRI-i-PB can be delivered by acquiring and increased the number of biopsy cores targeted to suspicious imaging findings and perilesional area ("focal saturation biopsy"). On the other hand, uncertainty still exists as to whether software-assisted fusion of MRI and transrectal ultrasound images can outperform cognitive fusion strategy. The role for operator's experience and quality assurance/quality control procedures are also discussed.
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Affiliation(s)
- Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, p.le S. Maria della Misericordia n. 15, 33100 Udine, Italy.
| | - Gianluca Giannarini
- Urology Unit, University Hospital Santa Maria della Misericordia, p.le S. Maria della Misericordia n. 15, 33100 Udine, Italy.
| | - Valeria Peruzzi
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, p.le S. Maria della Misericordia n. 15, 33100 Udine, Italy.
| | - Daniele Amparore
- Division of Urology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Torino, Italy.
| | - Stefano Pizzolitto
- Unit of Pathology, University Hospital S. Maria della Misericordia, p.le S. Maria della Misericordia n. 15, 33100 Udine, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria della Misericordia, p.le S. Maria della Misericordia n. 15, 33100 Udine, Italy.
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8
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de Rooij M, van Poppel H, Barentsz JO. Risk Stratification and Artificial Intelligence in Early Magnetic Resonance Imaging-based Detection of Prostate Cancer. Eur Urol Focus 2022; 8:1187-1191. [PMID: 34922897 DOI: 10.1016/j.euf.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/18/2021] [Accepted: 11/26/2021] [Indexed: 12/16/2022]
Abstract
Magnetic resonance imaging (MRI) has transformed the diagnostic pathway for prostate cancer and now plays an upfront role before prostate biopsies. If a suspicious lesion is found on MRI, the subsequent biopsy can be targeted. A sharp increase is expected in the number of men who will undergo prostate MRI. The challenge is to provide good image quality and diagnostic accuracy while meeting the demands of the expected higher workload. A possible solution to this challenge is to include a suitable risk stratification tool before imaging. Other solutions, such as smarter and shorter MRI protocols, need to be explored. For most of these solutions, artificial intelligence (AI) can play an important role. AI applications have the potential to improve the diagnostic quality of the prostate MRI pathway and speed up the work. PATIENT SUMMARY: The use of prostate magnetic resonance imaging (MRI) for diagnosis of prostate cancer is increasing. Risk stratification of patients before imaging and the use of shorter scan protocols can help in managing MRI resources. Artificial intelligence can also play a role in automating some tasks.
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Affiliation(s)
- Maarten de Rooij
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Hendrik van Poppel
- Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
| | - Jelle O Barentsz
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Hagens MJ, Fernandez Salamanca M, Padhani AR, van Leeuwen PJ, van der Poel HG, Schoots IG. Diagnostic Performance of a Magnetic Resonance Imaging-directed Targeted plus Regional Biopsy Approach in Prostate Cancer Diagnosis: A Systematic Review and Meta-analysis. EUR UROL SUPPL 2022; 40:95-103. [PMID: 35540708 PMCID: PMC9079161 DOI: 10.1016/j.euros.2022.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 11/26/2022] Open
Abstract
Context Systematic biopsies are additionally recommended to maximize the diagnostic performance of the magnetic resonance imaging (MRI) diagnostic pathway for men with suspected prostate cancer (PCa) and positive scans. To reduce unnecessary systematic biopsies (SBx), MRI-directed approaches comprising targeted plus regional biopsy (TBx + RBx) are being investigated. Objective To systematically evaluate the diagnostic performance of MRI-directed TBx + RBx approaches in comparison to MRI-directed TBx alone and TBx + SBx approaches. Evidence acquisition The MEDLINE and Embase databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Identified reports were critically appraised according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. Detection of grade group (GG) ≥2 PCa was the endpoint of interest. Fixed-effect meta-analyses were conducted to characterize summary effect sizes and quantify heterogeneity. Only MRI-positive men were included. Evidence synthesis A total of eight studies were included for analysis. Among a cumulative total of 2603 men with suspected PCa, the GG ≥2 PCa detection rate did not significantly differ between MRI-directed TBx + RBx and TBx + SBx approaches (risk ratio [RR] 0.95, 95% confidence interval [CI] 0.90-1.01; p = 0.09). The TBx + RBx results were obtained using significantly fewer biopsy cores and avoiding contralateral SBx altogether. By contrast, there was significant difference in GG ≥2 PCa detection between MRI-directed TBx + RBx and TBx approaches (RR 1.18, 95% CI 1.10-1.25; p < 0.001). Conclusions MRI-directed TBx + RBx approaches showed a nonsignificant difference in detection of GG ≥2 PCa compared to the recommended practice of MRI-directed TBx + SBx. However, owing to the extensive heterogeneity among the studies included, future prospective clinical studies are needed to further investigate, optimize, and standardize this promising biopsy approach. Patient summary We reviewed the scientific literature on prostate biopsy approaches using magnetic resonance imaging (MRI)-directed targeted biopsy plus regional biopsy of the prostate. The studies we identified found arguments to potentially embrace such a combined biopsy approach for future diagnostics in prostate cancer.
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Affiliation(s)
- Marinus J. Hagens
- Department of Urology, Amsterdam University Medical Centers VUmc, Amsterdam, The Netherlands
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Mar Fernandez Salamanca
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Anwar R. Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
| | - Pim J. van Leeuwen
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Henk G. van der Poel
- Department of Urology, Amsterdam University Medical Centers VUmc, Amsterdam, The Netherlands
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Ivo G. Schoots
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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10
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Diamand R, Hollans M, Lefebvre Y, Sirtaine N, Limani K, Hawaux E, Abou Zahr R, Mattlet A, Albisinni S, Roumeguère T, Peltier A. The role of perilesional and multiparametric resonance imaging-targeted biopsies to reduce the risk of upgrading at radical prostatectomy pathology: A retrospective monocentric study. Urol Oncol 2022; 40:192.e11-192.e17. [PMID: 35236622 DOI: 10.1016/j.urolonc.2022.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/18/2021] [Accepted: 01/17/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate histopathologic upgrading between biopsy methods and whole-mount prostatectomy specimens in International Society of Urological Pathology grade group. METHODS Overall, 134 patients, including 175 magnetic resonance imaging (MRI)-suspicious lesions, diagnosed on MRI-targeted (TB) and systematic (SB) biopsies before radical prostatectomy were retrospectively analyzed from a prospectively maintained database. Perilesional (PLB) and "extended" perilesional (ePLB) biopsies were defined as those taken within a circumferential zone of 5 and 10 mm around magnetic resonance imaging (MRI)-suspicious lesion respectively. Proportion of upgrading at prostatectomy pathology were compared between TB, TB + PLB, TP + ePLB and TB + SB. Uni- and multivariable logistic regressions assessed predictors of upgrading for TB + ePLB method. RESULTS Focusing on index lesion, median (interquartile range) number of cores taken was 4 (3-4) for TB, 5 (4-6) for TB + PLB, 6 (5-8) for TB + ePLB and 12 (12-15) for TB + SB. A higher upgrading proportion was detected upon comparing TB and TB + PLB methods to TB + SB (32 vs. 19%, P = 0.001, 26 vs. 19%, P = 0.04, respectively). Conversely, no significant difference was found between TB + ePLB compared to TB + SB (23 vs. 19%, P = 0.2). Proportion of downgrading was similar regardless of biopsy method (all P > 0.1). At multivariable analysis, Prostate Imaging-Reporting and Data System Steering score, total number of positive ePLB cores and International Society of Urological Pathology Grade Group were independent predictors of upgrading (all P ≤ 0.03). Similar results were found by adding data from non-index lesions. CONCLUSION Our finding suggest that MRI-targeted biopsies associated with perilesional sampling in a circumferential zone of 10 mm reduced upgrading proportion and showed similar accuracy as the current gold standard combination. Further prospective studies comparing biopsy methods are expected to validate this diagnostic strategy.
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Affiliation(s)
- Romain Diamand
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium.
| | - Marie Hollans
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Yoléne Lefebvre
- Department of Radiology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Sirtaine
- Department of Pathology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Ksenija Limani
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Hawaux
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Rawad Abou Zahr
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Aurore Mattlet
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium; Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
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11
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A clinical available decision support scheme for optimizing prostate biopsy based on mpMRI. Prostate Cancer Prostatic Dis 2022; 25:727-734. [PMID: 35067674 DOI: 10.1038/s41391-021-00489-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Combined MRI/Ultrasound fusion targeted biopsy (TBx) and systematic biopsy (SBx) results in better prostate cancer (PCa) detection relative to either TBx or SBx alone, while at the cost of higher number of biopsy cores and greater detection of clinically insignificant PCa. We therefore developed and evaluated a simple decision support scheme for optimizing prostate biopsy based on multiparametric (mp) MRI assessment. METHODS Total 229 patients with suspicion of PCa underwent mpMRI before combined TBx/SBx were retrospectively included. Impacts of MRI characteristics such as Prostate Imaging-Reporting and Data System (PI-RADS) score, lesion size, zonal origination, and location on biopsy performance were evaluated. A clinically available decision support scheme relying on mpMRI assessment was subsequently developed as a triage test to optimize prostate biopsy process. Cost (downgrade, upgrade, and biopsy core)-to-Effectiveness (detection rate) was systemically compared. RESULTS TBx achieved comparable detection rate to combined TBx/SBx in diagnosis of PCa and clinically significant PCa (csPCa) (PCa, 59% [135/229] vs 60.7% [139/229]; csPCa, 45.9% [105/229] vs 47.2% [108/229]; p-values > 0.05) and outperformed SBx (PCa, 42.4% [97/229]; csPCa, 28.4% [65/229]; p-values < 0.001). Specially, in personalized decision support scheme, TBx accurately detected all PCa (72.5% [74/102]) in PI-RADS 5 and larger (≥1 cm) PI-RADS 3-4 observations, adding SBx to TBx only resulted in 1.4% (1/74) upgrading csPCa. For smaller (<1 cm) PI-RADS 3-4 lesions, combined TBx/SBx resulted in relatively higher detection rate (51.2% [65/127] vs 48.0% [61/127]) and lower upgrading rate (30.6% [15/49] vs 36.7% [18/49]) than TBx. CONCLUSIONS The benefit of SBx added to TBx was largely restricted to smaller PI-RADS score 3-4 lesions. Using our personalized strategy of solo TBx for PI-RADS 5 and larger (≥1 cm) PI-RADS score 3-4 lesions would avoid excess SBx in 44.5% (102/229) of all biopsy-naïve patients without compromising detection rate.
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12
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Ippoliti S, Fletcher P, Orecchia L, Miano R, Kastner C, Barrett T. Optimal biopsy approach for detection of clinically significant prostate cancer. Br J Radiol 2022; 95:20210413. [PMID: 34357796 PMCID: PMC8978235 DOI: 10.1259/bjr.20210413] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 11/05/2022] Open
Abstract
Prostate cancer (PCa) diagnostic and therapeutic work-up has evolved significantly in the last decade, with pre-biopsy multiparametric MRI now widely endorsed within international guidelines. There is potential to move away from the widespread use of systematic biopsy cores and towards an individualised risk-stratified approach. However, the evidence on the optimal biopsy approach remains heterogeneous, and the aim of this review is to highlight the most relevant features following a critical assessment of the literature. The commonest biopsy approaches are via the transperineal (TP) or transrectal (TR) routes. The former is considered more advantageous due to its negligible risk of post-procedural sepsis and reduced need for antimicrobial prophylaxis; the more recent development of local anaesthetic (LA) methods now makes this approach feasible in the clinic. Beyond this, several techniques are available, including cognitive registration, MRI-Ultrasound fusion imaging and direct MRI in-bore guided biopsy. Evidence shows that performing targeted biopsies reduces the number of cores required and can achieve acceptable rates of detection whilst helping to minimise complications and reducing pathologist workloads and costs to health-care facilities. Pre-biopsy MRI has revolutionised the diagnostic pathway for PCa, and optimising the biopsy process is now a focus. Combining MR imaging, TP biopsy and a more widespread use of LA in an outpatient setting seems a reasonable solution to balance health-care costs and benefits, however, local choices are likely to depend on the expertise and experience of clinicians and on the technology available.
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Affiliation(s)
- Simona Ippoliti
- Urology Department, The Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, Norfolk, UK
| | - Peter Fletcher
- Urology Department, Cambridge University Hospitals, Cambridge, UK
| | | | | | - Christof Kastner
- Urology Department, Cambridge University Hospitals, Cambridge, UK
| | - Tristan Barrett
- Radiology Department, Cambridge University Hospitals, Cambridge, UK
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13
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Axumin ( 18F-Fluciclovine) PET imaging in men exhibiting no clinically significant cancer on initial negative biopsy of PI-RADS 4 and 5 regions of interest. World J Urol 2022; 40:2765-2770. [PMID: 36197506 PMCID: PMC9532230 DOI: 10.1007/s00345-022-04172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 08/26/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The objective of the study was to determine whether Axumin (18F-Fluciclovine) PET/MRI informs the decision to perform an early repeat biopsy of PI-RADS 4/5 region of interest (ROI) exhibiting no clinically significant prostate cancer (csPCa) on initial biopsy. METHODS This prospective study enrolled men with at least one PI-RADS 4/5 ROI on multi-parametric MRI and no csPCa on prior biopsy defined as Gleason grade group (GGG) > 1. All men underwent an Axumin PET/MRI and only-persistent PI-RADS > 2 ROI were advised to undergo a repeat biopsy. A PET cancer suspicion score (PETCSS) was internally developed to stratify PET avid lesions according to their suspicion of harboring csPCa. The sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of the PETCSS for predicting csPCa were assessed. Relative risk was calculated to analyze the association of baseline variables with csPCa on repeat biopsy. RESULTS Thirty-eight ROI on 36 enrolled men were analyzed. Fourteen (36.8%) were downgraded to PI-RADS 1/2 and were not subjected to repeat biopsy. Thirteen (92.9%) of these downgraded scans also exhibited low-risk PETCSS. Overall, 18/22 (81.2%) subjects underwent a repeat per protocol biopsy. Of the 20 ROI subjected to repeat biopsy, eight (40%) were found to harbour csPCa. The sensitivity, specificity, PPV and NPV of the PETCSS were 50, 50, 40, and 60%, respectively. No predictor of csPCa was found in the risk analysis. CONCLUSION Our pilot study showed that both MRI and PET sequences have limited performance for identifying those persistently suspicious PI-RADS 4/5 ROI that are found to harbor csPCa on repeat biopsy.
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14
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Immerzeel J, Israël B, Bomers J, Schoots IG, van Basten JP, Kurth KH, de Reijke T, Sedelaar M, Debruyne F, Barentsz J. Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 4: Transperineal Magnetic Resonance-Ultrasound Fusion Guided Biopsy Using Local Anesthesia. Eur Urol 2021; 81:110-117. [PMID: 34799197 DOI: 10.1016/j.eururo.2021.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/19/2021] [Accepted: 10/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Transperineal magnetic resonance imaging-transrectal ultrasound fusion guided biopsy (MFGB) is an increasingly popular technique due to increasing rates of biopsy-related infections. However, its widespread implementation has been hampered by the supposed necessity of epidural or general anesthesia. OBJECTIVE To demonstrate the technique, feasibility, and results of transperineal MFGB under local anesthesia, in an ambulatory setting without the administration of prophylactic antibiotics. DESIGN, SETTING, AND PARTICIPANTS This single-center study enrolled consecutive biopsy-naïve men with a clinical suspicion of prostate cancer into a prospective database between November 2015 and November 2020. Men with Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores 3-5 underwent transperineal MFGB. SURGICAL PROCEDURE Transperineal MFGB was performed in an ambulatory setting under local anesthesia by a single operator. MEASUREMENTS Procedure-associated adverse events were recorded. Patient discomfort during both the local anesthesia and the biopsy procedure was determined using a visual analogic scale (0-10). Detection rates of grade group (GG) ≥2 prostate cancer and the proportion of men with GG 1 cancer were assessed. RESULTS AND LIMITATIONS A total of 1097 eligible men underwent transperineal MFGB. The complication rate was 0.73% (8/1097); complications comprised five (0.46%) urinary tract infections including one hospitalization and three (0.27%) urinary retentions. In 735 men, the median pain scores were 2 (interquartile range [IQR] 2-3) for the local anesthesia procedure and 1 (IQR 0-2) for the biopsy. Prostate cancer was detected in 84% (926/1097) of men; 66% (723/1097) had GG ≥2 and 19% (203/1097) GG 1. CONCLUSIONS Transperineal MFGB can safely be performed as an outpatient procedure under local anesthesia in an ambulatory setting. The detection rate of clinically significant prostate cancer is high, and biopsy is well tolerated. Although no antibiotic prophylaxis was used, the rate of infectious complications is practicably negligible. PATIENT SUMMARY This article shows how tissue samples (biopsies) can accurately be obtained from suspicious regions seen on prostate magnetic resonance imaging via needles inserted in the perineum (skin between the scrotum and the anus) in men with suspected prostate cancer. This technique appears to be very well tolerated under local anesthesia and has a lower risk of infection without antibiotic prophylaxis than the more common biopsy route through the rectum, with antibiotics.
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Affiliation(s)
- Jos Immerzeel
- Department of Urology, Andros Clinics, Arnhem, The Netherlands
| | - Bas Israël
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joyce Bomers
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jean-Paul van Basten
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; Prosper Collaborative Prostate Cancer Clinics, Nijmegen-Eindhoven, The Netherlands
| | | | - Theo de Reijke
- Department of Urology, Andros Clinics, Arnhem, The Netherlands; Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel Sedelaar
- Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Prosper Collaborative Prostate Cancer Clinics, Nijmegen-Eindhoven, The Netherlands
| | - Frans Debruyne
- Department of Urology, Andros Clinics, Arnhem, The Netherlands
| | - Jelle Barentsz
- Department of Urology, Andros Clinics, Arnhem, The Netherlands; Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
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15
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Israël B, Immerzeel J, van der Leest M, Hannink G, Zámecnik P, Bomers J, Schoots IG, van Basten JP, Debruyne F, van Oort I, Sedelaar M, Barentsz J. Clinical implementation of pre-biopsy magnetic resonance imaging pathways for the diagnosis of prostate cancer. BJU Int 2021; 129:480-490. [PMID: 34358388 PMCID: PMC9291303 DOI: 10.1111/bju.15562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To assess the outcomes of pre‐biopsy magnetic resonance imaging (MRI) pathways, as a tool in biopsy‐naïve men with suspicion of prostate cancer, in routine clinical practice. Secondary outcomes included a comparison of transrectal MRI‐directed biopsy (TR‐MRDB) and transperineal (TP)‐MRDB in men with suspicious MRI. Patients and Methods We retrospectively assessed a two‐centre cohort of consecutive biopsy‐naïve men with suspicion of prostate cancer who underwent a Prostate Imaging‐Reporting and Data System version 2 (PI‐RADS v2) compliant pre‐biopsy MRI in a single, high‐volume centre between 2015 and 2019 (Centre 1). Men with suspicious MRI scans underwent TR‐MRDB in Centre 1 and TP‐MRDB with additional random biopsies (RB) in Centre 2. The MRI and histopathology were assessed in the same institution (Centre 1). Outcomes included: (i) overall detection rates of Grade Group (GG) 1, GG ≥2, and GG ≥3 cancer in men with suspicious MRI; (ii) Biopsy‐avoidance due to non‐suspicious MRI; and (iii) Cancer detection rates and biopsy‐related complications between TR‐ and TP‐MRDB. To reduce confounding bias for MRDB comparisons, inverse probability weighting (IPW) was performed for age, digital rectal examination, prostate‐specific antigen (PSA), prostate volume, PSA density, and PI‐RADS category. Results Of the 2597 men included, the overall GG 1, GG ≥2, and GG ≥3 prevalence was 8% (210/2597), 27% (697/2597), and 15% (396/2597), respectively. Biopsy was avoided in 57% (1488/2597) of men. After IPW, the GG 1, GG ≥2 and GG ≥3 detection rates after TR‐ and TP‐MRDB were comparable at 24%, 57%, and 32%; and 18%, 64%, and 38%, respectively; with mean differences of −5.7% (95% confidence interval [CI] −13% to 1.4%), 6.1% (95% CI −2.1% to 14%), and 5.7% (95% CI −1.7% to 13%). Complications were similar in TR‐MRDB (0.50%) and TP‐MRDB with RB (0.62%; mean difference 0.11%, 95% CI −0.87% to 1.1%). Conclusion This high‐volume, two‐centre study shows pre‐biopsy MRI as a decision tool is implementable in daily clinical practice. Compared to recent trials, a substantially higher biopsy avoidance rate was achieved without compromising GG ≥2/GG ≥3 detection and coinciding with lower over detection rates of GG 1 cancer. Prostate cancer detection and complication rates were comparable for TR‐ and TP‐MRDB.
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Affiliation(s)
- Bas Israël
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.,Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Jos Immerzeel
- Department of Urology, Andros Clinics, Arnhem, the Netherlands
| | - Marloes van der Leest
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Patrik Zámecnik
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joyce Bomers
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Frans Debruyne
- Department of Urology, Andros Clinics, Arnhem, the Netherlands
| | - Inge van Oort
- Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Michiel Sedelaar
- Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Jelle Barentsz
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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