Comparison of 12-core versus 8-core prostate biopsy: multivariate analysis of large series of US veterans

Comparison of contrast-enhanced ultrasound targeted biopsies versus standard systematic biopsies for prostate cancer correction in different PSA value groups in rural China

OBJECTIVE

To investigate prostate cancer detection rate of different biopsy protocols in different PSA value groups in rural China.

METHODS

A total of 186 patients underwent contrast-enhanced ultrasound (CEUS) in order to determine the puncture target prior to biopsy were enrolled in this retrospective study. All patients underwent 12-core SB combined with CEUS-TB. The biopsy results of different biopsy protocols were compared in patients with stratification by PSA value.

RESULTS

Among the 186 patients underwent prostate biopsy, the histopathologic results revealed prostate cancer (PCa) in 117 cases (62.9%) and benign lesions in 69 cases (37.1%). The PCa detection rate between 8-core SB and 12-core SB showed no significant difference in PSA 4-10 ng/ml group, while the 12-core SB was significantly higher than CEUS-TB (44.9% versus 32.7%, P = 0.01). In PSA 10-20 ng/ml group, the significant difference was not seen between SB and CEUS-TB (50.0% versus 45.7%, P = 0.15). As for PSA greater than 20 ng/ml group, the PCa detection rate by SB was higher than CEUS-TB, but showed no statistically significance (79.1% versus 76.9%, P = 0.15). In the overall patients, the biopsy core positive rate of CEUS-TB was significantly higher than SB (97% versus 55.5% and 28.5%, P = 0.0001).

CONCLUSION

The flexible use of SB combined with CEUS-TB can reduce the number of biopsy cores in higher PSA groups. It has clinical importance in the detection of PCa in different PSA value groups in rural China.

A Novel Prediction Tool Based on Multiparametric Magnetic Resonance Imaging to Determine the Biopsy Strategy for Clinically Significant Prostate Cancer in Patients with PSA Levels Less than 50 ng/ml

PURPOSE

To develop and internally validate nomograms to help choose the optimal biopsy strategy among no biopsy, targeted biopsy (TB) only, or TB plus systematic biopsy (SB).

PATIENTS AND METHODS

This retrospective study included a total of 385 patients who underwent magnetic resonance imaging (MRI)-guided TB and/or SB at our institute after undergoing multiparametric MRI (mpMRI) between 2015 and 2018. We developed models to predict clinically significant prostate cancer (csPCa) based on suspicious lesions from a TB result and based on the whole prostate gland from the results of TB plus SB or SB only. Nomograms were generated using logistic regression and evaluated using receiver-operating characteristic (ROC) curve analysis, calibration curves and decision analysis. The results were validated using ROC curve and calibration on 177 patients from 2018 to 2019 at the same institute.

RESULTS

In the multivariate analyses, prostate-specific antigen level, prostate volume, and the Prostate Imaging Reporting and Data System score were predictors of csPCa in both nomograms. Age was also included in the model for suspicious lesions, while obesity was included in the model for the whole gland. The area under the curve (AUC) in the ROC analyses of the prediction models was 0.755 for suspicious lesions and 0.887 for the whole gland. Both models performed well in the calibration and decision analyses. In the validation cohort, the ROC curve described the AUCs of 0.723 and 0.917 for the nomogram of suspicious lesions and nomogram of the whole gland, respectively. Also, the calibration curve detected low error rates for both models.

CONCLUSION

Nomograms with excellent discriminative ability were developed and validated. These nomograms can be used to select the optimal biopsy strategy for individual patients in the future.

Trans-Perineal Template-Guided Mapping Biopsy vs. Freehand Trans-Perineal Biopsy in Chinese Patients With PSA < 20 ng/ml: Similar Cancer Detection Rate but Different Lesion Detection Rate

The present study aimed to investigate the diagnostic efficacy and the regional location of prostate cancer (PCa) as well as the accuracy of assessment between trans-perineal template-guided mapping biopsy (TTMB) and freehand trans-perineal biopsy (FTPB) for men with PSA < 20 ng/ml. Thus, we evaluated 623 consecutive patients with PSA < 20 ng/ml who had prostate biopsies in our institute between July 2017 and September 2018. Patients were divided into two groups based on different biopsy methods: 217 (34.83%) patients with TTMB and 406 (65.17%) with FTPB. Thirty six patients with TTMB and 80 with FTPB had continued undergone radical prostatectomy after a cancer diagnosis. Then the Gleason score of the biopsy and the post-radical prostatectomy specimens in each patient were compared. Overall, the PCa detection rate was 34.35%. There was no significant difference in PCa detection rate between TTMB and FTPB (35.48 vs. 33.74%, respectively; p = 0.663). Besides, the detection rate of significant PCa (Gleason score ≥ 7) in TTMB was 29.03% while FTPB was 23.89% (p = 0.162). The detection rate at the apex of the prostate was higher than the detection rate at the base of the prostate (9.80 vs. 5.79%; p < 0.01) when performing the TTMB. The FTPB would miss 10% of the positive diagnosis and almost half of the lesions. The upgraded of Gleason score from biopsy to post-radical prostatectomy was 16.67% with the TTMB and 36.25% with the FTPB (p = 0.034). The TTMB had a similar cancer detection rate, but a higher lesion detection rate and more accuracy in assess the actual Gleason score when comparing to FTPB for men with PSA < 20 ng/ml. By performing a 20-core TTMB, the cancer detection rate at the apex of the prostate was higher than the base.

Quality indicators of clinical cancer care for prostate cancer: a population-based study in southern Switzerland

Background

Quality of cancer care (QoCC) has become an important item for providers, regulators and purchasers of care worldwide. Aim of this study is to present the results of some evidence-based quality indicators (QI) for prostate cancer (PC) at the population-based level and to compare the outcomes with data available in the literature.

Methods

The study included all PC diagnosed on a three years period analysis (01.01.2011–31.12.2013) in the population of Canton Ticino (Southern Switzerland) extracted from the Ticino Cancer Registry database. 13 QI, approved through the validated Delphi methodology, were calculated using the “available case” approach: 2 for diagnosis, 4 for pathology, 6 for treatment and 1 for outcome. The selection of the computed QI was based on the availability of medical documentation. QI are presented as proportion (%) with the corresponding 95% confidence interval.

Results

700 PC were detected during the three-year period 2011–2013: 78.3% of them were diagnosed through a prostatic biopsy and for 72.5% 8 or more biopsy cores were taken. 46.5% of the low risk PC patients underwent active surveillance, while 69.2% of high risk PC underwent a radical treatment (radical prostatectomy, radiotherapy or brachytherapy) and 73.5% of patients with metastatic PC were treated with hormonal therapy. The overall 30-day postoperative mortality was 0.5%.

Conclusions

Results emerging from this study on the QoCC for PC in Canton Ticino are encouraging: the choice of treatment modalities seems to respect the international guidelines and our results are comparable to the scarce number of available international studies. Additional national and international standardisation of the QI and further QI population-based studies are needed in order to get a real picture of the PC diagnostic-therapeutic process progress through the definition of thresholds of minimal standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4604-2) contains supplementary material, which is available to authorized users.

Prostate cancer prediction using the random forest algorithm that takes into account transrectal ultrasound findings, age, and serum levels of prostate-specific antigen

The aim of this study is to evaluate the ability of the random forest algorithm that combines data on transrectal ultrasound findings, age, and serum levels of prostate-specific antigen to predict prostate carcinoma. Clinico-demographic data were analyzed for 941 patients with prostate diseases treated at our hospital, including age, serum prostate-specific antigen levels, transrectal ultrasound findings, and pathology diagnosis based on ultrasound-guided needle biopsy of the prostate. These data were compared between patients with and without prostate cancer using the Chi-square test, and then entered into the random forest model to predict diagnosis. Patients with and without prostate cancer differed significantly in age and serum prostate-specific antigen levels (P < 0.001), as well as in all transrectal ultrasound characteristics (P < 0.05) except uneven echo (P = 0.609). The random forest model based on age, prostate-specific antigen and ultrasound predicted prostate cancer with an accuracy of 83.10%, sensitivity of 65.64%, and specificity of 93.83%. Positive predictive value was 86.72%, and negative predictive value was 81.64%. By integrating age, prostate-specific antigen levels and transrectal ultrasound findings, the random forest algorithm shows better diagnostic performance for prostate cancer than either diagnostic indicator on its own. This algorithm may help improve diagnosis of the disease by identifying patients at high risk for biopsy.

TRUS-guided transperineal prostate 12+X core biopsy with template for the diagnosis of prostate cancer

The objective of the present study was to explore the clinical value and safety of trans-rectal ultrasound (TRUS)-guided transperineal prostate 12+X core biopsy in the diagnosis of prostate cancer. Patients who received a TRUS-guided transperineal prostate biopsy for suspected prostate cancer at the General Hospital of The People's Liberation Army between September 2009 and May 2014 were retrospectively analyzed, this consisted of 1,300 patients. These patients were randomly divided into the 12+X core group or the standard 12-core group. The mean age of all the patients was 70.5 years old. Levels of prostate-specific antigen, digital rectal examination, transrectal ultrasound and magnetic resonance imaging (MRI) were checked and used as reference prior and subsequent to the biopsy procedure. The 12+X core group consisted of 937 patients and the 12-core group consisted of 363 patients. The mean number of core samples taken from both groups was 14.5 (ranging from 12 to 24) and the mean operative time of the whole group was 20.4 min (ranging from 15 to 40 min). The puncture positive detection rate of abnormal rectal examination, trans-rectal ultrasound, and MRI was 24.0, 30.1, and 59.2%, respectively, whereas the puncture positive rate was 47.2% in 12+X core group and 34.5% in 12-core group. Improved prostate needle biopsy with 12+X cores was found to have significantly higher detection rate than that with 12 cores as well as fewer post-operative complications, therefore making the method ideal for diagnosing prostate cancer.

Risk Stratification by Urinary Prostate Cancer Gene 3 Testing Before Magnetic Resonance Imaging-Ultrasound Fusion-targeted Prostate Biopsy Among Men With No History of Biopsy

OBJECTIVE

To determine whether a combination of prostate cancer gene 3 (PCA3) and magnetic resonance imaging (MRI) suspicion score (mSS) could further optimize detection of prostate cancer on MRI fusion-targeted biopsy (MRF-TB) among men with no history of biopsy.

MATERIALS AND METHODS

We included in this study 187 men presenting to our institution between June 2012 and August 2014 who underwent multiparametric MRI (mpMRI) and PCA3 before MRF-TB. Biopsy results, stratified by biopsy indication and PCA3 score, were recorded. Receiver operating characteristics curves and multivariable logistic regressions were used to model the association of PCA3 and mSS with cancer detection on MRF-TB.

RESULTS

PCA3 is associated with cancer detection on MRF-TB for men with no prior biopsies (area under the curve: 0.67, 95% confidence interval: 0.59-0.76). Using a cutoff of ≥35, PCA3 was associated with cancer risk among men with mSS 2-3 (P = .004), but not among those with mSS 4-5 (P = .340). The interaction of PCA3 and mSS demonstrated significantly higher discrimination for cancer than mSS alone (area under the curve: 0.83 vs 0.79, P = .0434).

CONCLUSION

Urinary PCA3 is associated with mSS and the detection of cancer on MRF-TB for men with no prior biopsies. PCA3 notably demonstrates a high negative predictive value among mSS 2-3. However, in the case of high-suspicion mpMRI, PCA3 is not associated with cancer detection on MRF-TB, adding little to cancer diagnosis. Further studies are needed to evaluate the utility of PCA3 in predicting cancer among men with normal mpMRI.

Diagnostic Value of Different Systematic Prostate Biopsy Methods in the Detection of Prostate Cancer with Ultrasonographic Hypoechoic Lesions--A Comparative Study

OBJECTIVE

To assess if a less extended biopsy in the transperineal approach is sufficient for detection of prostate cancer (PC) in patients with hypoechoic lesions.

METHODS

This was a prospective study of 167 consecutive patients with prostate hypoechoic lesion and who underwent transperineal ultrasound (TPUS)-guided 12-core and hypoechoic lesion core biopsy between January 2012 and February 2013.

RESULTS

PC was detected in 64.1% (107/167) of patients. The PC detection rate of the 12-core prostate biopsy scheme was the highest, but when including the hypoechoic lesion core, there was no difference between the 6- and 12-core schemes (all p > 0.05), irrespective of prostate volume or prostate-specific antigen levels (all p > 0.05).

CONCLUSIONS

A more limited biopsy scheme could be sufficient for the detection of PC if the hypoechoic lesion is sampled.

Transperineal ultrasound-guided 12-core prostate biopsy: an extended approach to diagnose transition zone prostate tumors

Objective

Transperineal ultrasound-guided (TPUS) 12-core prostate biopsy was evaluated as an initial strategy for the diagnosis of prostate cancer, The distribution of prostate cancer lesions was assessed with zone-specific biopsy.

Methods

From January 2010 to December 2012, 287 patients underwent TPUS-guided 12-core prostate biopsy. Multiple cores were obtained from both the peripheral zone (PZ) and the transition zone (TZ) of the prostate. Participants' clinical data and the diagnostic yield of the cores were recorded and prospectively analyzed as a cross-sectional study.

Results

The diagnostic yield of the 12-core prostate biopsy was significantly higher compared to the 6-core scheme (42.16 vs. 21.6%). The diagnostic yield of the 10-core prostate biopsy was significantly higher compared to the 6-core scheme (37.6 vs. 21.6%). The 12-core scheme improved the diagnostic yield in prostates >50 ml (12-core scheme: 28.1% vs. 10-core scheme: 20.4%; p = 0.034).

Conclusions

The 12-core biopsy scheme is a safe and effective approach for the diagnosis of prostate cancer. TZ biopsies in patients with larger prostates should be included in the initial biopsy strategy.

Androgen receptors in hormone-dependent and castration-resistant prostate cancer

In the United States, prostate cancer (PCa) is the most commonly diagnosed non-cutaneous cancer in males and the second leading cause of cancer-related death for men. The prostate is an androgen-dependent organ and PCa is an androgen-dependent disease. Androgen action is mediated by the androgen receptor (AR), a hormone activated transcription factor. The primary treatment for metastatic PCa is androgen deprivation therapy (ADT). For the most part, tumors respond to ADT, but most become resistant to therapy within two years. There is persuasive evidence that castration resistant (also termed castration recurrent) PCa (CRPC) remains AR dependent. Recent studies have shown that there are numerous factors that contribute to AR reactivation despite castrate serum levels of androgens. These include changes in AR expression and structure through gene amplification, mutation, and alternative splicing. Changes in steroid metabolism, cell signaling, and coregulator proteins are also important contributors to AR reactivation in CRPC. Most AR targeted therapies have been directed at the hormone binding domain. The finding that constitutively active AR splice variants that lack the hormone binding domain are frequently expressed in CRPC highlights the need to develop therapies that target other portions of AR. In this review, the role of AR in normal prostate, in PCa, and particularly the mechanisms for its reactivation subsequent to ADT are summarized. In addition, recent clinical trials and novel approaches to target AR are discussed.

Five-year downstream outcomes following prostate-specific antigen screening in older men

IMPORTANCE

Despite ongoing controversies surrounding prostate-specific antigen (PSA) screening, many men 65 years or older undergo screening. However, few data exist that quantify the chain of events following screening in clinical practice to better inform decisions.

OBJECTIVE

To quantify 5-year downstream outcomes following a PSA screening result exceeding 4.0 ng/mL in older men.

DESIGN AND SETTING

Longitudinal cohort study in the national Veterans Affairs health care system.

PARTICIPANTS

In total, 295,645 men 65 years or older who underwent PSA screening in the Veterans Affairs health care system in 2003 and were followed up for 5 years using national Veterans Affairs and Medicare data.

MAIN OUTCOME MEASURES

Among men whose index screening PSA level exceeded 4.0 ng/mL, we determined the number who underwent prostate biopsy, were diagnosed as having prostate cancer, were treated for prostate cancer, and were treated for prostate cancer and were alive at 5 years according to baseline characteristics. Biopsy and treatment complications were also assessed.

RESULTS

In total, 25,208 men (8.5%) had an index PSA level exceeding 4.0 ng/mL. During the 5-year follow-up period, 8313 men (33.0%) underwent at least 1 prostate biopsy, and 5220 men (62.8%) who underwent prostate biopsy were diagnosed as having prostate cancer, of whom 4284 (82.1%) were treated for prostate cancer. Performance of prostate biopsy decreased with advancing age and worsening comorbidity (P < .001), whereas the percentage treated for biopsy-detected cancer exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer. Among men with biopsy-detected cancer, the risk of death from non-prostate cancer causes increased with advancing age and worsening comorbidity (P < .001). In total, 468 men (5.6%) had complications within 7 days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction 588 men (13.7%).

CONCLUSIONS AND RELEVANCE

Performance of prostate biopsy is uncommon in older men with abnormal screening PSA levels and decreases with advancing age and worsening comorbidity. However, once cancer is detected on biopsy, most men undergo immediate treatment regardless of advancing age, worsening comorbidity, or low-risk cancer. Understanding downstream outcomes in clinical practice should better inform individualized decisions among older men considering PSA screening.

Formalin disinfection of biopsy needle minimizes the risk of sepsis following prostate biopsy

PURPOSE

We describe a simple and effective method to reduce the risk of infection after prostate biopsy.

MATERIALS AND METHODS

A total of 1,642 consecutive prostate biopsy procedures during a 4-year period (2008 to 2012) were included in the study. Inclusion criteria consisted of pre-biopsy negative urine culture, bisacodyl enema and fluoroquinolone antibiotics (3 days). Formalin (10%) was used to disinfect the needle tip after each biopsy core. All patients were monitored for post-biopsy infection. The rate of infection was compared to that of a historical series of 990 procedures. Two ex vivo experiments were conducted to test the disinfectant effectiveness of formalin against fluoroquinolone resistant Escherichia coli, and another experiment was performed to quantitate formalin exposure.

RESULTS

Post-biopsy clinical sepsis with positive urine and blood cultures (quinolone resistant E. coli) developed in 2 patients (0.122%). Both patients were hospitalized, treated with intravenous antibiotics and had a full recovery without long-term sequelae. Mild uncomplicated urinary infection developed in 3 additional patients (0.183%). All were treated with outpatient oral antibiotics and had a complete recovery. The overall rate of urinary infection and sepsis using formalin disinfection was approximately a third of that of a prior series (0.30% vs 0.80%, p=0.13). Ex vivo experiments showed a complete lack of growth of fluoroquinolone resistant E. coli on blood and MacConkey agars after exposure to formalin. The amount of formalin exposure was negligible and well within the safe parameters of the Environmental Protection Agency.

CONCLUSIONS

Formalin disinfection of the biopsy needle after each prostate biopsy core is associated with a low incidence of urinary infection and sepsis. This technique is simple, effective and cost neutral.

Investigation of optimal prostate biopsy schemes for Chinese patients with different clinical characteristics

PURPOSE

To investigate the optimal schemes of prostate biopsy according to prostate volume (PV), age and transrectal ultrasound (TRUS) status in Chinese men.

METHODS

923 consecutive patients who underwent initial TRUS-guided systematic 12-core prostate biopsy (12PBx) were enrolled in this study. The 12PBx was obtained by overlapping of conventional sextant, lateral base, mid-gland of peripheral zone and apex. Each sample was individually marked and inked before fixation. Patients were divided into 8 subgroups on the basis of independent risk factors investigated using logistic regression model. Subsequently, 12PBx was defined as self-control for the analysis of biopsy schemes (6-, 8- and 10PBx) on individual core basis. The prostate cancer detection rates (CDRs) of 6-, 8-, 10- and 12PBx were compared for each individual subgroup.

RESULTS

The 12PBx detected 253 (27.4%) cases of prostate cancer (PCa), of which 67.2, 47.1 and 61.3% were located in the base, mid-gland and apex, respectively. Multivariate analysis indicated that age, TRUS status and PV were independent risk factors for PCa detection. CDR increased with increasing biopsy cores. However, for patients with age ≥65 years, positive TRUS and PV <38.5 cm(3), CDR of 8PBx (30.6%) was similar to 10PBx (32.2%) and 12PBx (32.2%); for patients with age ≥65 years, negative TRUS and PV <38.5 cm(3) or ones with age ≥65 years, positive TRUS and PV ≥38.5 cm(3), 10PBx was as effective as 12PBx in detecting PCa (27.8, 27.5 vs. 28.9, 29.3%, respectively).

CONCLUSION

Age, TRUS status and PV were independent risk factors for PCa detection. Traditional sextant biopsy is not recommended. 8-, 10-, or 12PBx as an individual biopsy scheme might be adopted according to these risk factors for Chinese patients.

The association of diabetes and positive prostate biopsy in a US veteran population

BACKGROUND

Several studies have shown a protective effect of diabetes mellitus (DM) on incidence of prostate cancer; however, the data are not consistent. Moreover, whether or not DM is associated with a positive result among patients referred for prostate biopsy due to abnormal PSA and/or abnormal digital rectal examination is not clear.

METHODS

A retrospective review of 3162 consecutive men who underwent prostate biopsy between January 2000 and July 2009 at the Atlanta Veterans Affairs Medical Center was performed. Men with positive and negative biopsies were compared for various demographic and clinical factors. The data were analyzed using logistic regression models with results expressed as adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CI).

RESULTS

DM was associated with increased odds of positive biopsy in the overall cohort (OR 1.26, 95% CI: 1.01-1.55; P = 0.04). Subjects with DM had higher odds of more aggressive disease (Gleason ≥ 7) than those without the condition (OR 1.31, 95% CI: 0.98-1.74; P = 0.07). Race had no significant impact on these results.

CONCLUSIONS

In this large series of prostate biopsies, diabetes is associated with higher odds of positive biopsy and higher Gleason grade. More studies investigating the role of DM and its associated comorbidities in prostate carcinogenesis are needed.

The optimal rebiopsy prostatic scheme depends on patient clinical characteristics: results of a recursive partitioning analysis based on a 24-core systematic scheme

BACKGROUND

The most beneficial number and the location of prostate biopsies remain matters of debate, especially after an initial negative biopsy.

OBJECTIVE

To identify the optimal combination of sampling sites (number and location) to detect prostate cancer (PCa) in patients previously submitted to an initial negative prostatic biopsy.

DESIGN, SETTING, AND PARTICIPANTS

A transrectal ultrasound-guided systematic 24-core prostate biopsy (24PBx) was performed prospectively in 340 consecutive patients after a first negative biopsy (at least 12 cores).

MEASUREMENTS

We relied on a classification and regression tree analysis to identify three clinically different subgroups of patients at dissimilar risk of harboring PCa at second biopsy. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the optimal biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup.

RESULTS AND LIMITATIONS

After an initial negative biopsy, cancer was detected at rebiopsy in 95 men (27.9%). At a given number of cores, the cancer detection rates varied significantly according to the different combination of sites considered. Three different PCa risk groups were identified: (1) previous report of atypical small acinar proliferation of the prostate (ASAP), (2) no previous ASAP and ratio of free prostate-specific antigen (fPSA) to total PSA (%fPSA) ≤10%, and (3) no previous ASAP and %fPSA >10%. For patients with previous ASAP or patients with no previous ASAP and %fPSA ≤10%, two schemes with different combinations of 14 cores were most favorable. The optimal sampling in patients with no previous ASAP and %fPSA >10% was a scheme with a combination of 20 cores.

CONCLUSIONS

Both the number and the location of biopsy cores taken affect cancer detection rates in a repeated biopsy setting. We developed an internally validated flowchart to identify the most advantageous set of sampling sites according to patient characteristics.