Diagnosis of Prostate Cancer: The Clinical Use of Transrectal Ultrasound and Biopsy

MRI-guided biopsy for prostate cancer detection: a systematic review of current clinical results

In-bore magnetic resonance-guided biopsy (MRGB) has been increasingly used in clinical practice to detect prostate cancer (PCa). This review summarizes the current clinical results of this biopsy method. A systematic literature search was performed in the PubMed and Embase databases. Of 2,035 identified records, 49 required full review. In all, ten unique studies reporting clinical results of MRGB could be included. Reported PCa detection rates ranged from 8 to 59 % (median 42 %). The majority of tumors detected by MRGB were clinically significant (81-93 %). Most frequent complications of MRGB are transient hematuria (1-24 %) and short-term perirectal bleeding (11-17 %). Major complications are rare. Based on the reviewed literature, MRGB can be regarded an accurate and safe diagnostic tool to detect clinically significant PCa. However, as general availability is limited, this procedure should be reserved for specific patients. Appropriate indications will have to be determined.

The Potential Impact of Prostate Volume in the Planning of Optimal Number of Cores in the Systematic Transperineal Prostate Biopsy

OBJECTIVES

We compared the detection rates of different transperineal prostate biopsy protocols with the aim to optimize the number of cores to sample according to prostate volume.

MATERIAL AND METHODS

From October 2002 to October 2004 we evaluated 480 consecutive patients with PSA between 2.5 and 20 ng/ml undergoing the first set of prostate biopsy. All patients underwent a 14-core TRUS-guided transperineal prostate biopsy, including 12 cores in the peripheral and two in the transitional zone. The detection rate of the 14-core scheme was compared to the one of the other biopsy schemes obtained through the exclusion of pairs of cores. Data were stratified according to the different TRUS estimated prostate volumes.

RESULTS

The detection rate of the standard sextant was 35.2%, while those of the 8-core schemes ranged from 37.1 to 38.8%. The 10-core schemes yielded detection rates of 39.6-40.8% and the protocol with 12 biopsies in the peripheral zone diagnosed prostate cancer in 42.1% of the patients. In patients with <30 cc prostate volume, the detection rate of the 14-core scheme was 43.8% and resulted statistically overlapping to the 8-peripheral cores protocol. In patients with 30.1-50 cc prostate volume a 12-peripheral core biopsy reproduced the results of the 14-core sampling. In prostates larger than 50 cc, an even more extensive procedure was mandatory, considering the low detection rate of the 14-core scheme (24.2%).

CONCLUSION

Transperineal prostate biopsy is a safe procedure with a very low complication rate and high cancer detection rate. Prostate volume is the most relevant variable in the planning of the optimal number of cores in the extensive first biopsy set. A protocol with more than 8 peripheral cores) is recommended only in patients with prostate volume larger than 30 cc.

Patients' tolerance and early complications of transrectal sonographically guided prostate biopsy: prospective study of 300 patients

PURPOSE

To determine the degree of pain and discomfort associated with transrectal sonography (TRS)-guided biopsy of the prostate and to analyze the complications associated with this procedure.

METHODS

Three hundred men referred as part of an investigation to exclude prostate cancer were studied. The reasons for referral were suspected prostate cancer due to increased serum prostate-specific antigen level (>4 ng/ml), the finding of a palpable nodule or greater firmness of one prostatic lobe than the other on digital rectal examination, or the finding of a suspicious area of neoplasm of the prostate on TRS biopsy. All TRS-guided biopsies were performed as outpatient procedures without anesthesia. Ciprofloxacin prophylaxis was used in all patients before biopsy. Tolerance of the procedure was recorded immediately after the examination and graded on a scale of 0-4 as follows: 0, no pain; 1, very mild pain; 2, moderate pain; 3, severe pain; 4, intolerable pain. Complications recorded in the first week after the procedure were analyzed. They included mild pain, self-limiting hematuria, hematospermia, rectal bleeding, severe hematuria, septicemia, severe hemorrhage of the anus, and vasovagal attack.

RESULTS

Out of 300 TRS-guided biopsies, 10 early complications were recorded. The most frequent was septicemia, which was seen in 5 cases (1.7%). Hematuria occurred in 29 patients, 3 of which were severe. Rectal bleeding and vasovagal attack occurred in 1 patient each. All patients made a full recovery with appropriate conservative management. Ten cases (3.33%) of severe pain (grade 3) and intolerable pain (grade 4) were observed. Three out of these 10 patients completed the procedure. The procedure was terminated in 1 patient, and 6 patients required local anesthetic due to perianal disease.

CONCLUSIONS

TRS-guided prostate biopsy can be performed without local anesthesia in 90% of patients. Prophylactic antibiotics are mandatory to minimize approximately infectious complications.

Optimization of prostatic biopsy: a prospective randomized trial comparing the sextant biopsy with a 10-core biopsy. Impact of prostatic region of sampling

OBJECTIVE

New prostatic biopsy protocols suggest to increase the core numbers to enhance detection. Additional cores are usually sampled from the lateral part of the p-zone. We direct the sextant biopsy to the most lateral part of the p-zone, therefore we investigated if there is a gain by adding 4 median biopsy cores.

MATERIAL AND METHODS

The prospective randomized trial (n = 200) compared our modified sextant biopsy to a 10-core strategy with 2 additional median cores on both sides. Directed biopsies to suspicious areas were allowed in both groups. Morbidity was assessed by a self-administered questionnaire.

RESULTS

PC detection was 32% for 6 cores and 40% for 10 cores. Four patients were detected only by median biopsies. Using the binomial distribution table the gain of 4% is statistically significant. There was no statistical difference in morbidity, but a trend towards a higher rate of side effects in the 10-core group.

CONCLUSIONS

The gain in prostate cancer detection rate by additional median biopsies is low, but statistically significant. There is no difference in morbidity and patient acceptance is high, therefore we favor the 10-core biopsy in our patients.

Influence of transrectal ultrasound probe on prostate cancer detection in transrectal ultrasound-guided sextant biopsy of prostate

OBJECTIVES

To determine whether end-fire probes increase the prostate cancer (PCa) detection rate. Enhancing the PCa detection rate is the main goal of biopsy protocols. Prostate biopsy is limited by side-fire probes to a longitudinal axis, but end-fire probes allow biopsy cores to also be taken in the transverse section.

METHODS

A total of 2625 patients underwent systematic sextant biopsy in three institutions using the same protocol. Three different ultrasound probes were used-the Kretz Combisone and Bruel & Kjaer side-fire probes and the ATL HDI end-fire probe. We retrospectively evaluated the influence of the probe on the PCa detection rate.

RESULTS

The Kretz probe was used in 384 men, the Bruel & Kjaer probe in 598 men, and the ATL probe in 1643 men. Overall, 35.2% had PCa detected. Analyzing all patients, no statistically significant difference (P = 0.73) was found for the probes, but the subgroup with a prostate-specific antigen level of 4 to 10 ng/mL demonstrated a statistically significant improvement in the detection rate using the end-fire probe (31.3% versus 24.5% and 21.5% for the side-fire probes, P = 0.01). Patients with nonpalpable PCa also demonstrated a statistically significant increase in detection with the end-fire probe (P = 0.004). Multivariate analysis confirmed that the ultrasound probe is an independent parameter to enhance the PCa detection rate.

CONCLUSIONS

Our results showed that end-fire probes provide a statistically significant improvement in the PCa detection rate compared with side-fire probes in patients with a prostate-specific antigen level of 4 to 10 ng/mL and nonpalpable disease. The reason could be the facilitated sampling in the most lateral part of the peripheral zone. Our results suggest that the widespread use of end-fire probes for prostate biopsy could enhance the PCa detection rate.

Morbidity of Prostatic Biopsy for Different Biopsy Strategies: Is There a Relation to Core Number and Sampling Region?

OBJECTIVES

The standard sextant prostatic biopsy is a safe procedure associated with low morbidity. Newer biopsy protocols suggest an increase in core numbers or sampling in distinct areas. In this respect we investigated the morbidity of different biopsy regimens.

METHODS

Morbidity was assessed using self-administered questionnaires 1 week and 1 month after biopsy in a prospective randomized trial of 405 men with three different biopsy protocols. We compared a sextant biopsy regimen to a 10-core biopsy strategy, as well as patients with a re-biopsy including t-zone sampling. We investigated pain during and after biopsy, gross hematuria, rectal bleeding, hematospermia, fever and chills.

RESULTS

There is a trend towards a more painful biopsy and higher rate of side effects if the number of core samples is increased, this difference did not reach statistical significance. There was no increase in severity of side effects. Regarding the rate and severity of side effects of biopsy strategies to different areas of the prostate we could not find a difference. About 95% of patients would accept a repeat biopsy based on their experience on first biopsy.

CONCLUSIONS

Morbidity of transrectal prostatic biopsy is low and increasing the number of cores correlates with a minor and statistically not significant increase in the rate of side effects. Transrectal sextant prostatic biopsy and extensive biopsy protocols are generally well tolerated and widely accepted from patients.