THE OPTIMAL SYSTEMATIC PROSTATE BIOPSY SCHEME SHOULD INCLUDE 8 RATHER THAN 6 BIOPSIES:: RESULTS OF A PROSPECTIVE CLINICAL TRIAL

How Many Cores Should Be Sampled during Systematic Prostate Biopsy in Case of Negative Multiparametric Magnetic Resonance Imaging? Analysis of 274 Men with Clinical Suspicion of Prostate Cancer

INTRODUCTION

This study aimed to investigate the number of cores needed in a systematic biopsy (SB) in men with clinical suspicion of prostate cancer (PCa) but negative prebiopsy multiparametric magnetic resonance imaging and to test prostate-specific antigen (PSA) density as an indicator for reduced SB.

METHODS

Two hundred and seventy-four patients were analyzed, extracted from an institutional database. Detection rates of any PCa and clinically significant (CS) PCa for different reduced biopsy protocols were compared by using Fisher's exact test.

RESULTS

In total, 12-core SB revealed PCa in 103 (37.6%) men. Detection rates of reduced biopsy protocols were 74 (27%, 6-core) and 82 (29.9%, 8-core). Regarding CSPCa, 12-core SB revealed a detection rate of 26 (9.5%). Reduced biopsy protocols detected less CSPCa: 15 (5.5%) and 18 (6.6%), respectively. All differences were statistically significant, p < 0.05. PSA density ≥0.15 did not help to filter out men in whom a reduced biopsy may be sufficient.

CONCLUSIONS

Twelve-core SB still has the highest detection rate of any PCa and CSPCa compared to reduced biopsy protocols. If the investigator and patient agree - based on individual risk calculation - to perform a biopsy, this SB should contain at least 12 cores regardless of PSA density.

Doppler spectral waveform parameters at neurovascular bundle vessels in patients with prostate biopsy

INTRODUCTION AND OBJECTIVES

There is a need to improve prescreening determination of prostate cancer to better select patients who need biopsy. Such a strategy properly implemented, will decrease the number of negative biopsies for prostate cancer and in turn better balance the risks and morbidity for patients recommended for biopsy. The aim of study is to investigate Doppler spectral waveform parameters of neurovascular bundle (NVB) vessels and determine differences between benign and malignant pathologies.

PATIENTS AND METHODS

We performed a prospective analysis involving 292 patients who received prostate biopsy for elevated prostate-specific antigen (PSA) values or abnormal digital rectal examination, as well as 174 patients with symptomatic benign prostatic hyperplasia. Doppler spectral waveform (DSW) parameters (peak-systolic velocity [PSV], end-diastolic velocity [EDV], and resistive index [RI]) were measured at bilateral NVB vessels through Doppler transrectal ultrasound at the right lateral decubitus position, compared, and analyzed among patients with benign versus malignant histology for each side.

RESULTS

Overall, both PSV and EDV at malignant sides were significantly higher than those at benign sides, as well as lower RI (all p-values <0.05, unpaired t-test). In subgroup analysis with 93 patients of serum PSA between 10 and 20 ng/mL and 56 patients with one-side malignancy, higher EDV and lower RI were significantly associated with malignancies (all p<0.05). The values of PSV and EDV rather than RI might be influenced by the patients' position and RI by the prostate volume.

CONCLUSIONS

In this study, DSW parameters (mainly EDV and RI) at NVB vessels were significantly associated with prostate cancer, particularly in patients with serum PSA of 10-20 ng/mL. It should be in caution that the patients' position and prostate volume may influence the Doppler signal as demonstrated in the current study. These findings can provide more diagnostic information before prostate biopsy.

Salvage cryotherapy: is there a role for focal therapy?

Prostate cancer treatment has undergone vast development over the last few decades, but the most notable changes have included nerve-sparing open radical prostatectomy, laparoscopic radical prostatectomy, including robot-assisted and, more recently, cryotherapy and high-intensity focused ultrasound (HIFU). While radical surgery is the current gold standard, the less invasive therapeutic options of cryotherapy and HIFU are regarded as largely experimental by governing bodies. In the case of cryotherapy, a wealth of experience has been accumulated demonstrating its efficacy. Initially used as a salvage treatment for radiation-failed prostate cancer, cryotherapy has been widely used as a primary treatment for localized and locally advanced prostate cancer. More recently, there has been interest expressed in the concept of focal therapy in prostate cancer. This has been evaluated as a primary treatment for prostate cancer, but little information is available regarding the potential use as a salvage treatment. In this article, we evaluate the potential for focal treatment in the salvage setting.

The influence of prostate volume on prostate cancer detection using a combined approach of contrast-enhanced ultrasonography-targeted and systematic grey-scale biopsy

OBJECTIVE

To evaluate the influence of prostate volume (PV) on the detection of prostate cancer using a combined approach of contrast-enhanced ultrasonography (CEUS) and grey-scale US-guided systematic biopsy (SB).

PATIENTS AND METHODS

We evaluated 345 patients with prostate cancer and a total prostate-specific antigen (PSA) level of >/= 1.32 ng/mL (1.32-35.3, mean 6.6). Biopsies were taken by two independent examiners; one took five CEUS (Doppler) targeted biopsies of hypervascular regions in the peripheral zone, and subsequently the other took 10 systematic prostate biopsies. We assessed the cancer detection rates for the five different subgroups of prostate volumes, i.e. <20, 20-30, 30-40, 40-50 and > 50 mL.

RESULTS

Each technique, SB and CEUS, detected 73.4% and 77.1% of all detected cancers, respectively, but there were statistically significant differences in detection rate only in small glands. Only 69.0% and 70.4% of all cancers were detected by SB in glands of <20 and 20-30 mL, respectively, whereas 88.1% and 80.8% were detected by CEUS.

CONCLUSION

The prostate cancer detection rate for CEUS was significantly higher in prostates of <30 mL (48.1% of the study population) than for SB. Therefore the combined approach of CEUS and SB allows improved cancer detection in patients with small glands and low total PSA values.

Prostate gland volume is a strong predictor of biopsy results in men 70 years or older with prostate-specific antigen levels of 2.0-10.0 ng/mL

PURPOSE

The incidence of prostate cancer, benign prostatic enlargement and serum level of prostate-specific antigen (PSA) increase with patient age. Intermediate elevation of PSA in elderly populations is apt to be considered insignificant. We evaluated the impact of PSA and prostate volume on the presence of non-palpable prostate cancer in elderly men with an intermediate level of PSA.

MATERIALS AND METHODS

Clinical records of 154 men 70 years or older, with non-cancerous digital rectal examination findings and with serum PSA levels of 2.0-10.0 ng/mL, who underwent initial 6- to 10-core transrectal prostate biopsy, were reviewed for prostate volume, number of biopsy cores, PSA and associated parameters. Stepwise logistic regression and receiver operating characteristic (ROC) models were used to determine the impacts of the parameters on the biopsy results.

RESULTS

Overall cancer detection rate was 40/154 or 26.0%. Prostate-specific antigen showed no significant association with the presence of prostate cancer (P = 0.59, Mann-Whitney U-test), while prostate volume did (P < 0.0001). On stepwise logistic regression analysis, prostate volume (P = 0.024, 95% CI 1.008-1.116) and biopsy core density (P = 0.017, 95% CI 4.76-7.12 x 10(6)) were independently associated with a cancer diagnosis, whereas PSA density was not an independent factor for a positive biopsy result. The area under the ROC curve for prostate volume was significantly superior to that of PSA (0.802 vs. 0.529; P = 0.012).

CONCLUSIONS

In men 70 years or older with gray zone PSA, prostate cancer patients are equally distributed over any PSA range. Although PSA has less impact on cancer presence than mere prostate volume, prostate cancer would be detected in a substantial proportion of older patients with PSA levels of 2.0-10.0 ng/mL.

Extensive biopsy using a combined transperineal and transrectal approach to improve prostate cancer detection

PURPOSE

Previous studies have indicated that 6-core transrectal prostate biopsy misses a considerable number of cancers. We performed an extensive biopsy protocol of 12-core sampling using both transperineal and transrectal approaches to determine the impact on the cancer detection rate.

MATERIALS AND METHODS

We prospectively evaluated 402 men who underwent 6-core transperineal and 6-core transrectal biopsies simultaneously due to abnormal digital rectal examination (DRE) and/or elevated prostate-specific antigen (PSA) levels of 4.0 ng/mL or greater. Using the transperineal approach we obtained four cores from the bilateral peripheral zone targeting the lateral and parasagittal areas and two cores from the bilateral transition zone. The following transrectal biopsy was performed traditionally. We compared cancer detection rate between the extended 12-core procedure and conventional 6-core transperineal and transrectal groups in terms of total PSA and DRE findings.

RESULTS

Using the extensive combined method, prostate cancer was detected in 195 cases (48.5%) and the detection rate significantly increased 7.2% and 8.5% compared to the transperineal and transrectal groups, respectively. According to PSA levels and DRE findings, the cancer detection rate by the combined method was significantly improved in patients with PSA levels of 4-10 ng/mL and negative DRE: 10.3% and 11.6% compared to the transperineal and transrectal groups, respectively.

CONCLUSIONS

The extensive 12-core method significantly improved the overall cancer detection rate and was especially efficient for men with PSA levels of 4-10 ng/mL accompanied by a negative DRE finding.

Clinical staging of prostate cancer: a computer-simulated study of transperineal prostate biopsy

OBJECTIVE

To identify the precise location of prostate cancer within the gland and thus possibly permit more aggressive therapy of the lesion, while potentially sparing the noncancerous gland from ablative therapy.

MATERIALS AND METHODS

Three-dimensional "solid" computer models were reconstructed for 86 autopsy specimens and 20 stage T1c radical prostatectomy specimens. Transperineal biopsies were simulated for grid sizes of 5-mm (method A) and 10-mm (method B) with an 18 G, 23-mm long biopsy needle. One or two biopsies per grid point were obtained for a total of 12-108 biopsies, depending on the size of the prostate. Clinically threatening cancers were defined as having volumes of > or = 0.5 mL or Gleason sum > or = 7.

RESULTS

Method A detected significantly more carcinomas than method B in both the autopsy and prostatectomy specimens (autopsy, 72 vs 51; prostatectomy, 50 vs 32, both P < 0.001). Method A also detected more clinically threatening cancers found at autopsy (38/40 vs 31/40, P = 0.008). Among autopsy patients with negative sextant biopsies whose disease was localized to one side, method A detected 72% and method B detected 29-43% (P < 0.001).

CONCLUSIONS

The results of this computer simulation show that 5- and 10-mm grid biopsies detect three-quarters and a third, respectively, at autopsy, of patients with the disease localized to one side of the prostate, which may be useful when planning highly selective ablative treatments in the future.

Significance of routine transition zone biopsies in Japanese men undergoing transrectal ultrasound-guided prostate biopsies

BACKGROUND

The objective of this study was to evaluate the clinical significance of additional routine transition zone (TZ) biopsies in Japanese men undergoing transrectal ultrasound (TRUS)-guided systematic 8-core peripheral zone (PZ) biopsies.

METHODS

Between October 2002 and December 2004, a total of 788 consecutive patients underwent TRUS-guided systematic biopsy of the prostate for the fi rst time. As a rule, 10 cores were taken from each patient; that is, 8 cores from the PZ, including the standard sextant cores and 2 cores from the anterior lateral horns, and 2 additional cores from the bilateral TZ. The cancer detection rate was calculated according to several parameters. We also assessed the disease extent on radical prostatectomy specimens according to the cancer location within the biopsy specimens.

RESULTS

Prostate cancer was detected by 10-core biopsies in 209 (26.5%) of the 788 patients, and 11 of these patients had positive cores only in the TZ; that is, the increase in cancer detection rate by sampling two additional cores from the TZ was 5.3%. Among 209 patients diagnosed as having prostate cancer, radical prostatectomy without any neoadjuvant therapy was performed in 59 patients with positive biopsy cores in the PZ, 7 in the TZ and 32 in both the PZ and TZ. Patients with positive cores in both zones showed significantly less favorable characteristics, indicating more advanced disease than that in those with positive cores in either zone.

CONCLUSIONS

Routine TZ biopsy did not significantly increase the detection rate of prostate cancer; however, the anatomical location of positive biopsy cores could provide additional information concerning disease extension in patients undergoing radical prostatectomy.

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score

OBJECTIVE

To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score.

PATIENTS AND METHODS

We analysed retrospectively 404 patients from three centres (Seattle 162, Washington 107 and Chicago 135) who had RP for prostate cancer. Six, eight or 10 biopsies were taken based on the physician's preference and the patient's characteristics.

RESULTS

Before RP, 158 (39%) patients had six, 65 (16%) had eight and 181 (45%) had 10 biopsy cores taken. The accuracy of the Gleason sum of the three groups was 65/158 (41%), 26/65 (40%) and 104/181 (57.5%), respectively (P < 0.004, 10-core vs six-core). However, when comparing the Gleason score separately (i.e. 4 + 3 is not equal to 3 + 4), the accuracy of the three groups was 48/158 (30%), 20/65 (31%), and 95/181 (52.5%), respectively (P < 0.001, 10-core vs six core).

CONCLUSIONS

Taking more biopsy cores improves the accuracy of the biopsy Gleason score in predicting the final Gleason score at RP; the predictive accuracy of the final Gleason score may be increased from 41% to 58% by increasing the number of biopsies from six to 10.

Prostate-specific antigen, Gleason sum and clinical T stage for predicting the need for radionuclide bone scan for prostate cancer patients in Japan

AIM

In the present study, we evaluated the relationships between prostate-specific antigen (PSA) level and bone metastasis, between Gleason sum and bone metastasis, and between clinical T stage and bone metastasis in Japanese patients.

METHODS

Between November 1998 and June 2004, we performed ultrasound-guided biopsies on 709 patients (mean age: 70.5 years, range: 39-90). Prostate cancer was detected in 339 patients (47.8%), 297 (87.6%) of whom underwent a radionuclide bone scan. In close collaboration with orthopedists, bone computed tomography scans, bone magnetic resonance imaging and/or plain rentogenograms were performed for cases that were difficult to diagnose as bone metastasis through radionuclide bone scans only.

RESULTS

We detected 61 (20.6%) bone metastasis cases in 296 patients. A simple linear regression analysis between log[PSA] and bone metastasis (n = 296) produced a significant relationship (P < 0.05). When we set the cut-off PSA value for the indication for a bone scan at 15 ng/mL, the possibility of bone metastasis was 10%. However, from our experience, there was no bone metastasis in the patients whose Gleason sums were less than five, and in the patients whose Gleason sum were five or more, and the PSA levels were less than 15, there was no bone metastasis. The rate of bone metastasis increased with the increase of PSA level. In the clinical T1-T2 stage cases, there were significant higher PSA levels in the cases with bone metastasis. In the T1-T2 patients whose PSA levels were less than 16, there was no bone metastasis.

CONCLUSIONS

From the analysis of PSA, Gleason sum and clinical T stage, we suggest that bone scan is unnecessary for patients whose PSA level is less than 15 ng/mL or Gleason sum is less than five.

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.

Tolerability of Prostate Transrectal Biopsies Using Gel and Local Anesthetics: Results of a Randomized Clinical Trial

PURPOSE

To evaluate the role of intrarectal EMLA, a new topical anesthetic cream, and lidocaine gel as local anesthesia during transrectal prostate biopsy and to observe whether gel temperature can improve pain control.

PATIENTS AND METHODS

A series of 210 consecutive patients were randomized. Group 1 (N = 60) underwent intrarectal instillation of EMLA cream, group 2 (N = 50) 2.5% lidocaine gel, group 3 (N = 40) placebo, and group 4 (N = 60) no treatment. Patients in groups 2 and 3 were subdivided into subgroups according to instillation of warm or cooled gel. Pain control was assessed by a 10-point visual analog scale.

RESULTS

The median pain scores were 2.6 in group 1, 3.8 in group 2, 3.9 in group 3, and 3.6 in group 4. In 16 patients (7.6%), the procedure was suspended because of pain: none group 1, 6.0% in group 2, 10% in group 3, and 15% ing group 4. The temperature of the lidocaine gel did not affect tolerability.

CONCLUSION

Intrarectal instillation of EMLA cream is a simple, safe, and effective method of local anesthesia during transrectal prostate biopsy, superior to lidocaine gel, placebo, and no treatment.

Efficacy and morbidity of transrectal ultrasound-guided 12-core biopsy for detection of prostate cancer in Japanese men

BACKGROUND

The objectives of the present study were to determine whether an extensive biopsy scheme contributes to enhanced detection of prostate cancer in Japanese men and to assess the associated pain and morbidity.

METHODS

A total of 147 patients were included in this analysis, with 12 biopsy cores being obtained from each patient. Standard systematic sextant biopsy at the apex, mid-prostate and base of the prostate gland was carried out under local anesthesia and this was followed by the acquisition of additional sextant cores at the same levels from the far lateral peripheral zone. Each patient answered a self-administered questionnaire on pain and morbidity during the 5 days following biopsy.

RESULTS

Overall, 39 patients (26.5%) received a diagnosis of prostate cancer. Nine patients (23.1%) were positive only at the standard sextant sites, three patients (7.7%) were positive exclusively at the far lateral sites and the remaining 27 patients (69.2%) were positive at both sites. Cancer was found most frequently in cores obtained from the apex (P = 0.009), with this trend being more evident in patients with abnormal rectal findings, positive sonographic findings, gland volume < 40 cm(3) and prostate-specific antigen density > 0.15 ng/mL/cm(3) (P < 0.03). These findings were also true for those with a prostate-specific antigen range from 4.1 to 20.0 ng/mL. A gradual decrease in incidence and grade of pain, hematuria and rectal bleeding was observed during the first 5 days after biopsy (P < 0.0001).

CONCLUSIONS

Using this 12-core biopsy scheme, we found cancer most frequently in cores taken at the level of the apex. While the extensive procedure only marginally enhanced overall detection of prostate cancer, it was well tolerated with gradually decreasing pain and morbidity over a brief postbiopsy period. Further efforts to optimize biopsy schemes are warranted.

Importance of Transition Zone Prostate Biopsies in Patients with Gray-Zone PSA Levels Undergoing the Ultrasound-Guided Systematic Ten-Biopsy Regimen for the First Time

INTRODUCTION

We analyzed the efficacy of routine transition zone biopsies for patients undergoing ultrasound-guided systematic prostate biopsies for the first time because of an elevated serum prostate-specific antigen (PSA) level.

PATIENTS AND METHODS

Using the systematic ten-biopsy regime, four additional transition zone biopsies were performed in 236 consecutive patients, because they showed an elevated PSA level (range 4.0- 9.9 ng/ml).

RESULTS

The overall prostate cancer detection rate was 21.2% (50/236). In 24 patients (48.0%), cancers were detected only in the peripheral zone, in 4 (8.0%) only in the transition zone, and in 22 (44.0%) in both zones. No distinguishing characteristics could be determined for the cancers detected in the transition zone only.

CONCLUSIONS

Although the cancer detection rate for the transition zone was significantly lower than for the peripheral zone, it was higher than that reported in most other studies which may have included biopsy specimens from patients with advanced prostate cancers. The usefulness of transition zone biopsies for the detection of early-stage prostate cancer, especially in patients with a PSA gray zone, can, therefore, not be denied.