Transperineal Template-guided Mapping Biopsy Identifies Pathologic Differences Between Very–Low-risk and Low-risk Prostate Cancer: Implications for Active Surveillance

Utility of multiple core biopsies during transperineal template-guided mapping biopsy for patients with large prostates and PI-RADS 1–2 on multiparametric magnetic resonance imaging

Background

We investigated the necessity of multiple core biopsies when performing transperineal template-guided mapping biopsy (TTMB) for patients with large prostates and no suspicious lesions on multiparametric magnetic resonance imaging (mpMRI).

Materials and methods

We retrospectively analyzed 304 patients on active surveillance (AS), 212 patients with previously negative transrectal ultrasound-guided biopsy (TRUS-Bx) and 67 biopsy naïve patients who underwent TTMB between May 2017 and December 2020. The number of core biopsies and acute urinary retention (AUR) rates were analyzed in relation to the prostate volume (PV). Cancer detection rate according to the prostate volume and Prostate Imaging-Reporting and Data System (PI-RADS) scores were compared using the Pearson Chi-square test.

Results

AUR occurred more frequently in patients with PV over 39 cc (5.5% vs. 24.4%, P < 0.001). In addition, incidence of AUR was more in patients with PV over 39 cc and PI-RADS score of 1–2 on mpMRI (3.7% vs. 22.2%, P < 0.001). There was no significant difference in the detection rates of any prostate cancer or clinically significant prostate cancer (csPCA) between the patients on AS with PV < 39 cc and PV ≥ 39 cc and PI-RADS score 1–2 (57.4% vs. 50%, P = 0.507; 17% vs. 8.8%, P = 0.412, respectively). Additionally, no significant difference was found in the detection rates of any prostate cancer or csPCA between the patients with PV < 39 cc and PV ≥ 39 cc and PI-RADS score 1–2 who either had a previously negative TRUS-Bx or were biopsy naïve (27.9% vs. 16.2%, P = 0.101, 8.2% vs. 4.1%, P = 0.31, respectively).

Conclusion

Increasing the number of core biopsies of prostates measuring ≥39 cc with PI-RADS 1–2 on mpMRI does not significantly increase the detection rates of any prostate cancer or csPCA.

The Impact of Body Mass Index on Freedom From Therapeutic Intervention and Quality of Life in Active Surveillance Prostate Cancer Patients

OBJECTIVE

The objective of this study was to evaluate the impact of body mass index (BMI) on overall survival, freedom from distant metastases, rates of therapeutic intervention (TI), and quality of life (QOL) in active surveillance (AS) prostate cancer patients.

MATERIALS AND METHODS

Three hundred forty consecutive, prospectively evaluated AS patients underwent a staging transperineal template-guided mapping biopsy before AS enrollment and were stratified by BMI (<25, 25 to 29.9, 30 to 34.9, and >35 kg/m2). Evaluated outcomes included overall survival, freedom from distant metastases, TI, QOL to include urinary, bowel, sexual function and depression and serial postvoid residual urine measurements. The relationship between BMI and anterior prostate cancer distribution was evaluated. Repeat biopsy was based on prostate specific antigen kinetics, abnormal digital rectal examination and patient preference.

RESULTS

Of the 340 patients, 323 (95%) were Gleason 3+3 and 17 patients (5.0%) were Gleason 3+4. The median follow-up was 5.2 years (range: 1 to 14 y). At 10 years, TI was instituted in 4.7%, 2.2%, 9.5%, and 25.0% of patients in BMI cohorts <25, 25 to 29.9, 30 to 34.9, and ≥35 (P=0.075). No patient has developed distant metastases. The median time to TI was 4.86 years. In multivariate analysis, TI was most closely predicted by prostate specific antigen density (P=0.071). At 8 years, no statistical differences in urinary function, bowel function, depression or postvoid residual were noted. However, a trend for erectile dysfunction was identified (P=0.106).

CONCLUSION

At 10 years, BMI did not statistically predict for TI, geographic distribution of prostate cancer or QOL parameters.

The impact of age on prostate cancer progression and quality of life in active surveillance patients

Objectives

To evaluate the impact of age on overall survival (OS), freedom from distant metastasis (FDM), rates of therapeutic intervention (TI), and quality of life (QOL) in active surveillance (AS) prostate cancer patients.

Materials and methods

Three hundred and five consecutive, prospectively evaluated AS patients who underwent a staging transperineal template‐guided mapping biopsy (TTMB) prior to enrollment on AS were evaluated and stratified by age. Evaluated outcomes included OS, FDM, TI, and QOL to include urinary, bowel, sexual function, and depression. Post void residual (PVR) urine measurements were also followed. Repeat biopsy was based on PSA kinetics, abnormal digital rectal examination or patient preference.

Results

Of the 305 patients, 290 (95.1%) were Gleason 3 + 3 and 15 patients (4.9%) were Gleason 3 + 4. The median follow‐up was 5.5 years (range 1‐14 years). At 10 years, TI was 0%, 1.0%, and 11.4% for patients ≤59, 60‐69, and ≥70 years of age (P < .001). No patient has developed distant metastasis. The median time to TI was 4.71 years. No statistical differences in urinary function, bowel function, or depression were noted. Potency preservation was dependent on patient age.

Conclusion

Within the confines of the follow‐up of our series, younger patients were less likely to proceed to therapeutic intervention. In addition, patient age did not adversely impact QOL outcomes.

The clinical utility of transperineal template-guided saturation prostate biopsy for risk stratification after transrectal ultrasound-guided biopsy

Purpose

To investigate the clinical utility of transperineal template-guided saturation prostate biopsy (TPB) for risk stratification after transrectal ultrasound (TRUS)-guided biopsy.

Materials and Methods

We retrospectively reviewed 155 patients who underwent TPB after previously negative results on TRUS-guided biopsy (n=58) or who were candidates for active surveillance (n=97) fulfilling the PRIAS criteria between May 2017 and November 2018. The patients' clinicopathologic data were reviewed, and the detection of clinically significant cancer (CSC) and upgrading of Gleason grade were identified.

Results

The patients' median age and pre-TPB prostate-specific antigen (PSA) value were 65.0 years and 5.74 ng/mL, respectively. A median of 36 biopsy cores was obtained in each patient, with a median TPB core density of 0.88 cores/cm³. Of the 58 males with a previous negative result on TRUS-guided biopsy, prostate cancer (PCa) was detected in 17 males (29.3%), including 8 with CSC. Of the 97 patient candidates for active surveillance, upgrading of the Gleason grade was identified in 31 males (32.0%), 20 with a Gleason grade of 7 (3+4), 6 with a Gleason grade of 7 (4+3), and 5 with a Gleason grade of 8 (4+4). The overall complication rate was 14.8% (23/155), and there were no Clavien–Dindo grade 3 to 5 complications.

Conclusions

TPB helps to stratify the risk of PCa that was previously missed or underdiagnosed by TRUS-guided biopsy. TPB might be used as a diagnostic tool to determine risk classification and to help counsel patients with regard to treatment decisions.

Active surveillance outcomes in prostate cancer patients: the use of transperineal template-guided mapping biopsy for patient selection

PURPOSE

To evaluate active surveillance (AS) outcomes including overall survival (OS), freedom from distant metastases (FDM), freedom from therapeutic intervention (FTI), and quality of life (QOL) outcomes in prostate cancer patients using transperineal template-guided mapping biopsy (TTMB) for patient selection.

METHODS

From April 2005-January 2016, 226 consecutive, prospectively evaluated prostate cancer patients underwent TTMB for either low-grade prostate cancer or persistently elevated prostate-specific antigen (PSA) and/or the presence of ASAP. Evaluated outcomes included OS, FDM, FTI and QOL including urinary, bowel, sexual function and depression. Repeat biopsy was based on PSA kinetics and/or abnormal digital rectal examination.

RESULTS

Of the 226 patients, 212 (93.8%) were Gleason 3 + 3 and 14 (6.2%) were Gleason 3 + 4. The median follow-up was 5.0 years (range 0.8-13.0 years). The mean prostate volume was 61.3 cm³ with a mean of 59.5 TTMB cores/patient. At the time of AS enrollment, an average of 72.9 cores (TRUS + TTMB) had been obtained for each patient. At 8 years, OS, FTI and FDM were 92.5, 96.8 and 100%. Two hundred and twenty-two patients (98.2%) had a PSA doubling time of more than 3 years. No statistical changes in urinary function, bowel function or depression were noted. At 8 years, 73% of the patients maintained erectile function.

CONCLUSION

Within the confines of the follow-up of this study, the use of TTMB for patient selection identifies a cohort of patients unlikely to develop biochemical or clinical progression and maintain a favorable quality of life.

The transverse and vertical distribution of prostate cancer in biopsy and radical prostatectomy specimens

Background

Prostate biopsy is the most common method for the diagnosis of prostate cancer and the basis for further treatment. Confirmation using radical prostatectomy specimens is the most reliable method for verifying the accuracy of template-guided transperineal prostate biopsy. The study aimed to reveal the spatial distribution of prostate cancer in template-guided transperineal saturation biopsy and radical prostatectomy specimens.

Methods

Between December 2012 to December 2016, 171 patients were diagnosed with prostate cancer via template-guided transperineal prostate biopsy and subsequently underwent laparoscopic radical prostatectomy. The spatial distributions of prostate cancer were analyzed and the consistency of the tumor distribution between biopsy and radical prostatectomy specimens were compared.

Results

The positive rate of biopsy in the apex region was significantly higher than that of the other biopsy regions (43% vs 28%, P < 0.01). In radical prostatectomy specimens, the positive rate was highest at the region 0.9–1.3 cm above the apex, and it had a tendency to decrease towards the base. There was a significant difference in the positive rate between the cephalic and caudal half of the prostate (68% vs 99%, P < 0.01). There were no significant differences between the anterior and posterior zones for either biopsy or radical prostatectomy specimens.

Conclusion

The tumor spatial distribution generated by template-guided transperineal prostate biopsy was consistent with that of radical prostatectomy specimens in general. The positive rate was consistent between anterior and posterior zones. The caudal half of the prostate, especially the vicinity of the apex, was the frequently occurred site of the tumor.

Diagnostic accuracy of magnetic resonance-guided prostate biopsy and template-guided transperineal saturation biopsy

To compare the accuracy of magnetic resonance-guided prostate biopsy (MR-GPB) and template-guided transperineal prostate saturation biopsy (TTPSB).A total of 219 patients with elevated prostate-specific antigen, abnormal digital rectal examination or ultrasound findings were enrolled. All patients underwent multiparametric magnetic resonance image (mpMRI). Patients with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 to 5 underwent MR-GPB using 2 to 5 biopsy cores and then immediately underwent an 11-region TTPSB. Patients with a PI-RADS score of 1 to 2 underwent TTPSB alone. We compared the detection rates for any cancer, clinically significant prostate cancer (csPCA), and the spatial distribution of missed csPCA lesions.Among the 219 cases, 66 (30.1%) had a PI-RADS score of 1 to 2 on mpMRI. The detection rate of TTPSB in these patients was 9.1% (6/66). In total, detection rates for any cancer and csPCA were 48.9% (107/219) and 42.9% (94/219), respectively. Detection rates for any cancer (TTPSB 87/219, 39.7%; MR-GPB76/219, 34.7%, P = .161) and csPCA (TTPSB 76/219, 34.7%; MR-GPB 72/219, 32.9%, P = .636) did not significantly differ between the 2 groups. The csPCA lesions missed by MR-GPB were most commonly located on the left (8.5%, 8/94) and right (9.6%, 9/94) sides of the urethra.MR-GPB can reduce the rate of unnecessary prostate biopsies by approximately 30% and exhibits an efficacy comparable to TTPSB for the detection of any cancer and csPCA. Nevertheless, approximately 1/4 of csPCAs were missed by MR-GPB and were most commonly located on both sides of the urethra.

Magnetic Resonance and Ultrasound Image Fusion Supported Transperineal Prostate Biopsy Using the Ginsburg Protocol: Technique, Learning Points, and Biopsy Results

BACKGROUND

Prostate biopsy supported by transperineal image fusion has recently been developed as a new method to the improve accuracy of prostate cancer detection.

OBJECTIVE

To describe the Ginsburg protocol for transperineal prostate biopsy supported by multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound (TRUS) image fusion, provide learning points for its application, and report biopsy results. The article is supplemented by a Surgery in Motion video.

DESIGN, SETTING, AND PARTICIPANTS

This single-centre retrospective outcome study included 534 patients from March 2012 to October 2015. A total of 107 had no previous prostate biopsy, 295 had benign TRUS-guided biopsies, and 159 were on active surveillance for low-risk cancer.

SURGICAL PROCEDURE

A Likert scale reported mpMRI for suspicion of cancer from 1 (no suspicion) to 5 (cancer highly likely). Transperineal biopsies were obtained under general anaesthesia using BiopSee fusion software (Medcom, Darmstadt, Germany). All patients had systematic biopsies, two cores from each of 12 anatomic sectors. Likert 3-5 lesions were targeted with a further two cores per lesion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Any cancer and Gleason score 7-10 cancer on biopsy were noted. Descriptive statistics and positive predictive values (PPVs) and negative predictive values (NPVs) were calculated.

RESULTS AND LIMITATIONS

The detection rate of Gleason score 7-10 cancer was similar across clinical groups. Likert scale 3-5 MRI lesions were reported in 378 (71%) of the patients. Cancer was detected in 249 (66%) and Gleason score 7-10 cancer was noted in 157 (42%) of these patients. PPV for detecting 7-10 cancer was 0.15 for Likert score 3, 0.43 for score 4, and 0.63 for score 5. NPV of Likert 1-2 findings was 0.87 for Gleason score 7-10 and 0.97 for Gleason score ≥4+3=7 cancer. Limitations include lack of data on complications.

CONCLUSIONS

Transperineal prostate biopsy supported by MRI/TRUS image fusion using the Ginsburg protocol yielded high detection rates of Gleason score 7-10 cancer. Because the NPV for excluding Gleason score 7-10 cancer was very high, prostate biopsies may not be needed for all men with elevated prostate-specific antigen values and nonsuspicious mpMRI.

PATIENT SUMMARY

We present our technique to sample (biopsy) the prostate by the transperineal route (the area between the scrotum and the anus) to detect prostate cancer using a fusion of magnetic resonance and ultrasound images to guide the sampling.

To screen or nor to screen: the prostate cancer dilemma

The European Randomized Study of Screening for Prostate (ERSPC) has updated their previous seminal report on prostate cancer mortality comparing screened men to controls. Now with 13 years follow-up, the rate ratio of prostate cancer mortality was 0.79 favoring the screened population. The authors concluded that there was a "substantial reduction in prostate cancer mortality attributable to testing with prostate-specific antigen (PSA)" but they also stated that a "quantification of harms" needed to be addressed. The issue of harms was not addressed by the ERSPC (at least not in this report) and hence this additional statement most likely reflects the controversy currently surrounding the risks associated with over-diagnosis and treatment of indolent diseases inadvertently detected by a screening protocol. [1] In addition, the positive results from this trial conflict with those of the prostate, lung, colorectal and ovarian (PLCO) [2] study and require further elaboration.