Prospective evaluation of using multiparametric magnetic resonance imaging in cognitive fusion prostate biopsy compared to the standard systematic 12-core biopsy in the detection of prostate cancer

Effectiveness of cognitive fusion transrectal ultrasound prostate biopsy when compared with final prostatectomy histology

INTRODUCTION AND OBJECTIVES

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men. Cognitive fusion transrectal ultrasound prostate biopsy is one of several modalities for diagnosing this disease. However, no existing studies have shown the clear superiority of one image-guided technique over another. This investigation aimed to evaluate the efficacy of targeted biopsy through cognitive guidance, as well as to assess the accuracy of multiparametric magnetic resonance imaging (mpMRI) in the detection of PCa compared to the specimen obtained by radical prostatectomy (RP).

MATERIALS AND METHODS

We conducted a retrospective observational single-center study approved by the ethical committee, including men with prostate-specific antigen (PSA) levels between 2-10 mg/ml who underwent RP and cognitive fusion biopsy (CFB) between 2017 January and 2022 January.

RESULTS

A total of 639 patients were analyzed, 83 of whom met the inclusion criteria and were enrolled in this study. The overall rate of PCa detection with CFB was 79.5% (median of specific PCa detection was 100%), and the rate of detecting clinically significant prostate cancer (csPCa) was 74.7%. In addition, there was 42.2% agreement between the International Society of Urological Pathology (ISUP) score of the CFB and the RP specimen, which increased to 56.6% when the systematic biopsy was added. Regarding the accuracy of mpMRI, several parameters were evaluated with respect to RP sample histology. Of these, tumor location had a total match rate of 39.8% and a partial match rate of 55.4%. Moreover, regarding extraprostatic extension (EPE), the present study found a significant association between the RP specimen and mpMRI (p = 0.002), with an agreement rate of 60% if it was present in the histology and 79.5% if it was not. Additionally, larger prostates and tumors located in the transition zone were significantly associated with a lower CFB accuracy (p = 0.001 and p = 0.030, respectively). After adjusting for all variables evaluated, only prostate volume remains statistically significant (p = 0.029).

CONCLUSIONS

In this study, we conclude that mpMRI is highly accurate, allowing good characterization of suspicious tumors and reasonably guiding cognitive biopsy. However, the use of both targeted biopsy through cognitive guidance and systematic biopsy increases the diagnostic accuracy for PCa. Although there is no recommendation in the current literature for one guiding technique over another, we believe that cognitive-guided biopsy should only be reserved for centers with no access to ultrasound or magnetic resonance fusion software.

Transperineal biopsy devices in people with suspected prostate cancer - a systematic review and economic evaluation

Background

People with suspected prostate cancer are usually offered either a local anaesthetic transrectal ultrasound-guided prostate biopsy or a general anaesthetic transperineal prostate biopsy. Transperineal prostate biopsy is often carried out under general anaesthetic due to pain caused by the procedure. However, recent studies suggest that performing local anaesthetic transperineal prostate biopsy may better identify cancer in particular regions of the prostate and reduce infection rates, while being carried out in an outpatient setting. Devices to assist with freehand methods of local anaesthetic transperineal prostate may also help practitioners performing prostate biopsies.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of local anaesthetic transperineal prostate compared to local anaesthetic transrectal ultrasound-guided prostate and general anaesthetic transperineal prostate biopsy for people with suspected prostate cancer, and local anaesthetic transperineal prostate with specific freehand devices in comparison with local anaesthetic transrectal ultrasound-guided prostate and transperineal prostate biopsy conducted with a grid and stepping device conducted under local or general anaesthetic.

Data sources and methods

We conducted a systematic review of studies comparing the diagnostic yield and clinical effectiveness of different methods for performing prostate biopsies. We used pairwise and network meta-analyses to pool evidence on cancer detection rates and structured narrative synthesis for other outcomes. For the economic evaluation, we reviewed published and submitted evidence and developed a model to assess the cost-effectiveness of the different biopsy methods.

Results

We included 19 comparative studies (6 randomised controlled trials and 13 observational comparative studies) and 4 single-arm studies of freehand devices. There were no statistically significant differences in cancer detection rates for local anaesthetic transperineal prostate (any method) compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.00, 95% confidence interval 0.85 to 1.18) (n = 5 randomised controlled trials), as was the case for local anaesthetic transperineal prostate with a freehand device compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.40, 95% confidence interval 0.96 to 2.04) (n = 1 randomised controlled trial). Results of meta-analyses of observational studies were similar. The economic analysis indicated that local anaesthetic transperineal prostate is likely to be cost-effective compared with local anaesthetic transrectal ultrasound-guided prostate (incremental cost below £20,000 per quality-adjusted life-year gained) and less costly and no less effective than general anaesthetic transperineal prostate. local anaesthetic transperineal prostate with a freehand device is likely to be the most cost-effective strategy: incremental cost versus local anaesthetic transrectal ultrasound-guided prostate of £743 per quality-adjusted life-year for people with magnetic resonance imaging Likert score of 3 or more at first biopsy.

Limitations

There is limited evidence for efficacy in detecting clinically significant prostate cancer. There is comparative evidence for the PrecisionPoint™ Transperineal Access System (BXTAccelyon Ltd, Burnham, UK) but limited or no evidence for the other freehand devices. Evidence for other outcomes is sparse. The cost-effectiveness results are sensitive to uncertainty over cancer detection rates, complication rates and the numbers of core samples taken with the different biopsy methods and the costs of processing them.

Conclusions

Transperineal prostate biopsy under local anaesthetic is equally efficient at detecting prostate cancer as transrectal ultrasound-guided prostate biopsy under local anaesthetic but it may be better with a freehand device. local anaesthetic transperineal prostate is associated with urinary retention type complications, whereas local anaesthetic transrectal ultrasound-guided prostate has a higher infection rate. local anaesthetic transperineal prostate biopsy with a freehand device appears to meet conventional levels of costeffectiveness compared with local anaesthetic transrectal ultrasound-guided prostate.

Study registration

This study is registered as PROSPERO CRD42021266443.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR134220) and is published in full in Health Technology Assessment Vol. 28, No. 60. See the NIHR Funding and Awards website for further award information.

MRI-Targeted Prostate Biopsy Techniques: AJR Expert Panel Narrative Review

Prostate cancer is the second most common malignancy in men worldwide. Systematic transrectal prostate biopsy is commonly used to obtain tissue to establish the diagnosis. However, in recent years, MRI-targeted biopsy (based on an MRI examination performed prior to consideration of biopsy) has been shown to detect more clinically significant cancer and less clinically insignificant cancer compared to systematic biopsy. This approach of performing MRI prior to biopsy has become, or is becoming, a standard of practice in centers throughout the world. This growing use of an MRI-directed pathway is leading to performance of a larger volume of MRI-targeted prostate biopsies. The three common MRI-targeted biopsy techniques are cognitive biopsy, MRI-ultrasound software fusion biopsy, and MRI in-bore guided biopsy. These techniques for using MRI information at the time of biopsy can be performed via a transrectal or transperineal approach. This narrative review presents the three MRI-targeted biopsy techniques along with their advantages and shortcomings. Comparisons among the techniques are summarized based on the available evidence. Studies to date have provided heterogeneous results, and the preferred technique remains debated.

Low CFB expression is independently associated with poor overall and disease-free survival in patients with lung adenocarcinoma

Complement factor B (CFB) serves a pivotal role in the alternative signaling pathway of the complement system and exerts a key role in the labelling of target particles, resulting from effective clearance of the target. The present study aimed to investigate the association between low expression levels of CFB and the clinical features and survival status of patients with lung adenocarcinoma (LUAD). Patient data were based on RNA-sequencing and clinical data from The Cancer Genome Atlas database. All patients were divided into two groups based on the median expression of CFB. Kaplan-Meier curve and univariate Cox regression analyses were used to investigate the association between CFB and survival status. Gene set enrichment analysis was used to examine the effects of CFB expression on signaling pathway impairment. Furthermore, reverse transcription-quantitative PCR (RT-qPCR) and western blotting were used to verify the relative expression levels of CFB in LUAD tissues. The data revealed that residual tumor classification, Karnofsky performance score and cancer stage were associated with overall survival, and that Karnofsky performance score and stage were associated with disease-free survival. The results demonstrated that high expression levels of CFB were associated with increased patient overall and disease-free survival according to both continuous and categorical models. The results of multivariate analysis identified that high expression levels of CFB were associated with increased overall and disease-free survival according to both the continuous model [hazard ratio (HR), 0.48; 95% confidence interval (95% CI), 0.25-0.93; P=0.029 for overall survival; HR, 0.29; 95% CI, 0.15-0.59; P=0.001 for disease-free survival] and the categorical model (HR, 0.46; 95% CI, 0.22-0.93; P=0.031 for overall survival; HR, 0.25; 95% CI, 0.12-0.55; P=0.001 for disease-free survival) after adjusting for corresponding covariates (residual tumour classification, Karnofsky performance score and stage). Furthermore, the results of both RT-qPCR and western blotting indicated that the relative mRNA and protein expression levels of CFB in lung tumor tissues were downregulated compared with those in adjacent non-tumor tissues. Collectively, the present results suggested that CFB expression was an independent predictor of overall and disease-free survival in patients with LUAD.