Negative Transrectal Biopsy Research Articles

In-Bore MRI-guided Prostate Biopsies: Retrospective Observational Study of Complementary Nontargeted Sampling of Normal-appearing Areas at Multiparametric MRI.

To investigate the pathologic outcomes of additional random biopsies from areas with no visible MR targets in the setting of targeted in-bore MRI-guided biopsy and to assess the negative predictive value (NPV) of areas with no visible MR targets stratified according to patients' different biopsy statuses. A retrospective analysis of patients who underwent in-bore MRI-guided biopsy with additional random biopsies in areas with no visible MR targets (Prostate Imaging-Reporting and Data System, version 2 category 1 or 2) was conducted in this study. Diagnostic scans and in-bore MRI-guided biopsy were performed with a 3-T MRI scanner. Areas with no visible MR targets were biopsied in a random fashion whenever a zone or side did not have a visible focal target. Clinically significant cancers (CSCs) were defined as a Gleason score of 7 or greater. NPVs were stratified based on patient's prior biopsy status. Descriptive analysis was performed. A total of 59 consecutive patients were included, with a median age of 65 years (interquartile range [IQR], 59-71 years). The median prostate-specific antigen level was 7 ng/mL (IQR, 4.9-10.8 ng/mL). Of the 59 patients, 16 (27.1%) were biopsy naive, 24 (40.7%) had prior negative transrectal US-guided biopsy findings, and 19 (32.2%) had prior positive transrectal US-guided biopsy findings. Forty-two (71.2%) biopsies revealed prostate cancer. A total of 112 areas with no visible MR targets were biopsied, of which 20 (17.9%) were cancers and 11 (9.8%) were CSCs. The NPV of areas with no visible MR targets was approximately 78% for all cancers and was 88.1% for CSCs. NPVs in biopsy-naive patients, patients with prior negative transrectal US-guided biopsy findings, and patients with prior positive transrectal US-guided biopsy findings were 62.5%, 83.3%, and 84.2%, respectively, for all cancers and 75.0%, 91.7%, and 94.7%, respectively, for CSCs. Areas with no visible MR targets in patients with MR-suspicious foci may still harbor CSCs that may significantly affect management plans. Additional biopsies from areas with no visible MR targets are warranted in this population.Keywords: Biopsy/Needle Aspiration, Interventional-Body, MR-Imaging, Prostate, Urinary© RSNA, 2019.

Detección de cáncer de próstata incidental con resección transuretral de próstata en pacientes con síntomas de tracto urinario inferior y antígeno prostático específico elevado del Hospital General de México

Objetivo: Evaluar la tasa de detección temprana de cáncer de próstata en zona de transición mediante realización de resección transuretral de próstata en pacientes con sospecha de cáncer sin o con biopsia transrrectal de próstata negativa.
 Materiales y métodos: Estudio retrospectivo y transversal que compara la eficacia de la resección transuretral de próstata en detección temprana de cáncer de próstata en zona de transición. Se incluyeron pacientes masculinos mayores de 40 años, que acudieron a consulta externa de Urología del Hospital General de México por presencia de síntomas del tracto urinario bajo, antígeno prostático elevado, tacto rectal normal y biopsia transrrectal de próstata negativa.
 Resultados: En el grupo de pacientes con riesgo alto para cáncer de próstata con btrp, 121 (96.03%) resultaron con diagnóstico negativo para cáncer posterior a rtup; adicionalmente 5 (3.97%) resultaron con diagnóstico positivo para cáncer de próstata posterior a rtup a pesar de tener antecedente de biopsia transrrectal negativa; en cuanto al Gleason en 2 (40%) fue 6, y 7, 9 y 10 representaron 1 (20%) respectivamente. En el grupo de pacientes con riesgo bajo para cáncer de próstata no candidatos para btrp, pero con síndrome obstructivo bajo, resultaron 111 (88.09%) con diagnóstico negativo para cáncer de próstata posterior a rtup, adicionalmente 15 (11.91%) resultaron con diagnóstico de cáncer, 7 (46.7%) con Gleason 7, Gleason 6 en 3 (20%) y Gleason 9 con 3 (20%), Gleason 8 y 10 se presentaron en 1 (6.7%).
 Conclusiones: Los pacientes detectados con cáncer de próstata por rtup representan un grupo diverso en los cuales dicha técnica puede resultar diagnóstica y terapéutica; corroborando que la rtup como herramienta diagnóstica es útil, mejora la detección de cáncer de próstata en casos aislados y específicos como se muestra en dicho estudio. Es importante destacar que la rtup aislada con fines puramente diagnostico, no se recomienda.

Consecutive transperineal prostatic template biopsies employing cognitive and systematic approach: a single center study

Introduction The role of transperineal template biopsy for prostate cancer diagnosis is well established. Pre-biopsy multiparametric magnetic resonance imaging (MRI) is used in most centers for planning of prostate biopsies and staging. Cognitive and software fusion techniques are increasingly getting popular. Methods We retrospectively reviewed patients who underwent transperineal template biopsies from January 2016 till December 2018. This included patients on active surveillance, previous negative transrectal ultrasonography biopsies with persistently raised prostate-specific antigen/abnormal prostate on digital rectal examination and de-novo template biopsies. Two specialist uro-radiologists reported all the scans and the biopsies were performed by one experienced urologist. The cognitive biopsies were performed for PIRADS 3–5 lesions on MRI. Total of 330 patients underwent transperineal template biopsies and cognitive target biopsies were carried out in 75 patients who were included in the study. We evaluated the results as positive/negative cognitive biopsies and also according to the PIRAD scoring. Only the patients with prostate cancer on template biopsy histology were included. Results Fifty-seven (76%) of the cognitive biopsies were positive out of total 75. PIRAD Score P ositive N egative PIRAD 3 8 (53.33%) 7 PIRAD 4 36 (83.72%) 7 PIRAD 5 13 (76.47%) 4 Conclusions Combined cognitive and systematic biopsies have excellent diagnostic rate especially for PIRAD 4–5 MRI areas.

A Multicentre Analysis of the Detection of Clinically Significant Prostate Cancer Following Transperineal Image-fusion Targeted and Nontargeted Systematic Prostate Biopsy in Men at Risk

BackgroundProstate biopsy guided by magnetic resonance imaging (MRI) is increasingly used to obtain tissue from men with suspected prostate cancer (PC). ObjectiveTo report a multicentre series of image-fusion transperineal prostate biopsies and compare the diagnostic yield of clinically significant PC (csPC) between targeted and nontargeted biopsies. Design, setting, and participantsThe study included 640 consecutive patients with elevated prostate specific antigen (PSA) presenting for first biopsy or following a previous negative transrectal biopsy under the care of 13 urologists in 11 centres in the UK (April 2014–June 2017). InterventionMultiparametric MRI was carried out in 61 approved prostate MRI centres with transperineal targeted alone (n=283) or targeted plus nontargeted (n=357) transperineal rigid image-fusion targeted biopsy (MIM-Symphony-DX). Outcome measurements and statistical analysisRates of csPC and insignificant cancer detection in targeted and nontargeted biopsies were measured using a number of thresholds to define clinical significance. The primary definition was Gleason≥4+3 or any grade ≥6mm. Results and limitationsThe mean age, median PSA, and median prostate volume for the cohort were 63.8yr (standard deviation [SD] 8.4), 6.3 ng/ml (SD 5.8), and 42.0cm3 (SD 24.7), respectively. Overall, 276/640 men (43.1%) were diagnosed with csPC. csPC was detected from targeted biopsies alone in 263/640 cases (41.1%). Of the 357 men who underwent nontargeted biopsies, three (0.8%) had csPC exclusively in nontargeted cores, with no evidence of cancer in targeted cores. Overall, 32/357 (9.0%) had csPC in nontargeted biopsies regardless of the targeted biopsy findings. Clinically insignificant disease in nontargeted biopsies was detected in 93/357 men (26.1%). Our findings were consistent across all other thresholds of clinical significance. Limitations include the lack of nontargeted biopsies in all men. ConclusionsIn this large multicentre series, nontargeted prostate biopsy cores had a low yield of csPC and a high yield of clinically insignificant PC. An image-fusion targeted-biopsy-only approach maintains high detection for csPC and low detection of clinically insignificant cancers. Patient summaryIn this report, we found that following prostate multiparametric magnetic resonance imaging and targeted transperineal biopsies of suspicious areas, the clinical value of performing additional extensive unguided biopsies of nonsuspicious areas is limited and can often find insignificant cancers that do not need treatment.

Abbreviated Biparametric Prostate MR Imaging in Men with Elevated Prostate-specific Antigen.

Purpose To determine the diagnostic accuracy for clinically significant prostate cancer achieved with abbreviated biparametric prostate magnetic resonance (MR) imaging in comparison with full multiparametric contrast material-enhanced prostate MR imaging in men with elevated prostate-specific antigen (PSA) and negative transrectal ultrasonography (US)-guided biopsy findings; to determine the significant cancer detection rate of biparametric versus full multiparametric contrast-enhanced MR imaging and between-reader agreement for interpretation of biparametric MR imaging. Materials and Methods In this institutional review board-approved retrospective review of prospectively acquired data, men with PSA greater than or equal to 3 ng/mL after negative transrectal US-guided biopsy findings underwent state-of-the-art, full multiparametric contrast-enhanced MR imaging at 3.0-T including high-spatial-resolution structural imaging in several planes, diffusion-weighted imaging at 0, 800, 1000, and 1400 mm2/sec, and dynamic contrast-enhanced MR imaging, obtained without endorectal coil within 34 minutes 19 seconds. One of four radiologists with different levels of expertise (1-9 years) first reviewed only a fraction of the full multiparametric contrast-enhanced MR images, consisting of single-plane (axial) structural imaging (T2-weighted turbo spin-echo and diffusion-weighted imaging), acquired within 8 minutes 45 seconds (referred to as biparametric MR imaging), and established a diagnosis according to the Prostate Imaging Reporting and Data System (PI-RADS) version 2; only thereafter, the remaining full multiparametric contrast-enhanced MR images were read. Men with PI-RADS categories 3-5 underwent MR-guided targeted biopsy. Men with PI-RADS categories 1-2 remained in urologic follow-up for at least 2 years, with rebiopsy (transrectal US-guided or transperineal saturation) where appropriate. McNemar test was used to compare diagnostic accuracies. To investigate between-reader agreement, biparametric MR images of 100 patients were read independently by all three radiologists. Results A total of 542 men, aged 64.8 years ± 8.2 (median PSA, 7 ng/mL), were included. Biparametric MR imaging helped detect clinically significant prostate cancer in 138 men. Full multiparametric contrast-enhanced MR imaging allowed detection of one additional clinically significant prostate cancer (a stage pT2a, intermediate-risk cancer with a Gleason score of 3+4) and caused 11 additional false-positive diagnoses. Diagnostic accuracy for detection of clinically significant cancer of biparametric MR imaging (89.1%, 483 of 542) was similar to that of full multiparametric contrast-enhanced MR imaging (87.2%, 473 of 542). Between-reader agreement of biparametric MR imaging interpretation was substantial (κ = 0.81). Conclusion Biparametric MR imaging allows detection of clinically significant prostate cancer missed by transrectal US-guided biopsy. Biparametric prostate MR imaging takes less than 9 minutes examination time, works without contrast agent injection, and offers a diagnostic accuracy and cancer detection rate that are equivalent to those of conventional full multiparametric contrast-enhanced MR imaging protocols. © RSNA, 2017.

MRI-transrectal ultrasound cognitive fusion-targeted transperineal template-guided saturation prostate biopsies in a consecutive cohort of men.

43 Background: MRI of the prostate may improve diagnostic accuracy of prostate cancer. Different fusion approaches with transrectal ultrasound images are employed. Objective: To determine the detection rate of prostate cancer in men undergoing transperineal template-guided saturation biopsy (TTSB) with MRI-based cognitive fusion. Methods: Between the years 2010-2015, 164 consecutive men underwent a multiple-core prostate TTSB. Univariable and multivariable logistic regression analyses were used to address the relationship between clinical TTSB parameters and prostate cancer detection rate. Covariates consisted of age, prostate-specific antigen (PSA), prostate volume, PSA density, digital rectal examination findings, existence of suspicious prostate lesions on MRI, number of previous negative biopsy sets, and number of cores taken during TTSB. Results: Mean age was 65 years and mean PSA was 14 ng/ml, mean prostate volume was 63 ml. Seventy percent of patients had at least two previous negative transrectal biopsy series and another 19% had at least one negative biopsy. One-hundred and fourteen patients (70%) underwent prostate MRI prior to the biopsy. The detection rate of prostate cancer among these patients was 46% of which 69% had Gleason score ≥ 7. Men with a suspicious lesion on MRI (n=80) had a detection rate of 50%, compared to 33% in patients with negative MRI study. On multivariate analysis, the most significant independent predictive factor was PSA density (p= 0.001). Other nearly significant parameters were suspicious MRI lesion, prostate volume and suspicious digital examination. Of note, the prostate cancer detection rate among patients with no MRI study prior to TTSB was 26%. Conclusions: Utilizing MRI cognitive fusion approach increases the detection rate of clinically significant prostate cancer (Gleason score ≥ 7). In patients with existing suspicion for prostate cancer after multiple negative standard TRUS-guided biopsies, performing TTSB after taking into consideration the findings on MRI and PSA density will increase dramatically the detection rate of significant disease.

The detection and upgrade rates of prostate adenocarcinoma following transperineal template-guided prostate biopsy - a tertiary referral centre experience.

IntroductionWe aim to present transperineal template-guided prostate biopsy (template biopsy) outcomes at a tertiary referral centre. Furthermore, to identify the detection rate of prostate cancer in those with a previous negative transrectal ultrasound guided prostate biopsy and the upgrade rate of those on active surveillance for Gleason 3 + 3 = 6 prostate adenocarcinoma.Material and methodsWe conducted a prospective study of 200 consecutive men who underwent template biopsy over a 22-month period in a tertiary referral centre, using a standard 24 region template prostate biopsy technique. Indications and histology results, as well as complications, were recorded.ResultsMedian age was 67 years and median PSA was 10 ng/mL. Overall detection rate was 47%. 39.5% of cases with previous negative transrectal biopsies were found to have prostate adenocarcinoma. 47.5% of cases on active surveillance for Gleason 3 + 3 = 6 prostate adenocarcinoma were upgraded. The most frequent complication was acute urinary retention at a rate of 12.5%, however, the use of a single prophylactic dose of tamsulosin was found to be beneficial, with 13 cases needed to treat to prevent one episode.ConclusionsTemplate biopsies are safe and efficacious with an overall detection rate of 47% in the present series. Due to the high detection rate, one must consider template biopsy following one negative transrectal biopsy where there is persistent clinical suspicion. Furthermore, those considering active surveillance for Gleason 3 + 3 = 6 disease should be offered template biopsy to confirm the grade of their disease.

Role of MRI in the diagnosis and management of prostate cancer.

Multiparametric MRI of the prostate consists of T1- and T2-weighted sequences, which provide anatomical information, and one or more 'functional' sequences, that is, diffusion-weighted imaging, dynamic contrast-enhanced sequences and magnetic resonance spectroscopy. Prostate MRI is the most accurate imaging method for local staging of prostate cancer and can also be used for the noninvasive evaluation of tumor aggressiveness. By magnetic resonance-guided prostate biopsy it is possible to target the most cancer-suspicious areas of the gland, especially in patients with a negative transrectal biopsy. In patients with biochemical recurrence after radical treatment, MRI is a valuable tool for the detection of local tumor recurrence and whole-body MRI can be used for the diagnosis of distant metastases.

Indications, results and safety profile of transperineal sector biopsies (TPSB) of the prostate: a single centre experience of 634 cases

Objective To describe a protocol for transperineal sector biopsies (TPSB) of the prostate and present the clinical experience of this technique in a UK population. Patients and Methods A retrospective review of a single‐centre experience of TPSB approach was undertaken that preferentially, but not exclusively, targeted the peripheral zone of the prostate with 24–38 cores using a ‘sector plan’. Procedures were carried out under general anaesthetic in most patients. Between January 2007 and August 2011, 634 consecutive patients underwent TPSB for the following indications: prior negative transrectal biopsy (TRB; 174 men); primary biopsy in men at risk of sepsis (153); further evaluation after low‐risk disease diagnosed based on a 12‐core TRB (307). Results Prostate cancer was found in 36% of men after a negative TRB; 17% of these had disease solely in anterior sectors. As a primary diagnostic strategy, prostate cancer was diagnosed in 54% of men (median PSA level was 7.4 ng/mL). Of men with Gleason 3+3 disease on TRB, 29% were upgraded and went on to have radical treatment. Postoperative urinary retention occurred in 11 (1.7%) men, two secondary to clots. Per‐urethral bleeding requiring hospital stay occurred in two men. There were no cases of urosepsis. Conclusions TPSB of the prostate has a role in defining disease previously missed or under‐diagnosed by TRB. The procedure has low morbidity.

V6-14 ROBOTIC TRANSPERINEAL PROSTATE SATURATION BIOPSY: TECHNIQUE AND OUTCOMES

You have accessJournal of UrologyNovel Imaging/Prostate Oncology/Robotics1 Apr 2014V6-14 ROBOTIC TRANSPERINEAL PROSTATE SATURATION BIOPSY: TECHNIQUE AND OUTCOMES Kae Jack Tay, Henry Ho, John Shyipeng Yuen, and Christopher Cheng Kae Jack TayKae Jack Tay More articles by this author , Henry HoHenry Ho More articles by this author , John Shyipeng YuenJohn Shyipeng Yuen More articles by this author , and Christopher ChengChristopher Cheng More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1877AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostate biopsy is central to prostate cancer diagnosis and prognosis. The transperineal approach allows adequate anterior zone sampling and reduces the risk of sepsis. We demonstrate, in this video, our technique of robotic-assisted transperineal saturation prostate biopsy (rTPB). METHODS rTPB was performed in 249 patients from 2007 to 2012 via 2 transperineal punctures using our novel prostate biopsy device (Biobot Surgical, Singapore). The indications for biopsy were rising PSA despite prior negative transrectal biopsy in 199 patients, staging biopsy in 40 patients with low- intermediate risk prostate cancer, and active surveillance biopsy in 10 patients. RESULTS Mean time taken for the procedure was 16.4 minutes (±8.0). Mean prostate volume was 31.2 ml (±14.0). Mean number of cores obtained was 29.4 (±5.4, range 15 – 53), with a total of 7251 cores obtained. Repeat biopsy was performed for 71 cores in 36 patients for cores having no tissue, being too short and/or being fragmented. Prostate cancer was detected in 485 cores in 112 patients, with 68 having a Gleason ≤ 6, 28 Gleason 3+4, 12 Gleason 4+3 and 4 Gleason 8. The mean number of cores positive for those diagnosed with cancer was 4.3 (±3.6) and the median percentage core involvement was 15% (IQR 0.7 – 50). The rate of haematuria was 2.8%, sepsis 0.8% and urinary tract infection 0%. Twenty percent of patients with prostate volume larger than 50 ml had urinary retention requiring a urinary catheter for 2 – 7 days. CONCLUSIONS rTPB is a feasible procedure for prostate cancer diagnosis and prognosis with a low rate of complications. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e682 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Kae Jack Tay More articles by this author Henry Ho More articles by this author John Shyipeng Yuen More articles by this author Christopher Cheng More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transperineal template-guided biopsy for diagnosis of prostate cancer in patients with at least two prior negative biopsies

To evaluate the prostate cancer (PCa) detection rate, PCa location, PCa significance and complications of a standardized 24-core template-guided transperineal biopsy (TPB) approach in patients with at least two negative transrectal biopsies. We prospectively recruited 50 men who had at least two negative transrectal ultrasound-guided extended biopsies in the past 24 months, a prostate-specific antigen (PSA) <20ng/mL, a prostate volume <100mL, and life expectancy of at least 90% at 10 years. All patients underwent a standardized 24-core template-guided TPB biopsy. The PCa detection rate, PCa location, PCa significance, and complications were recorded. Median age was 57.5 years and the median PSA level was 7.3ng/ml. PCa was detected in 24 patients (48%). The anterior zone was involved in 16 (32%) PCa. Six PCa (25%) were insignificant. Biopsy related complications occurred in 2 patients (4%). A 24-core TPB is a safe procedure with a high PCa detection rate. Few of the detected PCa are clinically insignificant. Men with at least two negative transrectal biopsies may be counseled to undergo TPB.

Transperineal template‐guided saturation biopsy using a modified technique: outcome of 270 cases requiring repeat prostate biopsy

To determine the incidence of prostate cancer (PCa), and pathological grade and location of PCa, using a modified transperineal template-guided saturation biopsy (TTSB). To compare the acute urinary retention (AUR) rate found using modified TTSB with that of published reports. A total of 270 consecutive patients with persistent clinical suspicion of PCa, despite a median (range) of 2 (1-6) sets of negative transrectal ultrasonography-guided biopsies, were enrolled and prospectively studied. All underwent modified TTSB avoiding the peri-urethral area at the base of the prostate under general anaesthesia. Statistical analysis was performed using binary logistic regression to determine the prebiopsy predictors of PCa and AUR. The median (range) patient age was 64 (43-85) years, with a median (range) prostate-specific antigen (PSA) of 10 (1-114) ng/mL and median (range) prostate volume of 45 (17-106) mL. A mean (range) of 28 (16-43) cores were taken at modified TTSB. Prostate cancer was diagnosed in 54.8% (Gleason scores 6 in 27.7%, 7 in 43.2%, 8-10 in 29.1% of patients). The anterior third only was involved in 21%, the middle third in 6.8% and the posterior third in 8.7% of positive cases, although in 75% of positive cases there was some anterior involvement. Comparing uniquely anterior tumours with the 15.5% found uniquely in either the middle or posterior thirds, there was no significant difference between number of positive cores (2 vs 1, P = 0.091), maximum percentage core involvement (30 vs 17.5%, P = 0.315) and maximum tumour length (3.5 vs 2 mm, P = 0.092). Fourteen patients (5.2%) developed AUR. On multivariate analysis, PSA density (PSAD) and pre-TTSB PSA predicted PCa diagnosis, whilst prostate volume, prebiopsy PSA and PSAD predicted AUR. Modified TTSB has a high cancer yield, especially in the anterior region, in patients with previously negative histology but onward suspicion of PCa. The modified TTSB technique provides a low risk of AUR without compromising cancer yield.

Repeat transrectal prostate biopsies in diagnosing prostate cancer

Patients with negative prostate biopsy and persistent suspicion of prostate cancer (PCa) can pose a serious diagnostic problem. The AIM of our study was to determine the frequency of PCa found on repeat prostate biopsy and the factors leading to higher possibility of cancer positive histological result. We studied retrospectively 113 patients (82 from University Clinic, Jena, Germany and 31 from Department of Urology, Plovdiv, Bulgaria) with initial negative biopsy for cancer who underwent repeat biopsies. The patients were examined between January 1999 and May 2010. The target group included patients with Prostate Specific Antigen (PSA) level lower than 12.5 ng/ml and without suspicious finding on digital rectal examination (DRE). Different biopsy schemes were used in the initial and the following biopsies, depending on patient age and total prostate volume. Overall PCa detection rate was 22.1% (25 of 113). The repeat biopsy found PCa in 15.9% (18 of 113). In patients with 3 biopsies the PCa detection rate was considerably lower--only 8.6% (3 of 35). PCa was found in only 1 patient of 18 (5.5%) who underwent four or more biopsies. Transurethral resection of the prostate (TURP) was performed in 15 patients with at least two previously negative biopsies. The pathohistological examination of the resected tissue showed PCa in 3 of the patients (20%). The interval between biopsies is not a significant predictive factor for positive prostate biopsy. The chance for detecting PCa after the second negative transrectal biopsy procedure is low. Therefore, TURP can be used as an alternative procedure to harvest adequate tissue material for pathologic examination, especially in patients with obstructive voiding symptoms.

1134 PATTERNS OF PROSTATE CANCER ON TEMPLATE PROSTATE MAPPING BIOPSIES IN 291 MEN IMPLICATIONS FOR FOCAL THERAPY

You have accessJournal of UrologyProstate Cancer: Localized V1 Apr 20121134 PATTERNS OF PROSTATE CANCER ON TEMPLATE PROSTATE MAPPING BIOPSIES IN 291 MEN IMPLICATIONS FOR FOCAL THERAPY Hashim Ahmed, Paras Singh, Alex Freeman, Emma Dalton, Daniel Stevens, Omar Barbouti, and Mark Emberton Hashim AhmedHashim Ahmed London, United Kingdom More articles by this author , Paras SinghParas Singh London, United Kingdom More articles by this author , Alex FreemanAlex Freeman London, United Kingdom More articles by this author , Emma DaltonEmma Dalton London, United Kingdom More articles by this author , Daniel StevensDaniel Stevens Cardiff, United Kingdom More articles by this author , Omar BarboutiOmar Barbouti London, United Kingdom More articles by this author , and Mark EmbertonMark Emberton London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1243AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Template Prostate Mapping (TPM) biopsies using a 5mm sampling frame is an accurate test that can localise clinically significant prostate cancer in order to aid focal therapy. Our aim was to describe the patterns of prostate cancer on TPM and as a result determine the proportion of men who may be suitable for tissue-preserving therapy. METHODS Men undergoing TPM with no prior therapy were identified. Criteria used to decide suitability for focal therapy were those used in prospective ethics-committee approved trials recruiting during the period of this study. Thus, 4 broad categories were used to reflect inclusion criteria for these trials. So, cancer had to be either, 1) unifocal - suitable for unifocal ablation; 2) unilateral - suitable for ablation of the entire lobe (hemiablation); 3) bilateral and bifocal in which at least one neurovascular bundle could be avoided - suitable for bilateral bifocal ablation; or 4) bilateral multifocal with one dominant lesion by volume/grade (index lesion) and secondary lesions with Gleason </=3+3 and maximum cancer core length involvement </=3mm - suitable for index lesion ablation. RESULTS 377 men underwent TPM between 05/2006 to 05/2010; of these, 291 had no previous treatment. 80% (233/291) had low or low-intermediate risk cancer on previous transrectal biopsy, 12% (34/291) had previous negative transrectal biopsy and 8% (24/291) had no prior biopsy. Mean age was 62 years (SD+/-7.4), mean PSA 7.6ng/ml (SD+/-4.5). 85% (199/233) of men had unilateral cancer on TRUS biopsy. A mean of 29 (SD+/-17) biopsies were taken at TPM with a mean of 5 (SD+/-5) positive biopsies. 12% (34/291) had no cancer on TPM and 14% (42/291) required radical therapy due to large volume bilateral multifocal disease and/or Gleason >4+3. Overall, 74% (215/291) were suitable for at least one form of focal therapeutic strategy. These included unifocal ablation in 18%, hemi-ablation in 24%, bilateral and bifocal ablation in 12% and index lesion ablation in 20%. CONCLUSIONS TPM is an accurates means by which disease can be localised for the purpose of focal therapy. When it isapplied to men seeking re-classification of their disease status, three-quarters were potentially eligible for a form of focal therapy currently undergoing evaluation within prospective clinical trials. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e459-e460 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hashim Ahmed London, United Kingdom More articles by this author Paras Singh London, United Kingdom More articles by this author Alex Freeman London, United Kingdom More articles by this author Emma Dalton London, United Kingdom More articles by this author Daniel Stevens Cardiff, United Kingdom More articles by this author Omar Barbouti London, United Kingdom More articles by this author Mark Emberton London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

High detection rate of significant prostate tumours in anterior zones using transperineal ultrasound‐guided template saturation biopsy

Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Men with persistent suspicion for prostate cancer after previous negative standard transrectal biopsy series are offered saturation biopsy either transrectally or transperineally to increase cancer detection rate. A high-risk group of men with at least two previous negative transrectal biopsies underwent transperineal template-guided saturation biopsy. Prostate cancer was detected in 26%, predominantly in the anterior zones. PSA velocity or doubling time were the most powerful factors to predict cancer. To evaluate the detection rate and the regional location of prostate cancer in men undergoing transperineal template-guided saturation biopsy (TTSB). In all, 92 consecutive men with at least two previous negative transrectal biopsy series who underwent a multiple-core prostate TTSB at our centre were included in the study. • Univariable and multivariable logistic regression analyses were used to address the relationship between parameters before TTSB and prostate cancer-detection rate. • Covariates consisted of age at biopsy, free and total prostate-specific antigen (PSA), prostate volume, digital rectal examination findings, histological findings on previous biopsy, PSA velocity (PSAV), PSA-doubling time (PSADT) and the number of previous negative biopsy sets. Prostate cancer was diagnosed in 26% of the men. • A median of 30 cores was taken by TTSB. • Adenocarcinoma in >2 cores was detected in 58.5% and Gleason score ≥7 was detected in 46% of the diagnosed men. • Most of the tumours (83.3%) were found in the anterior zones of the gland, with a significantly higher number of positive cores vs the posterior zones (mean 4.9 vs 1.5, P= 0.015). • PSADT and PSAV were the only independent predictors of prostate cancer detection at multivariate analyses with odds ratios of 0.71 (P= 0.014) and 1.58 (P= 0.025), respectively. TTSB has a high prostate cancer-detection rate, especially in the anterior zones. • Men after at least two previous negative transrectal biopsy series and persistent suspicion of prostate cancer, as evidenced by rapid PSA dynamics, should be offered TTSB.

Transperineal prostate biopsy detects significant cancer in patients with elevated prostate‐specific antigen (PSA) levels and previous negative transrectal biopsies

Several authors have previously reported that transrectal prostate biopsy has a false-negative rate of 20-30%, and that a number of prostate cancers missed on transrectal biopsy can be detected by transperineal biopsy. It has also been shown that most of these tumours are located anteriorly in the prostate gland. The present study showed a high rate of prostate cancer in patients with previous negative transrectal biopsies but elevated PSA levels, and that the cancers were located anteriorly in the prostate gland. Also, most of these cancers were clinically significant in patients that underwent RP, i.e. a high proportion of cancers were high-grade/high-stage tumours. We also showed that the transperineal biopsy technique can be applied successfully to patients with a closed anal orifice after previous surgery for rectal cancer. Transperineal biopsy can be done safely without routine antibiotic prophylaxis. To investigate the outcomes of transperineal prostate biopsies in patients with elevated prostate-specific antigen (PSA) levels and negative transrectal biopsies. The aim of this retrospective study was to evaluate the diagnostic yield of the transperineal biopsy approach in these patients, and to evaluate the pathology findings in subsequent radical prostatectomy (RP) specimens in patients undergoing RP. In all, 69 consecutive patients with previous negative transrectal biopsies but elevated PSA levels investigated at urological units in Norway who had been referred to The Norwegian Radium Hospital were included. The patients had undergone a mean (median; range) of 2.42 (2; 0-7) transrectal biopsies. The mean (range) age was 63.1 (42-78) years. The median (range) PSA level was 12 (4.3-229) ng/mL. The patients were examined with transperineal biopsy of the prostate between July 2007 and February 2009. The results of the transperineal biopsies were reviewed for Gleason biopsy score, and these were compared with the histopathology results of the RP specimens, i.e. final Gleason scores. Pathological stage of the prostate specimens and tumour volume were also reviewed. Prostate cancer was found in the biopsies of 38 of 69 patients (55%). In all, 20 of 38 patients had a Gleason score estimated at ≥3 + 4 = 7. In all, 26 patients underwent RP. The surgical specimens revealed pathological stage pT2c in 65%, pT3a in 27% and pT3b in 8% of the cases. In all, 23 of the 26 RP specimens showed a final Gleason score of ≥7. The vast majority of cancers detected were situated in the anterior/ventral portion of the prostate. Transperineal biopsy of the prostate in patients with an elevated PSA level after negative transrectal prostate biopsies appears to be a feasible and important option for further investigation to detect prostate cancer. The present study shows that the transperineal biopsy allows good access of the anterior/ventral part of the prostate. Histopathology reports on the RP specimens obtained from the patients that underwent RP revealed significant cancer.

2304 STEREOTACTIC PROSTATE BIOPSY WITH PRE-INTERVENTIONAL MRI AND LIVE US FUSION

INTRODUCTION AND OBJECTIVES: The key challenge for focal therapy of prostate cancer is to identify index lesions. In this context, we describe our initial experience with a new stereotactic prostate biopsy system, which integrates pre-interventional MRI data with periinterventional ultrasound for perineal prostate biopsies. METHODS: 33 patients were stereotactically biopsied (mean age of 64yrs., mean PSA level of 8.2ng/ml and mean prostate vol. of 40ml). 21 of these 33 patients had already had a negative transrectal US-guided biopsy. All men underwent multimodal 3 Tesla MRI without endorectal coil including diffusion weighted imaging and dynamic contrast enhanced sequences as well as MR-spectroscopy. Suspicious lesions were marked by radiologists with over 10 years experience in reading prostate MRI before the obtained data were transferred to the stereotactic biopsy system. Using a custom-made biplane TRUS probe mounted on a stepper device, 3D ultrasound data were generated to set the anatomic landmarks. Then MRI and TRUS imaging data were fused manually. As a result, the suspicious MRI lesions were superimposed onto the TRUS data. Next, 3D biopsy planning was performed including systematic biopsies from the peripheral and transitional zones of the prostate. Perineal biopsies were taken under live US imaging, and the location of each biopsy was documented in 3D. RESULTS: 14 out of 33 patients were diagnosed with prostate cancer. These results showed a positive correlation between MRI findings and histopathology in 22 out of 33 patients. In MRI lesions marked as highly suspicious, the detection rate was 100%. Evaluating the biopsies from lesions marked as highly and as questionable suspicious together, prostate cancer was detected in 27.95%. In comparison, only 8% of the additional systematic biopsies were positive. Target registration error of the first 554 biopsy cores was 1.9 mm. For adverse effects, one patient experienced urinary retention. Postinterventional hemorrhage or urinary tract infection did not occur. CONCLUSIONS: Perineal stereotactic prostate biopsies guided by the combination of MRI and ultrasound enable effective examination of suspicious MRI lesions. Additionally, each biopsy core taken may be documented accurately for its location in 3D. Thus, MRI data may be validated and different treatment options stratified in depth. At the same time the morbidity of the procedure was minimal.

Patients with Elevated versus Non-Elevated Prostate Specific Antigen Levels before Suprapubic Prostatectomy: Long-Term Postoperative Follow-Up and Risk for Rising Prostate Specific Antigen and Detection of Prostate Cancer

Objective: Prostate specific antigen (PSA) is one of the most widely applied tumor markers in oncology. The marker is, however, not cancer-specific and may be elevated under other conditions. As prostate cancer may develop after surgery for benign prostate hyperplasia, postoperative follow-up of serum PSA levels is suggested in patients with at least a 10 year life expectancy. We evaluated the preoperative and monitored postoperative serum PSA levels in men who underwent suprapubic prostatectomy (SPP) for benign prostate hyperplasia, and specifically examined the rate of cancer detection in patients who had a non-elevated versus elevated age-related preoperative PSA. Patients and Methods: Two hundred and ninety-two patients who presented with benign histopathology after SPP, completed postoperative follow-up. Of those, 101 patients were found to have elevated preoperative PSA levels and a negative transrectal biopsy before the operation. The other group included 191 patients with preoperative PSA within age related limits. Results: PSA levels continued to be elevated in 11.8% of patients in the elevated PSA group compared with 3.5% in the non-elevated PSA group. Incidental surgical specimen cancer detection rate was 7 (6.5%) and 3 (1.5%) whereas follow-up cancer detection rate was 4 (3.9%) and zero in the elevated PSA group and non-elevated PSA group, respectively. In a logistic regression model, 2 factors were found to be statistically significant: age – the older the patient undergoing the operation, the greater was the likelihood to develop malignancy on follow-up. The second factor was the ratio between preoperative and postoperative PSA (prePSA – postPSA)/prePSA. Conclusions: This study is the first to compare long-term follow-up in patients after SPP with preoperative elevated PSA levels to those who have normal preoperative levels. The first group was found to have an increased risk incidental cancer in the surgical specimen, and of elevated PSA levels and eventually development prostate cancer upon follow-up.

Role of Transurethral Resection of the Prostate and Biopsy of the Peripheral Zone in the Same Session after Repeated Negative Biopsies in the Diagnosis of Prostate Cancer

ObjectiveTo determine the role of the transurethral resection of the prostate (TURP) together with biopsies of the peripheral zone in the diagnosis of prostate cancer after repeated negative transrectal biopsies and increasing prostate-specific antigen (PSA) levels. MethodsFrom 2003 to 2004, 43 patients, aged 53–69 yr, were seen for a history of at least two negative biopsies for prostate cancer. Thirty-five men had an increasing PSA level and underwent another set of biopsies. Seven patients had prostate cancer (20%); three were lost at follow-up and four had a Charlson comorbidity index >1. The remaining 21 were offered TURP and biopsy of the peripheral zone. Bladder outlet obstruction had no influence on decision-making. Fourteen men accepted. ResultsEight patients (57%) had prostate cancer and underwent radical prostatectomy. Six cancers were detected only with TURP, one with TURP and biopsy, and one with biopsy alone. After a median of 9 mo of follow-up, two of six patients underwent rebiopsy for a rising PSA level, but no cancer was detected. ConclusionsTURP combined with a set of transrectal needle biopsies of the lateral portion of the gland is a safe procedure with a high diagnostic power after repeated negative biopsies in patients with persistently increasing PSA levels.

Diagnosis of prostate adenocarcinoma using transurethral resection of the prostate after multiple negative transrectal biopsies and persistently elevated prostate-specific antigen level

We report a case of prostate cancer diagnosis by transurethral resection of the prostate in a man who underwent more than 50 needle biopsies by three different physicians for an increasing prostate-specific antigen level. Radical prostatectomy resulted in removal of an organ-confined tumor (T2aN0M0), and a short follow-up revealed an undetectable prostate-specific antigen level.