Prostate biopsy

From Wikipedia, the free encyclopedia - View original article

Prostate biopsy
Diagnostics
Prostate adenocarcinoma intermed mag hps.jpg
Micrograph of a prostate biopsy showing prostate adenocarcinoma, acinar type, the most common type of prostate cancer. HPS stain.
ICD-9-CM60.11-60.12
 
Jump to: navigation, search
Prostate biopsy
Diagnostics
Prostate adenocarcinoma intermed mag hps.jpg
Micrograph of a prostate biopsy showing prostate adenocarcinoma, acinar type, the most common type of prostate cancer. HPS stain.
ICD-9-CM60.11-60.12
MRI-US fusion biopsy
Diagnostics
Targeted MRI-US fusion prostate biopsy at UCLA.jpg
3d-reconstructed prostate gland indicating suspicious lesions for targeted biopsy. An informative video detailing the process of MRI-US fusion targeted biopsy can be found at the following website: http://urology.ucla.edu/body.cfm?id=455

Prostate biopsy is a procedure in which small needle-core samples are removed from a man's prostate gland to be examined microscopically for the presence of cancer. It is typically performed when the result from a PSA blood test rises to a level that is associated with the possible presence of prostate cancer. It may also be triggered by an abnormal digital rectal exam (DRE). PSA screening is controversial, and PSA may also be elevated by a benign enlargement of the (BPH, benign prostatic hyperplasia), by infection, or by manipulation of the prostate through surgery or catheterization.

The procedure, usually done as an outpatient, requires a local anesthetic; some men do report discomfort during the biopsy.[1] The most frequent side effect of the procedure is blood in the urine or stool for several days or blood in the ejaculate possibly for several weeks afterwards. These side effects are usually self-limited and do not require additional treatment.

Ultrasound-guided prostate biopsy[edit]

The procedure may be performed transrectally, through the urethra or through the perineum. The most common approach is transrectally, and historically this was done with tactile finger guidance.[2] The most common method of prostate biopsy currently is transrectal ultrasound-guided prostate (TRUS) biopsy.[3]

Extended biopsy schemes take 12-14 cores from the prostate gland through a thin needle in a systematic fashion from different regions of the prostate.[4]

Antibiotics are usually prescribed to minimize the risk of infection. An enema may also be prescribed for the morning of the procedure. In the transrectal procedure, the doctor inserts an ultrasound probe into the rectum to help guide the biopsy needles. A local anesthetic is then administered into the tissue around the prostate, similar to the local anesthetic administered for a dental procedure. A spring-loaded prostate tissue biopsy needle is then inserted into the prostate. It makes a clicking sound, and, if local anesthetic is satisfactory, discomfort is minimal.

Negative biopsy[edit]

In a large multicenter study of 2,299 patients examining cancer detection rates via various biopsy schemes, a 12-site biopsy scheme outperformed all other schemes, with an overall detection rate of 44.4%. PSA levels were directly correlated with cancer detection rates, ranging from 19% in patients with PSA <2, up to 68% inpatients with PSA >20.[5]

However a negative biopsy does not ensure the absence of disease. Systematic TRUS biopsy is "blind" since prostate cancer cannot often be seen with ultrasound. This problem is exacerbated in patients with larger prostate glands. In a 14-site biopsy, the additional cores are often taken at apical and anterior regions, a common site of "missed" tumors.[6]

Initial biopsies can miss 20–30% of clinically significant cancers. Thus, negative biopsies in men with persistently elevated PSA levels are often followed by subsequent biopsies. With each additional biopsy session, the rate of cancer detection decreases.[7]

Recently in order to address this problem, researchers have examined the ability of mitochondrial DNA to help diagnose prostate cancer in negative biopsy samples.[8][9]

Magnetic resonance imaging (MRI)-guided targeted biopsy[edit]

Since the mid-1980s, TRUS biopsy has been used to diagnose prostate cancer in essentially a blind fashion because prostate cancer cannot be seen on ultrasound due to poor soft tissue resolution. However, multiparametric MRI has since the mid-2000s been used to better identify and characterize prostate cancer.[10] A study correlating MRI and surgical pathology specimens demonstrated a sensitivity of 59% and specificity of 84% in identifying cancer when T2-weighted, dynamic contrast enhanced, and diffusion-weighted imaging together.[11] Many prostate cancers, missed by conventional biopsy, are detectable by MRI-guided targeted biopsy.[12]

Two methods of MRI-guided, or “targeted” prostate biopsy, are available: (1) direct "in-bore" biopsy within the MRI tube, and (2) fusion biopsy using a device that fuses stored MRI with real-time ultrasound (MRI-US). Visual or cognitive MRI-US fusion have been described.[13]

When MRI is used alone to guide prostate biopsy, it is done by an interventional radiologist. Correlation between biopsy and final pathology is improved between MRI-guided biopsy as compared to TRUS.[14]

In the fusion MRI-US prostate biopsy, a prostate MRI is performed before biopsy and then, at the time of biopsy, the MRI images are fused to the ultrasound images to guide the urologist to the suspicious targets. Fusion MRI-US biopsies can be achieved in an office setting with a variety of devices.[12]

MRI-guided prostate biopsy appears to be superior to standard TRUS-biopsy in prostate cancer detection. Several groups in the U.S.,[15][16] and Europe,[17][18] have demonstrated that targeted biopsies obtained with fusion imaging are several times more likely to reveal cancer than blind systematic biopsies. The more suspicious the MRI, the greater the likelihood of cancer on targeted biopsy. Considerable experience is required by the reader of prostate MRI studies. MRI scoring systems, to assign degree of cancer suspicion, have been described[19][20] and will undoubtedly evolve as experience with the new modality increases.

Up to 2013, indications for targeted biopsy have included mainly patients for whom traditional TRUS biopsies have been negative despite concern for rising PSA, as well as for patients enrolling in a program of active surveillance who may benefit from a confirmatory biopsy with the added confidence of more accurate staging.[15] Increasingly, men undergoing initial biopsy are requesting targeted biopsy, and thus, the use of pre-biopsy MRI is growing rapidly.

NIH-funded studies are underway to further clarify the benefits of targeted prostate biopsy.[21]

Gleason score[edit]

The tissue samples are then examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or Gleason score) of any cancer found. Gleason score, PSA, and digital rectal examination together determine clinical risk, which then dictates treatment options.

Tumor markers[edit]

Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of malignant cells that have metastasized.[22]

References[edit]

  1. ^ Essink-Bot, ML; de Koning HJ et al. (1998-06-17). "Short-term effects of population-based screening for prostate cancer on health-related quality of life". J Natl Cancer Inst. 90 (12): 925–31. doi:10.1093/jnci/90.12.925. PMID 9637143. Retrieved 2007-02-14. 
  2. ^ Ghei, M; Pericleous S et al. (September 2005). "Finger-guided transrectal biopsy of the prostate: a modified, safer technique". Ann R Coll Surg Engl 87 (5): 386–7. PMC 1963966. PMID 16402467. 
  3. ^ Tales from a prostate biopsy, MSNBC.com
  4. ^ Patel, A. R., & Jones, J. S. (2009). Optimal biopsy strategies for the diagnosis and staging of prostate cancer. Current opinion in urology, 19(3), 232–237. doi:10.1097/MOU.0b013e328329a33e
  5. ^ Presti, J. C. J., O'Dowd, G. J. G., Miller, M. C. M., Mattu, R. R., & Veltri, R. W. R. (2003). Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study. JURO, 169(1), 125–129. doi:10.1097/01.ju.0000036482.46710.7e
  6. ^ Presti, J. C. J. (2009). Repeat prostate biopsy--when, where, and how. Urologic oncology, 27(3), 312–314. doi:10.1016/j.urolonc.2008.10.029
  7. ^ Taira, A. V., Merrick, G. S., Galbreath, R. W., Andreini, H., Taubenslag, W., Curtis, R., et al. (2010). Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting. Prostate cancer and prostatic diseases, 13(1), 71–77. doi:10.1038/pcan.2009.42
  8. ^ Reguly B, Jakupciak JP, Parr RL. 3.4 kb mitochondrial genome deletion serves as a surrogate predictive biomarker for prostate cancer in histopathologically benign biopsy cores (2010). "3.4 kb mitochondrial genome deletion serves as a surrogate predictive biomarker for prostate cancer in histopathologically benign biopsy cores". Can Urol Assoc J. 4 (5): E118–22. PMC 2950771. PMID 20944788. 
  9. ^ Robinson K, Creed J, Reguly B, Powell C, Wittock R, Klein D, Maggrah A, Klotz L, Parr RL, Dakubo GD. Accurate prediction of repeat prostate biopsy outcomes by a mitochondrial DNA deletion assay. Prostate Cancer Prostatic Dis. 2010 Jun;13(2):126-31. Epub 2010 Jan 19. PubMed (2010). "Accurate prediction of repeat prostate biopsy outcomes by a mitochondrial DNA deletion assay". Prostate cancer and prostatic diseases 13 (2): 126–31. doi:10.1038/pcan.2009.64. PMID 20084081. 
  10. ^ Bonekamp D, Jacobs MA, El-Khouli R, Stoianovici D, Macura KJ. (May–June 2011). "Advancements in MR imaging of the prostate: from diagnosis to interventions.". Radiographics 31 (3 Suppl): 677–703. doi:10.1148/rg.313105139. PMC 3093638. PMID 21571651. 
  11. ^ Isebaert, S., Van den Bergh, L., Haustermans, K., Joniau, S., Lerut, E., De Wever, L., et al. (2012). Multiparametric MRI for prostate cancer localization in correlation to whole-mount histopathology. Journal of magnetic resonance imaging : JMRI, 37(6), 1392–1401. doi:10.1002/jmri.23938
  12. ^ a b Marks, L. L., Young, S. S., & Natarajan, S. S. (2013). MRI-ultrasound fusion for guidance of targeted prostate biopsy. Current opinion in urology, 23(1), 43–50. doi:10.1097/MOU.0b013e32835ad3ee
  13. ^ Moore, C. M., Kasivisvanathan, V., Eggener, S., Emberton, M., Futterer, J. J., Gill, I. S., et al. (2013). Standards of Reporting for MRI-targeted Biopsy Studies (START) of the Prostate: Recommendations from an International Working Group. European urology. doi:10.1016/j.eururo.2013.03.030
  14. ^ Hambrock, T., Hoeks, C., de Kaa, C. H.-V., Scheenen, T., Fütterer, J., Bouwense, S., et al. (2011). Prospective Assessment of Prostate Cancer Aggressiveness Using 3-T Diffusion-Weighted Magnetic Resonance Imaging–Guided Biopsies Versus a Systematic 10-Core Transrectal Ultrasound Prostate Biopsy Cohort. European urology, 1–8. doi:10.1016/j.eururo.2011.08.042
  15. ^ a b Sonn, G. A., Natarajan, S., Margolis, D. J. A., MacAiran, M., Lieu, P., Huang, J., et al. (2012). Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device. JURO, 189(1), 86–91. doi:10.1016/j.juro.2012.08.095
  16. ^ Vourganti, S., Rastinehad, A., Yerram, N. K., Nix, J., Volkin, D., Hoang, A., et al. (2012). Oncology: Prostate/Testis/Penis/UrethraMultiparametric Magnetic Resonance Imaging and Ultrasound Fusion Biopsy Detect Prostate Cancer in Patients with Prior Negative Transrectal Ultrasound Biopsies. JURO, 1–6. doi:10.1016/j.juro.2012.08.025
  17. ^ Kuru, T. H., Roethke, M. C., Seidenader, J., Simpfendörfer, T., Boxler, S., Alammar, K., et al. (2013). Critical evaluation of MRI-targeted TRUS-guided transperineal fusion biopsy for detection of prostate cancer. JURO, –. doi:10.1016/j.juro.2013.04.043
  18. ^ Fiard, G., Hohn, N., Descotes, J.-L., Rambeaud, J.-J., Troccaz, J., & Long, J.-A. (2013). Targeted MRI-guided Prostate Biopsies for the Detection of Prostate Cancer: Initial Clinical Experience With Real-time 3-Dimensional Transrectal Ultrasound Guidance and Magnetic Resonance/Transrectal Ultrasound Image Fusion. Urology, –. doi:10.1016/j.urology.2013.02.022
  19. ^ Natarajan, S., Marks, L. S., Margolis, D. J. A., Huang, J., Macairan, M. L., Lieu, P., & Fenster, A. (2011). Clinical application of a 3D ultrasound-guided prostate biopsy system. Urologic oncology, 29(3), 334–342. doi:10.1016/j.urolonc.2011.02.014
  20. ^ Dickinson, L., Ahmed, H. U., Allen, C., Barentsz, J. O., Carey, B., Futterer, J. J., et al. (2011). Magnetic Resonance Imaging for the Detection, Localisation, and Characterisation of Prostate Cancer: Recommendations from a European Consensus Meeting. European urology, 59(4), 477–494. doi:10.1016/j.eururo.2010.12.009
  21. ^ http://clinicaltrials.gov/ct2/results?term=prostate+mri+biopsy
  22. ^ Chuang AY, Demarzo AM, Veltri RW, Sharma RB, Bieberich CJ, Epstein JI (2007). "Immunohistochemical Differentiation of High-grade Prostate Carcinoma From Urothelial Carcinoma". The American Journal of Surgical Pathology 31 (8): 1246–1255. doi:10.1097/PAS.0b013e31802f5d33. PMID 17667550. 

External links[edit]