|Year : 2018 | Volume
| Issue : 1 | Page : 15-19
Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient?
Akın Soner Amasyali1, Uğur Yücetaş2, Erkan Erkan2, Murat Demiray2, Emre Karabay2, Cemalettin Murat2, Gökhan Toktaş2, Erdinç Ünlüer3
1 Department of Urology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
2 Department of Urology, Istanbul Training and Research Hospital, Istanbul, Turkey
3 Department of Urology, Faculty of Medicine, Kafkas University, Kars, Turkey
|Date of Submission||15-Jul-2017|
|Date of Acceptance||14-Sep-2017|
|Date of Web Publication||15-Jan-2018|
Asst. Prof. Akın Soner Amasyali
Department of Urology, School of Medicine, Adnan Menderes University, Aydin
| Abstract|| |
Background: We investigated the correlation between the sampled number of cores in rebiopsy and the cancer detection rate (CDR).
Materials and Methods: Two hundred and twelve patients with normal rectal examination who had undergone rebiopsy in the past 5 years were examined retrospectively. Moreover, 68% of them had undergone 12 cores (Group 1) while 32% had undergone 20 cores (Group 2). Both groups were compared with respect to the CDR.
Results: There was no difference between groups in terms of age, total prostate-specific antigen, and prostate volume (P > 0.05). Forty-one (19%) of 212 patients were diagnosed with cancer, and the CDR was significantly higher in Group 2 (30.9% vs. 13.9%, P = 0.004). This rate increased from 6.5% to 20% (P = 0.025) and from 0% to 33.3% (P = 0.023), respectively, with 12-core and 20-core rebiopsies in patients whose initial pathology indicated benign and high-grade prostatic intraepithelial neoplasia (HGPIN). Furthermore, cancer was detected in 24 (40%) of 60 patients who were diagnosed with atypical small acinar proliferation (ASAP) in the initial biopsy. However, despite being higher in 20-core biopsy group (47.6% vs. 35.9%), this was not statistically significant (P = 0.377).
Conclusions: At least 20 cores should be sampled in rebiopsy, especially in the patients diagnosed with benign and HGPIN. However, we believe that standard systematic sampling will be sufficient for the patients diagnosed with ASAP.
Keywords: Atypical small acinar proliferation, prostate cancer, transrectal ultrasound prostate rebiopsy
|How to cite this article:|
Amasyali AS, Yücetaş U, Erkan E, Demiray M, Karabay E, Murat C, Toktaş G, Ünlüer E. Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient?. Urol Ann 2018;10:15-9
|How to cite this URL:|
Amasyali AS, Yücetaş U, Erkan E, Demiray M, Karabay E, Murat C, Toktaş G, Ünlüer E. Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient?. Urol Ann [serial online] 2018 [cited 2020 Jan 29];10:15-9. Available from: http://www.urologyannals.com/text.asp?2018/10/1/15/223139
| Introduction|| |
Prostate cancer (PCa) is the most commonly diagnosed nonskin cancer and the sixth leading cause of cancer death in males around the world., The incidence is higher in the developed countries, and the 12-core systematic transrectal ultrasound (TRUS)-guided biopsy is the standard method for the diagnosis of PCa. The indications of prostate biopsy are high serum total prostate-specific antigen (PSA) levels and/or suspicion in digital rectal examinations (DRE). PCa is determined in approximately 25% of the patients who undergone first TRUS-guided biopsy; however, the studies estimate that up to 47% of cancer cases may not be detected in the initial biopsy., Patients with previously negative biopsy results should undergo rebiopsy in cases of elevated PSA, suspected DRE, atypical small acinar proliferation (ASAP), extensive high-grade prostatic intraepithelial neoplasia (HGPIN), and positive multiparametric magnetic resonance imaging (MRI) findings.
An increasing number of data have shown the value of MRI-targeted rebiopsy. Clinically, significant rate of cancer detection varies between 11% and 54% on MRI-targeted biopsy in the rebiopsy setting. However, 5%–15% of the clinically significant cancer cases remain undetected in these patients. Furthermore, this technique cannot be used widely, especially in the developing countries because of its cost and time requirements during the procedure. Moreover, it is recommended that concurrent systematic sampling at the time of targeted biopsy with MRI should be performed to increase the chance of clinically significant cancer detection as well. That's why systematic biopsy still maintains its clinical importance.
In general, PCa is detected between the rate of 10% and 25% in patients who undergone rebiopsy. Moreover, this rate depends on the previously reported histopathological findings and the number of core sampled during rebiopsy. The present study compares the cancer detection rates (CDRs) in terms of the different number of sampled cores in rebiopsy. We have also investigated whether the higher number of sampled cores increases CDRs in systematic rebiopsy, especially in cases with ASAP on the previous biopsy.
| Materials and Methods|| |
A total of 212 patients who had rebiopsy because of rising or persistently elevated PSA and/or suspected histopathology in initial biopsy were enrolled in the study between the years 2011 and 2016. All procedures were conducted in the same academic tertiary referral center (Istanbul Training and Research Hospital, Department of Urology), and only patients with normal DRE were included in the study. All patients were informed of the prostate biopsy and its potential complications, and informed consent for the procedure was signed by all patients.
The earliest repeat biopsy was held in the 6 months after the initial biopsy. Prostate biopsies (PBx) were carried out under the guidance of transrectal ultrasonography. As per our prostate biopsy protocol, an antibiotic treatment started 2 days before the procedure and it was recommended to continue this treatment for 3 days after the procedure. A rectal enema was applied 1–2 h before the biopsy procedure to obtain good ultrasound imaging and to avoid infection.
The histopathological evaluation of the initial biopsy had been reported as follows: benign, HGPIN, and ASAP. The number of sampled cores in rebiopsy was 10–12 in 68% (n = 144, Group 1) of all patients and 18–20 cores in remaining 32% (n = 68, Group 2). Comparison was done between these two groups in terms of CDR retrospectively.
SPSS ® 16.0 software (SPSS Inc; Chicago, IL, USA) was used for statistical analysis. A one-way ANOVA test was used to compare the ages, prostatic volumes, and serum total PSA levels of patients according to the number of biopsy cores performed. Chi-square test was used to analyze the differences in CDRs for the 10-12-PBx and 18-20-PBx groups. P < 0.005 was accepted as statistically significant.
| Results|| |
One hundred and forty-four patients were had 10–12-core rebiopsy (Group 1) and 68 patients were had 18–20-core rebiopsy (Group 2). Histopathological evaluation of the initial biopsy of all these patients (n = 212) had been reported as follows: benign (n = 127), HGPIN (n = 25), and ASAP (n = 60).
The median age, total PSA, and prostate volume of Group 1 and Group 2 were 63 (10) (48–75) years, 7.24 (5.4) (3.3–43) ng/mL, and 44.75 (25) (15–119) mL and 62 (11) (41–77 years, 6.62 (5.3) (2.9–58.9) ng/mL, and 40 (25) (18–123) mL, respectively. No significant difference was found between the groups, and they were similar in respect to the above-mentioned parameters. All baseline demographics and clinical characteristics were given in [Table 1].
|Table 1: Comparison of baseline demographics and clinical characteristics|
Click here to view
Overall CDR was 19% (41/212). According to initial histopathological subgroups, the rate of cancer detection for benign, HGPIN, and ASAP was 10.2%, 16%, and 40%, respectively (P< 0.0001) [Table 2].
|Table 2: Distribution of cancer detection rate between initial histopathological subgroups|
Click here to view
Furthermore, CDR was 13.9% in Group 1 while it was 30.9% in Group 2. We found a statistically significant difference between these groups (P = 0.004) [Table 3]. PCa was detected in 40% (24/60) of all patients whose initial prostate biopsy had been reported as ASAP. Moreover, again higher CDRs were noted in Group 2 compared to Group 1 in this specific patient group; however, it was not significant at all (47.6% vs. 35.9%, P = 0.377). On the other hand, CDRs were significantly higher when 20-core rebiopsy was performed in patients whose initial histopathology had been reported as benign and HGPIN. All CDRs of Group 1 and Group 2 are given in [Table 4] according to their initial prostate biopsy results.
|Table 4: Comparison of cancer detection rate according to initial histopathological findings between groups|
Click here to view
| Discussion|| |
The current study demonstrates that higher CDRs can be achieved by sampling 20 cores in rebiopsy, especially in patients who had benign or HGPIN in their initial biopsy. We found that the CDR increased when 20-core rebiopsy was performed in all three histopathological subgroups, independently from age, PSA, or prostate volume of patients. However, the increase in the CDR was statistically insignificant in ASAP group.
Our cohort consisted of patients with normal DRE which indicated probable clinically T1c candidates. There is no consensus about the definite indication and optimal protocol for rebiopsy in this patient group. Although PCa detection rate varies between 10% and 25% in rebiopsy, this rate could reach up to 41% in the previous negative biopsy series according to the initial histopathological findings., The most suspicious histopathological finding is ASAP which presents a rate between 1.5% and 24% in TRUS biopsy. It is hard for pathologist to decide ASAP and its potential for cancer. Therefore, rebiopsy should be done in these patients to rule out PCa. In these cases, CDR varies between 19% and 38%, which depends on the number of the sampled cores used in rebiopsy.,
The previous data showed that >12-core biopsy contributes no significant benefit to the CDR in initially performed TRUS biopsy.,,, However, increasing the number of cores used in rebiopsy is controversial. Stewart et al. revealed that CDR increased to 30%–34% when the cores were obtained with saturation technique in rebiopsy. However, in this study, sextant sampling was used in initial biopsy; therefore, more missing cancer cases were likely to be diagnosed during rebiopsy. Another supporting data by Presti concluded that at least 14-core biopsy should be taken during rebiopsy after a negative first biopsy. Terris also advocated 14 cores for rebiopsy and recommended an additional biopsy with saturation technique if it was still negative.
The National Comprehensive Cancer Network recommends an individualized rebiopsy decision for each patient based on the risk stratification factors such as PSA, PCA3, as well as percent-free PSA and prostate volume. However, these parameters were similar in our cohort, and these patients had normal DRE. Nevertheless, we found a significantly increased CDR in Group 2 which means that the higher number of sampled core in rebiopsy could achieve increased CDRs regardless of PSA and prostate volume. Recently, published data showed that the sampled >20 cores was associated with a higher likelihood of PCa diagnosis as consistent with our data. Furthermore, these data indicated that patients older than 70 years and the fourth TRUS biopsy were associated with higher CDRs as well. However, they stated that early consideration of saturation or MRI-guided targeted biopsy may be required in the rebiopsy setting appropriately.
Previous studies have suggested that adding the multiparametric MRI-guided targeted biopsy to the systematic biopsy could improve CDRs with a set number of cores instead of higher number of biopsy cores., It was also demonstrated that the multiparametric MRI-guided targeted biopsy increased not only clinically significant but also overall CDRs in patients with prior biopsy.,, Likewise, MRI-ultrasound fusion-guided targeted biopsy may decrease the multiple rebiopsy requirements and prevent the complications of prostate biopsy. However, this technique is not broadly used in every clinic appropriately. Moreover, it not only increases the cost of procedure but also does not eliminate the need for a systematic prostate biopsy.
In clinical practice, we suppose that prostate biopsy protocols should be introduced for each patient to minimize missing cancer without significant morbidity. In this regard, Scattoni et al. developed an individualized approach with respect to the clinical characteristics of the patients. Their study demonstrated that the optimal sampling for patients with or without previous ASAP diagnosis and <10% fPSA% (free PSA %), and two different combinations of a 14-core biopsy scheme (with or without transitional zone sampling) were most advantageous. On the other hand, if patients had previously no ASAP and fPSA% as >10%, 20-core biopsy was the most advantageous scheme. Thus, they could reach the similar CDRs with 24-core systematic biopsy. In consistent with this finding, we also found significantly increased CDRs in previously benign or HGPIN-diagnosed patients regardless of PSA and its derivatives when 20 cores were taken in rebiopsy.
The present study has some drawbacks in its retrospective nature. First, our cohort was heterogeneous in terms of initial histopathological evaluations. Second, we did not assess the area that should be sampled in case of the prostate. Moreover, we have not classified the detected PCa as clinically significant (Gleason >6) and clinically insignificant (Gleason <7). However, it was not within the scope of the current study.
| Conclusions|| |
We suggest that if rebiopsy is indicated for the patients with previously benign or HGPIN diagnosis in initial biopsy, higher number of cores should be sampled regardless of PSA and prostate volume even if DRE is normal. ASAP is another important factor influencing the decision-making process to perform rebiopsy since the CDR for ASAP is two times higher than the other pathological results in 20-core rebiopsy. However, the individualized approach and optimal scheme should be implemented with respect to characteristics of the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arnold M, Karim-Kos HE, Coebergh JW, Byrnes G, Antilla A, Ferlay J, et al.
Recent trends in incidence of five common cancers in 26 European countries since 1988: Analysis of the European cancer observatory. Eur J Cancer 2015;51:1164-87.
Center MM, Jemal A, Lortet-Tieulent J, Ward E, Ferlay J, Brawley O, et al.
International variation in prostate cancer incidence and mortality rates. Eur Urol 2012;61:1079-92.
Eskicorapci SY, Baydar DE, Akbal C, Sofikerim M, Günay M, Ekici S, et al.
An extended 10-core transrectal ultrasonography guided prostate biopsy protocol improves the detection of prostate cancer. Eur Urol 2004;45:444-8.
Taira AV, Merrick GS, Galbreath RW, Andreini H, Taubenslag W, Curtis R, et al.
Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting. Prostate Cancer Prostatic Dis 2010;13:71-7.
Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, et al.
EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, diagnosis, and local treatment with curative intent. Eur Urol 2017;71:618-29.
Rosenkrantz AB, Verma S, Choyke P, Eberhardt SC, Eggener SE, Gaitonde K, et al.
Prostate magnetic resonance imaging and magnetic resonance imaging targeted biopsy in patients with a prior negative biopsy: A Consensus statement by AUA and SAR. J Urol 2016;196:1613-8.
Filson CP, Natarajan S, Margolis DJ, Huang J, Lieu P, Dorey FJ, et al.
Prostate cancer detection with magnetic resonance-ultrasound fusion biopsy: The role of systematic and targeted biopsies. Cancer 2016;122:884-92.
Campos-Fernandes JL, Bastien L, Nicolaiew N, Robert G, Terry S, Vacherot F, et al.
Prostate cancer detection rate in patients with repeated extended 21-sample needle biopsy. Eur Urol 2009;55:600-6.
Stav K, Leibovici D, Sandbank J, Lindner A, Zisman A. Saturation prostate biopsy in high risk patients after multiple previous negative biopsies. Urology 2008;71:399-403.
Walz J, Graefen M, Chun FK, Erbersdobler A, Haese A, Steuber T, et al.
High incidence of prostate cancer detected by saturation biopsy after previous negative biopsy series. Eur Urol 2006;50:498-505.
Moore CK, Karikehalli S, Nazeer T, Fisher HA, Kaufman RP Jr., Mian BM, et al.
Prognostic significance of high grade prostatic intraepithelial neoplasia and atypical small acinar proliferation in the contemporary era. J Urol 2005;173:70-2.
Hong YM, Lai FC, Chon CH, McNeal JE, Presti JC Jr. Impact of prior biopsy scheme on pathologic features of cancers detected on repeat biopsies. Urol Oncol 2004;22:7-10.
Eichler K, Hempel S, Wilby J, Myers L, Bachmann LM, Kleijnen J, et al.
Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: A systematic review. J Urol 2006;175:1605-12.
Jones JS, Patel A, Schoenfield L, Rabets JC, Zippe CD, Magi-Galluzzi C, et al.
Saturation technique does not improve cancer detection as an initial prostate biopsy strategy. J Urol 2006;175:485-8.
Pepe P, Aragona F. Saturation prostate needle biopsy and prostate cancer detection at initial and repeat evaluation. Urology 2007;70:1131-5.
Scattoni V, Roscigno M, Raber M, Dehò F, Maga T, Zanoni M, et al.
Initial extended transrectal prostate biopsy – Are more prostate cancers detected with 18 cores than with 12 cores? J Urol 2008;179:1327-31.
Stewart CS, Leibovich BC, Weaver AL, Lieber MM. Prostate cancer diagnosis using a saturation needle biopsy technique after previous negative sextant biopsies. J Urol 2001;166:86-91.
Presti JC Jr. Repeat prostate biopsy – When, where, and how. Urol Oncol 2009;27:312-4.
Terris MK. Strategies for repeat prostate biopsies. Curr Urol Rep 2009;10:172-8.
Carroll PR, Parsons JK, Andriole G, Bahnson RR, Barocas DA, Catalona WJ, et al.
Prostate cancer early detection, version 1.2014. Featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2014;12:1211-9.
Abraham NE, Mendhiratta N, Taneja SS. Patterns of repeat prostate biopsy in contemporary clinical practice. J Urol 2015;193:1178-84.
Mitterberger M, Horninger W, Pelzer A, Strasser H, Bartsch G, Moser P, et al.
Aprospective randomized trial comparing contrast-enhanced targeted versus systematic ultrasound guided biopsies: Impact on prostate cancer detection. Prostate 2007;67:1537-42.
Halpern EJ, Ramey JR, Strup SE, Frauscher F, McCue P, Gomella LG, et al.
Detection of prostate carcinoma with contrast-enhanced sonography using intermittent harmonic imaging. Cancer 2005;104:2373-83.
Hoeks CM, Schouten MG, Bomers JG, Hoogendoorn SP, Hulsbergen-van de Kaa CA, Hambrock T, et al.
Three-tesla magnetic resonance-guided prostate biopsy in men with increased prostate-specific antigen and repeated, negative, random, systematic, transrectal ultrasound biopsies: Detection of clinically significant prostate cancers. Eur Urol 2012;62:902-9.
Vourganti S, Rastinehad A, Yerram N, Nix J, Volkin D, Hoang A, et al.
Multiparametric magnetic resonance imaging and ultrasound fusion biopsy detect prostate cancer in patients with prior negative transrectal ultrasound biopsies. J Urol 2012;188:2152-7.
Sonn GA, Chang E, Natarajan S, Margolis DJ, Macairan M, Lieu P, et al.
Value of targeted prostate biopsy using magnetic resonance-ultrasound fusion in men with prior negative biopsy and elevated prostate-specific antigen. Eur Urol 2014;65:809-15.
Scattoni V, Raber M, Capitanio U, Abdollah F, Roscigno M, Angiolilli D, et al.
The optimal rebiopsy prostatic scheme depends on patient clinical characteristics: Results of a recursive partitioning analysis based on a 24-core systematic scheme. Eur Urol 2011;60:834-41.
[Table 1], [Table 2], [Table 3], [Table 4]