基于mpMRI第二版PI-RADS分区经会阴前列腺穿刺的安全性和有效性

Safety and efficacy of individualized transperineal prostate biopsy based on the segmentation of PI-RADS version 2 for mpMRI

目的探讨基于多参数磁共振(mpMRI)第二版前列腺影像报告和数据系统(PI-RADS v2)分区进行个体化经会阴前列腺穿刺的安全性和有效性。方法回顾性分析北京友谊医院2018年12月至2021年11月收治的228例行前列腺穿刺患者的临床资料。中位年龄65(49~83)岁。中位tPSA 9.87(4.1~89.0)ng/ml,其中<10 ng/ml 102例(44.7%),10~20 ng/ml 108例(47.4%),>20 ng/ml 18例(7.9%)。228例中,186例(81.6%)行mpMRI检查,PI-RADS 1~2分32例(14.0%),3分47例(20.6%),4分66例(28.9%),5分41例(18.1%)。局麻或静脉麻醉下行经直肠超声引导下经会阴前列腺靶向穿刺(TB)和系统穿刺(SB)。未行mpMRI检查和PI-RADS 1~2分者共74例仅行系统穿刺(SB组),PI-RADS 3~5分者154例行认知融合靶向穿刺+系统穿刺(TB+SB组)。超声下拟合PI-RADS分区,每层选择左右侧叶的前移行区、后移行区、前外周带、后外外周带、中央区或后内外周带共10个分区,每个分区穿刺1针共10针;前列腺矢状位长度<3 cm者,穿刺1个层面及左右尖部各2针,共14针;3~6 cm者,穿刺2个层面,共20针;>6 cm者,穿刺3个层面,共30针。对于PI-RADS 3~5分的病灶,每个病灶再靶向穿刺2针。记录前列腺癌和有临床意义前列腺癌(csPCa)检出率,以及并发症发生率。比较SB组和TB+SB组的前列腺癌、csPCa检出率差异。结果本研究228例中,穿刺1、2、3个层面分别为46、148、34例,穿刺病理确诊前列腺癌131例(57.5%),其中csPCa 91例(39.9%)。TB+SB组前列腺癌检出率61.0%(94/154)高于SB组50.0%(37/74),但差异无统计学意义(P=0.114)。TB+SB组csPCa检出率46.8%(72/154)高于SB组25.6%(19/74),差异有统计学意义(P=0.002)。TB+SB组中,单独TB的csPCa检出率44.8%(69/154)显著高于单独SB的33.8%(52/154)(P=0.047)。单独SB漏诊前列腺癌7例(4.5%),少于单独TB漏诊的18例(11.7%)(P=0.022),但单独SB漏诊csPCa 20例(13.0%),多于单独TB漏诊的3例(1.9%)(P<0.001)。37例发生并发症,其中Clavien-Dindo分级1级29例(12.7%),2级7例(3.1%),3级1例(0.4%)。结论基于mpMRI PI-RADS v2分区的经会阴前列腺个体化穿刺安全可靠,结合认知融合穿刺,可以提高caPCa检出率。系统穿刺是必不可少的补充,可以检出靶向穿刺漏诊的前列腺癌。

Objective To investigate the safety and efficacy of individualized transperineal prostate biopsy based on the segmentation of PI-RADS v2 for mpMRI.Method The clinical data of patients undergoing prostate biopsy in Beijing Friendship Hospital from December 2018 to November 2021 were analyzed retrospectively.A total of 228 patients with a median age of 65(49-83)years underwent biopsy.There were 102(44.7%)with tPSA<10 ng/ml,108(47.4%)with tPSA 10-20 ng/ml,and 18(7.9%)with tPSA>20 ng/ml,with the median tPSA of 9.87(4.1-89.0)ng/ml.There were 42(18.4%)cases without MRI results,and 32(14.0%)cases with PI-RADS score of 1-2,47(20.6%)cases of PI-RADS 3,66(28.9%)cases of PI-RADS 4 and 41(18.1%)cases of PI-RADS 5,respectively.Transrectal ultrasound-guided transperineal prostate targeted biopsy(TB)and systematic biopsy(SB)were performed under local anesthesia or intravenous anesthesia.SB was performed for those without MRI and PI-RADS score of 1-2(SB group),and TB and SB were performed for those with PI-RADS score of 3-5(TB+SB group).Prostate image under ultrasound was cognitively fused according to PI-RADS v2.One needle per area was distributed in 10 areas of each layer(the transition zone anterior and posterior sectors,the peripheral zone anterior,lateral,and medial sectors or central zone in left and right lobe).For those whose prostate length was less than 3cm,10 needles were punctured,and two needles were added to each lateral lobe of the apex with a total of 14 needles.For those whose prostate length was from 3 to 6 cm,selected two layers with a total of 20 needles.For those with a length greater than 6cm,selected three layers with a total of 30 needles.If there was a suspicious lesion with PI-RADS score of 3-5,two needles were targeted for each lesion.The detection rate and complication rate of prostate cancer and clinically significant prostate cancer(csPCa)in the overall samples were observed,and the difference of the detection rate of prostate cancer and csPCa between the two groups was compared.Results Of the 228 cases,there were 46 cases undergoing biopsy of one layer,148 cases of two layers,and 34 cases of three layers,detecting 131 prostate cancer(PCa)diagnosed by pathology,with a detection rate of 57.5%,including 40 cases(17.5%)of clinically insignificant PCa and 91 cases(39.9%)of csPCa.The detection rate of PCa in TB+SB group was 61.0%(94/154),which was higher than that in SB group,but there was no significant difference(P=0.114).However,the detection rate of csPCa in TB+SB group was higher than that in SB group,which was 46.8%(72/154)vs.25.6%(19/74),respectively(P=0.002).In the combined TB and SB group(TB+SB group),the detection rate of csPCa by TB was 44.8%(69/154),which was higher than that of 33.8%(52/154)by SB(P=0.047).In the TB+SB group,7(4.5%)PCa were missed by SB,which was less than 18 cases(11.7%)missed by TB(P=0.022),but csPCa were missed by SB more than that missed by TB(P<0.001).There were 37 cases suffered from complications,with Clavien Dindo classification grade 1 of 29 cases(12.7%),grade 2 of 7 cases(3.1%),and grade 3 of 1 case(0.4%).Conclusions Individualized transperineal prostate biopsy based on the segmentation of PI-RADS v2 for mpMRI is safe and reliable.Target biopsy by cognitive fusion can improve the detection rate of significant PCa.Systematic biopsy is also an important and essential supplement,which can detect prostate cancer missed by TB.Combined TB and SB are the best choice.