Outcomes of combination MRI-targeted and transperineal template biopsy in restaging low-risk prostate cancer for active surveillance

Objective:Active surveillance(AS)offers a strategy to reduce overtreatment and now is a widely accepted treatment option for low-risk prostate cancer.An ideal tool for risk-stratification would detect aggressive cancers and exclude such men from taking up AS in the first place.We evaluate if a combination of transperineal template biopsy with magnetic resonance imaging(MRI)-targeted biopsy identifies significant prostate cancer amongst men initially diagnosed with low-risk prostate cancer.Methods:This prospective,single-blinded study included men with low-risk prostate cancer(D’Amico’s Criteria)diagnosed on conventional transrectal ultrasound-guided biopsy.Patients first underwent multiparametric MRI of the prostate
6 weeks after initial biopsy.Each suspicious lesion is mapped and assigned a Prostate Imaging Reporting and Data System(PIRADS)score.Template biopsy is first performed with the surgeon blinded to MRI findings followed by MRI-targeted biopsy using a robotic transperineal biopsy platform.Results:The age of the 19 men included is 65.4±4.9 years(mean±SD).Prostate specific antigen(PSA)at diagnosis and at the time of transperineal biopsy were comparable(7.3±1.7 ng/mL and 7.0±1.8 ng/mL,p Z 0.67),so were prostate volumes(34.2±8.9 mL and 32.1±13.4 mL,p Z 0.28).MRI-targeted biopsy had a higher percentage of cancer detection per core compared to template biopsy(11.7%vs.6.5%,p Z 0.02),this was more than 3 times superior for Gleason 7 disease(5.9%vs.1.6%,p<0.01).Four of 18(22.2%)patients with MRI lesions had significant disease with MRI-targeted biopsy alone.Three of 19 patients(15.8%)had significant disease with template biopsy alone.In combination,both techniques upclassified five patients(26.3%),all of whom underwent radical prostatectomy.Whole mount histology confirmed tumour location and grade.All six patients with PIRADS 5 lesions had cancer detected(66.6%significant disease).Conclusion:A combination of MRI-targeted and template biopsy may optimally risk-classify“low-risk”patients diagnosed on initial conventional transrectal ultrasonography(TRUS)prostate biopsy.

Transperineal core-needle biopsy of a rectal subepithelial lesion guided by endorectal ultrasound after contrast-enhanced ultrasound: A case report

BACKGROUND Rectal subepithelial lesions(SELs) are commonly seen in endoscopic examination, generally manifested as bumps with a smooth surface. Precise preoperative diagnoses for rectal SELs are difficult because abnormal tissues are not easily to be obtained by regular endoscopic forceps biopsy. Traditional guidance modalities of preoperative biopsy, including endoscopic ultrasound, computed tomography, and transabdominal ultrasound, are often unsatisfactory. An updated, safe, and effective biopsy guidance method is required. We herein report a new biopsy guidance modality—endorectal ultrasound(ERUS) combined with contrastenhanced ultrasound(CEUS).CASE SUMMARY A 32-year-old woman complained of a mass inside the rectovaginal space for 9 years, which became enlarged within 1 year. A rectal SEL detected by endoscopy was suspected to be a gastrointestinal stromal tumor or exophytic uterine fibroid. Pathological diagnosis was difficult because of unsuccessful transabdominal core needle biopsy with insufficient tissues, as well as vaginal hemorrhage. A second biopsy was suggested after multiple disciplinary treatment discussion, which referred to a transperineal core needle biopsy(CNB) guided by ERUS combined with CEUS. Adequate samples were procured and rectal gastrointestinal stromal tumor was proved to be the pathological diagnosis. Imatinib was recommended for first-line therapy by multiple disciplinary treatment discussion. After the tumor shrunk, resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall. Adjuvant therapy was applied and no recurrence or metastasis has been found by the last follow-up on December 13, 2019.CONCLUSION Transperineal CNB guided by ERUS and CEUS is a safe and effective preoperative biopsy of rectal SELs yet with some limitations.

Freehand transperineal prostate biopsy with a coaxial needle under local anesthesia:Experience from a single institution in Malaysia

Background Freehand transperineal prostate biopsy(TPPBx)using a coaxial needle technique offers an alternative to probe-mounted freehand or template-guided techniques in the diagnosis of prostate cancer(PCa).It only requires the same equipment used for transrectal ultrasound-guided(TRUS)biopsy.Our study is the first in Malaysia to report this experience and its outcomes.We aim to determine PCa detection rate and pain tolerability of freehand TPPBx utilizing a coaxial needle under local anesthesia(LA).Methods Institutional review board approval was obtained from National Medical Research Register(NMRR ID-21-02052-VIL).We retrospectively reviewed the medical records of patients who underwent TPPBx between August 2020 and April 2022.Records were reviewed for patients’characteristics,prostate volume,prostate-specific antigen(PSA)results,biopsy results and pain tolerability.Data was analyzed to determine PCa and clinically significant prostate cancer(csPCa)detection rate.LA was achieved using perineal skin infiltration and a periprostatic nerve block.The commonly used standard side-firing transrectal ultrasound with its Prostate Biplane Transducer was used as an imaging guide.The principles of the Ginsburg protocol were followed.Pain tolerability was assessed using a visual analog scale.Results A total of 55 patients with elevated PSA levels underwent freehand TPPBx under LA.The mean age was 67.3 years,the median PSA was 14.2 ng/mL,and the median PSA density(PSAD)was 0.33 ng/mL/cc.The optimal PSAD cutoff for predicting csPCa was 0.35 ng/mL/cc(area under the curve[AUC],0.792;sensitivity,87.5%;specificity,69.2%).PCa was detected in 24 patients(43.6%),of whom 16(29.1%)had csPCa.The median pain scores during LA infiltration and biopsy were four and two,respectively,which were significant different(P<0.05).TPPBx exhibited an infection rate of zero.Conclusion The PCa detection rate and patient tolerability of freehand TPPBx using a coaxial needle are similar to those of a contemporary published series.The use of existing equipment that is used for TRUS biopsy allows for widespread use and transition from TRUS biopsy.

Comparison of systematic and combined biopsy for the detection of prostate cancer

Systematic prostate biopsy has limitations,such as overdiagnosis of clinically insignificant prostate cancer and underdiagnosis of clinically significant prostate cancer.Magnetic resonance imaging(MRI)-guided biopsy,a promising alternative,might improve diagnostic accuracy.To compare the cancer detection rates of systematic biopsy and combined biopsy(systematic biopsy plus MRI-targeted biopsy)in Asian men,we conducted a retrospective cohort study of men who underwent either systematic biopsy or combined biopsy at two medical centers(Queen Mary Hospital and Tung Wah Hospital,Hong Kong,China)from July 2015 to December 2022.Descriptive statistics were calculated,and univariate and multivariate logistic regression analyses were performed.The primary and secondary outcomes were prostate cancer and clinically significant prostate cancer.A total of 1391 participants were enrolled.The overall prostate cancer detection rates did not significantly differ between the two groups(36.3%vs 36.6%,odds ratio[OR]=1.01,95%confidence interval[CI]:0.81-1.26,P=0.92).However,combined biopsy showed a significant advantage in detecting clinically significant prostate cancer(Gleason score≥3+4)in patients with a total serum prostate-specific antigen(tPSA)concentration of 2-10 ng ml−1(systematic vs combined:11.9%vs 17.5%,OR=1.58,95%CI:1.08-2.31,P=0.02).Specifically,in the transperineal biopsy subgroup,combined biopsy significantly outperformed systematic biopsy in the detection of clinically significant prostate cancer(systematic vs combined:12.6%vs 24.0%,OR=2.19,95%CI:1.21-3.97,P=0.01).These findings suggest that in patients with a tPSA concentration of 2-10 ng ml−1,MRI-targeted biopsy may be of greater predictive value than systematic biopsy in the detection of clinically significant prostate cancer.

Value of contrast-enhanced ultrasound in deep angiomyxoma using a biplane transrectal probe:A case report

BACKGROUND Deep angiomyxoma(DAM)is a very rare tumor type.Magnetic resonance imaging(MRI)is considered the best imaging modality for diagnosing DAM.Computed tomography(CT)is used mainly to assess the invasion range of DAM.The value of ultrasonography in the diagnosis of DAM is still controversial.Through a literature review,we summarized the current state of ultrasonic examination for DAM and reported for the first time the contrast-enhanced ultrasound(CEUS)features of DAM seen using a biplane transrectal probe.CASE SUMMARY A 37-year-old woman presented with a sacrococcygeal mass that had gradually increased in size over the previous 6 mo.MRI and CT examinations failed to allow a definite diagnosis to be made.Transperineal core needle biopsy(CNB)guided by transrectal ultrasound and CEUS was suggested after a multidisciplinary discussion.Grayscale ultrasound of the lesion showed a layered appearance with alternating hyperechoic and hypoechoic patterns.Transrectal CEUS showed a laminated distribution of the contrast agent that was consistent with the layered appearance of the tumor on grayscale ultrasound.We performed transperineal CNB of the enhanced area inside the tumor under transrectal CEUS guidance and finally made a definitive diagnosis of DAM through histopathology.The patient underwent laparoscopic-assisted transabdominal surgery combined with transperineal surgery for large pelvic tumor resection and pelvic floor peritoneal reconstruction.No recurrence or metastasis was found at the ninemonth follow-up.CONCLUSION Transrectal CEUS can show the layered perfusion characteristics of the contrast agent,guiding subsequent transperineal CNB of the enhanced area within the DAM.

Transperineal prostate biopsies for diagnosis of prostate cancer are well tolerated： a prospective study using patient-reported outcome measures

We aimed to determine short-term patient-reported outcomes in men having general anesthetic transperineal （TP） prostate biopsies. A prospective cohort study was performed in men having a diagnostic TP biopsy. This was done using a validated and adapted questionnaire immediately post-biopsy and at follow-up of between 7 and 14 days across three tertiary referral hospitals with a response rate of 51.6%. Immediately after biopsy 43/201 （21.4%） of men felt light-headed, syncopal, or suffered syncope. Fifty-three percent of men felt discomfort after biopsy （with 95% scoring 〈5 in a 0-10 scale）. Twelve out of 196 men （6.1%） felt pain immediately after the procedure. Despite a high incidence of symptoms （e.g., up to 75% had some hematuria, 47% suffered some pain）, it was not a moderate or serious problem for most, apart from hemoejaculate which 31 men suffered. Eleven men needed catheterization （5.5%）. There were no inpatient admissions due to complications （hematuria, sepsis）. On repeat questioning at a later time point, only 25/199 （12.6%） of men said repeat biopsy would be a significant problem despite a significant and marked reduction in erectile function after the procedure. From this study, we conclude that TP biopsy is well tolerated with similar side effect profiles and attitudes of men to repeat biopsy to men having TRUS biopsies. These data allow informed counseling of men prior to TP biopsy and a benchmark for tolerability with local anesthetic TP biopsies being developed for clinical use.