A biopsy simulation study to assess the accuracy of several transrectal ultrasonography (TRUS)‐biopsy strategies compared with template prostate mapping biopsies in patients who have undergone radical prostatectomy

Abstract

Study Type – Diagnostic (validating cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Transrectal ultrasonography (TRUS)‐guided biopsies can miss prostate cancer and misclassify risk in a diagnostic setting; the exact extent to which it does so in a repeat biopsy strategy in men with low–intermediate risk prostate cancer is unknown. A simulation study of different biopsy strategies showed that repeat 12‐core TRUS biopsy performs poorly. Adding anterior sampling improves on this but the highest accuracy is achieved using transperineal template prostate mapping using a 5 mm sampling frame. OBJECTIVE To determine the effectiveness of two sampling strategies; repeat transrectal ultrasonography (TRUS)‐biopsy and transperineal template prostate mapping (TPM) to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL using computer simulation on reconstructed three‐dimensional (3‐D) computer models of radical whole‐mount specimens. PATIENTS AND METHODS Computer simulation on reconstructed 3‐D computer models of radical whole‐mount specimens was used to evaluate the performance characteristics of repeat TRUS‐biopsy and TPM to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL. In all, 107 consecutive cases were analysed (1999–2001) with simulations repeated 500 times for each biopsy strategy. TPM and five different TRUS‐biopsy strategies were simulated; the latter involved a standard 12‐core sampling and incorporated variable amounts of error, as well as the addition of anterior cores. Sensitivity, specificity, negative and positive predictive values for detection of lesions with a volume of ≥0.2 mL or ≥0.5 mL were calculated. RESULTS The mean (sd) age and PSA concentration were 61 (6.4) years and 8.5 (5.9) ng/mL, respectively.In all, 53% (57/107) had low–intermediate risk disease. In all, 665 foci were reconstructed; there were 149 foci ≥0.2 mL and 97 ≥ 0.5 mL in the full cohort and 68 ≥ 0.2 mL and 43 ≥ 0.5 mL in the low–intermediate risk group. Overall, TPM accuracy (area under the receiver operating curve, AUC) was ≈0.90 compared with AUC 0.70–0.80 for TRUS‐biopsy. In addition, at best, TRUS‐biopsy missed 30–40% of lesions of ≥0.2 mL and ≥0.5 mL whilst TPM missed 5% of such lesions. CONCLUSION TPM under simulation conditions appears the most effective re‐classification strategy, although augmented TRUS‐biopsy techniques are better than standard TRUS‐biopsy.

The use of targeted MR-guided prostate biopsy reduces the risk of Gleason upgrading on radical prostatectomy

“…All patients underwent an additional TRUS-GB during the same biopsy session. Gleason grading was measured by two different methods: the conventional Gleason score (Berg et al 2011;McKenney et al 2011) and, more importantly, by the sampling error of undirected systematic TRUS-GB (Hu et al 2012). Improved prediction of the final prostatectomy Gleason grading would help to better assess the patient's risk, and the choice of treatment options could be more easily determined.…”

Transperineal Template-guided Mapping Biopsy Identifies Pathologic Differences Between Very–Low-risk and Low-risk Prostate Cancer

“…20,23,24 TTMB has been shown to closely correlate with whole-mount radical prostatectomy pathology in identifying high-grade cancer, 23 which also reinforces earlier simulation studies. 25 To select patients best suited for AS, we evaluated whether TTMB would indentify differences in AS eligibility between very-low-risk (Gleason score r6, r2 positive biopsies, PSA density <0.15, and r50% involvement on any core) and low-risk (Gleason score r6, PSA r10 ng/mL, and clinical stage T1c/T2a, excluding those who qualify for verylow-risk assignment) patients.…”

Diagnosis and Monitoring of Prostatic Lesions: A Comparison of Three Modalities: Multiparametric MRI, Fusion MRI/Transrectal Ultrasound (TRUS), and Traditional TRUS

“…TRUS-guided biopsies often fail to detect cancerous lesions, misclassify the cancer risk, and have been found to have sensitivity for detection as low as 60% [7, 11]. A study by Ouzzane, et al found up to 46% of 12-core biopsies in their trial had missed anteriorly located cancerous lesions [12-13].…”

“…A study by Ouzzane, et al found up to 46% of 12-core biopsies in their trial had missed anteriorly located cancerous lesions [12-13]. Hu, et al determined that transperineal prostate mapping (TPM) was more accurate versus five traditional TRUS-guided strategies at detecting and excluding lesions of tumor volume thresholds of 0.2 mL and 0.5 mL [11]. Additionally, TRUS-biopsy failed to detect 30-40% of lesions > 0.2 mL compared to 5% missed in TPM [11].…”

“…Hu, et al determined that transperineal prostate mapping (TPM) was more accurate versus five traditional TRUS-guided strategies at detecting and excluding lesions of tumor volume thresholds of 0.2 mL and 0.5 mL [11]. Additionally, TRUS-biopsy failed to detect 30-40% of lesions > 0.2 mL compared to 5% missed in TPM [11]. Schulte, et al determined that in men classified with unilateral disease on extended 12-core biopsy, only 40.4% had true unilateral disease when reevaluated on radical prostatectomy [14].…”