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| Outcomes of combination MRI-targeted and transperineal template biopsy in restaging low-risk prostate cancer for active surveillance |
Kenneth Chena,Kae Jack Taya,Yan Mee Lawb,Hakan Aydinc,Henry Hoa,Christopher Chenga,John Shyi Peng Yuena*( )
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a Department of Urology, Singapore General Hospital, Singapore
b Department of Diagnostic Radiology, Singapore General Hospital, Singapore
c Department of Pathology, Singapore General Hospital, Singapore |
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Abstract 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 = 0.67), so were prostate volumes (34.2 ± 8.9 mL and 32.1 ± 13.4 mL, p = 0.28). MRI-targeted biopsy had a higher percentage of cancer detection per core compared to template biopsy (11.7% vs. 6.5%, p = 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.
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Received: 18 August 2016
Published: 23 July 2018
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Corresponding Authors:
Shyi Peng Yuen John
E-mail: john.yuen.s.p@singhealth.com.sg
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| T2-Weighted | DWI | DCE | | Echo time/Repetition time (ms) | 82/5700 | 93/7700 | 1.76/4.86 | | Slice thickness (mm) | 3 | 3 | 3 | | Matrix | 384 × 384 | 144 × 160 | 154 × 192 | | Field of view (mm) | 200 | 260 | 260 | | Interslice gap (%) | 10 | 10 | 0 |
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Flowchart of trial protocol. MRI, magnetic resonance imaging; PIRADS, Prostate Imaging Reporting and Data System; PSA, prostate specific antigen; TRUS, transrectal ultrasonography.
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| Baseline characteristics | TRUS biopsy | rTPB | MRTB | p-Value | | Age (year)a | | 65.4 ± 4.9 | | | PSA at biopsy (ng/mL)a | 7.3 ± 1.7 | 7.0 ± 1.8 | 0.67 | | Interval of last PSA to biopsy (week)b | 4 (1-11) | 8 (4-57) | | | Prostate volume at biopsy (mL)a | 34.2 ± 8.9 | 32.1 ± 13.4 | 0.28 |
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| Variables | MRTB | rTPB | p-Value | | Total no. of cores | 239 | 511 | | | No. of positive cores | 28 | 33 | | | No. of Gleason 7 cores | 14 | 8 | | | Percentage of cancer detection per core (%) | 11.7 | 6.5 | 0.02 | | Percentage of Gleason 7 detection per core (%) | 5.9 | 1.6 | <0.01 | | Per patient analysis (mean ± SD) | | No. of biopsy cores | 13.3 ± 5.8 | 26.9 ± 8.2 | <0.05 | | Biopsy intensity (cores/mL) | | 0.87 ± 0.12 | | | No. of positive cores | 1.56 ± 2.79 | 1.74 ± 2.23 | 0.83 | | Max percentage core (%) | 25.6 ± 29.6 | 9.40 ± 9.15 | 0.03 |
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Proportion of upclassification with rTPB and MRTB. MRTB, magnetic resonance imaging-targeted prostate biopsy; rTPB, robotic transperineal template prostate biopsy.
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Flow diagram of outcomes of all 19 men. MRI, magnetic resonance imaging; MRTB, MRI-targeted prostate biopsy; rTPB, robotic transperineal template prostate biopsy.
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| Patient code | Age (year) | PSA at biopsy (ng/mL) | Prostate volume (mL) | MRI highest PIRADS | rTPB | MRTB | | No. positive cores/total cores taken | Gleason score | No. positive cores/total cores taken | Gleason score | | 1 | 75 | 6.2 | 33.3 | 4 | 0/22 | NA | 0/8 | NA | | 2 | 65 | 8.3 | 40.0 | 4 | 1/28 | 6 | 0/10 | NA | | 3a | 61 | 5.6 | 31.0 | 5 | 10/26 | 7 | 2/18 | 7 | | 4 | 71 | 7.0 | 37.0 | 4 | 1/26 | 6 | 0/23 | NA | | 5 | 59 | 9.7 | 17.5 | 5 | 1/18 | 6 | 2/18 | 6 | | 6 | 63 | 7.1 | 22.0 | NA | 0/20 | NA | NA | NA | | 7 | 66 | 8.2 | 37.0 | 4 | 1/27 | 6 | 0/18 | NA | | 8b | 58 | 5.8 | 21.0 | 4 | 2/24 | 7 | 1/12 | 6 | | 9 | 68 | 7.6 | 36.6 | 4 | 2/28 | 6 | 0/8 | NA | | 10c | 68 | 9.9 | 14.0 | 5 | 3/17 | 6 | 12/12 | 7 | | 11c | 68 | 5.8 | 20.0 | 5 | 2/20 | 6 | 3/6 | 7 | | 12 | 69 | 10.0 | 49.0 | 3 | 0/32 | NA | 0/6 | NA | | 13 | 72 | 6.1 | 60.0 | 4 | 3/52 | 6 | 1/19 | 6 | | 14 | 58 | 4.7 | 58.0 | 3 | 0/38 | NA | 0/24 | NA | | 15 | 71 | 7.8 | 28.7 | 5 | 2/23 | 6 | 2/17 | 6 | | 16 | 64 | 4.0 | 32.0 | 3 | 1/25 | 6 | 2/12 | 6 | | 17a | 61 | 7.0 | 26.0 | 5 | 2/22 | 7 | 2/6 | 7 | | 18 | 63 | 8.2 | 31.0 | 3 | 0/28 | NA | 0/10 | NA | | 19 | 63 | 4.7 | 39.0 | 3 | 2/35 | 6 | 1/12 | 6 |
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| Parameters of biopsy quality | Combination biopsy | | Gleason 6 (n = 9) | Gleason 7 (n = 5) | | No. of positive cores compared to TRUS Biopsy | Greater
Equal
Less | 5
3
1 | 5
0
0 | | Volume reclassification (Max core percentage) compared to TRUS Biopsy | Yes
No | 5
4 | 5
0 |
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| Variables | MRTB | rTPB | p-Value | | Total No. of cores | 102 | 201 | | | No. of positive cores | 12 | 21 | | | Mean maximum core percentage of positive cores (%) | 27.5 | 16.1 | 0.21 | | Percentage of cancer detection per core (%) | 11.8 | 10.4 | 0.71 |
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| Patient | TRUS | rTPB | MRTB | RRP | | Location of positive cores | Gleason | Location of positive cores | Gleason | Location of positive cores | Gleason | Location of tumour | Gleason | | 1 | Unknown | 6 | Mid gland AZ | 6 | Not detected | | Not done | | | 2 | Unknown | | Mid gland AZ | 6 | Not detected | | Not done | | | 3 | Right mid gland PZ | 6 | Right mid gland TZ | 6 | Not detected | | Not done | | | 4 | Right mid gland PZ | 6 | Left mid gland PZ | 6 | Right mid gland PZ | 6 | Not done | | | 5 | Right mid gland PZ | 6 | Midline mid gland PZ | 6 | Right mid gland PZ | 6 | Not done | | | 6 | Right mid gland AZ | 6 | Left mid gland AZ | 6 | Left mid gland AZ | 6 | Not done | | | 7 | Right mid gland AZ | 6 | Right mid gland TZ AZ | 6 | Right mid gland AZ | 6 | Not done | | | 8 | Right mid gland PZ | 6 | Left apex to mid gland TZ PZ | 6 | Not detected | | Left apex to mid gland PZ
Right mid gland PZ | 6
6 | | 9 | Left mid gland AZ | 6 | Right apex AZ | 7 | Left apex to mid gland AZ | 6 | Bilateral AZ | 7 | | 10 | Unknown | 6 | Left base to mid gland AZ | 6 | Left base to mid gland AZ | 6 | Not done | | | 11 | Left mid gland AZ | 6 | Right mid gland TZ
Left mid gland AZ | 7 | Left mid gland AZ | 7 | Left AZ | 7 | | 12 | Right mid gland AZ | 6 | Right base to mid gland TZ | 6 | Right base to mid gland TZ | 7 | Bilateral AZ | 7 | | 13 | Unknown | 6 | Midline apex AZ | 6 | Midline apex AZ | 7 | Bilateral apex AZ | 7 | | 14 | Bilateral mid gland PZ | 6 | Right apex to mid gland TZ PZ | 7 | Right apex to mid gland TZ PZ | 7 | Right apex to mid gland PZ | 7 |
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Correlation of multiparametric MRI detected lesions with targeted biopsy plan and whole mount histology. Red arrows point to corresponding lesions and each column represents an individual case. First row shows multiparametric magnetic resonance imaging detected lesions, second row shows the biopsy planning and location of cores, and third row shows the whole mount histology slide.
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