Computed tomography-guided pararectal prostate fusion biopsy

Background. Prostate cancer (PCa) is one of the most common malignancies. The gold standard of PCa diagnostics is morphological examination of prostate tissues obtained using 10-12-core biopsy. However, the number of false-negative results and detected clinically insignificant forms of cancer remain high. Magnetic resonance imaging (MRI) is the most sensitive and specific method of radiation diagnosis of PCa. The use of MRI data for prostate biopsy (fusion-biopsy) increases the accuracy of this procedure.

Objective: to increase the accuracy of PCa diagnostics using targeted pararectal prostate biopsy guided by computed tomography (CT)/MRI.

Materials and methods. A total of 95 patients underwent CT/MRI-guided targeted pararectal biopsy between March 2015 and March 2020. The mean level of prostate specific antigen (PSA) was 13.7 ± 12.6 ng/mL. All men were found to have 1 to 3 lesions with a PI-RADS score between 3 and 5.

Patients were divided into 4 groups: 1^st group (n = 33) included patients in whom transrectal access was impossible; 2^nd group (n = 22) included patients with suspected local recurrence of PCa after brachytherapy; 3^rd group (n = 28) included patients with a negative result of primary biopsy, but with growing PSA level; 4th group (n = 12) included patients who preferred targeted biopsy. We performed targeted biopsy of each suspicious lesion according to MRIscans. Then we performed ‘blind’ systematic 10-14-core biopsy, where we did not take into account the location of suspicious foci and they could be, therefore, accidentally used for sample collection for the second time.

Results. Histological examination revealed PCa in 71 out of 95 patients (74.7 %): in 27 out of 33 in 1^st group (81.8 %), in 19 out of 22 in 2^nd group (86.4 %), in 17 out of 28 in 3^rd group (60.7 %), and in 8 out of 12 in 4^th group (66.7 %). In 21 patients (29.6 %), PCa was diagnosed only in samples obtained using targeted biopsy; in 9 patients (12.7 %), PCa was diagnosed only in samples after systematic biopsy; in 41 patients (57.7 % PCa was detected by both targeted and systematic biopsy. Clinically significant cancer (Gleason score ≥7) was diagnosed in 84.5 % of cases after targeted biopsy and in 70.4 % of cases after systemic biopsy.

Conclusion. CT/MRI-guided prostate fusion biopsy increases the accuracy of PCa diagnostics by additional detection of clinically significant tumors, including those in patients in whom the rectal access is impossible.

1. Pernar C.H., Ebot E.M., Wilson K.M., Mucci L.A. The Epidemiology of prostate cancer. Cold Spring Harb. Perspect Med 2018;8(12). DOI: 10.1101/cshperspect.a030361.

2. State of oncological care in Russia in 2017. Eds.: A.D. Kaprin, V.V. Starinskiy, G.V. Petrova. Moscow: MNIOI im. P.A. Gertsena - filial FGBU “NMITS radiologii” Minzdrava Rossii, 2018. 236 p. (In Russ.).

3. State of oncological care in Russia in 2007. Eds.: V.I. Chissov, V.V. Starinskiy, G.V. Petrova. Moscow: FGU MNIOI im. P.A. Gertsena Rosmedtekhnologiy, 2008. 184 p. Available at: http://www.gks.ru. Accessed: 19.02.2020. (In Russ.).

4. Bell K.J.L., Del Mar C., Wright G. et al. Prevalence of incidental prostate cancer: a systematic review of autopsy studies. Int J Cancer 2015;137(7):1749-57. DOI: 10.1002/ijc.29538.

5. Mottet N., Cornford P., van den Bergh R.C.N. et al. EAU. Guideline. Prostate cancer. 2020. Available at: https://uroweb.org/guideline/prostate-cancer/.

6. Valerio M., Ahmed H.U., Emberton M. et al. The Role of focal therapy in the management of localised prostate cancer: a systematic review. Eur Urol 2014;66(4):732-51. DOI: 10.1016/j.eururo.2013.05.048.

7. Hambrock T., Diederik H.S., Hoeks C. et al. Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen. J Urol 2009;183(2):520-7. DOI: 10.1016/j.juro.2009.10.022.

8. Margel D., Yap S.A., Lawrentschuk N. et al. Impact of multiparametric endorectal coil prostate magnetic resonance imaging on disease reclassification among active surveillance candidates: a prospective cohort study. J Urol 2012;187(4):1247-52. DOI: 10.1016/j.juro.2011.11.112.

9. Lemaitre L., Puech P., Poncelet E. et al. Dynamic contrast-enhanced MRI of anterior prostate cancer: morphometric assessment and correlation with radical prostatectomy findings. Eur Radiol 2009;19(2):470-80. DOI: 10.1007/s00330-008-1153-0.

10. Djavan B., Ravery V., Zlotta A. et al. Prospective evaluation of prostate cancer detected on biopsies 1, 2, 3 and 4: when should we stop? J Urol 2001;166(5):1679-83.

11. Shariat S.F., Roehrborn C.G. Using biopsy to detect prostate cancer. Rev Urol 2008;10(4):262-80.

12. Ukimura O., Coleman J.A., de la Taille A. et al. Contemporary role of systematicprostate biopsies: indications, techniques, and implications for patient care. Eur Urol 2013;63(2):214-30. DOI: 10.1016/j.eururo.2012.09.033.

13. Serefoglu E.C., Altinova S., Ugras N.S. et al. How reliable is 12-core prostate biopsyprocedure in the detection of prostate cancer? Can Urol Assoc J 2013;7(5-6):293-8. DOI: 10.5489/cuaj.11224.

14. Roehrborn C.G., Pickens G.J., Sanders J.S. Diagnostic yield of repeated transrectal ultrasound-guided biopsies stratified by specific histopathologic diagnoses and prostate specific antigen levels. Urology 1996;47(3):347-52. DOI: 10.1016/s0090-4295(99)80451-8.

15. Rud E., Baco E., Eggesb0 H.B. MRI and ultrasound-guided prostate biopsy using soft image fusion. Anticancer Res 2012;32(8):3383-9.

16. Kayano P.P., Carneiro A., Castilho T.M.L. et al. Comparison of Gleason upgrading rates in transrectal ultrasound systematic random biopsies versus US-MRI fusion biopsies for prostate cancer. Intl Braz J Urol 2018;44(6):1106-13. DOI: 10.1590/S1677-5538.IBJU.2017.0552.

17. Lai W.J., Wang H.K., Liu H.T. et al. Cognitive MRI-TRUS fusion-targeted prostate biopsy according to PI-RADS classification in patients with prior negative systematic biopsy results. J Chin Med Assoc 2916;79(11):618-24. DOI: 10.1016/j.jcma.2016.05.004.

18. Hambrock T., Futterer J.J., Huisman H.J. et al. Thirty-two-channel coil 3T magnetic resonance-guided biopsies of prostate tumor suspicious regions identified on multimodality 3T magnetic resonance imaging: technique and feasibility. Invest Radiol 2008;43(10):686-94. DOI: 10.1097/RLI.0b013e31817d0506.

19. Sidelsky S., Setia S., Vourganti S. Spatial tracking of targeted prostate biopsy locations: moving towards effective focal partial prostate gland ablation with improved treatment planning. Curr Urol Rep 2017;18(12):93. DOI: 10.1007/s11934-017-0741-4.

20. Verma S., Choyke P.L., Eberhardt S.C. et al. The current state of MR imaging-targeted biopsy techniques for detection of prostate cancer. Radiology 2017;285(2):343-6. DOI: 10.1148/radiol.2017161684.

21. Maggi M., Panebianco V., Mosca A. Prostate imaging reporting and data system 3 category cases at multiparametric magnetic resonance for prostate cancer: a systematic review and meta-analysis. Eur Urol Focus 2020;6(3):463-78. DOI: 10.1016/j.euf.2019.06.014.

22. Clinical recommendations. Coloproctology. Ed.: Yu.A. Shelygina. Moscow: GEOTAR-Media, 2015. 528 p. [(In Russ.).

23. Gorelov V.P., Gorelov S.I., Artyushkin A.V., Gudkin G.V. Patent of the Russian Federation No. 130854, MPK A61N5/00. Device for the installation of radioactive implants: No. 2011138819/14: published on 10.08.2013. 9 p. (In Russ.).

24. Gorelov V.P., Ratnikov V.A., Margaryants N.B. Patent of the Russian Federation No. 2657200, MPK A61B5/55, A61B6/03, A61B10/02. Technique of targeted pararectal prostate biopsy guided by computed tomography/ magnetic resonance imaging: No. 2017100580: published on 08.06.2018. 9 p. [(In Russ.).

25. Jelidi A., Ohana M., Labani A. et al. Prostate cancer diagnosis: efficacy of a simple electromagnetic MRI-TRUS fusion method to target biopsies. Eur J Radiol 2017;86:127-34. DOI: 10.1016/j.ejrad.2016.11.016.

26. Mozer P., Roupret M., Le Cossec C. et al. First round of targeted biopsies using magnetic resonance imaging/ ultrasonography fusion compared with conventional transrectal ultrasonography-guided biopsies for the diagnosis of localised prostate cancer. BJU Int 2014;115(1):50-7. DOI: 10.1111/bju.12690.