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Repeat prostate biopsy strategies after initial negative biopsy: Meta-regression comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy, "Beyond the Abstract," by Adam W. Nelson and Vincent J. Gnanapragasam

BERKELEY, CA (UroToday.com) - Prostate cancer presents a significant problem to health care providers. It is the most common male cancer, affecting 214 per 1 000 men in Europe  and is the cause of 15% of male deaths from cancer.[1, 2] Despite all the progress that has been made in our understanding of the disease, the tools used to diagnose prostate cancer have barely changed in the last 25 years, and so, even now in 2013, we are still largely dependent on the digital rectal examination (DRE), PSA, and a transrectal ultrasound-guided biopsy (TRUS-B) which has changed little since its initial description in 1989 by Hodge.[3]

That’s not to say that there haven’t been widespread attempts to advance this particular area of urological practice. There have been modified TRUS-B protocols, extended TRUS-B protocols,[4] transrectal saturation biopsy schemes (TS-B),[5] transperineal saturation biopsy schemes (TP-B)[6] and, more recently, numerous forms of MRI-guided prostate biopsy (MRI-B).[7] All of these have aimed to improve the yield of clinically significant prostate cancer from the diagnostic investigation and deal with the well-known problem of standard TRUS-B – namely a false-negative rate of 30%, which commonly results in multiple prostate biopsies for those men deemed to have ongoing risk of cancer, despite a negative biopsy.[8]

The technology has progressed at an incredible rate, particularly with the advent of MRI-B. Almost every conceivable combination of various MR-imaging modalities with each possible anatomical approach to the prostate has been attempted.[9, 10, 11, 12] The resulting body of data now available in the literature on the subject of prostate biopsy therefore becomes very difficult for the clinician and patient to analyse as each author makes the case for his/her particular technique. This becomes even more difficult when addressing the question of which technique to use in the repeat biopsy setting, as many of the studies in the literature do not look specifically at these men with negative initial biopsy but ongoing suspicion of cancer.

Thus, the evidence lags behind the technical innovation, and it was therefore our purpose in designing this study to establish whether, based on currently available published data, one repeat biopsy strategy could be shown to have a higher cancer detection rate than the others.[13] This was not a straightforward undertaking. Widespread heterogeneity of the published data meant that of over 1 900 papers identified in the initial literature search, only 46 were suitable for inclusion in the analysis. Our aim was to obtain as broad a snapshot of the current evidence as possible within the limits of our strict inclusion criteria; hence the deliberate decision to group all forms of MRI-B together and the use of statistical methodology to correct for as many of the remaining variables as possible.

We believe the results to be very informative. To our knowledge, this study represents the first attempt to compare several prostate biopsy techniques in the repeat biopsy setting. Our findings establish a benchmark and a reference point against which the cancer detection rates of future techniques and innovations in prostate diagnostics can be compared.

The overall message of our study is simple: on the basis of the currently available evidence there is no difference in cancer detection rate between MRI-B, TS-B or TP-B when used in the repeat biopsy setting. However, exploration of the detail provides interesting insight. As discussed in the paper, prior to conducting the sensitivity analysis to correct for the number of previous biopsy episodes, MRI-B was shown to have significantly greater cancer detection rate than TS-B and a trend, although statistically non-significant, towards greater cancer detection than TP-B. One must bear in mind the range of MRI-B techniques included in the study and the fact that the cancer detection rates of included MRI-B studies ranged from 9.5%[14] to 59%.[15] The mean cancer detection rate for all 20 MRI-B studies included was 37.6%, but if only papers published since 2010 are included,[9, 10, 11, 15, 16, 17] the mean cancer detection rate increases to 47.4%, indicating clear progress as the technology has developed.

This is mirrored in our own experience. In our institution we have been using a MRI/TRUS fusion platform with a transperineal biopsy approach. Data from our early experience with the technique are encouraging.[18] In patients undergoing repeat prostate biopsy, cancer was detected in 41% of patients, with 75% of those cancers detected in suspicious lesions identified on the MRI for targeted biopsy. However, MRI gave a false negative result (i.e., no lesion identified, but cancer detected on biopsy) in 10%, so there is clearly further work to be done between urologists and radiology colleagues in developing the imaging modalities and reporting techniques to improve upon these outcomes.

It seems logical to us that pursuing imaging-guided prostate biopsy is the right way forward for prostate cancer diagnosis. It is somewhat ludicrous that in the 21st century we are still largely dependent on an essentially blind, predetermined biopsy scheme for the diagnosis of the majority of prostate cancers. It is inconceivable for example, to imagine the same methodology being applied to sampling of the breast for the diagnosis of breast cancer. This diagnostic model perhaps then provides us with a ‘golden goal’ towards which we can direct our efforts. Namely, that a man with suspicion for prostate cancer, on the basis of his DRE or PSA, firstly undergoes MRI followed by targeted biopsy if a lesion is identified, or if no lesion is identified then we reassure the patient of their normal imaging and no biopsy is performed. The recently published Health Technology Assessment (HTA) report evaluating the diagnostic accuracy and cost-effectiveness of various MRI-B techniques is supportive of this approach, suggesting that if the sensitivity and specificity of multimodal MRI can be improved to a point where negative imaging negates the need for biopsy, then MRI-B becomes a cost-effective alternative to TRUS-B for prostate cancer diagnosis.[19]

So the ‘golden goal’ remains just out of range for now, but we’re clearly heading in the right direction.

References:

  1. Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. European Urology. 2011;59(1):61-71. Epub 2010/11/09.
  2. Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, et al. EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer. European Urology. 2011;59(4):572-83. Epub 2011/02/15.
  3. Hodge KK, McNeal JE, Stamey TA. Ultrasound guided transrectal core biopsies of the palpably abnormal prostate.  Journal of Urology. 1989;142(1):66-70. Epub 1989/07/01.
  4. Aganovic D, Prcic A, Kulovac B, Hadziosmanovic O. Prostate cancer detection rate and the importance of premalignant lesion in rebiopsy. Medicinski Arhiv. 2011;65(2):109-12. Epub 2011/05/19.
  5. Sajadi KP, Kim T, Terris MK, Brown JA, Lewis RW. High yield of saturation prostate biopsy for patients with previous negative biopsies and small prostates. Urology. 2007;70(4):691-5. Epub 2007/11/10.
  6. Pinkstaff DM, Igel TC, Petrou SP, Broderick GA, Wehle MJ, Young PR. Systematic transperineal ultrasound-guided template biopsy of the prostate: three-year experience. Urology. 2005;65(4):735-9. Epub 2005/04/19.
  7. Beyersdorff D, Taupitz M, Winkelmann B, Fischer T, Lenk S, Loening SA, et al. Patients with a history of elevated prostate-specific antigen levels and negative transrectal US-guided quadrant or sextant biopsy results: value of MR imaging. Radiology. 2002;224(3):701-6. Epub 2002/08/31.
  8. Roehl KA, Antenor JA, Catalona WJ. Serial biopsy results in prostate cancer screening study. Journal of Urology. 2002;167(6):2435-9. Epub 2002/05/07.
  9. Franiel T, Stephan C, Erbersdobler A, Dietz E, Maxeiner A, Hell N, et al. Areas suspicious for prostate cancer: MR-guided biopsy in patients with at least one transrectal US-guided biopsy with a negative finding--multiparametric MR imaging for detection and biopsy planning. Radiology. 2011;259(1):162-72. Epub 2011/01/15.
  10. Hadaschik BA, Kuru TH, Tulea C, Rieker P, Popeneciu IV, Simpfendorfer T, et al. A novel stereotactic prostate biopsy system integrating pre-interventional magnetic resonance imaging and live ultrasound fusion. Journal of Urology. 2011;186(6):2214-20. Epub 2011/10/22.
  11. Roethke M, Anastasiadis AG, Lichy M, Werner M, Wagner P, Kruck S, et al. MRI-guided prostate biopsy detects clinically significant cancer: analysis of a cohort of 100 patients after previous negative TRUS biopsy. World Journal of Urology. 2012;30(2):213-8. Epub 2011/04/23.
  12. Wetter A, Hubner F, Lehnert T, Fliessbach K, Vorbuchner M, Roell S, et al. Three-dimensional 1H-magnetic resonance spectroscopy of the prostate in clinical practice: technique and results in patients with elevated prostate-specific antigen and negative or no previous prostate biopsies. European Radiology. 2005;15(4):645-52. Epub 2005/01/01.
  13. Nelson AW, Harvey RC, Parker RA, Kastner C, Doble A, Gnanapragasam VJ. Repeat prostate biopsy strategies after initial negative biopsy: meta-regression comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy. PloS One. 2013;8(2):e57480. Epub 2013/03/06.
  14. Bhatia C, Phongkitkarun S, Booranapitaksonti D, Kochakarn W, Chaleumsanyakorn P. Diagnostic accuracy of MRI/MRSI for patients with persistently high PSA levels and negative TRUS-guided biopsy results. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2007;90(7):1391-9. Epub 2007/08/23.
  15. Hambrock T, Somford DM, Hoeks C, Bouwense SA, Huisman H, Yakar D, et al. Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen. Journal of Urology. 2010;183(2):520-7. Epub 2009/12/17.
  16. Sciarra A, Panebianco V, Ciccariello M, Salciccia S, Cattarino S, Lisi D, et al. Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for detecting prostate cancer foci in men with prior negative biopsy. Clinical Cancer Research : an official journal of the American Association for Cancer Research. 2010;16(6):1875-83. Epub 2010/03/04.
  17. Testa C, Schiavina R, Lodi R, Salizzoni E, Tonon C, D'Errico A, et al. Accuracy of MRI/MRSI-based transrectal ultrasound biopsy in peripheral and transition zones of the prostate gland in patients with prior negative biopsy. NMR in Biomedicine. 2010;23(9):1017-26. Epub 2010/10/01.
  18. Tang SYW, Lawrence EM, Koo B, Nelson AW, Wadhwa K, Barrett T, et al. Performance of MRI-TRUS fusion in transperineal template prostate re-biopsy. Eur Urol Suppl. 2013;12(e142).
  19. Mowatt G, Scotland G, Boachie C, Cruickshank M, Ford J, Fraser C, et al. The diagnostic accuracy and cost-effectiveness of magnetic resonance spectroscopy and enhanced magnetic resonance imaging techniques in aiding the localisation of prostate abnormalities for biopsy: a systematic review and economic evaluation. Health Technol Assess. 2013;17(20):1-281. Epub 2013/05/24.

 

Written by:
Adam W. Nelsona,* and Vincent J. Gnanapragasamb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

aDepartment of Urology, Addenbrooke’s Hospital, Cambridge, United Kingdom
bDepartment of Urology, Addenbrooke’s Hospital, Cambridge, United Kingdom; Translational Prostate Cancer Group, Hutchison/MRC Research centre, University of Cambridge, Cambridge, United Kingdom
*To whom correspondence should be addressed:

Repeat prostate biopsy strategies after initial negative biopsy: Meta-regression comparing cancer detection of transperineal, transrectal saturation and MRI guided biopsy - Abstract

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