J. Stephen Jones

Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection.

Study Type – Diagnostic (exploratory cohort)

Saturation Technique Does Not Improve Cancer Detection as an Initial Prostate Biopsy Strategy

PURPOSE We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.

Contemporary Role of Systematic Prostate Biopsies: Indications, Techniques, and Implications for Patient Care

CONTEXT Prostate cancer (PCa) screening to detect early stage PCa has resulted in increased identification of small-volume, low-grade PCa, many of which meet criteria for clinically indolent disease. Nevertheless, there remains some degree of underdetection of high-risk PCa in substantial numbers of men despite current diagnostic strategies. OBJECTIVE To discuss the contemporary role of prostate biopsy (PB), focusing on the indications, techniques, and limitations of current PB techniques and evolving techniques affecting patient care. EVIDENCE ACQUISITION A comprehensive Medline search was performed using the medical subject heading search terms prostate cancer, detection, prostate biopsy, significant cancer, and diagnosis, with restriction to the English language. Emphasis was given to publications within the past 5 yr. EVIDENCE SYNTHESIS Because abnormal digital rectal examination (DRE) and prostate-specific antigen (PSA) tests alone lack specificity for cancer, there is no universal indication for PB. This lack has inspired exploration for a cancer-specific biomarker and prediction tools such as risk calculators. Indication for biopsy should involve a balance between the underdiagnosis of high-risk cancers and the potential risks for the overdetection of clinically insignificant cancers as well as biopsy-related morbidity. Evidence supports the inclusion of laterally directed cores during transrectal ultrasound (TRUS) PB in addition to the traditional sextant pattern, which significantly improves cancer detection without a demonstrable increase in morbidity. These data indicate that such PB templates, typically 12 cores, represent the optimal template in initial PB. Optimised techniques and templates for repeat PB remain controversial. However, debate continues regarding indications, sampling number, and location as well as on the potential of modern image-guided approaches or three-dimensional (3D) mapping biopsy in this unique setting. Additional limitations of repeat PB techniques include associated procedural risks if general anaesthesia is required and inherent sampling errors of template-based techniques that are not targeted to the specific tumour site. CONCLUSIONS Current data support the utility of extended PB templates for initial TRUS PB intended to detect clinically significant PCa. Repeat PB in the setting of prior negative PB on the grounds of clinical suspicion or for risk-stratified approaches to management of low risk PCa requires balancing overdetection of low-risk cancer with the potential to miss significant cancer. Several options, including modern image-guided targeting, biomarker development, transrectal saturation PB, and 3D template mapping PB, are changing the clinical paradigms for evaluation and management. Evidence to support adopting approaches other than the current established standards should be tested through appropriately designed prospective studies.

Salvage Prostate Cryoablation: Initial Results From the Cryo On-Line Data Registry

PURPOSE We report contemporary outcomes of salvage cryoablation at a large number of centers which have participated in the COLD (Cryo On-Line Data) Registry. MATERIALS AND METHODS A secure online database was developed to collect data for patients undergoing prostate cryoablation. Kaplan-Meier analysis was performed with biochemical failure defined using the American Society of Therapeutic Radiology and Oncology, and the Phoenix definitions. RESULTS Data from 279 patients who had undergone salvage cryoablation were entered. Average patient age was 70.0 +/- 7.1 years. Pretreatment prostate specific antigen was 7.6 +/- 8.2 ng/ml and Gleason score was 7.5 +/- 1.1 (median 7). Patients were followed for 21.6 +/- 24.9 months and 47 were followed longer than 5 years. The 5-year actuarial biochemical disease-free rates were 58.9% +/- 5.7% (American Society of Therapeutic Radiology and Oncology) and 54.5% +/- 4.9% (Phoenix). As predicted based on the preservation of some prostatic tissue, 83% +/- 3.5% of patients had a detectable prostate specific antigen 0.2 ng/ml or greater at 5 years. Positive biopsies were observed in 15 of the 46 patients (32.6%) who underwent prostate biopsy after salvage cryotherapy. The incontinence rate (requiring pad use) was 4.4%. The rectal fistula rate was 1.2% and 3.2% of patients underwent transurethral prostate resection to remove sloughed tissue. CONCLUSIONS Biochemical and local control rates support the use of salvage cryoablation for localized recurrence following failed radiation therapy. Efforts to continue to minimize these complications and to improve disease control in patients with persistent cancer following definitive radiotherapy should continue.

Emergence of fluoroquinolone-resistant Escherichia coli as cause of postprostate biopsy infection: implications for prophylaxis and treatment.

OBJECTIVES To report the sensitivity and resistance of Escherichia coli in patients with infectious complications after prostate biopsy in a North American cohort. Increasing antibiotic-resistant E. coli has been observed worldwide. METHODS Data were available for 1446 patients who had undergone transrectal ultrasound-guided prostate biopsy from 2001 to 2010. Of the 1446 patients, 932 were administered 500 mg of ciprofloxacin 1 hour before prostate biopsy and 514 were administered a 3-day course of ciprofloxacin starting 1 day before biopsy plus an enema the night before. The sensitivity and resistance of E. coli were attained through the analysis of the blood and urine cultures of patients with suspected infection. RESULTS Of the 1446 patients, 40 (2.77%) developed an infection after biopsy. Of these 40 patients, 31 (2.14%) had a febrile urinary tract infection and 9 (0.62%) were diagnosed with sepsis requiring hospitalization. Of the 40 patients, 20 (50%) had urine cultures positive for E. coli. Of these 20 patients, 11 (55%) had fluoroquinolone-resistant infection and 9 had fluoroquinolone-sensitive E. coli. Of the remaining 20 patients, culture was not obtained for 9, and 5 had negative urine culture findings. Of the 7 patients (78%) with sepsis had blood cultures positive for E. Coli; 4 (57.1%) of which were fluoroquinolone-resistant and 3 were fluoroquinolone-sensitive. CONCLUSIONS In the present study, a significant risk of fluoroquinolone-resistant E. coli was observed in patients with both febrile urinary tract infection and sepsis after prostate biopsy. Alternative prophylactic antibiotics should be researched further, and postbiopsy infections developing after standard quinolone prophylaxis should be treated with cephalosporins until culture findings are available to guide therapy.

Whole Gland Primary Prostate Cryoablation: Initial Results From the Cryo On-Line Data Registry

PURPOSE We report the largest data set to date to our knowledge regarding outcomes for primary whole gland prostate cryoablation. MATERIALS AND METHODS The COLD (Cryo On-Line Data) Registry consists of case report forms obtaining pretreatment and posttreatment information for patients undergoing whole gland prostate cryoablation. A total of 1,198 patients were stratified into low, intermediate and high risk groups. Biochemical success was defined according to the traditional American Society for Therapeutic Radiology and Oncology definition (3 increases) and the newer (Phoenix) definition (nadir +2). Biopsy was performed at physician discretion but most commonly for cause if a patient had an increasing or suspicious prostate specific antigen. RESULTS Average patient age was 69.8 +/- 7.5 years. Pretreatment prostate specific antigen was 9.6 +/- 8.6 ng/ml and median Gleason sum was 7 (range 4 to 10). Patients were followed for 24.4 +/- 25.9 months with 136 having minimum 5-year data. The 5-year biochemical disease-free status for the entire population was 77.1% +/- 2.1% (American Society for Therapeutic Radiology and Oncology) and 72.9% +/- 2.1% (Phoenix). Five-year American Society for Therapeutic Radiology and Oncology biochemical disease-free status was 84.7% +/- 4.5%, 73.4% +/- 4.3% and 75.3% +/- 3.7% for the low, moderate and high risk groups, respectively. Using the Phoenix definition the biochemical disease-free status was 91.1% +/- 2.9%, 78.5% +/- 3.6% and 62.2% +/- 4.9%, respectively. As predicted based on intentional preservation of some prostatic tissue, 72.5 +/- 1.8% had a detectable prostate specific antigen 0.2 ng/ml or greater at 5 years. Biopsy after cryotherapy was positive during empiric without cause biopsy in 30 of 207 patients (14.5%), and the highly selected group biopsied based on suspicion of treatment failure due to abnormal or increasing prostate specific antigen had positive results in 38.0% (49 of 129). The rectal fistula rate was 0.4% and incontinence was 4.8% with 2.9% of patients using pads. Intercourse was reported by 25.2% but only 8.8% without pharmaceutical or device assistance. CONCLUSIONS Whole gland cryoablation, practiced in a spectrum of academic and community users, maintains efficacy and morbidity similar to that of single center reports.

Focal cryotherapy for localized prostate cancer: a report from the national Cryo On-Line Database (COLD) Registry

Study Type – Therapy (cohort)

Inadequacy of Biopsy for Diagnosis of Upper Tract Urothelial Carcinoma: Implications for Conservative Management

OBJECTIVE To report changes in grade and stage between initial diagnostic and repeat biopsies or resection for urothelial carcinoma (UTUC) and investigate the consequences for endoscopic management. Ureteroscopic management of upper tract UTUC is an alternative to nephroureterectomy, which is less invasive and preserves renal function. However, concerns about potential understaging, inaccurate grading, incomplete resection, lack of effective tertiary chemoprevention, and need for ureteroscopic surveillance limits it appeal. METHODS Clinicopathological records of patients with UTUC treated at our institution were reviewed. Fifty-six patients with a histologic diagnosis of UTUC and 2 or more consecutive biopsies or biopsy followed by surgical resection were included, resulting in 65 biopsy specimens. RESULTS The median interval between diagnostic biopsy and subsequent biopsy or resection was 6 weeks (range, 1 week to 60 months). Change in grade from the diagnostic biopsy occurred in 24 of 65 biopsies (37%), including 9 in which diagnosis changed from low to high grade. Change in the stage from the diagnostic biopsy occurred in 25 of 65 biopsies (38%). Overall, 24 (43%) patients were reclassified from low-grade, noninvasive disease to high-grade and/or invasive disease. CONCLUSION A change in grade and/or stage from the diagnostic biopsy occurred in more than one third of patients with UTUC managed conservatively. Because of the short median time interval between biopsies, this finding likely represents variability in tumor sampling on biopsy. Because of the concerns of undergrading and understaging, appropriate patient selection and vigilant endoscopic surveillance are mandatory for UTUC managed endoscopically.

Focal cryotherapy for localized prostate cancer

Study Type – Therapy (cohort)

Saturation Prostate Biopsy With Periprostatic Block Can be Performed in Office

PURPOSE Recent reports of saturation prostate biopsy performed in the operating room with the patient under anesthesia have shown increased cancer detection rates over repeat office based prostate biopsy. We report equivalent success and tolerability of saturation biopsy in the office using local anesthesia. MATERIALS AND METHODS We performed 24 core saturation prostate biopsies in 15 patients using periprostatic local anesthesia. Before biopsy 20 cc 2% lidocaine (10 cc per side) were injected under ultrasound guidance into the periprostatic nerve entry into the prostate bilaterally. After measurements were made a random 24 core prostate biopsy was performed using a spring loaded biopsy gun. Pain was determined using a visual analog scale to assess tolerability. RESULTS Complete 24 core biopsies were successful and well tolerated in all 15 patients. Cancer detected in 5 patients (33%) was clinical stage T1C. Mean prostate specific antigen before biopsy was 11.2 ng./dl. (range 5 to 24.1). The indication for biopsy was elevated prostate specific antigen after a previous normal biopsy in 12 patients. In 2 patients prostatic intraepithelial neoplasia was noted on a previous biopsy and in 1 previous atypia was identified on biopsy. The mean visual analog scale pain score was 0.7 (range 0 to 3). Prolonged minor hematuria greater than 5 days in duration occurred in 3 cases requiring no intervention. No other complications occurred. Nerve sparing was not more difficult in the single patient who underwent radical prostatectomy. CONCLUSIONS Saturation prostate biopsy is well tolerated in the office setting with the patient under local anesthesia. The additional risk, time and cost of performing these procedures in the operating room using anesthesia may be safely avoided.