prostate biopsy--new emerging trends, dr. muhammad bin zulfiqar

DR. MUHAMMAD BIN ZULFIQARPGR IV FCPS SIMS/SHL

Alnoor Diagnostic Centre

PROSTATE BIOPSY— New emerging trends

AgendaAnatomyTransrectal US TechniqueCarcinoma ProstateBiopsy Technique

IndicationsTechniqueComplications

Anatomy

• Shape– Inverted flattened cone– tip represents apex– flattened part represents base

• Zones—Three major zones– Peripheral (70 % glandular tissue)– Central (20 % glandular tissue)– Transitional (20 % glandular tissue)– Anterior fibromuscular stroma

• AFS = anterior fibro muscular stroma, CZ = central zone, ED = ejaculatory ducts, NVB = neurovascular bundle, PUT = periurethral tissue, PZ = peripheral zone, SV = seminal vesicle, TZ = transition zone, U = urethra, V = verumontanum.

ULTRASOUND TECHNIQUE• Either the right or left lateral decubitus position (lying on left side).

• A topical anesthetic ointment is applied to the index finger prior to performing the DRE.

• A 7.5mHz transducer is used for transrectal imaging of the prostate.

• The probe is gently advanced into the rectum, to the base of the bladder until the seminal vesicles are visualized.

Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques. RadioGraphics 2012; 32:819–837 DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACREl-Hakim and Moussa. CUA guidelines on prostate biopsy methodology. CUAJ • April 2010 • Volume 4, Issue 2Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED

Biplane and 3-D Prostate Imaging

• By using advanced machines with latest softwares and 3D probes we can acquire prostate images in 2 planes or 3 planes simultaneously.

• This helps us in guiding and targeting biopsy needle to area of interest.

Biplane Prostate Imaging

• A three-dimensional US image of the prostate acquired using an endocavity rotational three-dimensional scanning approach (rotation of a transrectal US transducer). The transducer was rotated around its long axis, while three-dimensional US images were acquired and reconstructed. The three-dimensional US image using an end-firing transducer is displayed using the cube-view approach and has been sliced to reveal: (a) a transverse view, (b) a sagittal view and (c) a coronal view, not possible using conventional two-dimensional US techniques.A. Fenster et al. Three-dimensional ultrasound scanning. Interface Focus (2011)

1, 503–519

• Figure 11. The display for viewing the three-dimensional US image of the prostate and to perform the segmentation of the prostate. The user can verify that the prostate has been segmented accurately and perform any required edits to the boundary.A. Fenster et al. Three-dimensional ultrasound scanning. Interface Focus (2011) 1, 503–519

• Figure 12. The three-dimensional US-guided prostate biopsy system interface is composed of four windows: (top left) the three dimensional TRUS image sliced to match the real-time TRUS probe orientation; (bottom left) the live two-dimensional TRUS video stream; and (right side) the three-dimensional location of the biopsy core within the three-dimensional prostate model. The targeting ring in the bottom right window shows all the possible needle paths that intersect the preplanned target by rotating the TRUS about its long axis.A. Fenster et al. Three-dimensional ultrasound

scanning. Interface Focus (2011) 1, 503–519

VAS Deferens / Seminal Vesicle

Colour Doppler

• Normally, the flow is very sparse• Role is controversial• Increased flow within tumour mass– flow is very slow and low

• increased flow also seen in infection

DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

Normal Flow

Acute Prostatitis

Acute Prostatis

Prostatic Carcinoma

• Second most common malignancy in males after lung cancer.

• Histologically it is Adenocarcinoma

Prostatic Carcinoma Location• Peripheral zone-----80%• Central zone------5%• Transitional zone------15%• Multifocal-------40%

Radiology Review Manual Wolfgang Dahnert, M.D.

Sonographic features of prostatic Carcinoma

• Echogenicity– Hypoechoic—61 %– Hyperechoic—2 %– Mixed—2 %– Not detectable isoechoic—35%

• Asymmetric enlargement• Deformed contour of prostate (irregular bulge

sign 75 % PPV) • Heterogeneous texture

ULTRASOUND FINDINGS in CA• Hypoechoic lesion (dark compared to normal tissue) in the peripheral zone is

usually a neoplasm.

• Classic hypoechoic peripheral zone lesion:– Sensitivity of cancer detection of 85.5%– Specificity of 28.4%– Positive predictive value of 29%– Negative predictive value of 85.2%– Overall accuracy of 43%.

• Isoechoic or nearly invisible prostate cancers on TRUS– 25 to 42%.

To date, no biologic differences have been noted between isoechoic and hypoechoic prostate cancers.

Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

Escape routes of Prostatic Cancer

• (1) capsular margin at neurovascular bundle• posterolaterally (80%) due to intrinsic

weakness of capsule at this location• (2) apex• (3) seminal vesicles

Advanced stage of Prostate ca

• Seminal Vesicle invasion• Bony metastases• Bladder invasion• Lymphadenopathy

DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

Prostatic cancer Staging

• Stage 1: Occult (focal or diffuse)

• Stage 2: cancer confined to prostatic capsule

• Stage 3: Extracapsular spread

• Stage 4: Distant Metastases

Radiology Review Manual Wolfgang Dahnert, M.D.

Known case of carcinoma prostate with bony metastasis

TRUS guided Prostatic biopsy• Indications:

– Men with an abnormal DRE

– Elevated PSA (>4.0 ng/ml)

– PSA velocity (rate of PSA change) >0.4 to 0.75 ng/ml/yr.

– Repeat biopsy 3 to 12 months later who were diagnosed with high-grade prostatic intraepithelial neoplasia (PIN) or atypia on a previous prostate needle biopsy.

– Patient with metastatic adenocarcinoma with unknown primary.


PATIENT’S PREPARATION

• Aspirin and non-steroidal anti-inflammatory (NSAIDS) should be discontinued for 7-10 days.

• Low fiber diet 3 days prior to biopsy.

• One-day prophylaxis of an oral quinolone (Ciprofloxacin).

• Cleansing enema (sodium phosphate and dibasic sodium phosphate) prior to the biopsy to eliminate gas and remove feces.


TRUS guided Prostatic biopsy-Advantages / Disadvantages

• Merits– Simple outpatient procedure– improved patient tolerance– fewer inadequate samples– decreased need for anaesthesia

• Demerits– Low sensitivity and low PPV– bleeding into urine, rectum or semen– Infection acute urinary retention– Large interobserver variability


Preprocedural assessment by TRUS

• Nodule on Digital rectal examination (DRE).• Raised > 4 ng / ml Prostate specific antigen

(PSA). • Provide visual guidance for biopsy.

• TRUS alone should not be used as a first-line screening study.


BIOPSY TECHNIQUE• An 18-gauge 25 cm long biopsy needle loaded in a spring-

action automatic biopsy device.

• Needle tip to be placed precisely at the boundary of the lesion.If the prostate capsule is “tented up” by the needle tip, tissue

may be taken too deep inside the gland and a tumor located in the peripheral zone may be missed.

• The excursion of the needle tip during a biopsy is approximately 2.2 cm and the biopsy notch, which procures the tissue, is approximately 1.5-2.0 cm.


BIOPSY TECHNIQUE—Local Anesthesia

• 65% to 95% men report some level of discomfort during transrectal ultrasound guided prostate needle biopsy.

• Pain predominantly occurs when the needle penetrates the prostatic capsule and stroma, which has a rich supply of autonomic nerve fibers.

• 10ml of 1% lidocaine is injected into the prostate gland at the lateral edge of the gland on each side from the base to the apex.


Contribution from Dr. Knud V Pedersen PhD, Senior Urologist, Länssjukhuset Ryhov Jönköping, Sweden

OPTIMIZATION OF BIOPSY• At the prostate base:– Lateral biopsies will sample the peripheral zone– Medially directed biopsies are more likely to sample the

central zone

• In the mid gland:– Medially directed biopsy in this area can traverse the

peripheral zone and predominantly sample the transition zone.

• At the prostatic apex:– Sample the distal aspect of the transition zone.


• AFS = anterior fibro muscular stroma, CZ = central zone, ED = ejaculatory ducts, NVB = neurovascular bundle, PUT = periurethral tissue, PZ = peripheral zone, SV = seminal vesicle, TZ = transition zone, U = urethra, V = verumontanum.

SEXTANT biopsy sampling

• Sample from 6 sites of peripheral zone

• WHY?– Finding may not be cancer– cancer is often multifocal


Cross-sectional view of commonly biopsied zones.TZ-transition zone, Mid PZ-mid peripheral zone, Lat PZ-lateral

peripheral zone, AH-anterior horn, LH-lateral horn.


• (a) Coronal (left) and axial (right) schematics show the positions of the needle and the locations that are sampled in the prostate with the standard sextant biopsy technique. (b) Coronal (left) and axial (right) schematics of the modified sextant biopsy technique show more lateral positions of the needle at the middle level (M) of the prostate with this technique than with the standard technique. (c) Coronal schematics show the additional prostate locations (open circles) that may be sampled in an extended systematic biopsy, for a total of eight, 10, or 12 specimens. Filled circles indicate the six locations of sampling in a standard sextant biopsy.

a c

Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques . RadioGraphics 2012; 32:819–837

• Photograph shows a spring-loaded 18-gauge biopsy needle and 12 specimen cups laid out in preparation for an extended systematic biopsy. AFS = anterior fibromuscular stroma, CZ = central zone, ED = ejaculatory ducts, NVB = neurovascular bundle, PUT = periurethral tissue, PZ = peripheral zone, TZ = transition zone.

Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques . RadioGraphics 2012; 32:819–837

Pitfalls and prevention• Sampling error (20% to 30%)

• Lack of sampling adequacy

• Overall cancer detection rates undergoing repeat prostate needle biopsy (10% - 38%).

• Alternate “extended pattern” biopsy schemes– Increasing the number of core biopsies – Directing the biopsies more laterally to better

sample the anterior horn (the far lateral regions of the peripheral zone).


2D Prostate Biopsy

• The three-dimensional US-guided prostate biopsy system interface is composed of four windows: (top left) the three dimensional TRUS image sliced to match the real-time TRUS probe orientation; (bottom left) the live two-dimensional TRUS video stream; and (right side) the three-dimensional location of the biopsy core within the three-dimensional prostate model. The targeting ring in the bottom right window shows all the possible needle paths that intersect the preplanned target by rotating the TRUS about its long axis.A. Fenster et al. Three-dimensional ultrasound

scanning. Interface Focus (2011) 1, 503–519

COMPLICATIONS• Minor (range 60% to 79%)• Major (range 0.4% to 4.3%)• Hospitalization (0.4% to 3.4%)

• Immediate Complications• Delayed complications


COMPLICATIONS• Immediate complications– Vasovagal episodes (5.3%)– Rectal bleeding (8.3%)– Hematuria (70.8%)

Persistent hematuria (47.1%) typically lasts 3 to 7 days.


COMPLICATIONS• Delayed complications– Dysuria (9.1%)– Vague pelvic discomfort (13.2%)– Persistent hematuria (47.1%)– Hematochezia (rectal bleeding) (9.1%)– Hematospermia (9.1%)


Indications for a repeat prostate biopsy

• Include the following:

– 1) A highly suspicious DRE (digital rectal examination)

– 2) A persistently rising serum PSA (> 0.4 – 0.75 ng/ml/yr.)

– PSA level greater than 10 ng/ml or rising.– 4) Presence of PIN (prostatic intraepithelial

neoplasia) or atypia on prior biopsy

Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY

Take Home Message

• 12 core biplane / 3 dimensional TRUS guided biopsy of prostate is more convenient, effective and result oriented mode of biopsy.

THANK YOU

prostate biopsy--new emerging trends, dr. muhammad bin zulfiqar

Health & Medicine