Mayayo Dehesa T, Rodríguez-Patrón R, Zuccarino A L, Arias Funez F, Carrera Puerta C, García González R
Unidad de Ecografía Urológica Dr. T. Mayayo Dehesa, Madrid, España.
Arch Esp Urol. 1999 Jun;52(5):453-63.
To compare the results of US-guided transrectal biopsy in 1,900 patients with the diagnostic yield of DRE, transrectal US, PSA, PSA density and free PSA/total PSA ratio and to describe our approach based on the results of the comparative study.
Over the last two years 1,900 patients have undergone biopsy; 4 to 6 specimens were obtained randomly from both prostatic lobes and areas identified by transrectal US and/or DRE as being suspicious. All patients underwent transrectal US, DRE and determination of serum total PSA and PSA density. Free PSA and free PSA/total PSA ratio were determined in 128 patients with PSA 4-10 ng/ml. Seventy had a second biopsy, 8 a third and 3 had a fourth biopsy.
The overall diagnostic yield was 40%. Biopsy was positive in 27% of patients with PSA 4-10 ng/ml; of these, 64% showed a positive DRE, 21% showed a negative DRE and 13% were negative for both DRE and transrectal US. DRE was positive in 32% of patients with PSA greater than 10 ng/ml, 39% of those with PSA 10-20 ng/ml and 62% of those with PSA greater than 20 ng/ml; transrectal US was positive in 58% of patients with PSA 10-20 ng/ml and in 77% of those with PSA greater than 20 ng/ml. A high specificity was found for both DRE and transrectal US. In patients with PSA 4-10 ng/ml, PSA density at a cutoff of 0.15 ng/ml/cc showed a sensitivity of 81% and a specificity of 20%, respectively. A second biopsy was positive in 20% of patients with a persistently elevated PSA and the incidence of tumors theoretically of little importance was 13%.
Patients aged less than 70 years whose general condition permit aggressive treatment of prostate cancer should undergo US-guided transrectal biopsy if PSA is greater than 4 ng/ml, regardless of DRE and ultrasound findings. PSA less than 20 ng/ml, PSA density and free PSA/total PSA ratio must be considered for a second biopsy. Sextant biopsy appears to have a good diagnostic accuracy and does not require taking additional specimens or including the transitional zone in the first biopsy. Before classifying a tumor as being of little importance on the basis of the biopsy findings, another biopsy must be performed.
比较1900例患者经超声引导下经直肠穿刺活检的结果与直肠指检（DRE）、经直肠超声（TRUS）、前列腺特异抗原（PSA）、PSA密度及游离PSA/总PSA比值的诊断率，并根据对比研究结果描述我们的方法。
在过去两年中，1900例患者接受了活检；从前列腺两叶及经直肠超声和/或直肠指检确定为可疑的区域随机获取4至6个标本。所有患者均接受经直肠超声、直肠指检及血清总PSA和PSA密度测定。对128例PSA为4 - 10 ng/ml的患者测定了游离PSA及游离PSA/总PSA比值。70例患者进行了第二次活检，8例进行了第三次活检，3例进行了第四次活检。
总体诊断率为40%。PSA为4 - 10 ng/ml的患者中，27%活检呈阳性；其中，64%直肠指检阳性，21%直肠指检阴性，13%直肠指检和经直肠超声均为阴性。PSA大于10 ng/ml的患者中，32%直肠指检阳性；PSA为10 - 20 ng/ml的患者中，39%直肠指检阳性；PSA大于20 ng/ml的患者中，62%直肠指检阳性。经直肠超声在PSA为10 - 20 ng/ml的患者中阳性率为58%，在PSA大于20 ng/ml的患者中阳性率为77%。直肠指检和经直肠超声均具有较高的特异性。在PSA为4 - 10 ng/ml的患者中，PSA密度临界值为0.15 ng/ml/cc时，敏感性和特异性分别为81%和20%。PSA持续升高的患者中，20%第二次活检呈阳性，理论上意义不大的肿瘤发生率为13%。
年龄小于70岁、一般状况允许积极治疗前列腺癌的患者，若PSA大于4 ng/ml，无论直肠指检和超声检查结果如何，均应接受经超声引导下经直肠穿刺活检。PSA小于20 ng/ml时，进行第二次活检必须考虑PSA密度及游离PSA/总PSA比值。六分区活检似乎具有良好的诊断准确性，且在首次活检时无需额外取材或包含移行带。在根据活检结果将肿瘤分类为意义不大之前，必须进行再次活检。
