Department of Urology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK.
King's College London, Medical School, London, UK.
BJU Int. 2020 Aug;126(2):280-285. doi: 10.1111/bju.15092. Epub 2020 May 19.
To assess whether targeted cognitive freehand-assisted transperineal biopsies using a Precisionpoint device still require additional systematic biopsies to avoid missing clinically significant prostate cancer, and to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy.
Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were performed using the Precisionpoint device (Perineologic, Cumberland, MD, USA) under either local anaesthetic (58%, 163/282), i.v. sedation (12%, 34/282) or general anaesthetic (30%, 85/282). A mean (range) of 24 (5-42) systematic and 4.2 (1-11) target cores were obtained. Magnetic resonance imaging (MRI) scans were reported using the Likert scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed.
A total of 282 patients were included in this study. Their mean (range) age was 66.8 (36-80) years, median (range) prostate-specific antigen level 7.4 (0.91-116) ng/mL and mean prostate volume 45.8 (13-150) mL. In this cohort, 82% of cases (230/282) were primary biopsies and 18% (52/282) were patients on surveillance. In all, 69% of biopsies (195/282) were identified to have clinically significant disease (Gleason ≥3 + 4). Any cancer (Gleason ≥3 + 3) was found in 84% (237/282) of patients. Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195), with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score; 73% of Likert score 3 disease was detected by target biopsy, 92% of Likert score 4 and 100% of Likert score 5. Target biopsies with additional same-quadrant-only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target.
Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy, but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (Likert score 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatments (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.
评估使用 Precisionpoint 设备进行靶向经会阴前列腺活检是否仍需要额外的系统活检以避免遗漏有临床意义的前列腺癌，并探讨仅进行象限活检的方法是否可以替代系统活检。
患者在一家机构接受了联合系统映射和靶向经会阴前列腺活检。使用 Precisionpoint 设备（Perineologic，Cumberland，MD，USA）在局部麻醉（58%，163/282）、静脉镇静（12%，34/282）或全身麻醉（30%，85/282）下进行活检。平均（范围）获得 24 个（5-42）系统和 4.2 个（1-11）靶向核心。磁共振成像（MRI）扫描使用 Likert 量表进行报告。有临床意义的癌症定义为 Gleason 7 或以上。组织病理学结果与 MRI 异常在空间象限内及其相邻或不相邻（对侧）象限内的存在相关。分析与根治性前列腺切除术标本的组织学一致性。
共有 282 名患者纳入本研究。他们的平均（范围）年龄为 66.8（36-80）岁，中位（范围）前列腺特异性抗原水平为 7.4（0.91-116）ng/mL，前列腺体积为 45.8（13-150）mL。在本队列中，82%的病例（230/282）为初次活检，18%（52/282）为监测患者。共有 69%的活检（195/282）发现有临床意义的疾病（Gleason≥3+4）。84%（237/282）的患者发现任何癌症（Gleason≥3+3）。在有临床意义的疾病患者中，靶向活检单独检出 88%（171/195），系统活检检出靶向活检遗漏的额外 12%（24/195）。这与 Likert 评分有关；73%的 Likert 评分 3 疾病通过靶向活检检出，92%的 Likert 评分 4 和 100%的 Likert 评分 5。在靶向活检的基础上增加同象限的系统核心活检，可检出靶向活检仅漏诊的 24 例（18/24）有临床意义的癌症，这些癌症位于与靶向活检相同的象限。
当评估所有因前列腺活检而转诊的患者时，系统活检仍然是一种重要的工具，但随着 MRI 怀疑程度的增加，其必要性降低。对于高度怀疑前列腺癌（Likert 评分 5）的患者，除非需要进行代表周围组织的活检以进行其他特定治疗（如局灶性治疗或手术规划），否则可能不需要进行系统活检。需要更多的前瞻性研究来全面评估这一点。
