Image-Guided Transperineal Prostate Biopsy: Advantages For Our Patients

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Image-Guided Transperineal Prostate Biopsy: Advantages For Our Patients

By Arvind B. Soni, M.D.

Most patients suspected of having prostate cancer undergo a ‘workup’ battery of laboratory tests that doctors use to determine the presence of cancer and how far it has spread when present. While the testing may not be a pleasant experience, the results are crucial to determine if treatment is necessary and to decide which form of treatment will be most appropriate for each individual case. The more you understand the results of your laboratory tests, the better able you will be to make informed decisions with your doctor. The bottom line is that taken together these lab tests, including the prostate biopsy, may save your life.

According to a recent study, more than 1 million men in the U.S. undergo prostate biopsies annually (Abhinav Sidana, Ther Adv Urol. 2022 Jan-Dec). Most of these biopsies are the result of abnormalities indicated by the Prostate Specific Antigen (PSA) blood test and/or by the Digital Rectal Exam (DRE), which are the two most common screening tests for early detection of the disease. When either or both of these tests raise a red flag, a prostate biopsy is performed to confirm or rule out prostate cancer. This procedure involves removing tissue from the prostate gland for pathological examination.

Because the prostate biopsy is an invasive procedure and can cause infections in some men, you and your doctor will want to be sure that the PSA and other lab tests indicate that a biopsy is advisable. Other tests may include transrectal ultrasound imaging (TRUS) and magnetic resonance imaging (MRI). A biopsy should not be undertaken based on only one PSA test; rather, it is the PSA trend over time that is most telling. Other tests like Multiparametric MRI and standardized interpretive analyses such as PI-RADS can be used to screen and triage those men who are at high-risk for clinically significant prostate cancer and should be advised to undergo biopsy.

A prostate biopsy is a procedure by which samples of tissue are removed from suspicious areas of the prostate gland for microscopic examination by a pathologist. A biopsy is absolutely necessary to confirm or rule out the presence of cancer and should be undertaken prior to any treatment of the disease. The biopsy also provides physicians with a wealth of information about the specific characteristics of the cancer when disease is present.
There are two types of biopsy. The transrectal approach involves inserting a needle through the rectum to extract sample tissues from the prostate. This technique was the standard for several decades, but the risks and limitations of transrectal biopsies have increasingly led to the use of transperineal prostate biopsies as the preferred alternative. With the transperineal biopsy, the doctor inserts a needle into the prostate through the skin between the scrotum and anus (perineum) and takes a number of tissue samples that are sent to the laboratory. Recent studies have demonstrated the transperineal approach for prostate biopsies is more effective, associated with far less pain, infection and blood loss compared to traditional transrectal biopsies.
At our center, we perform image-guided biopsies utilizing 3D Color-Flow Power Doppler Ultrasound (3D-CFPDU) coupled or fused with MRI imaging in order to accurately guide the needles into the prostate. The Dattoli Team has published results on the superiority of biopsies that are guided by real time 3D Color-Flow Power Doppler Ultrasound over conventional, grey-scale ultrasound guidance, which is employed by most physicians (Dattoli MJ, et al, Prostate biopsies using both gray scale and 3D color flow power Doppler ultrasound (3D-CFPDU), American Society of Clinical Oncology Genitourinary Cancer Symposium, ASCO-GU, February 26-28, 2015).

The prostate biopsy has traditionally involved obtaining at least six core samples of tissue. This procedure, known as the sextant biopsy, draws two tissue samples from the base, mid-gland and apex for a total of six samples. Studies have shown that increasing the number of samples can significantly increase the detection of malignancy. The number of biopsy samples taken now typically ranges from 12 to 18 or more. The 5-region biopsy approach obtains additional samples from the mid-gland tissue and the lateral zones or lobes on each side of the gland. When a large discreet mass is identified, only a few biopsy samples may be necessary. When a very large number of samples are obtained, this approach is called “saturation biopsy.”
Your biopsy report should indicate how many tissue samples were taken from specific areas of the prostate, and how many specimens showed cancer. The biopsy enables a pathologist to determine the patient’s Gleason score by microscopic evaluation of tissue samples. This scoring system is a method for classifying the cellular differentiation of cancerous tissue in the prostate gland in order to determine how aggressive the cancer is. Slow-growing tumors appear similar to normal tissue and are called “well-differentiated.” Fast-growing cancers appear abnormal and are called “poorly differentiated.” Between the two extremes are cancers which are classified as “moderately differentiated.” The Gleason system defines five glandular patterns of cancerous cell tissue, from completely differentiated to completely undifferentiated.

Tumors often possess more than one cellular pattern in different tissue samples, and therefore, both primary and secondary patterns are graded. The two grades are combined (added together) to get the actual Gleason score, ranging from 2 (1+1) to 10 (5+5), with most cancers falling somewhere in between. The higher the Gleason score, the more likely it is that the cancer is more aggressive and has already spread beyond the prostate gland or metastasized to other parts of the body. We inform our patients that the Gleason score and the serum PSA value are essential criteria for making informed decisions about appropriate treatment if and when necessary.

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