Medium‐term oncological outcomes for extended vs saturation biopsy and transrectal vs transperineal biopsy in active surveillance for prostate cancer

Abstract

ObjectiveTo assess, in men undergoing active surveillance (AS) for low-risk prostate cancer, whether saturation or transperineal biopsy altered oncological outcomes, compared with standard transrectal biopsy. Patients and MethodsRetrospective analysis of prospectively collected data from two cohorts with localised prostate cancer (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012) undergoing AS. Prostate cancer-specific, metastasis-free and treatment-free survival, unfavourable disease and significant cancer at radical prostatectomy (RP) were compared for standard (<12 core, median 10) vs saturation (>12 core, median 16), and transrectal vs transperineal biopsy, using multivariate analysis. ResultsIn all, 650 men were included in the analysis with a median (mean) follow-up of 55 (67) months. Prostate cancer-specific, metastasis-free and biochemical recurrence-free survival were 100%, 100% and 99% respectively. Radical treatment-free survival at 5 and 10 years were 57% and 45% respectively (median time to treatment 7.5 years). On Kaplan-Meier analysis, saturation biopsy was associated with increased objective biopsy progression requiring treatment (log-rank P = 0.01). On multivariate Cox proportional hazards analysis, saturation biopsy (hazard ratio 1.68, P < 0.01) but not transperineal approach (P = 0.89) was associated with increased objective biopsy progression requiring treatment. On logistic regression analysis of 179 men who underwent RP for objective progression, transperineal biopsy was associated with lower likelihood of unfavourable RP pathology (odds ratio 0.42, P = 0.03) but saturation biopsy did not alter the likelihood (P = 0.25). Neither transperineal nor saturation biopsy altered the likelihood of significant vs insignificant cancer at RP (P = 0.19 and P = 0.41, respectively).

Can MRI/TRUS fusion targeted biopsy replace saturation prostate biopsy in the re-evaluation of men in active surveillance?

“…Linder et al [19] found that 214 AS candidates undergoing extended biopsy (124 cases) versus saturation biopsy (94 cases) showed no difference in the rate of upgrading and upstaging at definitive specimen based on biopsy technique (p = 0.26); on the contrary, Abouassaly et al [20] reported a more accurate assessment of the extent and grade of disease in men enrolled in AS protocol using saturation biopsy in when compared to extended biopsy. In addition, the saturation biopsy scheme increases progression to treatment in AS on comparison with extended prostate biopsy (10 cores) [21], thus improving the detection rate of PCa located solely in the anterior zone of the gland (about 10 % of the cases) [22]; on the other hand, no significant difference was detected in upgrading or morbidity between a 24-core template or a template gland based on volume gland with an average of 1 core per cc. [23].…”

“…[23]. In recent years, mpMRI and mpMRI/TRUS fusion targeted biopsy have a good degree of accuracy in diagnosing clinically significant PCa secondary to the high sensitivity for lesion upgrading [8][9][10][11], especially when the cancer is located in the anterior prostate [6,7] or in the presence of micro-focal PCa (1 positive core of GS and GPC ≤ 5 %) [21]. Ouzzane et al [24] reporting on 281 patients in AS found that mpMRI targeted biopsy reclassified 10 % of patients who were eligible for AS based on systematic biopsy.…”

Pathologic Outcomes of Candidates for Active Surveillance Undergoing Radical Prostatectomy: Results from a Contemporary Turkish Patient Cohort

“…Thompson et al[25] recently compared different biopsy techniques (standard [<12 core, median 10] vs. saturation [>12 core, median 16], and transrectal vs transperineal biopsy), which showed that the AS protocol with saturation biopsies at the initial diagnosis and during follow-up reduced treatment-free survival during AS, while the AS protocol with transperineal biopsies reduced the likelihood of unfavorable disease in patients who underwent RP during follow-up. Similarly, Da Rosa et al [26] compared prospectively MRI-US fused targeted biopsy versus systematic ultrasound-guided biopsy for detecting clinically significant (CS) prostate cancer in patients on active surveillance and reported that MRI-ultrasound fusion biopsy detected CS cancer with far fewer cores and multiparametric MRI had a perfect negative predictive value in this population.…”

Active Surveillance in Prostate Cancer

“…Tablo 2'de farklı merkezlerin uygulamış olduğu takip protokolleri özetlenmiştir (10,11,12,13,14,15,16,17,18). Genel olarak Aİ'den definitif tedaviye geçmedeki nedenler progresyon olmadığı halde hastanın tercihi veya hastada oluşturduğu anksiyete, başlangıçtaki yüksek veya izlemde yükselen PSA değerleri, başlangıçtaki veya tekrar biyopsilerde saptanan yüksek evre, Gleason skor veya korlardaki yüksek kanser oranıdır (23).…”

“…Zamanlamada standart olmamakla birlikte konfirmasyon biyopsisi sonrası genellikle 6-12 ay içinde, sonra da merkeze göre değişmekle birlikte yıllık veya 3-4 yıllık periyotlarla yapılmaktadır (10,11,12). Konfirmasyon biyopsisi sonrası hasta seçimine ve biyopsi tekniğine bağlı değişmekle birlikte %2,5-28 oranında Gleason derecesinde değişiklik bildirilmiştir (15). Takip biyopsilerinde ise farklı merkezlerde %22-30 oranında progresyon saptanmıştır (11,12,13).…”