Prostate Imaging and Biopsy - Dr Graham ... - Parkside Hospital
Prostate Imaging and Biopsy - Dr Graham ... - Parkside Hospital
Prostate Imaging and Biopsy - Dr Graham ... - Parkside Hospital
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<strong>Prostate</strong> <strong>Imaging</strong> <strong>and</strong> <strong>Biopsy</strong><br />
<strong>Dr</strong> <strong>Graham</strong> Munneke<br />
Consultant Interventional Radiologist<br />
St George’s <strong>Hospital</strong> London
Introduction<br />
• Epidemiology<br />
• Development of TRUS<br />
• Guidelines for best practice<br />
• Morbidity<br />
• Future changes <strong>and</strong> challanges
History<br />
• Ultrasound first used to image<br />
the prostate in 1967<br />
• TRUS as we know it developed<br />
in the mid 1980’s
The Disease<br />
• If men live long enough the presence of<br />
histological evidence of cancer in the prostate is<br />
a almost universal<br />
• But only 3% of men die as a consequence of<br />
prostate cancer<br />
• Most common cancer in men accounting for<br />
25% of new diagnoses in the UK<br />
• <strong>Prostate</strong> cancer is the second highest cause of<br />
cancer related death at 13% second only to lung<br />
cancer.<br />
• 3 fold increase in incidence in black men
Diagnosis<br />
• Digital rectal examination<br />
• PSA level<br />
• Trans-rectal Ultrasound<br />
• MRI<br />
• <strong>Biopsy</strong><br />
• Between 56 <strong>and</strong> 89 thous<strong>and</strong> biopsies in<br />
Engl<strong>and</strong> <strong>and</strong> Wales per year
Diagnosis on ultrasound<br />
• Cancer becomes visible on Ultrasound because of surrounding<br />
histological changes<br />
– Fibrosis, oedema, neo-vascularity<br />
• Larger, poorly differentiated <strong>and</strong> palpable tumours are more likely to<br />
be visualised<br />
• Contemporary tumors are investigated at an earlier stage <strong>and</strong> this is<br />
not the usual situation<br />
• Typical findings: A hypo- echoic nodule in the peripheral zone
TRUS<br />
• Hypo echoic nodule<br />
• Increased vascularity<br />
• Focal bulge in the capsule<br />
• Loss of definition of the<br />
capsule
• Most cancers are occult/isoechoic on<br />
TRUS<br />
• The PPV for TRUS was estimated at<br />
60%<br />
• This is historic<br />
• Modern cancers are of lower stage<br />
<strong>and</strong> PSA level the PPV is now much<br />
lower.<br />
• Poor PPV because<br />
– Poor specificity –BPH<br />
• Prostatitis<br />
• Calcification<br />
– Poor sensitivity<br />
• Early grade, isoechoic<br />
cancers<br />
• Gleeson scoring is needed to direct<br />
management<br />
Why <strong>Biopsy</strong>
Anatomy<br />
• Peripheral Zone<br />
• Central zone<br />
• Transitional zone
Location of cancer
Number of Cores<br />
• Increasing cores<br />
increases diagnosis<br />
• But may increase<br />
complications<br />
6 cores<br />
8 cores 10 cores<br />
12 cores
Sampling the peripheral Zone
Saturation biopsy<br />
– 20-40 cores. Local Anaesthetic ± Sedation<br />
– Post Procedure observation for 4 hours<br />
– Has been reported to be positive in 13-34% of<br />
selected patients<br />
– Increased complication rate<br />
• 8% Urinary retention rate *<br />
• 4-12% Major Haemorrhage rate **/***
Pain Relief
Two methods:<br />
• Apical Infiltration<br />
• Basal Infiltration<br />
Pain Relief
Bleeding Complications<br />
Table 9.4: The frequency <strong>and</strong> Duration of Post <strong>Prostate</strong> <strong>Biopsy</strong><br />
Morbidity<br />
35<br />
30<br />
25<br />
20<br />
%<br />
15<br />
10<br />
5<br />
0<br />
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7<br />
Data based on the authors experience of<br />
sextant biopsies<br />
Haematuria<br />
PR bleed<br />
Haematospemia
Future Directions<br />
• More accurate<br />
mapping of the<br />
cancer<br />
• Template biopsy<br />
• Ablative therapies
Current best Practice<br />
• NHS Cancer Screening Program: Guidelines for<br />
Undertaking a Transrectal Ultrasound Guided <strong>Biopsy</strong> of<br />
the <strong>Prostate</strong> (<strong>Dr</strong>aft)<br />
– 10-12 biopsies targeted onto the peripheral zone<br />
– Routine Transition zone biopsies are unnecessary<br />
– No size correction<br />
– At the least the cores should be separated into left<br />
<strong>and</strong> right lobes; best to analyse each core separately