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