Rationale and Objectives
Accuracy of ultrasound-guided biopsy and Gleason score is limited, and diagnosis of insignificant cancer with Gleason score ≤6 is frequent when extended biopsy schemes are used. We evaluated whether the magnetic resonance imaging (MRI)-targeted in-bore prostate biopsy correctly identifies the Gleason score of prostate cancer in histopathologic correlation after prostatectomy. Simultaneously a targeted concept is expected to keep down the rate of insignificant cancer.
Materials and Methods
We compared retrospectively the Gleason score of the MRI-targeted in-bore biopsy with prostatectomy specimens in 50 men with prostate cancer. Endorectal MRI included T2-weighted imaging, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and spectroscopy. Lesions with a prostate imaging–reporting and data system (PI-RADS) score ≥3 were considered. Upgrading and downgrading of tumors was evaluated, and significant upgrading was defined as a shift in Gleason score from 6 to 7 or more.
Results
Gleason score was concordant in 66% of the patients, overall upgraded in 30% of patients, and downgraded in 4% of patients. Significant upgrading of the Gleason score from 6 to 7 occurred in eight patients; upgrading did not exceed one step in the Gleason score. After prostatectomy the Gleason score 6 was found in 20% of patients. The median number of cores obtained was 4 (range 2–6), and the median number of positive cores was 2 (range 1–4).
Conclusions
In-bore MRI-targeted biopsy offers good accuracy in the Gleason score with postprostatectomy histopathologic control when compared to the literature. A limited number of cores are sufficient to achieve these results. The fraction of insignificant cancer identified by targeted only-biopsy is low. Upgrading is restricted to one step in the Gleason score. Clinicians should be aware of positive findings in MRI and the biopsy technique used when assessing prostate biopsy results.
Prostate cancer has become the most common cancer among men. Widespread use of prostate-specific antigen (PSA) screening has led to an increasing number of diagnoses and at the same time to an increasing detection rate of insignificant cancer. Prediction of cancer significance is predominantly based on the Gleason score. According to the Consensus Conference on Gleason grading, the Gleason score combines the most frequent and the highest Gleason grade in biopsy and the most frequent and second most frequent Gleason grade in prostatectomy specimens .
Now there are alternative treatment options to radical prostatectomy (RP) such as radiation therapy or active surveillance. Appropriate treatment depends on preoperative tumor grading in biopsy specimens.
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Materials and methods
Patients
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Imaging
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Biopsy
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Table 1
MRI Protocol for MR-Targeted In-bore Prostate Biopsy
Objective Sequence Plane TR/TE (msec) Slice Thickness (mm) Matrix FOV (mm) Voxel Size (mm) Flip Angle Acquisitions PAT Time of Acquisition Planning of slice orientation trueFISP Axial, coronal, sagittal 4.2/2.1 msec 3.5 256 × 256 400 × 400 1.6 × 1.6 × 3.5 57 1 2 45 seconds Define landmarks ( Fig 4 a) T2-weighted TSE Axial 4930/100 3 205 × 256 200 × 200 1.0 × 0.8 × 3.0 1 1:53 minutes Navigation of needle holder ( Fig 4 b and c) trueFISP Sagittal and coronal 4.2/2.1 3.5 256 × 256 400 × 400 1.6 × 1.6 × 1.6 × 3.5 57 1 2 27 seconds Control of needle position ( Fig 4 d) BLADE Sagittal 4260/138 3 320 × 320 420 × 420 1.3 × 1.3 × 3 148 1 2 34 seconds Control of needle position ( Fig 4 e) trueFISP Axial 4.5/2.3 3.5 384 × 384 400 × 400 1.0 × 1.0 × 3.5 57 2 2 39 seconds
BLADE, proprietary name for periodically rotated overlapping parallel lines with enhanced reconstruction; FOV, field of view; MRI, magnetic resonance imaging; PAT, parallel imaging technique; TE, echo time; TR, repetition time; trueFISP, true fast imaging with steady-state precession; TSE, turbo spin echo.
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Data Analysis
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Results
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Table 2
Patient Characteristics
Variable Mean Median Range Age (years) 66 66 47–80 PSA (ng/mL) 10.79 8 3.03–38.8 Prostate volume (mL) 40.5 36.5 20–79 PSA density (ng/mL 2 ) 0.28 0.24 0.09–0.9 Time between biopsy and surgery (days) 39.78 38.5 12–106 Biopsy cores obtained per patient 3.96 4 2–6 Cores with tumor per patient 2.4 2 1–4 Tumor length per core (mm) 4.47 4 0.3–15 Tumor percentage per core (%) 39.8 33 3–100
PSA, prostate-specific antigen.
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Table 3
Distribution of Biopsy and Prostatectomy Gleason Grades
Biopsy Grades Prostatectomy Grades (% of Biopsy Grades) Total 5 6 7 8 9 6 1 (6%)9 (50%) 8 (44%) — — 18 7 — —19 (79%) 5 (21%) — 24 8 — — 1 (20%)2 (40%) 2 (40%) 5 9 — — — —3 (100%) 3 Total 1 9 28 7 5 50
Concordant Gleason scores are set in bold.
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Discussion
Overall Accuracy
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Table 4
Data Published for an Accuracy of Gleason Score in Prostate Biopsy
Study_n_ Patients Time Period Biopsy Technique Number of Cores Obtained Accuracy Upgrading Significant Upgrading (Gleason Score 6 to >7 or More) Downgrading Prevalence of Gleason score ≤6 Capitanio et al. 301
Only Gleason score ≤6 2001–2007 TRUS 18 (Median) — — 32% — — Chun et al. 2982 1992–2004 TRUS 6–12 56% 29% 37% 14% 47% Chung et al. 247 2006–2011 TRUS ≥12 57% 35% 42% 8% 30% Cohen et al. own data 2890 1982–2007 TRUS — 58% 36% 46% 5% 40% Cohen et al. meta-analysis 14,839 1973–2007 TRUS — 63% 30% 38% 7% 47% Corcoran et al. 1629 1995–2010 TRUS 8 (Median) 62% 29% 41% 10% 17% Corcoran et al. 684
Only Gleason score 6, 7 2003–2008 TRUS 10, 3–30 (Median, range) — — 67% — — Divrik et al. 206 1998–2005 TRUS 11, 10–14 (Median, range) 57% 34% — 10% 50% 186 1998–2005 TRUS 6–9 (Sextant biopsy) 41% 38% — 22% 46% Epstein et al. 7643 2002–2010 TRUS ≥10 73% ∗ 19% ∗ 36% 8% ∗ 50% Fanning et al. 206 2003–2008 TRUS ≥12 52% ∗ 36% ∗ 52% 12% 31% Freedland et al. 1113 1996–2006 TRUS 10, 6–40 (Median, range) 62% 27% 32% 11% 53% Gofrit et al. 448
Only Gleason score 6 2003–2006 TRUS ≥8 — — 20% — — Kahl et al. 185 1999–2003 TRUS 24, 13–33 (Mean, range) 20% 57% — 24% 42% 55 1997–2001 TRUS 9 (Mean, ≤12) 24% 60% — 16% 37% Numao et al. 143 2002–2006 TRUS + transperineal 26 92% — 26% — 20% Richstone et al. 4035 1983–2003 TRUS 6, 2–39 (Median, range) 66% ∗ 30% 36% 6% 49% Sfoungaristos et al. 271 2005–2010 TRUS 11–13 (Mean, different groups) 44% 42% 64% 14% 31% Arsov et al. 8 2010–2011 TRUS + MRI visually directed 11 (Median) 63% 37% 25% 0% 0% Baco et al. 128 2010–2013 TRUS + MRI fusion Targeted cores 2, 1–4 per lesion (median, range) + mapping biopsies (number not specified) 80% ∗ 16% 30% 14% 20% Hambrock et al. 64 2006–2009 TRUS 10 55% 44% 56% 1% 28% 34 MRI in-bore 3, 1–5 (Median, range) 88% 12% 8% 0% 35% Labanaris et al. 70 2004–2009 TRUS + MRI visually directed 3–6 90% 9% 9% 1% — Le et al. 54 2010–2013 TRUS + MRI fusion combined 18, 15–20 (Mean, range) 72% 7% — 20% 13% 54 2010–2013 TRUS 12 50% 39% — 11% 54 2010–2013 MRI fusion 6, 4–8 (Mean, range) 57% 31% — 11% Zhang et al. 40 (48 Tumors in 40 patients) 2010–2013 TRUS 12-core versus TRUS + MRI visually directed 12–18 77% 13% 29% 2% 29% Own data 50 2007–2014 MRI in-bore 4, 2–6 (Median, range) 66% 30% 44% 4% 20%
MRI, magnetic resonance imaging; TRUS, transrectal ultrasound.
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Upgrading
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Significant Upgrading
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Downgrading
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Number and Quality of Positive Cores
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Limitations
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Conclusions
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References
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