Prostate biopsy is a procedure in which small hollow needle-core samples are removed from a man's prostate gland to be examined microscopically for the presence of cancer. It is typically performed when the result from a PSA blood test rises to a level that is associated with the possible presence of prostate cancer. It may also be considered advisable after a digital rectal exam (DRE) finds possible abnormality. PSA screening is controversial as PSA may become elevated due to non-cancerous conditions such as a benign enlargement of the prostate (BPH, benign prostatic hyperplasia), by infection, or by manipulation of the prostate during surgery or catheterization; and many prostate cancers detected by screening develop so slowly that they would not cause problems during a man's lifetime, making the complications due to treatment unnecessary.
The procedure, usually done as an outpatient, requires a local anesthetic; some men do report discomfort during the biopsy. The most frequent side effect of the procedure is blood in the urine or stool for several days or blood in the ejaculate possibly for several weeks afterwards. These side effects are usually self-limited and do not require additional treatment.
- Ultrasound-guided prostate biopsy 1
- Negative biopsy 2
- MRI-guided targeted biopsy 3
- Side effects 4
- Gleason score 5
- Tumor markers 6
- External links 7
Ultrasound-guided prostate biopsy
The procedure may be performed transrectally, through the urethra or through the perineum. The most common approach is transrectally, and historically this was done with tactile finger guidance. The most common method of prostate biopsy as of 2014 was transrectal ultrasound-guided prostate (TRUS) biopsy.
Extended biopsy schemes take 12-14 cores from the prostate gland through a thin needle in a systematic fashion from different regions of the prostate.
A biopsy procedure with a higher rate of cancer detection is template prostate mapping (TPM) or transperineal template-guided mapping biopsy (TTMB), whereby typically 50 to 60 samples are taken of the prostate through the outer skin between the rectum and scrotum, to thoroughly sample and map the entire prostate, through a template with holes every 5mm, usually under a general or spinal anaesthetic.
Antibiotics are usually prescribed to minimize the risk of infection. An enema may also be prescribed for the morning of the procedure. In the transrectal procedure, an ultrasound probe is inserted into the rectum to help guide the biopsy needles. A local anesthetic is then administered into the tissue around the prostate. A spring-loaded prostate tissue biopsy needle is then inserted into the prostate, making a clicking sound. If local anesthetic is satisfactory, discomfort is minimal.
In a large multicenter study of 2,299 patients examining cancer detection rates via various biopsy schemes, a 12-site biopsy scheme outperformed all other schemes, with an overall detection rate of 44.4%. PSA levels were directly correlated with cancer detection rates, ranging from 19% in patients with PSA <2, up to 68% inpatients with PSA >20.
However a negative biopsy does not ensure the absence of disease. Systematic TRUS biopsy is "blind" since prostate cancer cannot often be seen with ultrasound. This problem is exacerbated in patients with larger prostate glands. In a 14-site biopsy, the additional cores are often taken at apical and anterior regions, a common site of "missed" tumors.
Initial biopsies can miss 20–30% of clinically significant cancers. Thus, negative biopsies in men with persistently elevated PSA levels are often followed by subsequent biopsies. With each additional biopsy session, the rate of cancer detection decreases. TPM provides a better detection rate, and fewer false negatives, making further biopsies in future less necessary.:10
To address this problem, in 2010 researchers examined the ability of mitochondrial DNA to help diagnose prostate cancer in negative biopsy samples.
MRI-guided targeted biopsy
Since the mid-1980s, TRUS biopsy has been used to diagnose prostate cancer in essentially a blind fashion because prostate cancer cannot be seen on ultrasound due to poor soft tissue resolution. However, multi-parametric magnetic resonance imaging (mpMRI) has since about 2005 been used to better identify and characterize prostate cancer. A study correlating MRI and surgical pathology specimens demonstrated a sensitivity of 59% and specificity of 84% in identifying cancer when T2-weighted, dynamic contrast enhanced, and diffusion-weighted imaging were used together. Many prostate cancers missed by conventional biopsy are detectable by MRI-guided targeted biopsy.
Two methods of MRI-guided, or “targeted” prostate biopsy, are available: (1) direct "in-bore" biopsy within the MRI tube, and (2) fusion biopsy using a device that fuses stored MRI with real-time ultrasound (MRI-US). Visual or cognitive MRI-US fusion have been described.
When MRI is used alone to guide prostate biopsy, it is done by an interventional radiologist. Correlation between biopsy and final pathology is improved between MRI-guided biopsy as compared to TRUS.
In the fusion MRI-US prostate biopsy, a prostate MRI is performed before biopsy and then, at the time of biopsy, the MRI images are fused to the ultrasound images to guide the urologist to the suspicious targets. Fusion MRI-US biopsies can be achieved in an office setting with a variety of devices.
MRI-guided prostate biopsy appears to be superior to standard TRUS-biopsy in prostate cancer detection. Several groups in the U.S., and Europe, have demonstrated that targeted biopsies obtained with fusion imaging are more likely to reveal cancer than blind systematic biopsies. Recently, AdMeTech Foundation, American College of Radiology and European Society of Eurogenital Radiology developed Prostate Imaging Reporting and Data System (PI-RADS v2) for global standardization of image acquisition and interpretation, which similarly to BI-RADS standardization of breast imaging, is expected to improve patient selection for biopsies and precisely-targeted tissue sampling. PI-RADS v2  created standards for optimal mpMRI image reporting and graded the level of suspicion based on the score of one to five, with the goal to improve early detection (and exclusion) of clinically significant (or aggressive) prostate cancer. The higher suspicion on mpMRI and the higher PI-RADS v2 score, the greater the likelihood of aggressive prostate cancer on targeted biopsy. Considerable experience and training is required by the reader of prostate mpMRI studies.
Up to 2013, indications for targeted biopsy have included mainly patients for whom traditional TRUS biopsies have been negative despite concern for rising PSA, as well as for patients enrolling in a program of active surveillance who may benefit from a confirmatory biopsy and/or the added confidence of more accurate non-invasive monitoring. Increasingly, men undergoing initial biopsy are requesting targeted biopsy, and thus, the use of pre-biopsy MRI is growing rapidly.
Clinical trials of mpMRI and PI-RADS v2, including NIH-funded studies are underway to further clarify the benefits of targeted prostate biopsy.
Side effects of a TRUS or TPM biopsy include:
- rectal pain or discomfort (very common)
- burning when passing urine (very common)
- bruising (very common with TPM only)
- bloody urine for 2–3 days (very common)
- bloody semen for ~3 months (30% with TRUS; ~100% with TPM)
- poor erections for ~8 weeks (30% with TRUS; ~100% with TPM)
- infection of skin or urine (1-8%)
- infection of skin or urine requiring hospitalisation and intravenous antibiotics (1-4%)
- difficulty urinating (1% with TRUS; >5% with TPM)
The tissue samples are then examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or Gleason score) of any cancer found. Gleason score, PSA, and digital rectal examination together determine clinical risk, which then dictates treatment options.
Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of malignant cells that have metastasized.
- Essink-Bot, ML; de Koning HJ; et al. (1998-06-17). "Short-term effects of population-based screening for prostate cancer on health-related quality of life". J Natl Cancer Inst. 90 (12): 925–31.
- Ghei, M; Pericleous S; et al. (September 2005). "Finger-guided transrectal biopsy of the prostate: a modified, safer technique". Ann R Coll Surg Engl 87 (5): 386–7.
- Tales from a prostate biopsy, MSNBC.com
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- PROMIS - Prostate MRI Imaging Study. An evaluation of multi-parametric magnetic resonance imaging in the diagnosis and characterisation of prostate cancer. (UK) Medical Research Council - Clinical Trials Unit - PROMIS Trials Office. MRC: PR11, 2 February 2012
- Taira A. V., Merrick G. S., Galbreath R. W., Andreini H., Taubenslag W., Curtis R.; et al. (2010). "Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting". Prostate cancer and prostatic diseases 13 (1): 71–77.
- Presti J. C. J., O'Dowd G. J. G., Miller M. C. M., Mattu R. R., Veltri R. W. R. (2003). "Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study". JURO 169 (1): 125–129.
- Presti J. C. J. (2009). "Repeat prostate biopsy--when, where, and how". Urologic oncology 27 (3): 312–314.
- Reguly B, Jakupciak JP, Parr RL. 3.4 kb mitochondrial genome deletion serves as a surrogate predictive biomarker for prostate cancer in histopathologically benign biopsy cores (2010). "3.4 kb mitochondrial genome deletion serves as a surrogate predictive biomarker for prostate cancer in histopathologically benign biopsy cores". Can Urol Assoc J. 4 (5): E118–22.
- Robinson K, Creed J, Reguly B, Powell C, Wittock R, Klein D, Maggrah A, Klotz L, Parr RL, Dakubo GD. (2010). "Accurate prediction of repeat prostate biopsy outcomes by a mitochondrial DNA deletion assay". Prostate cancer and prostatic diseases 13 (2): 126–31.
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- Hambrock, T., Hoeks, C., de Kaa, C. H.-V., Scheenen, T., Fütterer, J., Bouwense, S., et al. (2011). Prospective Assessment of Prostate Cancer Aggressiveness Using 3-T Diffusion-Weighted Magnetic Resonance Imaging–Guided Biopsies Versus a Systematic 10-Core Transrectal Ultrasound Prostate Biopsy Cohort. European urology, 1–8. doi:10.1016/j.eururo.2011.08.042
- Sonn G. A., Natarajan S., Margolis D. J. A., MacAiran M., Lieu P., Huang J.; et al. (2012). "Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device". JURO 189 (1): 86–91.
- Vourganti S., Rastinehad A., Yerram N. K., Nix J., Volkin D., Hoang A.; et al. (2012). "Oncology: Prostate/Testis/Penis/UrethraMultiparametric Magnetic Resonance Imaging and Ultrasound Fusion Biopsy Detect Prostate Cancer in Patients with Prior Negative Transrectal Ultrasound Biopsies". JURO 188 (6): 1–6.
- Kuru, T. H., Roethke, M. C., Seidenader, J., Simpfendörfer, T., Boxler, S., Alammar, K., et al. (2013). Critical evaluation of MRI-targeted TRUS-guided transperineal fusion biopsy for detection of prostate cancer. JURO, –. doi:10.1016/j.juro.2013.04.043
- Fiard, G., Hohn, N., Descotes, J.-L., Rambeaud, J.-J., Troccaz, J., & Long, J.-A. (2013). Targeted MRI-guided Prostate Biopsies for the Detection of Prostate Cancer: Initial Clinical Experience With Real-time 3-Dimensional Transrectal Ultrasound Guidance and Magnetic Resonance/Transrectal Ultrasound Image Fusion. Urology, –. doi:10.1016/j.urology.2013.02.022
- "AdMeTech". www.admetech.org. Retrieved 2015-09-28.
- "Prostate Imaging Reporting and Data System (PI-RADS) - American College of Radiology". www.acr.org. Retrieved 2015-09-28.
- Shtern, Faina (September 28, 2015). "Synopsis of PI-RADS v2". Journal of European Urology.
- Search of: prostate mri biopsy - List Results - ClinicalTrials.gov
- Chuang AY, Demarzo AM, Veltri RW, Sharma RB, Bieberich CJ, Epstein JI (2007). "Immunohistochemical Differentiation of High-grade Prostate Carcinoma From Urothelial Carcinoma". The American Journal of Surgical Pathology 31 (8): 1246–1255.
- Yaghi, Mohand (9.8.2015). "MD PgD ChM". Urology annals 7 (4): 417-427 .
- How a prostate biopsy is done
- An informative video detailing the process of MRI-US fusion targeted biopsy can be found at the UCLA Department of Urology website.