OBJETIVES: Ultrasound guided prostate biopsy is the only method to obtain the confirmation diagnosis of prostate cancer. Since its introduction at the end of the `80s multiple modifications of the technique have been implemented to improve cancer detection ratesand to diminish the rate of false negative results, with maximum patient comfort and less complications.METHODS: Bibliographic review and critical analysis of the literature on prostate biopsy.RESULTS/CONCLUSIONS: Published studies suggest extensive biopsy schemes increase detection rates in comparison to sextant biopsies, both first and successivebiopsies, being necessary to sample the most lateral areas of the gland and the dorsal apex where the diagnosticyield is greater. The indications for repeated biopsiesafter a negative one include high grade PIN and/orAtypical Small Acinar Proliferation (ASAP), persistent PSA elevation and/or total PSA doubling time increase. There is no consensus about the time for repeating biopsies, although it seems that cancer detection rates descend after the third biopsy. The introduction of periprostatic anesthetic blockage techniques has enabled pain control, mainly in more extensive biopsies.
OBJECTIVES: The endorectal MR spectroscopic imaging (MRS) is a new imaging technique that allows a more accurate and reliable evaluation for the localization and staging of prostate cancer(PCa) than the solemorphological study offered by endorectal MR alone. The combination of endorectal MRI and MRS allows a simultaneous morphologic and metabolic study thatimproves the detection of PCa. Moreover, the technical improvements recently introduced in the spectroscopic study of the prostate have led to an increase of reliability in the detection of PCa.METHODS AND RESULTS: We present in this article the advantages this technique offers in the detection of PCa in patients at high risk, as well as in patients with progressive PSA rising and previous negative biopsies. It also seems to be useful in the study of biochemical recurrences of PSA in previously treated patients, and for the study of the central gland. We comment, as well, the chance to use this tool in the staging of PCa. Our group is actually working with MRS in the detection of PCa, in collaboration with AATRM (Agency of Evaluation ofmedical technology for medical research) and wepresent some recent results in the use of this technique.CONCLUSIONS: MRS is a non-invasive method that allows the detection of PCa in the peripheral gland with a greater reliability than endorectal MRI alone, in selectyed patients. It is also a good technique for the study of the central gland, in which the detection of PCa is difficult by morphological methods. So, RMS allows the evaluation of metabolic disorders in the whole prostatic gland and improves the overall accuracy in the detection of PCa, either in the central or peripheral gland.
OBJECTIVES: Ultrasound guided biopsies are the mainstay in the diagnosis of prostate cancer. With the aim of improving diagnostic performancesdifferent protocols of prostate biopsy have been designed. The addition of vascular contrasts to the ultrasound allows for identification of hypervascular regions more likely to be cancer. The new ultrasound modalities enhance contrast signal and specifically differentiate its signal from the tissue reflections.METHOD: A non structured review of the literature was conducted on the utility of the different ultrasound modalities and types in targeting the biopsies of the prostate.RESULTS: There are four types of ultrasound guided biopsies of the prostate: ultrasound guided biopsy of hypoechoic nodes, systematic biopsy protocols, Doppler guided biopsy and Contrast Enhanced Doppler guided biopsy. In spite of the broad literature only few series possess a methodologically correct design related to the use of reference standards. The diagnostic performance of each one of the different types of biopsy varies widely. Sensitivity and specificity of ultrasound guided biopsy of hypoechoic nodes depends on the type of population included in the study but in general its positive predictive value is low. The protocols of systematic biopsy increase the sensitivity of the prostate biopsy but still specificity is low. The Doppler techniques offer a marginal benefit.Contrast Enhanced Doppler guided biopsies series have reported only a slightly increase in sensitivity and asignificant improvement of the odds risk for diagnostic of prostate cancer. New arising ultrasound modalities present with promising preliminary results.CONCLUSIONS: Ultrasound guided biopsy have an acceptable sensitivity in the diagnosis of prostate cancer, however specificity is overall low. Among the differentultrasound techniques only Contrast Enhanced Ultrasound improves significantly the diagnostic risk of the biopsy although the sensitivity remains quite stable. New specific contrast ultrasound techniques are currently underinvestigation.
OBJECTIVES: To evaluate if radicalprostatectomy may positively influence cancer-specific survival (CSS), hormone-resistance-free time, metastasis-free time, and quality of life(QoL) of patients with prostate adenocarcinoma and seminal vesicle invasion, and also to update our thoughts about seminal vesicle biopsy.METHODS: 114 patients were included. Forty-six cases were diagnosed of seminal vesicle invasion after radical prostatectomy; 68 cases were diagnosed of seminal vesicle invasion after biopsy, not undergoing then surgery. Cancer specific survival, time to hormone resistance from the start of hormonal treatment, metastasis free time and QoL, measured as need for hospital care, were compared between groups. Median follow-up time was 52.6 mos.RESULTS: There were not statistically significant differences between groups in CSS, time to hormone resistance, metastasis free time and QoL. Three and five-year cancer specific survival were 100% and 80.77% for the radical prostatectomy group and 74.4% and 56.2% for the biopsy group. Primary grade and Gleason Score were independent predictors for CSS in the Cox regression test; clinical stage was independent predictor for time to hormone resistance.CONCLUSIONS: Radical prostatectomy as monotherapy does not show a statistically significant influence onfollow-up time, CSS, time to hormone resistance, metastasis free time or QoL in patients with prostate cancer and seminal vesicle invasion associated with other bad prognostic factors (unfavourable Gleason and PSA). The value of seminal vesicle biopsy remains for the study of new multimodal treatments, such as chemotherapy + surgery, and it is to be defined in the planning of radio and cryosurgery.
This paper presents a review of the concept of “nomogram” applied to prostate cancer, and specifically as a staging tool.METHODS/RESULTS: We describe the essentialparameters for the evaluation of such type of predictive models: Calibration, discrimination and clinical usefulness. Such requisites are analyzed using a real clinical case in our clinical setting, comparing the “Partin`s tables” and the “Miguel Servet University Hospital´s nomogram”. We demonstrate its correct calibration, discrimination and clinical usefulness after previous selection of proper cut points.CONCLUSION: The application of the predictivemodel to our clinical practice has achieved a clinical understaging of 17.3% after radical prostatectomy.
The management of prostate cancerrepresents a real clinical problem for its unknown natural history, and unpredictable outcome and prognosis. The stage is the most important prognostic variable of any tumor. The use of nomograms, such as Partin`s tables, supplies important information for the evaluation of the local stage. Nevertheless, these methods have lowreliability because they do not use anatomical informationof the gland. The development of MRI techniquesincorporating high-resolution anatomical evaluation of the prostate in conjunction with metabolic information (MRI spectroscopy) offer the imaging technique of choice for the staging of prostate cancer in selected patients candidates to curative surgery. Prostate MRI offers the most reliable evaluation of local and regional staging. Anyway, many studies have described a wide variability in the reliability of prostate cancer staging by MRI,indicating that MRI is not a perfect imaging test because it cannot detect microscopic involvement. The objective of this article is to evaluate the current role of prostatic MRI for prostate cancer staging, evaluating its advantages,limitations and future expectations.
Prostate cancer preferentially metastasizesto regional lymph nodes and bone. The incidence ofdissemination has been reduced over the last years mainly due to the compost use of PSA. For this reason, the indication of complementary diagnostic tests has evolved with the aim of improving the diagnostic yield. Some of these techniques are currently under evaluation and may contribute in the close future to change the study of dissemination in the clinical practice. CT scan or MRI are the standard imaging studies for lymph node dissemination, whereas bone scan continues to be the routine test for bone dissemination.
Positron emission tomography (PET) is anon-invasive nuclear medicine technology which usesradiotracers and cameras slightly different from the onesused in other nuclear medicine tests. Most current indicationsare for oncological diseases; in nephrology-urology itsuse has been reduced because of the characteristics ofthe most commonly used radiotracer,18F-fluor deoxiglucose(18F-FDG, a glucose analogue), which is excreted bythe kidney, limiting the interpretation of the study in urologicmalignancies. Currently, 18F-choline is a promisingradiotracer for both staging and restaging, especially ifhybrid PET/CT scan devices are used. New radiotracerswill be needed in the evolution of PET to obtain informationabout more specific aspects of prostate carcinoma thatwill modify therapy and follow-up
Prostate cancer is one of the main health problems of the male population. Radical prostatectomy has demonstrated to have an excellent long-term cure rate. Nevertheless, globally, a 25% of the operated patients will suffer a PSA increase over 15 years offollow-up. Generally, the PSA value associated with a higher risk of clinical progression, that may be establishedas the cut point for biochemical recurrence is 0.4 ng/ml. Once biochemical recurrence is diagnosed, the most important clinical data is to determine if clinical recurrence is going to be local or systemic, because it will determine treatment. Main parameters helping to differentiate between one and another are: time interval to PSA increase, PSA velocity, PSA doubling time (PSADT), pathologic stage and specimen’s Gleason’s score. The possibilities of treatment of biochemical failure after radical prostatectomy are under debate. Nevertheless, it is currently considered that patients with biochemical recurrence without radiological evidence of distantmetastases are ideal candidates for local treatment with radiotherapy.
OBJECTIVES: Due to the permanence of the prostate, PSA does not descend to undetectablelevels after radical radiotherapy the way it happens after radical prostatectomy. PSA as response parameter after radiotherapy or for the characterization of biochemical recurrence is very sensitive but not much specific. The positive predictive value for local or systemic clinicalrecurrence is low, so that the use of PSA alone for the indication of rescue therapies is open to debate. There are different definitions of biochemical recurrence after radiotherapy. To date, the most standardized definition was that of the American Society for Therapeutic Radiologyand Oncology (ASTRO) in 1996, but it was exclusive for patients treated with external beam radiotherapy as monotherapy. It was very sensitive to the follow-up time, but it was based on retrospective data, and its correlationwith clinical progression was suboptimal. With the aim of improving the definition of biochemical failure ASTRO reunited a new expert commission in 2005 that gave a new definition of biochemical failure more specific for clinical events and valid in the context of short-termandrogen deprivation or brachytherapy. The finalrecommendations were to consider biochemical recurrencea PSA increase of 2 ng/ml or greater over the nadir, or patients that have received rescue therapies. Prostate biopsy after radiotherapy is employed in patients with suspicion of exclusively local recurrence to direct them to rescue therapies. The criteria for the diagnosis of posttherapy carcinoma must be homogenized beforeestablishing this test as a routine in the evaluation of treatment response. Standard imaging techniques for the localization of clinical recurrences (99-technetium bone scan, CT scan and MRI) are not much sensitive and it is predictable that other diagnostic tests which have a metabolic character (such as PET with various tracers, MR spectroscopy) will be used for the study of biochemical recurrence after radiotherapy in the near future.
Currently prostate cancer is the mostfrequent extracutaneous neoplasia in males in the USA, and second after lung cancer in our country. Over the last years the profile of prostate cancers diagnosed has changed due to the wide diffusion of PSA determination. Currently, almost 47% of prostate cancers are low risk at diagnosis. In this situation, the minimally invasive therapiessuch as brachytherapy have a growing acceptance in our environment. We analyze the special PSA kinetics after brachytherapy, and the difficulty entailed by thediagnosis of biochemical recurrence after brachytherapy,performing a bibliographic review of the available scientific evidence.
OBJECTIVES: To evaluate the current role of PSA as a diagnostic method for prostate cancer, as well as to analyze possible new markers.METHODS: We perform a bibliographic review for PSA, and its molecular forms, as a marker to deﬁne the presence of prostate cancer. We review the factors related to PSA modiﬁcations, predictive models, or the current controversies about the usefulness of its cutpoint to deﬁne the risk of prostate cancer or the marker itself. We analyze possible new markers and the most interesting work lines in the development of new markers. We used MEDLINE for the bibliographic search.RESULTS: Available data conﬁrm that PSA has a high sensitivity; although speciﬁcity is low, mainly in the ≤ 10 ng/ml range, it may be increased with the use of various molecular isoforms, ratios or predictive models. Nevertheless, it is true that despite such studies it is difﬁcult to increase speciﬁcity, so biopsies are reduced. Currently we have new markers, some of them already marketed, others in development, which seem to improve the speciﬁcity of PSA (isoforms, use of molecular biology).CONCLUSIONS: PSA is still the standard marker for the diagnosis of prostate cancer. It is important to improve the speciﬁcity; therefore we need new predictive models or new isoforms that help us to do a better selection of candidates for biopsy. There are various promising research lines with new markers, but there is not ideal substitute for PSA yet.
OBJECTIVES: To review the value of PSA kinetics in the diagnosis and prognosis of prostate cancer.METHODS: Review of the literature through a Medline search. CONCLUSIONS: A pre-tretament PSAV value >2ng/ml/yr is a risk factor for increased mortality from prostate cancer after surgery or radiation therapy. A PSADT 10 is more likely associated with local recurrence.
This review article presents the lateadvances in the pathologic diagnosis of prostate cancer, new concepts and predictive factors, emphasizing the new biomolecular markers in prostate cancer.