Trus biopsy prostate

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TRUS GUIDED

PROSTATE BIOPSYBY: PARTH NATHWANI

GUIDE: DR.NITIN JOSHI

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INTRODUCTION

• There is a significant decline in prostate cancer related mortality due to early prostate cancer detection programs.

• Role of PSA screening efforts, introduction & refinement of systematic transrectal ultrasonography (TRUS)– guided prostate biopsy techniques, and increased public awareness about prostate cancer.



• TRUS of the prostate- first described by Watanabe et al(1968).

• TRUS-guided systematic sextant biopsy protocol- introduced by Hodge et al(1989).

• TRUS: mainstay of many image-guided prostate interventions, including prostate biopsy, brachytherapy, cryotherapy, & high-intensity focused ultrasonography (HIFU), evaluation of appropriate patients for treatment of BPH.



ULTRASONOGRAPHICANATOMY OF PROSTATE

• The prostate lies between bladder neck and urogenital diaphragm, just anterior to rectum, an ideal position to be imaged by TRUS.



• On the basis of pathologic zonal architecture, prostate is divided into:

Anterior fibromuscular stroma (AFS) that is devoid of glandular tissue,

transition zone (TZ), central zone (CZ), periurethral zone, and peripheral zone (PZ).

• But these regions are not visible sonographically as distinct entities.





TRANSVERSE SAGITTAL



• Normal CZ and PZ(posterior): majority of adenocarcinomas; homogeneous echogenic appearance.

• TZ(anterior) is more heterogeneous.• Calcification along the surgical capsule known

as corpora amylacea highlight the plane between PZ & TZ

• Small , multiple , diffuse calcifications are normal



• The prostatic urethra traverses the length of the gland in the midline and thus must be imaged in the sagittal plane to be simultaneously viewed along the entirety of its course .

• The distended urethral lumen has a hypoechoic appearance whereas periurethral calcifications may produce a thin echogenic outline.

• The smooth muscle of the internal sphincter extends from the bladder neck, encircling the urethra to the level of the verumontanum.



• These muscle fibers may be visualized sonographically as a hypoechoic ring around the upper prostatic urethra, giving it a funneled appearance proximally as it arises from the bladder neck.

• On reaching the verumontanum the urethra angles anteriorly and runs through the remainder of the gland to exit at the apex of the prostate.

• This angle gives the prostatic urethra an anteriorly concave appearance when viewed along its entire course in the sagittal plane.



• The paired seminal vesicles (SVs) are positioned posteriorly at the base of the prostate.

• They have a smooth, saccular appearance and should be symmetrical.

• The normal SV measures 4.5 to 5.5 cm in length and 2 cm in width.



A, In the transverse plane with the hypoechoic urethra centrally located (star) and dotted line representing transverse measurement.

B, Midline sagittal view with the hypoechoic urethra running the length of the gland, D1 represents longitudinal and D2 anteroposterior measurement.



Seminal vesicles and vasadeferentia in the transverse plane



GRAY-SCALE TRUS

• Most common imaging modality for prostate.

• Most commonly used for:prostate cancer detectionevaluation of other conditions such as

infertilitydirecting the biopsy of prostate cancer.Staging of carcinoma prostate (limited role).



• Endorectal probes available in both side- and end-fire models; transmits frequencies of 6 to 10 MHz.

• Newer biplane probes provide simultaneous sagittal and transverse imaging modes.

• Probes provide a scanning angle approaching 180 degrees to allow simultaneous visualization of the entire gland in both the transverse and sagittal planes.

• Increasing frequency yields increased resolution



• As the frequency of the probe is increased, the portion of the image that is in focus (focal range) is closer to the transducer.

• The commonly used 7-MHz transducer produces a high resolution image with a focal range from 1 to 4 cm from the transducer (best for PZ where most cancers arise).

• Lower-frequency transducers (e.g., older 4-MHz transducers) have a focal range from 2 to 8 cm but at lower resolution they improve anterior deliniation of large gland & provides poor internal architecture visualization



TECHNIQUE

• Medium-gray image of normal PZ serves as the "reference point" for judging lesions as hypoechoic (darker than the normal PZ), isoechoic (similar to the normal PZ), hyperechoic (lighter than the normal PZ), or anechoic (completely black).

• Patients are scanned in left lateral ducubitus position

• TRUS should be performed in both transverse and sagittal planes.



VOLUME CALCULATION

• π/6 × transverse diameter × AP diameter × longitudinal diameter

• Mature average prostate-20-25 g and remains constant until age 50.

• For more accurate determination of prostate volume (Brachytherapy), Planimetry is required.

• PSA density = serum PSA/gland volume• Elevated PSAD have sensitivity & specificity

of 75% & 44%, but it is operator dependent.



PROSTATE CANCER IMAGING ON TRUS

• All hypoechoic lesions within the PZ: consider biopsy.

• A hypoechoic lesion is malignant in 17-57% of cases, but they are not pathognomonic for cancer.

• Lack of a distinct hypoechoic focus doesn't preclude biopsy, as 39% of Ca prostate cases are isoechoic, & 1% hyperechoic on conventional gray scale TRUS.



• Granulomatous prostatitis, prostatic infarct & lymphoma- all may produce hypoechoic lesions.

• Extracapsular extension of prostate cancer, although not well visualized if present as a microfocus, is suggested by a focal loss of the typically bright white periprostatic fat.



Classic hypoechoic peripheral zone (PZ) lesion(dotted line) in the right midgland that transrectal

ultrasonography–guided biopsy proved to be aGleason 3 + 3 = 6 adenocarcinoma.



CYSTIC LESION OF PROSTATE

• Simple cysts have the same sonographic appearance as in any other part of the body: they are thin walled, are anechoic, and show acoustic enhancement posterior to the cyst.

• Congenital prostatic cystic lesions may arise from either müllerian (müllerian duct cysts and prostatic utricles) or wolffian (ejaculatory duct and seminal vesicle cysts) structures.

• They appear in the midline as anechoic lesion



• Ejaculatory duct cysts are typically small, lie off of the midline, and may accompany ejaculatory duct obstruction/obliteration with azoospermia.

• Seminal vesicle cysts can be caused by congenital or acquired obstruction of the ejaculatory duct and are associated with cystic renal disease; up to two thirds of men with seminal vesicle cysts may also have renal agenesis



Prostatic cyst



INDICATIONS FOR PROSTATE BIOPSY

TRUS without Biopsy

• Treatment planning volume measurements: brachytherapy, cryotherapy, BPH therapy (e.g.TUMT, RFA)

• Volume measurement during hormonal downsizing for EBRT or brachytherapy

• Placement of fiducial markers for EBRT• Evaluation of azoospermia: ejaculatory duct cysts, seminal

vesicle cysts, etc.• Therapeutic aspiration or unroofing of prostatic cysts;

drainage of prostatic abscess



TRUS-Directed Biopsy

• Diagnosis of suspected symptomatic prostate cancer (i.e., bone metastasis, cord compression)

• Screening for prostate cancer in asymptomatic patient > age 50 with > a 10-year life expectancy (if strong family history or if African-American, consider screening at age 45)

Prostate nodule or significant prostate asymmetry regardless of PSA level

PSA > 4.0 ng/dL regardless of age In men < age 60 to 65 years, consider biopsy if PSA > 2.5 ng/dL If PSA > 0.6 ng/dL at age 40 Increased PSA velocity (>0.75 ng/dL/year) Free PSA in considering initial biopsy with PSA < 10 ng/mL: >25%

no biopsy; >10% and <15%, consider biopsy; <10%, biopsy



• Prior to intervention in symptomatic BPH (e.g., surgical therapy or initiation of 5α-reductase inhibitors)

• Prior to cystoprostatectomy or orthotopic urinary diversion

• To diagnose failed radiation therapy before use of second-line therapy

• Follow-up biopsy (3-6 months) after diagnosis of high-grade PIN or Atypical small acinar proliferation.



• Data from the Prostate Cancer Prevention Trial have shown that no safe PSA threshold can rule out prostate cancer in any age range.

• For a serum PSA value between 4.0 and 10.0 ng/mL, using a % free PSA threshold of <25% allowed detection of 95% of cancers while eliminating 20% unnecessary biopsies.



• Volume-based PSA parameters evaluated to reduce confounding from BPH.

• These include:PSA density (PSAD; PSA divided by prostate

volume),complexed PSA density (complexed PSA

divided by prostate volume), andPSA transition zone density (PSA divided by

transition zone volume).



• PSA levels between 4 and 10 ng/mL and a normal DRE:

PSAD ≥ 0.15- prostate biopsy recommended.PSA transition zone volume was the parameter

with highest overall sensitivity & specificity.



PSA Dynamics/PSA Velocity(PSAV):• Rate of change in PSA.• With PSA levels between 4-10 ng/mL, PSAV ≥ 0.75

ng/mL/year: a specific marker for the presence of prostate cancer.

• In PSA <4, PSAV > 0.5ng/mL/yr is significant.• PSAV may play a role in the prediction of life-

threatening prostate cancer . • A PSAV > 0.35 ng/mL/year 10-15 years prior to

diagnosis- fivefold increased risk of life-threatening prostate cancer more than a decade later.



CONTRAINDICATIONS TO PROSTATE BIOPSY

• Significant coagulopathy

• Painful anorectal conditions

• Severe immunosuppression, and

• Acute prostatitis.



PATIENT PREPARATION

• Written, informed consent.• All anticoagulant therapy (warfarin,

clopidogrel, aspirin/NSAIDs, herbal supplements) should be stopped 7-10 days before prostate biopsy.

• For coagulopathic pts., INR should be below 1.5.

• A small amount of urine can facilitate the examination .



ANTIBIOTIC PROPHYLAXIS

• Oral FQ one dose 30-60 min.before biopsy - continue for 3 days.

• Single dose oral FQ=3day regimen.

• High risk pts.(endocarditis, prosthetic joints, pacemakers, automated implanted cardiac defibrillators)- i.v. Ampicillin/Vancomycin + Gentamicin preop f/b 3days oral FQ.



Cleansing enema:

• decreases the amount of faeces in the rectum, thereby producing a superior acoustic window for prostate imaging.

• may reduce bacterial seeding of the prostate.



Analgesia

• Topical lidocaine jelly.• Infiltration anesthesia around nerve

bundles.• Direct infiltration(Intraprostatic

injection).• Skin & subcut.infiltration for

transperineal biopsy.



POSITION

• Left lateral decubitus position with knees and hips flexed 90 degrees.

• Lithotomy position preferred for transperineal biopsies, brachytherapy treatment planning, or placement of fiducial gold markers for external-beam therapy.

• Lithotomy position is preferred when color Doppler imaging is used to identify areas of hyperemia for targeted biopsy of the prostate(distribution of color Doppler flow within the prostate is dependent on patient position)



TRUS PROSTATE BIOPSY TECHNIQUES

• Assess prostate volume.

• Prostate imaging in transverse & sagittal planes(from base to apex).

• Note location and characteristics of any lesions (i.e., hypoechoic, hyperechoic, calcifications, contour abnormalities, cystic structures).



• A spring-driven, 18-gauge, needle core biopsy device or biopsy gun, passed through the needle guide attached to the ultrasound probe.

• Biopsy gun advances the needle 0.5 cm and samples subsequent 1.5 cm of tissue with the tip extending 0.5 cm beyond the area sampled.



BIOPSY GUN









18-gauge prostate needle biopsy core specimen



SEXTANT BIOPSY:• one core, bilaterally,

each from base, mid, and apex.

• samples both PZ & TZ.

• Vast majority of AdenoCa- posterolateral PZ.

TRUS BIOPSY SCHEMES



EXTENDED CORE BIOPSY SCHEMES

• Improved cancer detection rates by incorporating additional laterally directed cores into the standard systematic sextant technique.

• At present, 6 cores are considered inadequate for routine prostate biopsy for cancer detection.



• TZ and SVs are not routinely sampled(low yields for cancer detection at initial biopsy).

• TZ and anteriorly directed biopsies may occasionally prove necessary to diagnose prostate cancer in patients with persistently elevated PSA levels and prior negative biopsies.

• A role for TZ biopsies in men with gland size > 50 mL, with an additional yield of 15% cancer detection.



• Seminal vesicle biopsy is not routinely performed unless there is a palpable abnormality, when PSA value > 30, or if brachytherapy is being considered.



Various reported systematic biopsy schemes. A, Sextant biopsy scheme originally proposed by Hodge and

associates (Hodge et al, 1989b)B, The 10-core biopsy of Presti and coworkers (2000).C, The 12-core, or double sextant, biopsy.D, The 13-core “5-region biopsy” of Eskew and colleagues



Rp & lp-right &left periphery,rpm &lpm – rt & lt paramedian



Cross-sectional view of commonlybiopsied zones.





A 36 core biopsy scheme



• Proper sampling and labelling• Sample should be sent in 10% formalin filled

bottles• Preferably each individual sample should be

sent in different bottle, some prefer to send right & left only separately

• Some pathologists believe strongly that each site should be specifically identified because certain locations predisposed to cancer may look-alike(cooper’s gland at apex , seminal vesicle at base)



REPEAT PROSTATE BIOPSY

• Use of a 2nd prostate biopsy in all cases of a negative finding on initial biopsy is justified.

• But 3rd and 4th repeat biopsies should only be obtained in selected patients with high suspicion of cancer and/or poor prognostic factors on the 1st or 2nd biopsy.



• Overall cancer detection rates for repeat prostate needle biopsy with various biopsy templates ranges from 10% - 38%.

• Indications for a repeat prostate biopsy include the following:

1) A highly suspicious DRE (digital rectal examination)2) A persistently rising serum PSA (> 0.4 – 0.75

ng/ml/yr.)3) A low free PSA (certainly < 10%, maybe < 22% -

25%)4) Presence of PIN or atypia on prior biopsy



RISKS & COMPLICATIONS OF PROSTATE BIOPSY

Immediate:• Hematuria• Vasovagal episode• Rectal bleeding• Urinary retention

Delayed:• Persistent hematuria• Vague pelvic discomfort• Dysuria• Hematochezia• Hematospermia• Postbiopsy infections(low grade febrile illness, UTI,acute prostatitis,

epididymitis, fatal septicemia)



INTERPRETATION

• Benign prostatic hyperplasia • Acute inflammation • Chronic granulomatous inflammation • Atrophy • High grade prostatic intraepithelial neoplasm

(PIN) • Suspicious (lesion too small or insufficient

criteria present) • Adenocarcinoma.



ADVANCED USG TECHNIQUES FOR PROSTATE IMAGING

COLOR & POWER DOPPLER TRUS:• Color Doppler imaging is based on the

frequency shift in the reflected sound waves from the frequency of insonation

• Thus it depicts the velocity of blood flow in a directionally dependent manner.



• Color assignment is based on the direction of blood flow related to the orientation of the transducer receiving the signal; flow toward the transducer- red and flow away in shades of blue; color is not specific for arterial or venous flow.



Transrectal ultrasonography.

• Top image, solid white arrow depicts hypoechoic lesion within the peripheral zone concerning for prostate cancer.

• Lower image depicts hypervascular area seen with color Doppler imaging, yellow and red area corresponds to the hypoechoic area seen on the grayscale ultrasonography above.



POWER DOPPLER IMAGING (enhanced color Doppler, color amplitude imaging [CAI], or color angiography) uses amplitude shift to detect flow in a velocity and directionally independent manner.

• Advantages: ability to detect slower flow and to have less reliance on the Doppler angle, making it more suitable for detection of prostate cancer neovascularity.



A. Color Doppler transrectal ultrasonography (TRUS) andB. Power Doppler TRUS identify a Gleason 4 + 4 = 8

adenocarcinoma in the left midgland



• Patients with detectable color Doppler flow within their dominant tumor at the time of TRUS-guided biopsy are at a 10-fold increased risk for PSA recurrence after radical retropubic prostatectomy.

• The presence of increased flow was also accociated with high gleason grade, increased incidence of SV invasion & lower incidence of biochemical disease free survival rate.



CONTRAST ENHANCED TRUS(CE-TRUS)

• Intravenous microbubble ultrasound contrast agents, infused systemically during gray-scale and TRUS Doppler imaging amplify flow signals within the microvasculature of prostate tumors, allowing selective visualization of malignant foci.

• These agents increase the echogenicity of the intravascular space on grey-scale imaging and provide a dramatic visible increase in the Doppler signal.

• These are constructed with air or higher-molecular-weight gas agents encapsulated (albumin or polymer hard shell, lipid- or surfactant-coated) for longevity.



• CE-TRUS + 3D IMAGE RECONSTRUCTION of enhanced power doppler.

• GREY-SCALE HARMONIC imaging: better spatial & temporal resolution.

• FLASH REPLENISHMENT IMAGING: improved visualisation of vessels.



Unenhanced color (A) transrectal ultrasonography (TRUS) and power Doppler (B) TRUS fail to detect evidence of an underlying malignancy. After infusion of a

microbubble contrast agent, color (C) TRUS and power Doppler (D) TRUS demonstrate an area of increased flow in the left midgland that proved to be a Gleason

3 + 4 = 7 adenocarcinoma on targeted biopsy



OTHER TECHNIQUESARTIFICIAL NEURAL NETWORKS

ELASTOGRAPHY: • New sonography technique.• employs real-time sonographic imaging of

the prostate at baseline and under varying degrees of compression.

• Through computerized calculations, differences in displacement between ultrasonic images from baseline and during compression may be visualized, and regions with decreased tissue elasticity may be tagged as suggestive of malignancy.



Elastography demonstrates an area of decreased compliance in the right base consistent with an underlying malignancy (blue near arrow). Note color scale in upper right corner indicating relative tissue “firmness.” Targeted biopsy of

this region revealed a Gleason 4 + 4 = 8 adenocarcinoma



ENDORECTAL MRI & MR SPECTROSCOPIC IMAGING(MRSI):

• MRSI identifies biochemical changes within the tissue that may predate the appearance of histological changes.

• MRSI suggestive of malignancy may not have biopsy detectable PCa at the time of MRSI but may develop histological cancer at a later date.



TAKE HOME MESSAGE

• TRUS ALONE CANNOT DIAGNOSE PROSTATE CANCER WITHOUT A TISSUE BIOPSY

• MAINSTAY OF IMAGING FOR PROSTATE BIOPSY,BRACHYTHERAPY, CRYOTHERAPY & HIFU

• HYPOECHOIC FOCI SEEN ON GRAY SCALE TRUS SHOULD BE CONSIDERED S/O ADENOCARCINOMA & INCLUDED IN BIOPSY SPECIMEN



• 39% OF PROSTATE CANCER ARE NOT VISIBLE ON ROUTINE GRAY SCALE USG

• SEXTANT BIOPSY IS INADEQUATE, PREFER 10 TO 14 CORE BIOPSY.

• CONTRAST ENHANCED TRUS & BIOPSY , COLOUR & POWER DOPPLER IMAGING MODES MAY IMPROVE CANCER DETECTION IN FUTURE

• TRUS GRAY SCALE CORE NEEDLE BIOPSY IS THE GOLD STANDARD FOR DIAGNOSIS OF PROSATE CANCER AT PRESENT



ThankYou!

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Trus biopsy prostate