Optimizing patient's selection for prostate biopsy: A single institution experience with multi-parametric MRI and the 4Kscore test for the detection of aggressive prostate cancer

Prostate biopsy is the gold standard diagnostic technique for the detection of prostate cancer. Patient selection for prostate biopsy is complex and is influenced by emerging use of prebiopsy imaging. The introduction of the magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion prostate biopsy has clear advantages over the historical standard of care. There are several biopsy techniques currently utilized with unique advantages and disadvantages. We review and summarize the current body of literature pertaining to when and how a prostate biopsy should be performed. We discuss current recommendations regarding patient selection for biopsy and discuss future directions regarding prebiopsy imaging. We offer a description of the MRI–TRUS fusion biopsy technique and a comparison of many of the currently available fusion software platforms. Articles pertaining to the title were obtained via PubMed index search with relevant keywords supplemented with personal collection of related publications. Prostate biopsy should be considered for patients with gross digital rectal exam (DRE) abnormality, patients with a prostate-specific antigen (PSA) greater than 4 ng/ml, and concomitant risk factors for prostate cancer or patients with lesions identified on multiparametric MRI (mpMRI) with Prostate Imaging Reporting and Data System 2 (PI-RADS2) score of 4 or 5. MRI–TRUS fusion biopsy has demonstrated advantages in cancer detection when compared with TRUS-guided biopsy. There are currently several fusion software platforms available with a variety of biopsy approaches. Future efforts should detail the role of prebiopsy imaging as a triage tool for prostate biopsy. Consensus should be sought regarding the preferred modality of fusion biopsy. Additional data describing each fusion software platform would enable a more rigorous comparison of platform sensitivities.

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Among men with low-grade prostate cancer on prostate biopsy, the 4Kscore to predict prostate cancer aggressiveness at prostatectomy.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.2_suppl.65 ◽

2016 ◽

Vol 34 (2_suppl) ◽

pp. 65-65

Author(s):

Bruno Nahar ◽

Sanoj Punnen ◽

Stephen M Zappala ◽

Daniel Sjoberg ◽

Dipen Parekh

Keyword(s):

Prostate Cancer ◽

United States ◽

Radical Prostatectomy ◽

Prostate Biopsy ◽

The United States ◽

Low Grade ◽

Surgical Specimen ◽

Aggressive Prostate Cancer ◽

Free Psa ◽

Cancer Aggressiveness

65 Background: Most men diagnosed with prostate cancer in the United States have low-grade tumors. While many of these men are good candidates for active surveillance, a proportion will have a bad outcome due to the presence of a more aggressive prostate cancer that was missed on initial biopsy. A recent study confirmed the 4Kscore accurately predicts the likelihood of aggressive cancer on prostate biopsy. We analyzed if the 4Kscore could predict the presence of more significant cancer in men with low-grade tumors on the diagnostic biopsy. Methods: A recent prospective validation of the 4Kscore was conducted at 26 sites throughout the United States. We selected men who were found to have low-grade (Gleason 6) cancer on biopsy for this analysis. The 4Kscore calculates the risk of aggressive prostate cancer on prostate biopsy by a blood test that measures levels of four kallikrein biomarkers (total PSA, free PSA, intact PSA, and human kallikrein-2) plus age, DRE findings, and prior biopsy status. We investigated whether the 4Kscore was associated with more significant cancer among men found to have Gleason 6 cancer on prostate biopsy. We also looked at a subset of these men who underwent radical prostatectomy to see if the 4Kscore was associated with prostate cancer being upgraded in the surgical specimen. Results: Among the 1,312 men enrolled in this trial, 306 men were found to have Gleason 6 cancer on prostate biopsy. The 4Kscore was significantly associated with the number of positive cores (p=0.001) and the millimeters of cancer seen (p=0.0002), with higher 4Kscores relating to more extensive cancer present on biopsy. In the subpopulation of 51 men who underwent radical prostatectomy, the median 4Kscore was significantly higher among men who had an upgrade to Gleason 7 or higher [15% (8,25)] compared to men who did not experience an upgrade [7% (4,14)] (p=0.032) in their final pathology. Conclusions: Among men with Gleason 6 prostate cancer on biopsy, the 4Kscore was associated with the prostate cancer being upgraded in the surgical specimen at radical prostatectomy. The 4Kscore test may facilitate the selection of men who can be observed versus those who should undergo immediate treatment.

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