Original article
Clinical performance of transperineal template guided mapping biopsy for therapeutic decision making in low risk prostate cancer
Rendimiento clínico de biopsia de mapeo guiada por plantilla transperineal para la toma de decisiones terapéuticas en el cáncer de próstata de bajo riesgo
Y. Ahallal, R. Sanchez-Salas
, A. Sivaraman, E. Barret, F.P. Secin, P. Validire, F. Rozet, M. Galiano, X. Cathelineau
Corresponding author
Departamento de Urología, Institut Mutualiste Montsouris , París, France
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Ahallal, R. Sanchez-Salas, A. Sivaraman, E. Barret, F.P. Secin, P. Validire, F. Rozet, M. Galiano, X. Cathelineau" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Ahallal" ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Sanchez-Salas" "email" => array:1 [ 0 => "rafaelsanchezsalas@imm.fr" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Sivaraman" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Barret" ] 4 => array:2 [ "nombre" => "F.P." "apellidos" => "Secin" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Validire" ] 6 => array:2 [ "nombre" => "F." "apellidos" => "Rozet" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Galiano" ] 8 => array:2 [ "nombre" => "X." "apellidos" => "Cathelineau" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Urología, Institut Mutualiste Montsouris , París, France" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rendimiento clínico de biopsia de mapeo guiada por plantilla transperineal para la toma de decisiones terapéuticas en el cáncer de próstata de bajo riesgo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Early detection of prostate cancer (PCa) has evolved over the past 20 years. Although Prostate Specific Antigen (PSA) screening increases the PCa detection, it also adversely leads to the identification of small, low-grade tumors.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> PSA screening has also resulted in lower prostate cancer mortality.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2,3</span></a> However, radical prostatectomy did not reduce prostate-cancer or all-cause mortality more than observation in men with localized prostate cancer after at least 12 years of follow-up.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> Better understanding of the prostate cancer has widened the treatment options with Active Surveillance (AS) and Focal Therapy (FT) being increasingly used. Long-term studies have shown that patients based on TRUS results alone in Active Surveillance had a 20–40% risk of detecting significant cancer and 20–30% patients had bilateral disease at focal therapy.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5,6</span></a> Thus, prostate biopsy should be as accurate as possible in order to precisely evaluate the prostate cancer stage, grade and volume.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1989, Hodge et al. first described the transrectal ultrasound-guided sextant biopsy as the standard tool for PCa diagnosis and later underwent several modifications.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> Nowadays, it has been shown that the most widely used bi-sextant approach can have high false-negative rates (30%) and we also know that increasing the number of cores taken improves the PCa detection in approximately 40%.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">8–10</span></a> Moreover, extended biopsy approaches have been shown to be superior to sextant biopsy schemes in high-grade PCa diagnosis.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> TTMB is an exhaustive biomechanical engineering approach that uses brachytherapy grid and transperineal approach to overcome the limitations of conventional TRUS biopsy. Several authors have published the advantages of this technique in specific clinical situations including prior to AS.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the present study, we evaluated the clinical use of TTMB in re-stratifying cancer risk in patients designated with low-risk disease by TRUS biopsy, according to D’Amico criteria (Gleason score<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>6, PSA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml and clinical stage<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>T2a), and its influence on therapeutic selection (active surveillance, focal therapy or surgery).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study is an Institutional Review Board-approved analysis of patient data retrospectively collected for TTMB performed between February 2008 and June 2011. In this time frame, we performed 169 TTMB for several indications – prior negative biopsy, prior to the start of AS, discrepancy between TRUS report and PSA value, prior to focal therapy and primary TTMB in very few patients. We identified 98 patients who underwent TTMB prior to AS and they met the following inclusion criteria at initial TRUS biopsy: Gleason score<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>6, PSA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml, clinical stage<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>T2a, unilateral disease, less than one-third of the cores positive, and less than 50% of the core involved. Patients subjected to AS underwent TTMB, either at the time of induction or within the first 12 months of the AS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All the TTMBs were performed as a day care procedure under general anesthesia with prophylactic antibiotics. The patients were positioned in dorsal lithotomy and a standard brachytherapy grid with holes of 5<span class="elsevierStyleHsp" style=""></span>mm apart as demonstrated by Barzell was used as a template. To accurately mark the location of each core, grid coordinates A–M were placed in <span class="elsevierStyleItalic">x</span> axis and 1–12 in <span class="elsevierStyleItalic">y</span> axis were used and the co-ordinate D2 was positioned in midline corresponding to urethra. All the biopsy cores were named according to the co-ordinates and if more than one core was taken from a single hole, additional tag as proximal (apex) or distal (base) is used. The grid was attached to a cradle and firmly positioned against the perineum. Standard transrectal probe with 7.5<span class="elsevierStyleHsp" style=""></span>MHz transducer was introduced and prostate scanned from base to apex. Biopsies were performed with 18<span class="elsevierStyleHsp" style=""></span>G automated biopsy gun. The position of the biopsy gun during the biopsy was tracked through the TRUS probe and made sure that the whole length of the prostate was biopsied. Care was taken to avoid injury to the urethra and the region of the bladder neck. All the biopsy containers were appropriately tagged and each core was reported for core length, presence of cancer, Gleason grade, cancer length, and ratio of cancer to core length. Patients were discharged from the hospital care on the same day unless there were complications. Complications were prospectively recorded and graded according to the DCS (Clavien and Dindo score).<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We defined “Upgrading” as increase in the Gleason score more than the TRUS detection and “Upstaging” as detection of bilateral disease. We analyzed the percentage of patients eligible for AS that finally had upgrade and/or upstage in the TTMB and also compared their clinical characteristics to those with similar tumor characteristics to TRUS. The eventual change in the treatment decision was also documented.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Continuous variables were reported as mean (SD). Parametric variables were compared using Student's <span class="elsevierStyleItalic">t</span>-test and non-parametric variables using Mann Whitney test. All statistical analyses were performed using SPSS software version 22 (SPSS Inc, Chicago, IL, USA, IBM<span class="elsevierStyleSup">®</span>) and statistical results were considered significant at a level of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The mean age of the patients was 64 (48–77), the mean total PSA and prostate volume was 6.34 (2.03–9.96)<span class="elsevierStyleHsp" style=""></span>ng/ml and 43.1 (11–85)<span class="elsevierStyleHsp" style=""></span>cc respectively. All our patients had a Gleason score of 6 (3<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3) at initial TRUS and 89 (90%) patients had a T1c and 10 (10%) patients had a T2a clinical stage. The clinical and TTMB characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The mean number of TTMB cores was 25.6 (14–56), and the mean total sample size was 251.6 (82–591)<span class="elsevierStyleHsp" style=""></span>mm. TTMB detected cancer in 64 (65%) patients and initial TRUS understaged/undergraged cancer in 34 (53%) patients – 8 patients had bilateral disease, 21 patients had a Gleason score of 7 or higher, and both criteria were found in 5 other patients. Comparison of clinical and tumor characteristics of the upgraded and/or upstaged patient to those that had results similar to TRUS showed significantly smaller prostate volume in the former group (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). 81% of the patients with unmodified stage and/or grade in the TTMB were treated with either active surveillance or focal therapy, while 73% of upgraded and/or upstaged patients received a radical treatment (surgery or radiation therapy). TTMB failed to detect cancer in 34 patients (35%) out of which 15 opted for focal therapy and the other 19 were included in an active surveillance program (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">There were 12% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12) overall TTMB related complications. Two patients (17%) had a grade 1 complication: one patient had hematuria and the other had a pelvic pain requiring the use of analgesics. Ten patients (83%) had grade 2 complications, one had severe hematuria treated with transfusion and the other 9 patients had transient Foley catheter placement for urinary retention.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Currently, TTMB finds clinical application in specific clinical scenarios.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11,14</span></a> In patients with high clinical suspicion of PCa and prior negative or atypical acinar cells in TRUS biopsy, TTMB increases cancer detection.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> TTMB offers the advantage of volume-based increase in core number bypassing the rectal complications of saturation biopsy. The other potential advantage of TTMB is accurate characterization of cancer in patients for AS and FT. Onik et al. evaluated transperineal 3D mapping biopsy in selecting patients for focal therapy. 110 patients with unilateral PCa on transrectal ultrasound (TRUS) biopsies were restaged using the 3D mapping method. 55% of men who were found to have unilateral prostate cancer on initial biopsy had bilateral disease on TTMB and 23% of patients were upgraded on Gleason scoring by providing higher accuracy compared to TRUS biopsy.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> Arumainayagam et al. even went further by validating multiparametric magnetic resonance imaging for PCa detection using transperineal template prostate mapping biopsies as the reference standard.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> The Transatlantic Consensus Group on active surveillance and focal therapy for prostate cancer recommend emerging detecting tools such as new imaging technique and transperineal mapping biopsy to improve prostate cancer management.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Active surveillance is a widely accepted treatment alternative to low risk PCa and Focal Therapy with various energies that is still evolving to find an appropriate place in the treatment algorithm of PCa. Active surveillance requires appropriate patient understanding of the AS protocol<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> and can result in varying percentage of Gleason score upgrade in follow-up biopsies.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> Long-term follow-up studies on active surveillance have shown in patients on active surveillance that 30–40% will have significant cancer detected in future biopsies.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> This can be possibly due to inadequate information in the initial TRUS biopsy. In the present study, we used TTMB to re-stratify the cancer risk in patients potentially eligible for AS according to D’Amico criteria (Gleason score<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>6, PSA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml, clinical stage<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>T2a) and Epstein criteria for clinically non-significant PCa (unilateral disease, less than one-third of the cores affected, and less than 50% of the core involved).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The transperineal approach enables a longitudinal access to the prostate gland, with a more accurate sampling, especially on the peripheral anterior and apical part of the gland. The number of cores obtained was volume adjusted in each case. We sampled the entire prostate using a 5-mm sampling frame guided by a brachytherapy template grid, so the bigger the prostate, the higher the number of cores taken. Prostatic volume has to correlate with the number of cores taken in order to achieve optimal results.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21,22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">We identified significant upgrading/upstaging in the TTMB and the final treatment decision was eventually influenced by the results. Our study has important clinical implications – routine use of TTMB in patients before AS or FT can potentially stratify the patients accurately for the treatment groups. This can further translate to fewer patients during AS to have clinically significant cancer detection and also fewer FT treatment failures. However, as we try to improve the prostate biopsy technique toward lesser targeted cores, TTMB appears to be retracing backwards in technology. A modified template guided and targeted biopsy can be an optimal solution for this subset of patients. Routine use of MRI and guided biopsy can improve the accuracy of TRUS biopsies both for AS and FT but still there is no long-term data following MRI guided biopsies. The feasibility of performing TTMB in the outpatient setting with perineal block anesthesia should be explored in the future.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the present study, 35% of patients had negative TTMB in spite of positive TRUS biopsy and it is slightly higher than those reported in other studies, which estimate this prevalence at approximately 26%.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> This subset of patients represents low-volume disease and associated with a low risk of progression at 10 years. However, a negative TTM does not confirm the absence of PCa.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> Thus, closely monitoring these patients, and providing treatment when necessary according to tumor progression are valid options even in young patients. In our series, 56% of patients with negative TTMB were included in an active surveillance program and the remaining opted for focal therapy as it is considered a very promising middle ground between active surveillance and radical therapy with an acceptable morbidity.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Another interesting finding noted in the study was significantly smaller prostate volumes in patients with upgrade or upstage noted at TTMB. Similar findings have not been reported earlier in the literature. However, the clinical significance of the finding needs to be evaluated in the future studies.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our series, we had a 12% complication rate, all mild and mostly Clavien-Dindo Grade 2 (83%). These figures are similar to those rates described in the literature for sextant and extended biopsy schemes.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> Recently, Tsivian et al. reported the complications associated with transperineal template prostate mapping biopsy. They found 19% overall biopsy-related complications. Most of them were mild and transient complications.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> Actually, only one patient required intervention (bladder irrigation for hematuria). Thus, reSBx is safe with acceptable complications and easily reproducible in the clinical practice.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Several limitations in our study should be acknowledged. This is a retrospective study of a small series of patients with a short follow-up period. While longer follow-up is necessary before more definite conclusions can be drawn. We did not have a comparison arm with transrectal saturation biopsy which would have given the actual advantage offered by the TTMB. MRI was not routinely used during this study period which can definitely influence the TRUS biopsy results.</p><p id="par0095" class="elsevierStylePara elsevierViewall">TTMB can be a useful clinical tool in assigning appropriate treatment options in patients with low-risk prostate cancer. It can be hypothesized that TTMB can reduce the chances of finding clinically significant cancer during active surveillance and also reduce the chance of missing bilateral disease before focal therapy. The complications are mild and infrequent, which makes it a safe and effective procedure.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres762898" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec764373" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres762897" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec764374" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-19" "fechaAceptado" => "2016-05-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec764373" "palabras" => array:5 [ 0 => "Active surveillance" 1 => "Prostate cancer" 2 => "Prostate biopsy" 3 => "Transperineal biopsy" 4 => "Template guided biopsy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec764374" "palabras" => array:5 [ 0 => "Vigilancia activa" 1 => "Cáncer de próstata" 2 => "Biopsia prostática" 3 => "Biopsia transperineal" 4 => "Biopsia guiada por plantilla" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the role of transperineal template guided mapping biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one-third positive cores at first biopsy and <50% of the core involved. TTMB results were analyzed for Gleason score upgrading and upstaging as compared to initial transrectal ultrasound (TRUS) biopsies and its influence on the change in the treatment decisions.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">TTMB detected cancer in 64 (65%) patients. The upgrade, upstage and both were noted in 33% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21), 12% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8) and 7% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5) respectively of the detected cancers. The disease characteristics were similar to initial TRUS in 30 (48%) patients and TTMB was negative in 34 (35%) patients. Prostate volume was significantly smaller in patients with upgrade and/or upstage noted at TTMB (45.4 vs 37.9; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">=</span><span class="elsevierStyleHsp" style=""></span>0.03). TTMB results influenced 73.5% of upgraded and/or upstaged patients to receive radical treatment while 81% of the patients with unmodified stage and/or grade continued active surveillance or focal therapy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In patients with low risk PCa diagnosed by TRUS, subsequent TTMB demonstrated cancer upgrade and/or upstage in about one-third of the patients and resulted in eventual change in treatment decision.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar el papel de la biopsia de mapeo guiada por plantilla transperineal (TTMB) en la determinación de la estrategia de manejo en pacientes con cáncer de próstata (CaP) de bajo riesgo.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Evaluamos retrospectivamente 169 pacientes que se sometieron a TTMB en nuestra institución entre febrero de 2008 y junio de 2011. Noventa y ocho de ellos albergaban CaP indolente definido como: antígeno prostático específico <<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml, puntuación de Gleason 6 o menos, estadio clínico T2a o menos, enfermedad unilateral y un máximo de un tercio de núcleos positivos en la primera biopsia y <<span class="elsevierStyleHsp" style=""></span>50% del núcleo en cuestión. Se analizaron los resultados TTMB para clasificación al alza y estadificación al alza de puntuación de Gleason en comparación con las biopsias iniciales de ecografía transrectal (ETR) y su influencia en el cambio en las decisiones de tratamiento.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">TTMB detectó el cáncer en 64 (65%) pacientes. La clasificación al alza y estadidificación al alza se observaron en el 33% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21), 12% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8) y 7% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5), respectivamente, de los cánceres detectados. Las características de la enfermedad fueron similares a la ETR inicial en 30 (48%) pacientes y TTMB fue negativa en 34 (35%) pacientes. El volumen de la próstata fue significativamente menor en los pacientes con clasificación al alza y/o estadificación al alza observado en TTMB (45,4 vs 37,9; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">=</span><span class="elsevierStyleHsp" style=""></span>0,03). Los resultados de TTMB influenciaron en el 73,5% de los pacientes clasificación al alza y/o estadificación al alza para recibir tratamiento radical, mientras que el 81% de los pacientes con estadio y/o grado sin modificar continuaron la vigilancia activa o terapia focal.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En los pacientes con CaP de bajo riesgo diagnosticados por ETR, una posterior TTMB demostró clasificación al alza y/o estadificación al alza en aproximadamente un tercio de los pacientes, y dio lugar a un cambio final en la decisión de tratamiento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ahallal Y, Sanchez-Salas R, Sivaraman A, Barret E, Secin FP, Validire P, et al. Rendimiento clínico de biopsia de mapeo guiada por plantilla transperineal para la toma de decisiones terapéuticas en el cáncer de próstata de bajo riesgo. Actas Urol Esp. 2016;40:615–620.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (48–77) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean PSA (ng/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.34 (2.03–9.96) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean prostate volume (cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.1 (11–85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of TRUS cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.37 (6–24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of positive cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.28 (1–4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of TTMB cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.6 (14–56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean overall TTMB core length \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">251.6 (82–591) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean positive TTMB length \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.91 (1–10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of patients with GS 7 or more \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of patients with bilateral disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of patients with both upgrade and upstage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260327.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient and TTMB characteristics.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Similar to TRUS/negative TTMB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Upgraded/upstaged patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean PSA (ng/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean prostate volume (cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of TRUS cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of positive cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean number of TTMB cores \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean overall TTMB core length \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">241.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">260 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean positive TTMB length \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260328.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of upgraded and/or upstaged patients with negative TTMB/similar to TRUS.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RT \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upstaged/upgraded patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (34.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Similar as TRUS biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (30.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative TTMB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (34.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total % of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260329.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Treatment decided by patients after TTMB.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EAU guidelines on prostate cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. 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