|Year : 2017 | Volume
| Issue : 1 | Page : 18-21
Prostate biopsy in a rural hospital: Our experience
Suresh K Jariwala
Department of Urology, Rajah Muthiah Medical College Hospital, Chidambaram, Tamil Nadu, India
|Date of Submission||11-Dec-2016|
|Date of Acceptance||15-Mar-2017|
|Date of Web Publication||1-Jun-2017|
Suresh K Jariwala
215, Arun Chambers, Tardeo Road, Mumbai - 400 034, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims: We have seen middle-aged and elderly patients with lower urinary tract symptoms (LUTS) or retention of urine in our hospital. Digital rectal examination (DRE) and prostate-specific antigen (PSA) were done for workup. Prostate biopsy (PB) was done whenever indicated. We wanted analysis of PB in our rural setup.
Materials and Methods: The study period includes from January 2008 to May 2012 and January 2015 to May 2016. Any patient aged 45 years or more presenting with LUTS or retention of urine was included in the study. PSA and DRE were done in all patients. Inclusion criteria were abnormal DRE or PSA ≥4 ng/ml. Exclusion criteria were immunocompromised status, coagulopathy, urinary tract infection, acute prostatitis or abscess, uncontrolled diabetes mellitus, or previous biopsy. Histopathology report was noted.
Statistical Analysis: No special software was used. Author used his arithmetical skill learned in school days to do analysis.
Results: One hundred and thirty-four patients were included in the study. Average age was 69 years. PSA ranged from 1 to 1700, average being 65.3 ng/ml. Prostate cancers (PCs) was found in 65 cases. Adenocarcinoma of prostate was found in 54 cases, average PSA being 110.8 ng/ml. Small cell PC (SCPC) found in 11 cases, average PSA being 55 ng/ml. Prostatic intraepithelial neoplasia was found in six cases, average PSA being 18.8 ng/ml.
Conclusion: PC is not uncommon in India. Patients present in advanced stages and with high PSA values. Transrectal ultrasound-guided 12-core systematic PB is the standard to confirm diagnosis of PC. Incidence of SCPC is high in our series. They presented with high PSA values. This need further study.
Keywords: Benign hyperplasia, biopsy, carcinoma, prostate, prostatic intraepithelial neoplasia, prostatitis
|How to cite this article:|
Jariwala SK. Prostate biopsy in a rural hospital: Our experience. BLDE Univ J Health Sci 2017;2:18-21
Diseases of prostate such as prostate cancer (PC) and benign prostatic hyperplasia (BPH) are common in elderly males. Prostatitis is common in younger patients. PC is one of the most common cancers in males. Prostate biopsy (PB) is done to confirm the diagnosis. We are presenting our experience of PB in a rural hospital.
| Materials and Methods|| |
Any patient above the age of 45 years who presented with symptoms suggestive of prostate disease such as lower urinary tract symptoms or retention of urine was included in the series. The study was conducted from January 2008 to May 2012 and January 2015 to May 2016. Digital rectal examination (DRE) and prostate-specific antigen (PSA) were done in all patients. Inclusion criteria were abnormal DRE or PSA ≥4 ng/ml. Exclusion criteria were immunocompromised status, coagulopathy, urinary tract infection (UTI), acute prostatitis or abscess, uncontrolled diabetes mellitus, or previous biopsy. Finger-guided 8-core biopsy was done. A 14- or 16-gauge needle was used. All samples were sent in a single container. Prophylactic antibiotic was given for 4 days. Antiplatelet agents were stopped 1 week before biopsy. Only initial biopsies were included in the study.
| Results|| |
No special software was used for statistical analysis. Author used his arithmetical skill learned in school days to do analysis.
A total number of patients studied were 134. Age varied from 45 to 95 years, average being 69 years. PSA was available in 94 cases. PSA ranged from 1 ng/ml to 1700 ng/ml. Average PSA was 65.3 ng/ml irrespective of histopathological (HP) diagnosis. It was divided into three groups: 1–4, 4–10, and ≥10 ng/ml. The result is shown in [Table 1].
PB was done in all cases. The HP diagnosis is shown in [Table 2].
PSA was not available in forty cases. Fourteen cases had PC on biopsy, positive in 35% of cases. Total number of HP diagnosis exceeds total number of patients as some patients had two pathologies on biopsy. PSA was done in fifty cases of androgen-dependent PC (ADPC), average PSA being 110.8 ng/ml. PSA was done in eight cases of small cell PC (SCPC), average PSA being 55 ng/ml. No patient with SCPC had PSA <4 ng/ml. PSA was done in 38 cases of BPH, average PSA being 16.7 ng/ml. PSA was done in six cases of prostatitis, average PSA being 14.5 ng/ml. PSA was done in four cases of prostatic intraepithelial neoplasia, average PSA being 18.8 ng/ml.
Gleason score was available in 34 patients. It is shown in [Table 3].
Secondaries were found in eight cases. The result is shown in [Table 4].
Total number of patients with secondaries exceeds total number of patients as the same patient may have multiple secondaries.
Complications of PB are shown in [Table 5].
Two patients developed fever and UTI. They were treated with appropriate antibiotics. One patient developed bleeding per rectum and treated conservatively. One patient presented with inability to swallow after 1 month of PB and found to have oral and esophageal candidiasis. He was treated with oral fluconazole.
| Discussion|| |
PC is a common cancer in Western world. It is the most common cancer in males in the USA. Lifetime risk is one in seven. It is less common in Japan, Southeast Asia, and India. Indian data on PC are scarce. PC is a slow-growing tumor. Presentation varies from asymptomatic to secondaries. PSA is the best tumor marker for PC. PSA screening program in Western world has led to stage migration and reduced mortality. It has also led to over and unnecessary treatment for PC. The United States Preventive Services Task Force has banned screening program in the USA. We have seen PC in advanced stage in India, with high PSA values. Screening program is not practical or economical in India.
PB is done to confirm the tissue diagnosis of PC. Ultrasound, magnetic resonance imaging (MRI), or tumor marker such as PSA cannot confirm the diagnosis. We did finger-guided PB using manual needle in our cases. Minimum 8 cores were taken. Lignocaine jelly was instilled per rectum for local anesthesia. Patients withstood procedure well. Transrectal ultrasound (TRUS)-guided periprostatic block gives better analgesia. TRUS-guided 12-core systematic PB is the gold standard to confirm the tissue diagnosis of PC. We did not have this facility in our hospital. Not more than 2 cores should be sent in one jar. Site-specific labeling does not help in decision-making for treatment management.
There are two indications for PB: abnormal DRE and PSA ≥4 ng/ml. PSA threshold value of 4 ng/ml is reduced to 2.5 ng/ml though no lower value excludes PC. The highest PSA value recorded in our series was 1700 ng/ml. Such high values are not seen in Western world. This indicates that our patients present with advanced stages and high PSA values. PC is not that uncommon in India as thought. Proper data are required to disprove this myth.
DRE is still important in our country though its value is questioned recently. Old dictum, “if you do not put your finger into the rectum, put your foot into it” still holds true. PSA was not available in forty cases and PC was found in 14 cases on PB, 35% being positive only on abnormal DRE.
PC was found in 65 cases out of 134, 48.5% of patients in our series. One in two patients had PC on PB. Patients with PSA ≤4, 4–10, and ≥10 ng/ml had PC in nil, 38%, and 62% of cases, respectively.
We found 11 SCPC in 65 cases of PC in our series. Incidence was 17% of all PC. This is very high. Incidence of SCPC described in literature is <2%., Average PSA in SCPC in our series was 55 ng/ml. No patient had PSA ≤4 ng/ml. PSA reported in literature in SCPC is usually within normal range (≤4 ng/ml) though high PSA is noted occasionally. 25%–50% of SCPC are preceded by or having concomitant ADPC., We did not find this; all 11 cases had pure SCPC. Guo et al. have reported 87% of pure SCPC. Immunohistochemistry (IHC) markers are required to confirm SCPC. We did not have this facility in our hospital. Poorly differentiated, high grade (Gleason 5) ADPC must be differentiated from SCPC. Here, IHC markers help. Gleason score is not allotted in SCPC.
Two patients in our series developed fever and UTI (2 out of 134) with incidence of 1.5%. They were treated with appropriate antibiotics (ceftriaxone and amikacin). Rectal swab and targeted antibiotics are suggested to reduce the incidence of postbiopsy infectious complications. One patient developed oral and esophageal candidiasis. He presented 1 month after biopsy with inability to swallow. He was treated with oral fluconazole. He did not have diabetes mellitus or immunocompromised status. This complication after PB is not reported in the literature and is probably due to antibiotics use.
To our knowledge, this is the first report on PB in India from a rural setup. The present practice is to do targeted fusion biopsy with the help of MRI and ultrasound combined. Borkowetz et al. conclude that cancer detection for PC in the first biopsy for targeted biopsy was equal to systematic biopsy. Fusion biopsy has a place only in initial negative biopsy. Our result matches with that of literature. Borkowetz et al. also recommend doing systematic biopsy in addition to fusion biopsy. There is definitely a place for systematic or blind biopsy if TRUS not available in our country.
There are limitations to our study. We did not have standard TRUS-guided 12-core PB. IHC markers were not available to confirm SCPC. Our aim was to present overall picture of PB in rural setup. To discuss histopathology reports was not our aim. Referring patients to another center is not an option in rural setup where patients come from far away villages. Ideal scenario does not exist in rural setup in India.
| Conclusion|| |
PC is not uncommon in India. Patients present in advanced stages and with high PSA values. TRUS-guided 12-core PB is the standard to confirm diagnosis of PC. Incidence of SCPC is high in our series. They presented with high PSA values. This needs further study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]