Nghiên cứu ứng dụng sinh thiết tuyến tiền liệt 12 mẫu dưới hướng dẫn của siêu âm qua trực tràng trong chẩn đoán ung thư tuyến tiền liệt tt tiếng anh

Based on that fact, we have implemented the project titled “Studying the application of 12-core prostate biopsy by transrectal ultrasound guidance for diagnosis of prostate cancer ” to a

to improved prostate biopsy techniques, especially increasing the number of biopsy pieces, has helped increase the early diagnosis rate of prostate cancer The early diagnosis of prostate cancer has helped to monitor and treat it more actively, reducing the mortality rate of this pathology Based on that fact, we have implemented the project titled

“Studying the application of 12-core prostate biopsy by transrectal ultrasound guidance for diagnosis of prostate cancer ” to achieve the

The urgency of the thesis

Prostate biopsy is crucial in diagnosis of prostate cancer, stage of the tumor and its treatment However, the biopsy results depend on the biopsy method and technique

Curative treatment of prostate cancer (removal of the entire prostate gland and seminal vesicles) depends on the stage of the disease when the tumor is localized in the gland, stage T1, T2 and the age of the patient is < 70 years old and has period expect to live for more than 10 years, but the symptoms of prostate cancer are poor, mainly diagnosed based on serum PSA (Serum Prostate Specific antigen) and DRE detect abnormal mass In fact, patients come to health facilities with

complications of prostate hyperplasia and signs of metastatic prostate cancer such as urinary retention, urinary tract infections, kidney failure, bone pain, urinary retention, secretive defecation ., including young people under 60

Vietnam is considered a country that is not in the focus area of prostate cancer, but according to the research results at two large medical centers of Viet Duc University Hospital and Cho Ray Hospital, most patients are treated for prostate cancer at a late stage From 2011-2015), in Cho Ray Hospital, among 222 patients with prostate cancer, most of the cancer was in the stage of metastasis and local progression, accounting for 70.7% and 16.2% respectively and local-stage cancer only accounted for 12.1% According to the research by Vu Nguyen Khai Ca (2012), for two years (2010-2011), the Urology Department of Viet Duc Hospital treated 119 patients with prostate cancer, only 8 patients at the early stages T1 and T2 (6.7%) To increase the rate and the ability to identify the early prostate cancer by prostate biopsy under the guidance of transrectal ultrasound at Viet Duc University Hospital from which to give curative treatment indications for patients we choose topic

New contributions of the thesis

- Successfully applying 12-core transrectal prostate biopsy, the

study showed signs or combination of clinical and subclinical examinations, analyzing the results, thereby proposing indications of prostate biopsy for diagnosis to identity the prostate cancer, especially the cases of early-stage cancer

- The first domestic study analyzed prostate biopsy values at the levels of 6 cores; 10 cores and 12 cores on the same patient

- Replicating the prostate biopsy procedure to provincial hospitals for early diagnosis and effective treatment of prostate cancer patients

Layout of the thesis

The thesis has 126 pages, including parts: Introduction (2 pages), Literature overview (44 pages), Research subjects and methods (16 pages), Results (23 pages), Discussion (39 pages), Conclusion (2 pages) The thesis has 34 tables, 15 figures, 3 charts, 150 references (133 ones in English and 17 ones in Vietnamese)

Chapter 1 LITERATURE OVERVIEW 1.1 The situation of prostate cancer in the world and in Vietnam

1.1.1 The situation of prostate cancer in the world

Prostate cancer is the 2nd most common cancer and the 5th most common death rate for men worldwide In 2013, over 3 million prostate cancer patients were alive worldwide, while in the United States, 238,590 patients and 29,720 patients died

1.1.2 The situation of prostate cancer in Vietnam

In Vietnam, prostate cancer incidence and adjusted death rate by age are 3.4 and 2.5 respectively per 100,000 people The disease is the

10th most common cancer in both sexes with 1275 new cases and 872 estimated annual deaths nationwide

In 2012, the authors of the Binh Dan Hospital reported the results

of prostate cancer screening at Binh Dan Hospital Among 1098 men aged ≥ 50 who participated in the study, 222 cases were biopsied, 33 cancer were detected, accounting for 3%

1.2 Prostate surgery

According to Mc Neal S H Selman, prostate parenchyma is divided into 5 zones

Figure 1.1: External appearance of prostate (rear view)

- Anterior zone: Fibromy muscle structure has no glandular structure

- Central zone: Accounting for 25% of gland volume,

- Transitional zone: Occupying 5-10% of prostate volume, this is the area where benign prostatic hyperplasia develops, and also about 25% of prostate cancer is produced

- Peripheral zone: Accounting for 70% of the gland volume, which forms the lower part of the gland and produces about 67% of prostate carcinoma

- The zone around the urethra gland

1.3 Anatomy of prostate cancer

1.3.1 Some precancerous lesions

- Prostate Intraepithelial Neoplasia - PIN

Lesions including 2 types: High grade PIN and Low grade PIN

1.3.2 Adenocarcinoma

- Most prostate cancer is adenocarcinoma adenocarcinoma> 95%

- Other types very rare:

1.3.3 Gleason grading system

Most commonly used based on cell structure with degree of malignancy Gleason divides 5 grades of differentiation from a very differentiated structure (grade 1) to a non-differentiated structure (grade 5)

1.4 Prostate biopsy

1.4.1 History of transrectal prostate biopsy under the guidance of ultrasound

Transrectal prostate biopsy was first performed by Astraldi in

1937 In 1989, prostate biopsy under the guidance of 6-core transectal ultrasound was first introduced by Hodge et al standardized to transrectal prostate biopsy and today this method is popular all over the world

1.4.2 Study on prostate biopsy in Vietnam

From June 2004 to May 2005, Do Anh Toan reported the results of

116 cases of prostate biopsy of 6 samples through the perineum at Medic Medical Diagnostic Center The findings of prostate cancer accounted for 14.7 %

In 2005, Le Ngoc Bang reported conducting a study of 53 patients receiving biopsy transrectal prostate under the orientation of abdominal ultrasound and index finger at Viet Duc University Hospital, the results

of 21/53 (39.6%) of patients have prostate cancer results

In 2010, some authors reported the results of transrectal prostate biopsy research under ultrasound guidance using 6 standard samples and the results of prostate cancer detection, Vu Van Ty 20.5%, Nguyen Tuan Vinh 11.5% and Vu Le Chuyen in 2012 were 14.8%

From March 2008 to March 2011 at Viet Duc University Hospital, rectal prostate cancer was conducted under ultrasound guidance for 104 patients, resulting in 56.7% prostate cancer

From December 2013 to June 2016 at Hanoi Cancer Hospital, prostate biopsy under the guidance of transrectal ultrasound was performed for 83 patients, of which 73.8% of patients had 10 biopsies, resulting in Result of 52 patients with prostate cancer The positive biopsy rate of the method is 61.9%

For the 12-core biopsy method, the two authors, Phan Van Hoang and Le Quang Trung, reported cancer detection rates of 17.07% and 26% of prostate cancer patients

CHAPTER 2 RESEARCH SUBJECTS AND METHODS

2.1 Research subjects

Including all patients who visited Viet Duc University Hospital or Friendship Hospital and had 12-core prostate biopsy from October 2015

to April 2017

2.1.2 Criteria for selecting patients

Patients with one or more of the following signs are indicated for prostate biopsy:

- Patients with PSA>10 ng/ml or

- Prostate rectal probe suspected prostate cancer or

- CT scanner or magnetic resonance imaging of prostate with images of suspected prostate cancer

- Patient had 12 biopsy samples by rectal ultrasound

2 2 1

p p

In which:

n is the minimum number of patients in the study

- Type 1 mistake, acceptable α = 0.05 then Z2 1-α/2= 1.96 2

p= 0.26 (The proportion of patients who found prostate cancer

on a biopsy of 12 cores was 26% in a study of Le Quang Trung

In which:

- Type 1 mistake, acceptable α = 0.05 then

- q: q = 1-p => q = 0.74

- Absolute accuracy, accepted ∆ = 0,1

Replaced into the formula we have n = 1.962 (0.26x 0.74) = 74 0.12

2.3.2 Factors to indicate a biopsy

The standard biopsy designation is recommended in Vietnam

- Patients with PSA> 10 ng/ml or

- Patients with prostate rectal probe abnormalities

In addition to 02 additional indications:

Developing the biopsy designation, technical procedure for biopsy of glandular material for 12 samples

- Ultrasound machine

- Sine tools:

Biopsy gun, Pliers biopsy

- Sample container

Preparing the patient

- Antibiotic treatment

- Indentation of the colon

- Posture of the patient

- General anesthesia:

pre- anesthesia with propofon

- Biopsy location: 12

samples, each lobe has 6 samples, the right lobe of the samples 1,2,3,4,5,6, the left lobe of the samples 7,8,9,10,11, 12

- Patient has an ultrasound of the prostate gland through the rectum or an MRI scan showing the images of suspected cancer

* Results of Digital rectal examination

- Prostate examination via rectum

+ Suspecting cancer: Palpating solid nucleus, firm tumor, losing boundary

+ No suspicion of cancer: prostate is soft, not multiply, clear boundaries

* Transrectal prostate ultrasound

- Image of suspected prostate cancer: Negative cell, asymmetric prostate, disrupting the prostate

* Magnetic resonance imaging of prostate

- Image of suspected prostate cancer as negative zones or surrounding cancers: bladder neck, seminal vesicles, rectum or distant metastasis (Liver, lung, bone )

- Whether or not subregional lymph nodes

2.3.1.2 Means, equipment, procedure of transrectal prostate biopsy under the guidance of ultrasound

* Tools containing and fixing specimen:

- Includes 12 vials of specimen containing Bouin immobilized solution, recording the location of prostate biopsy in the order of 1 - 12

* Biopsy procedure: Preparing patients such as colorectal cleansing,

antibiotics to prevent infections, anesthetic methods, patient's posture

follow the agreed standard procedure

* Biopsy techniques and biopsy location:

Perform a biopsy of 12 cores, 6 cores for each lobe and according

to the location of the prostate gland

To the right, symbolized (I): 1, 2, 3, 4, 5, 6

To the left, symbolized (II): 7,8,9,10,11,12

2.4 Biopsy results

- Number of patients, number of samples by each biopsy location

to detect cancer cells

- Assessing the number of cancer patients detected by biopsy of 6 standard cores, 10 cores, 12 cores on the same patient

- Calculate the differentiation of cancer cells according to the Gleason scale

- Diagnosis of prostate cancer stage

- Complications and complications of the method

2.5 Several factors related to biopsy results

- Related Digital rectal examination results

- Related results ultrasound transrectal prostate

- Related PSA values

- Related magnetic resonance imaging results

Chapter 3 RESEARCH RESULTS

From October 2015 to April 2017, a total of 120 patients had 12 cores prostate biopsies under the patient selection criteria

3.1 Factors that specify a biopsy

3.1.1.Digital Rectal examination

Table 3.1: Results of Digital rectal examination

3.1.2 Transrectal prostate ultrasound

Table 3.2: Transrectal ultrasound results

Transrectal prostate

ultrasound

Number of patients Rate (%)

Table 3.3: Serum PSA concentration

3.1.4 Results of MRI of the prostate

Table 3.4: Magnetic resonance imaging results

Magnetic resonance imaging results Quantity Rate (%)

3.2 Clinical characteristics

3.2.1 Age of biopsied patients

Table 3.5: Age distribution of studied group

Age group Number of patients Rate %

in the age group of 60-79 years old, accounting for 75.83%

3.2.2 Reason for admission to the hospital

Figure 3.1: Reasons for hospitalization

3.3 Prostate biopsy results

3.3.1 Results of pathology

Table 3.6 Results of pathology

Biopsy results Quantity Rate %

Low-grade squamous intraepithelial lesion 1 0,83 High-grade squamous intraepithelial lesion 1 0,83

Comments:

- Biopsy results found 33.33% of prostate cancer cases

- 50% of cases of benign hyperplasia, 15% of patients with accompanying benign prostatitis, 0.83 cases of Low-grade squamous intraepithelial lesion, 0.83% High-grade squamous intraepithelial lesion

3.3.2 Biopsy results by standard 6-core biopsy location

Table 3.7 Biopsy results by standard 6-core biopsy location

12 cores, reducing 15% (34/40) of cancer detection patients

3.3.3 Result of disease anatomy by biopsy location of 10 cores

Table 3.8 Biopsy results by 10 cores

Diseased anatomical results by the location of 10 cores detected

39 prostate cancer patients accounting for 32.5%, reducing 1 patient (0.83%) compared to the 12-core biopsy method, down 2.5% (39/40) of patients with cancer detection

3.3.4 The location of biopsy samples to detect prostate cancer cells Table 3.9 The location of biopsy samples to detect prostate cancer cells

The location of a biopsy sample

to detect cancer cells Times Rate %

Among those samples (+) with cancer cells were found at all sites Among the 34 patients with pathology results who specifically answered each sample number (+) with cancer cells, the peripheral zone had 54/130 samples (+), accounting for 41.5%), the transition zone had the number of samples ( +) 58.5%

3.4 Several factors related to biopsy results

3.4.1 Relationship between biopsy results and Digital rectal examination

results (DRE)

Table 3.10: Prostate biopsy results with DRE results

Rectal examination Biopsy results Total p

- Calculate the sensitivity and specificity of the diagnosis of prostate cancer through rectal examination:

Table 3.11 Evaluate biopsy results with prostate weight

Prostate volume Biopsy results Total

<0.05

- Biopsy results compared with ultrasound results

Table 3.12 Biopsy results compared with ultrasound results

Calculate the sensitivity and specificity of Transrectal prostate ultrasound to detect cancer

3.4.3 Relationship between biopsy results and MRI results

Table 3.13 Relationship between biopsy results and MRI results

The value of MRI from prostate cancer detection is

3.4.4 Relationship between biopsy results and PSA values

Table 3.14 Compare biopsy results with total PSA values