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

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INTRODUCTION
Prostate cancer is the 2nd most common cancer and the 5th most
common death rate for men worldwide. The definitive diagnosis should
be based on digital rectal examination (DRE), serum PSA, prostate
biopsy results. Biopsy plays a decisive role in diagnosis of prostate
cancer, however biopsy results depend on biopsy methods and
techniques. At Viet Duc Hospital, Trans-rectal ultrasound guided
(TRUS) biopsy has been done since 2008, the 6-core and 10-core
prostate biopsy in the 2008-2011 period resulted in the positive cancer
rate of 59/104 (56.7%). But in this study, the vast majority of prostate
cancer patients were discovered at a later stage. In recent years, thanks
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
following objectives:
1. Developing the indications and procedures of 12-core prostate
biopsy under transrectal ultrasound guidance.
2. Evaluating the results and giving the comments on relevant
factors of 12-core prostate biopsy under transrectal
ultrasound guidance.
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


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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 20112015), 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).


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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.


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- 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.


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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. Research Methods
2.2.1. Sample size
Calculate sample size based on formula
n=

Z



2
1−

2

p(1 − p)
2



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In which:
n is the minimum number of patients in the study.
- Type 1 mistake, acceptable α = 0.05 then Z21-α/2= 1.962
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
2.2.2. Research Methods.
Descriptive, prospective
2.3. Research contents
2.3.1. Preparing the designation, technical process
Developing the biopsy designation, technical procedure
for biopsy of glandular material for 12 samples

Indications

3. for
biopsy 4.
- Examination of
5.
rectum, prostate
6.
abnormality
- PSA> 10
- TRUS: Prostate
with cancer image
- MRI: The
prostate has
cancer images

Equipment
and machines
- 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

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:


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- Patient has an ultrasound of the prostate gland through the
rectum or an MRI scan showing the images of suspected cancer.
* PSA concentration
Serum PSA concentrations were divided into the following

groups:
- PSA < 10 ng/ml
- 10 < PSA < 20 ng/ml.
- PSA: > 20 ng/ml.
* 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
* Ultrasound machine:
- Using the BK Pro Focus 2202 ultrasound system: The color SA - 3D
machine.
* Biopsy equipment:
- Biopsy gun, Bard Magnum biopsy needle size MN1816 or MN1816,
disinfectant, biopsy solution ...
* 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:


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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
Rectal examination
Quantity
Rate
Normal
93
77,50
Suspected cancer
27
22,50
Total
120
100,00
Comments:
Rectal examination found 22.5% of patients with suspected
lesions of prostate cancer.


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3.1.2. Transrectal prostate ultrasound
Table 3.2: Transrectal ultrasound results
Transrectal prostate
Number of
Rate (%)
ultrasound
patients
Suspected cancer
62
51,67

Not suspected cancer
58
48,33
Total
120
100
Comments:
Rectal ultrasound revealed 51.67% of suspected lesions of
prostate cancer.
3.1.3. PSA value
Table 3.3: Serum PSA concentration
PSA (ng/ml)
Quantity
Rate %
< 10
17
14.2
10 – 20
54
45.0
> 20
49
40.8
Total
120
100.0
[ PSA]
3,89 - 105,7 ng/ml.
PSA mean
24,79 ± 2,09 ng/ml

Comments:
The average total PSA value of the study group was 24.79 ±
2.09 ng/ml. Patients with PSA in the group of 10-20 ng/ml accounted
for the majority (44.2%), less than 10 ng/ml accounted for 15%, the
smallest was 3.89 ng/ml, the largest was 105.7 ng/ml.
3.1.4. Results of MRI of the prostate.
Table 3.4: Magnetic resonance imaging results
Magnetic resonance imaging results

Quantity

Rate (%)

Suspected cancer
42
79,2
Not suspected cancer
11
20,8
Total
53
100
Comments: There were 53 cases of MRI of the prostate, resulting in 42
patients with suspected prostate cancer image accounting for 79.2%.


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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 %
< 50
1
0,83
50 - 59
14
11,67
60 – 69
45
37,50
70 – 79
46
38,33
≥ 80
14
11,67
Total
120
100
Comments:
The average age of the studied group is 69.37 ± 8.2, the
youngest is 49 years old, the oldest is 87 years old, mostly concentrated
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
Comments:
Patients admitted to the hospital with the main reason is having

lower urinary tract disorders accounting for 54.17%, high PSA 32/120
(26.67%), the reason for urinary retention 15.83%.


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3.3. Prostate biopsy results
3.3.1. Results of pathology

Table 3.6. Results of pathology
Biopsy results
Quantity

Rate %

Prostate cancer
Benign hyperplasia

40
60

33,3
50

Benign hyperplasia with prostatitis
Low-grade squamous intraepithelial lesion
High-grade squamous intraepithelial lesion

18
1

1

15
0,83
0,83

120

100%

Total

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
Biopsy results

Quantity

Rate %

Cancer patient

34

28,3

Patients without cancer

84

70

High PIN

1

0,83

Low PIN

1

0,83

Total

120

100

Comments:
Anatomy results by location of biopsy samples 6 standard cores
detected 34 prostate cancer patients accounting for 28.33% of biopsy
patients decreased 6 patients (4.16%) compared to the method of birth
12 cores, reducing 15% (34/40) of cancer detection patients.

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3.3.3. Result of disease anatomy by biopsy location of 10 cores
Table 3.8. Biopsy results by 10 cores
Biopsy results

Quantity

Rate %

Cancer patient

39

32,50

Patients without cancer

79

65,84

High PIN

1

0,83

Low PIN

1

0,83

Total

120

100

Comments:
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
Sample number 1
Peripheral zone
Sample number 2
Sample number 3
Sample number 4
Sample number 5
Sample number 6
Transition zone
Sample number 7
Sample number 8

Sample number 9
Sample number 10
Peripheral zone
Sample number 11
Sample number 12
Most have cancer
Comments:

Times

Rate %

10
9
12
16
15
12
11
12
10
4
11
8
6

25,00
22,50
30,00
40,00

37,50
30,00
27,50
30,00
25,00
10,00
27,50
20,00
15%


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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
Biopsy results

Rectal examination

Cancer

No cancer

15

12

Suspected cancer

Total

p

27

0,02
Not suspected cancer
25
68
93
Total
40
80
120
Comments:
DRE suspected prostate cancer was 27/120 patients and biopsy
detected 15/40 patients (55.55%) of prostate cancer. Prostate
examination results suspect prostate cancer and biopsy findings of
prostate cancer are positively correlated.
- Calculate the sensitivity and specificity of the diagnosis of
prostate cancer through rectal examination:
+ Sensitivity P ( A ) = 15/(15+25) = 37.5%

B

+ Specificity P ( A ) = 68/(68+12) = 85%

B

+ Diagnostic value P(Đ) = 15/(15+12) = 55.55%
3.4.2. Relationship between biopsy results and ultrasound transrectal
results.
- Biopsy results with prostate weight


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Table 3.11. Evaluate biopsy results with prostate weight
Prostate volume
< 30 g
30 – 50 g
50 – 100 g
>100 g
Total
P

Biopsy results
Cancer
No cancer
17(42,5%)
8(10%)
13(32,5%)
32(40%)
10(25%)
28(35%)

0
12(15%)
40 (100%)
80(100%)
0,004

Total
25
45
38
0
120

Comments:
The highest cancer rate was found in patients with prostate
weight less than 30 g (41.03%), then in the group with prostate gland
volume from 30 - 50 g (32.5%) and decreased 25% when prostate gland
volume is between 50 - 100 grams. Thereby, the smaller the prostate
weight is, the more significant the result of cancer detection biopsy is p
<0.05.
- Biopsy results compared with ultrasound results
Table 3.12. Biopsy results compared with ultrasound results
Biopsy results
Transrectal prostate
Total
ultrasound
Cancer
No cancer
Suspected cancer
29(72,5%)

33(41,3%)
62
p=
0,006
Not suspected cancer
11(27,5%)
47(57,7%)
58
Total
40
80
120
Comments:
Biopsy results found 72.5% of prostate cancer patients in the
Transrectal prostate ultrasound group had suspected cancer and
decreased to 17.5% in the rectal ultrasound group, there was a
relationship between biopsy detect prostate cancer and patients with
rectal ultrasound suspected prostate cancer significant with p <0.05
Calculate the sensitivity and specificity of Transrectal prostate
ultrasound to detect cancer.


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Sensitivity P ( A ) = 29/(29+11) = 72.50%

B

Specificity P ( A ) = 47/(47+33) = 58.75%

B

Diagnostic value P(Đ) = 29/(29+33) = 46.77%
3.4.3. Relationship between biopsy results and MRI results
Table 3.13. Relationship between biopsy results and MRI results
Biopsy results
MRI
Total
P
Cancer
No cancer
Suspected cancer
18
24
42
0,5
Not suspected cancer
3
8
11
Total
21
32
53
Comments:
Among 42 patients who had MRI suspected of having prostate
cancer, biopsy results detected 18 prostate cancer patients accounting
for 42.85%, there was no correlation between MRI results. Suspect
prostate cancer with biopsy results that detect prostate cancer.
The value of MRI from prostate cancer detection is
Sensitivity P ( A )= 18/(18+3)= 85.71%

B

Specificity P ( A ) = 8/(8+24)= 25%

B

Diagnostic value P(Đ) = 18/(18+24) = 42.85%
3.4.4. Relationship between biopsy results and PSA values
Table 3.14. Compare biopsy results with total PSA values
PSA(ng/ml)
< 10
10 - 20
> 20
Total
Rate
Rate
Rate
N
N Rate % N
N
Results
%
%
%
Cancer
2
5
15
37,5

23
57,5
40
100
Benign
15 18,99 37
46,83
26 32,91
78
100
hyperplasia
Low PIN
0
1
100
0
1
100
High PIN
1
100
1
Total
17 14,17 54
45
49 40,83 120
100
P
0,049

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Comments:
Prostate cancer detected in the patients with PSA <10 ng \ ml
was 5% after the increase to 37.5% in the group with PSA from 10-20
ng/ml and the highest increase in patients with PSA > 20 ng/ml was
46.94% of patients with prostate cancer detected, there was a
relationship between increased PSA values and increased prostate
cancer biopsy results. < 0.05.
3.5. Differentiation of cancer cells
Table 3.15. Cancer subgrouping according to Gleason score
Gleason

N

Rate %

2-6
7
8-10
Total

7
17
16
40

17,5
42,5
40

100

Comments:
Malignant prostate patients had a low malignancy of 17.5%, an
average malignancy of 42.5% and patients of prostate cancer with a
high malignancy of 40%.
3.6. Diagnosis of the stage of the cancer group
Table 3.16: Stage of cancer patient group
Chẩn đoán giai đoạn

Quantity

Rate %

Stage I
Stage II
Stage III
Stage IV
Total

3
24
6
7
40

7,5
60
15
17,5

100

Comments:
Patients with prostate cancer in stage II are mainly accounted
for 60%, stage I is 7.5%, stage III is 15% and stage IV is 17.5%.


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3.7. Accidents and complications
Table 3.17. The accidents and complications of a biopsy
Complications
N
Rate (%)
No complications
86
71,7
Anal bleeding - rectum
12
10
Massive hematuria
19
15,8
Compli
Urinary tract infections
9
7,5
cations
Sepsis
1

0,83
Urinary retention after biopsy
5
4,16
Comments:
There were 86 cases (71.7%) without complications after
biopsy. 15.8% had hematuria, mainly pink urine, 10% of patients had
rectal bleeding, urinary tract infection 7.5%, 0.83% septicemia and 4.16
Patients with urinary retention after biopsy.
3.8. Pain sensations after a biopsy
Table 3.18. Pain sensations after a biopsy
Pain points
Pain level
N
Rate %
0-1
No pain
0
0
2-3
Little Pain
94
78,33
4-5
Average pain
23
19,17
6-7
Moderate pain
3

2,5
8-9
Severe pain
0
0
10
Quite severe pain
0
0
Total
120
100
Comments:
Mainly, patients with low pain were 78.33%, average pain was
19.17%, and moderate pain was 2.5%. There were no patients with
severe pain and quite severe pain.


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Chapter 4
DISCUSSION
4.1. Developing the prostate biopsy designations and procedures for
12 samples.
4.1.1. Factors that specify a biopsy.
4.1.1.1. Digital rectal examination.
Of the 120 patients on transrectal examination we found on
January 27, accounting for 22.5% of patients with suspected prostate
cancer, rectal examination suspected cancer was an absolute indication
for prostate biopsy.

Digital rectal examination is a simple, cheap and effective way to
detect prostate cancer. Cancer usually appears in the peripheral zone of
the prostate and can be detected by rectal examination when the volume
is about 0.2 ml or larger. Richie et al. Showed that 18% of prostate
cancer patients were detected transrectal examination when abnormal.
4.1.1.2. Transrectal prostate ultrasound.
Transrectal prostate ultrasound we suspect prostate cancer is
62/120 (51.67%), images of suspected prostate cancer by ultrasound are
negative cells, cancer suspects, irregular protruding edges , the
boundary between the peripheral prostate region and the unknown
transition zone may be caused by the block located in the peripheral
zone, even if the negative structure of the peripheral prostate does not
change much..
4.1.1.3. PSA test.
While rectal examination and prostate ultrasound are somewhat
subjective, the serum PSA test is objective and potentially helps assess
a patient's cancer risk, which is also a valuable test. Highest cancer
prediction from that indicates prostate biopsy. In our study, most
patients were ordered a biopsy because the test had PSA> 10 ng/ml,
accounting for 85.8%, 14.2% of the patients had PSA <10 ng/ml. The
rate of prostate cancer increases with serum PSA values. When PSA
<4ng/ml, the positive biopsy rate is 1/50
4.1.1.4. MRI of the prostate.


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In our study, 53 patients had an MRI of the prostate before
prostate biopsy, resulting in 42 suspected lesions of prostate cancer
accounting for 79.2% of the patients had MRI.
Combining rectal prostate examination factors, rectal ultrasound

and serum PSA tests, MRI of the prostate has since indicated prostate
biopsy for definitive diagnosis of prostate cancer. In our study, 17
patients had PSA <10 ng/ml but were indicated for prostate biopsy
because of the 17 patients mentioned on transrectal examination,
prostate ultrasound or magnetic resonance imaging with suspected
images. suspected prostate cancer.
4.2. Means, equipment and process of biopsy.
Prostate biopsy of 12 cores through the rectum under ultrasound
guidance similar to transrectal prostate biopsy method of 6 cores or 10
cores.
4.3. Transrectal 12-core biopsy techniques and location
The biopsy site of 12 cores in addition to a 6-core biopsy is the
standard method of Hodge; we also biopsy an additional 6 cores at the
sites outside the peripheral zone on each side of the medial medial and
top of each 3-core lobe .
Perform biopsy of 12 cores, 6 cores per lobe and according to the
position of the prostate gland (the top, center and bottom of the prostate,
right lobe, left lobe of prostate). Take 12 cores in the correct numerical
order and from the right to the left: samples 1, 2 and 3 in the right
peripheral zone; numbers 4, 5, 6 belong to transition zone on the right;
numbers 7, 8, 9 belong to the left transition zone, and the numbers 10,
11, 12 belong to the left peripheral zone.
4.3.1. Discussing the development of indications and procedure for 12
sample prostate biopsy.
The prostate biopsy method under the guidance of ultrasound for
biopsy of 6 samples, 8 samples, 10 samples, 12 samples and more
biopsies can be obtained, means, machines, disease preparation In
particular, doctors who perform biopsies must have a lot of experience,
strictly follow all procedures that have been built beforehand.
Technically biopsy, biopsy method of 12 samples is performed

according to the following procedure:


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- Perform a 12-sample biopsy, located on the right with the symbols (I):
1, 2, 3, 4, 5, 6, to the left of the symbol (II): 7, 8, 9, 10, 11, 12.
Vietnam is considered a country not in the focus area of prostate
cancer, the rate of prostate cancer is low but prostate cancer patients in
Vietnam are often detected at a later stage, according to a number of
research results at Cho Ray Hospital, monitoring prostate cancer
treatment within 5 years (from 2011-2015), of 222 patients with
prostate cancer, of which most were in metastases and local
progression, accounting for 70.7% and 16.2%, respectively.
According to research by Vu Nguyen Khai Ca (2012). In 2 years
(2010-2011), the Urology Department of Viet Duc University Hospital
treated 119 patients with prostate cancer, only 8 patients at the early
stages T1 and T2 (6.7%). In Vietnam, the designation of prostate biopsy
is agreed by the authors two classic standards for prostate biopsy are
based on PSA and prostate rectal probe that are abnormal, this standard
is applied in Vietnam with Recommended PSA> 10 ng/ml. Based on
literature, studies in developed countries indicate that prostate biopsy is
more extensive. All treatment guidelines from the American and
European Urological Association use the "threshold value" of PSA from
2 - 4 ng/ml to indicate prostate biopsy. Currently the US National
Cancer Dissemination Network (NCCN) proposes a threshold value of
PSA for prostate biopsy design in the United States of 2.5 ng/mL. Their
results show that with PSA <10ng/ml, 2 patients found prostate cancer.
Therefore, through our research, we propose to expand prostate
biopsy designation for early diagnosis of prostate cancer with PSA
threshold> 4 ng/ml in combination with rectal visit and based on

imaging diagnosis to Prostate biopsy designation and a number of other
related factors such as PSA density, fPSA/tPSA ratio, PSA weight,
complementing prostate biopsy designation.
4.4. Biopsy results
From October 2015 to April 2017, the total of 120 patients had 12core prostate biopsy under the patient selection criteria.
4.4.1. The age of the patients
Of the 120 patients undergoing biopsy, the average age of the
research team was 69.37 ± 8.2, the youngest was 49 years old, the


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highest was 87 years old, mostly concentrated in the age group from 6080 years old, accounting for 75, 83%.
4.4.2. Results of 12-core prostate biopsy
Among 120 patients with biopsy, 33.33% of cases of prostate
cancer were found, 50% were benign, 15% were accompanied by
benign prostatitis, 0.83 cases. Low-grade squamous intraepithelial
lesion and 0.83% of patients High-grade squamous intraepithelial
lesion.
4.4.2.1. Prostate biopsy results using the standard 6 core method
The biopsy method of 6 cores took the results of anatomy in the
sample sets 4,5,6 (right lobe) and 7,8,9 (left lobe), the anatomical
results according to the location of the biopsy sample 6 standard sample
detected 34 prostate cancer patients, reached the rate of prostate cancer
detection of 28.33%.
Thus, if the 6-core prostate biopsy will not detect 6 patients with
prostate cancer, the cancer detection rate will be reduced by 5%
compared to the 12-core biopsy method, by 15% ( 34/40) number of
prostate cancer patients detected.
4.4.2.2. Prostate biopsy results using the 10-core method
Methods of biopsy according to the number of biopsy samples of

10 samples including the set of samples according to positions 1,2,4,5,6
(right lobe) and 7,8,9,10,1, anatomical results diseases by position of
samples detected 39 prostate cancer patients accounting for 32.5%,
reducing 1 patient (0.83%) compared with 12-sample biopsy, reducing
2.5% (39/40) of diseases In the case of cancer detectors, only one
patient in sample 3 detected cancer cells.
4.5. Factors related to biopsy results
4.5.1. Discussing the results of the transrectal prostate examination
and its relationship with the biopsy results.
In our study, there were 27/120 suspected cancer patients
accounting for 22.5% and among rectal examination patients with
suspected prostate cancer biopsy results there were 15 cases of cancer
and in No. 93 rectal examination patients did not find prostate
abnormalities, biopsy results detected 25 patients with prostate cancer
which concluded the increased rate of prostate cancer detection through


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biopsy in the cases. rectal examination suspected prostate cancer was
significant with p <0.05.
4.5.2. Discussing the results through the transrectal prostate
ultrasound and its relationship to the biopsy results.
In our study, 100% of patients who received ultrasound transrectal
prostate. In 62 cases of suspected prostate cancer, 29/62 patients with
biopsy detected cancer accounted for 46.77%, in the non-cancer rectal
ultrasound group had 11/58 patients (18.96 %) biopsy detects prostate
cancer. Among prostate cancer patients, Transrectal prostate ultrasound
suspected prostate cancer and prostate cancer biopsy result was 29/40
(72.5%). increase the rate of prostate cancer detection biopsy in patients
with rectal ultrasound suspected prostate cancer significant with p

<0.05, sensitivity, specificity and diagnostic value of Transrectal
prostate ultrasound to diagnose prostate cancer through our research is:
sensitivity 75.5%, specificity 58,75% and diagnostic value of transrectal
ultrasound is 46,77%.
4.5.3. Discussion on the value of PSA and its relation to the biopsy
results.
The average total PSA value in the study is 24,79 ± 2,09 ng/ml, in
which PSA belongs to the group of 10 - 20 ng/ml, accounting for 45%
(the majority), PSA group> 20 ng/ml is 40.8%, the group with PSA less
than 10 ng/ml accounted for 14.2%, the smallest PSA was 3.89 ng/ml,
the largest was 105.7 ng/ml. The average PSA of the prostate cancer
group detected was 32.03 + 2.29 ng/ml
In our study, prostate cancer detected in the group of patients with
PSA <10 ng \ ml was 5% after the increase to 37.5% in the group with
PSA from 10 to 20 ng/ml and the highest increase. In patients with
PSA> 20 ng/ml, 46.94% of patients had prostate cancer detected, there
was a correlation between increased PSA value and increased prostate
cancer biopsy results. Statistical significance with p <0.05.
Results of the study included 17 patients with PSA test
<10 ng/ml, the ratio of free PSA/total PSA <0.1 has 2 patients
(11.76%), from 0.1 to 0.25 is 52.94 and> 0.25 is 35, 30%. Biopsy
results in patients with PSA <10 ng/ml had 2 patients with prostate
cancer detected and these 2 patients had a free PSA/PSA ratio <0.1.


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According to the European Urological Association guidelines, a
prostate biopsy is required if the fPSA/tPSA ratio is below 0.1 and is
considered in the case of the range of 0.1 to 0.25.
4.6. Diagnosis of cancer stage

Based on the biopsy results, the location of the sample and the
number of biopsy samples with cancer cells, the results of the MRI
scan, according to AJCC 2017 we diagnose the stage of prostate cancer
patients. stage I is 7.5%, in stage II is mainly accounted for 60%, stage
III is 15% and stage IV 17.5%, thereby showing that mainly patients are
diagnosed in stage I and Stage II (67.5%), this result reflects that most
patients are diagnosed at an early stage when the tumor is localized and
indicated for curative treatment.
CONCLUSION
From October 2015 to April 2017, 120 patients underwent a 12core transrectal prostate biopsy under the ultrasound guidance at Viet
Duc Hospital.
1. Formulating indications and application of 12-core transrectal
prostate biopsy method
* Indications for biopsy:
- Rectal prostate probe detected abnormalities.
- PSA > 4 ng/ml.
- Ultrasound of the prostate gland through the rectum with
suspected cancer
- MRI of suspected prostate
- fPSA/tPSA factors in patients with PSA <10 ng/ml less than 01,
PSAD <0.15 in addition to biopsy indications.
* Prostate biopsy procedure.
- Preparing the patient: Cleaning the rectum, antibiotics to prevent
infections, anesthesia method, patient's position follow the standard
procedure currently applied at Viet Duc University Hospital.
- Technique and biopsy site of 12 samples through the rectum


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Performing 12 biopsies, according to positions 1, 2, 3, 4, 5, 6 in

the right lobe. 7, 8, 9 10, 11, 12 in the left lobe of the prostate gland
according to the following diagram:
2. Results of 12-core prostate biopsy
- Biopsy results found 33.33% of prostate cancer cases.
+ An increase of 5% (28.33%) compared to a traditional 6-core
biopsy and an increase of 15% in prostate cancer patients detected
34/40 (85%).
+ Increasing 0.83% of prostate cancer signaling rate and increasing
2.5% of patients detecting prostate cancer compared with 10-sample
biopsy.
+ Cancer in stage I is 7.5%; Stage II 60%; Stage III 15%; Stage IV
17.5%.
- Cancer patients have low malignancy of 17.5%, average
malignancy of 42.5% and high malignancy of 40%.
- Grouping the risk factors:
+ The local state accounts for 67.5%. (in which the high-risk group
is 55.56%, the average risk is 44.44%).
+ On-the-spot progression stage: 27.5%
+ Metastatic stage: 5%
- Complications after biopsy:
+ Massive haematuria of 15.8%; Rectal anal bleeding 10%;
Urinary tract infections 7.5%; Blood bacteremia 0.83%.
2.2. Several factors related to biopsy results.
- The higher the PSA value, the higher the rate of prostate cancer
detection increased significantly with P <0.05.
- Rectal examination of prostate abnormalities related to biopsy
findings for significant prostate cancer with P <0.05
- Transrectal prostate ultrasound:
+ The smaller the prostate weight is, the more significant the rate
of prostate cancer detection is

+ Ultrasound of prostate gland suspects prostate cancer is
associated with significant cancer detection biopsy.
Transrectal 12-core prostate biopsy under ultrasound guidance is
an effective and safe method of diagnosis of prostate cancer.