Ch 150 Prostate Biopsies Flashcards
Prostatic corpora amylacea are calcifications found where?
Between transition and peripheral zone
Which of the following states is TRUE about TRUS of the seminal vesicles?
A) masses in the SV are the most common lesion seen on TRUS of the prostate
B) SV are usually asymmetrical and normally measure <2cm in length in an adult
C) Most cystic masses in the SV are malignant and related to prostate CA
D) A solid mass in the SV is always associated with malignany
E) Solid masses in the SV can be caused by schistosomiasis in endemic regions.
E) Solid masses in the SV can be caused by schistosomiasis in endemic regions.
Calcifications diffusely seen in the prostate on TRUS are:
A) called corpora amylacea
B) always considered abnormal and mandate biopsy
C) considered diagnostic of prostate CA
D) incidental finding usually due to advanced age
E) walls of blood vessels
D) incidental finding usually due to advanced age
Which of the following statements about the seminal vesicle (SV) when imaged by ultrasound is TRUE?
a. The average seminal vesicle is approximately 4.5 to 5.5 cm in length.
b. A unilaterally absent seminal vesicle suggests an undescended testicle on the ipsilateral side.
c. Seminal vesicles are usually asymmetric.
d. The ejaculatory ducts run alongside the seminal vesicles and cannot be visualized on transrectal ultrasound.
e. The seminal vesicles are difficult to image using standard TRUS probes.
a. The average seminal vesicle is approximately 4.5 to 5.5 cm in length.
Which of the following statements concerning ultrasonographic estimates of prostate size/volume is TRUE?
a. Only one formula (prolate ellipse) is acceptable to determine prostate volume.
b. There is a poor correlation between radical prostatectomy specimen weights and volume as measured by TRUS.
c. The mature average prostate is between 20 and 25 g and remains relatively constant until approximately age 50, when the gland enlarges in many men.
d. Prostate cancer is always associated with an increase in overall volume of the prostate.
e. Planimetry with a stepping device should be used for routine prostate volume determinations.
c. The mature average prostate is between 20 and 25 g and remains relatively constant until approximately age 50, when the gland enlarges in many men.
A hypoechoic lesion of the prostate can be caused by all of the following EXCEPT:
a. granulomatous prostatitis.
b. transition zone, benign prostatic hyperplasia nodules.
c. prostate cancer.
d. hematologic malignancies.
e. normal urethra.
d. hematologic malignancies.
Which of the following statements is TRUE about anesthesia for TRUS prostate biopsy?
a. Intrarectal lidocaine gel is as effective as the inMection of lidocaine.
b. It is not necessary even with extended-core biopsies, owing to the small size of the needle.
c. It is best performed using direct inMection of lidocaine into the prostate gland.
d. It is typically performed using lidocaine, a long 22-gauge spinal needle, and the biopsy channel of the ultrasound probe.
e. It is typically performed using digital guidance to ensure that the base of the prostate near the seminal vesicles is infiltrated.
d. It is typically performed using lidocaine, a long 22-gauge spinal needle, and the biopsy channel of the ultrasound probe.
When performing TRUS prostate biopsy:
a. the left lateral decubitus position is most commonly used.
b. the right lateral decubitus position is most commonly used.
c. enemas should not be used before the procedure and may increase the risk of bleeding.
d. intravenous antibiotic prophylaxis is necessary in all patients to prevent urosepsis.
e. the dorsal lithotomy position with the use of stirrups increases the diagnostic accuracy of the prostate biopsies.
a. the left lateral decubitus position is most commonly used.
When performing TRUS prostate biopsy:
a. only hypoechoic lesions should be sampled.
b. sextant biopsy represents the current standard of care for the diagnosis of prostate cancer.
c. the transition zone should be included in all initial biopsies because of the high incidence of cancer in this area.
d. a minimum of 12 systematic biopsies is currently recommended.
e. isoechoic lesions are rarely cancerous and should not be sampled unless they are calcified.
d. a minimum of 12 systematic biopsies is currently recommended.
Sextant biopsy - 6 cores
Systematic biopsy - 12 cores
Saturation biopsy - ~18 cores
Which of the following statements is TRUE concerning TRUS appearance after treatment?
a. With an ideal permanent implant, seeds should be distributed evenly throughout the gland with periurethral sparing.
b. TRUS findings are accurate in determining residual cancer following external beam radiation.
c. Androgen ablation will always reduce the size of theprostate by more than 50% regardless of baseline size.
d. With prostate-specific antigen (PSA) recurrence following radical prostatectomy, the anastomosis should be biopsied.
e. Prostate volume decreases by more than 50% at 6 months using agents such as finasteride.
a. With an ideal permanent implant, seeds should be distributed evenly throughout the gland with periurethral sparing.
Which of the following statements about antibiotic prophylaxis for TRUS biopsy is TRUE?
a. It eliminates the risk of any infection.
b. It reduces the risk of febrile urinary tract infection requiring hospitalization but does not prevent them.
c. It is not necessary if the probe is sterilized and an enema is given.
d. Epididymitis is the most common infection after TRUS biopsy even if antibiotics are used.
e. Bacteriuria is the only indication for antibiotics after TRUS prostate biopsy.
b. It reduces the risk of febrile urinary tract infection requiring hospitalization but does not prevent them.
Preferred: Fluoroquinolone
If w valve, IM Ampicilin + Gentamicin
Hematospermia after TRUS biopsy:
a. usually requires hospitalization.
b. is eliminated with the routine use of antibiotics.
c. usually clears immediately after TRUS biopsy.
d. can persist for up to 4 to 6 weeks after TRUS biopsy.
e. is eliminated if the probe is held firmly against the prostate after the needle is passed.
d. can persist for up to 4 to 6 weeks after TRUS biopsy.
Which of the following statements is TRUE in men with a negative prostate biopsy?
a. They can be assured that no cancer is present.
b. They will require repeated biopsy if one of the cores contains seminal vesicle.
c. Transurethral biopsy is the next step after an initial negative biopsy.
d. Additional biopsies demonstrate decreasing yield of detecting cancer, and the cancer tends to be of lower grade and stage.
e. They should undergo transperineal biopsy for all future biopsies because these have been shown to be the most accurate approach in large randomized European trials.
d. Additional biopsies demonstrate decreasing yield of detecting cancer, and the cancer tends to be of lower grade and stage.
Risk factors for prostate biopsy related infection include all of the following EXCEPT:
a. recent antibiotic use.
b. diabetes mellitus.
c. prostate enlargement.
d. foreign travel.
e. White race.
e. White race.
Which of the following statements is TRUE concerning TRUS/magnetic resonance imaging (MRI) fusion biopsy?
a. It must be performed in an “in-bore MRI.”
b. The MRI must be obtained within 24 hours of the prostate biopsy.
c. TRUS/MRI fusion biopsy relies on coregistration of the MRI and TRUS images at the time of biopsy.
d. It relies on a method known as “cognitive fusion.”
e. Any MRI of the prostate can be used for the fusion biopsy.
c. TRUS/MRI fusion biopsy relies on coregistration of the MRI and TRUS images at the time of biopsy.
Which of the following statements is TRUE concerning TRUS/magnetic resonance imaging (MRI) fusion biopsy?
a. It must be performed in an “in-bore MRI.”
b. The MRI must be obtained within 24 hours of the prostate biopsy.
c. TRUS/MRI fusion biopsy relies on coregistration of the MRI and TRUS images at the time of biopsy.
d. It relies on a method known as “cognitive fusion.”
e. Any MRI of the prostate can be used for the fusion biopsy.
c. TRUS/MRI fusion biopsy relies on coregistration of the MRI and TRUS images at the time of biopsy.
Name the 5 divisions of the prostate
1) Anterior fibromuscular stroma
2) Central zone
3) Transition zone — BPH
4) Peripheral zone — AdenoCA
5) Periurethral zone
Which zone appears more homogenous on ultrasound?
CZ, PZ = homogenous echogenic appearnce
TX = more heterogenous
A distended urethral lumen is hyperechoic of hypoechoic on UTS?
HYPOechoic
Periurethral calcifications = thin echogenic line
Smooth muscle of internal sphincter circling urethra at verumontanum is hyperechoic or hypoechoic?
HYPOechoic ring around prostatic urethra, giving it a funneled appearance proximally as it arises from the bladder neck
What is the normal length and width of the seminal vesicles?
Length: 4.5-5.5 cm
Width: 2cm
An absent SV is associated with?
Ipsilateral renal agenesis (79%)
Optimal brightness setting results in a medium-gray image of the normal PZ, TZ, or CZ?
PZ — This gray tone serves as the reference point for judging lesions as hypoechoic (darker than the normal PZ), isoechoic (similar to the normal PZ), hyperechoic (lighter than the normal PZ), or anechoic (completely black).
An elevated PSAD has a sensitivity and specificity of 75% and 44%, respectively, for predicting cancer on repeat biopsy
Useful for ruling out prostate CA
After external beam radiation monotherapy (EBRT), the irradiated prostate:
A. WIll appear diffusely hypoechoic
B. Will have decreased in volume by six months post-treatment
C. Smaller cancer foci responding to treatment tend to become isoechoic, but TRUS findings correlate poorly with pathologic findings and outcomes
D. All are true
D. All are true
In old TRUS studies, hypoechoic lesions were considered pathognomonic for prostate cancer. However, more contemporary studies show that this type of lesion occur in prostate cancer in almost 40% of cases and is the second most common echogenicity characteristic in prostate cancer patients.
A. Isoechoic
B. Hyperechoic
C. Hypoechoic
D. Hypoechoic with prostate concentrations
A. Isoechoic
PSA is best viewed as a dynamic screening tool, and not simply a static dichotomous tool; there is no safe PSA threshold that can definitively rule out cancer in any age range. In men with PSA < 4.0 ng/ml, the following is TRUE
A. The overall cancer detection rate in men with PSA < 4.0 ng/ml is 15%
B. The overall cancer detection rate in men with PSA < 4.0 ng/ml increases to 50% if PSA density (PSAD) is taken into account at a cut-off of > 0.15
C. The overall cancer detection rate in men with PSA < 4.0 ng/ml approaches 5 %
D. The overall cancer detection rate in men with PSA < 4.0 ng/ml increases to 50% if PSA velocity (PSAV) is taken into account at a cut-off of > 0.75 ng/ml / year
A. The overall cancer detection rate in men with PSA < 4.0 ng/ml is 15%
In urothelial carcinoma patients who have been treated with bladder instillation of BCG (Bacillus Calmette-Guerin), the following is a common TRUS finding:
A. Hypoechoic lesions in the prostate, commonly granulomas
B. Hyperechoic lesions in the prostate, commonly granulomas
C. Isoechoic lesions in the prostate, commonly granulomas
A. Hypoechoic lesions in the prostate, commonly granulomas
With interstitial brachytherapy will show the following changes in TRUS, except
A. Post implantation edema
B. Seeds should appear evenly distributed throughout the gland
C. Seeds should spare the peri-urethral area and should not be visible outside of the prostate
D. Seeds are hyperechoic but without posterior shadowing
D. Seeds are hyperechoic but without posterior shadowing
Androgen-ablation with hormonal agents such as LHRH antagonists will show the following on TRUS:
A. A decrease in volume by 30%
B. An increase in echogenicity (prostate becomes hyperechoic)
C. A decrease in echogenicity (prostate becomes hypoechoic)
D. Differentiation of architectural zones becomes poorer post-treatment
A. A decrease in volume by 30%
Planimetry is defined as a more precise determination of gland volume (for example, in brachytherapy planning). This is commonly done using the following technique
A. Serial transverse images are obtained and the surface area of each serial image is determined. The integral exponent of these measures is multiplied by total gland length to yield prostate volume
B. Serial transverse images are obtained and the surface area of each serial image is determined. The sum of these measures is multiplied by total gland length to yield prostate volume
C. This is defined as (π/6 x Dt3) where Dt is the transverse diameter of the prostate. The result is then measured with both axial tomography, and ultrasonography, and a regression analysis is done on the resulting value to ensure the most accurate volume possible.
D. This is defined as (π/6 x Dt3) where Dt is the transverse diameter of the prostate. The result is then measured with both axial tomography, and ultrasonography, and a linear analysis is done on the resulting value to ensure the most accurate volume possible.
B. Serial transverse images are obtained and the surface area of each serial image is determined. The sum of these measures is multiplied by total gland length to yield prostate volume
Ultrasound energy can be transmitted to water and soft tissue because they have similar acoustic properties. Ultrasound energy goes not propagate through air, however. For this reason, a water-density substance called a coupling medium is required. The coupling medium (such as lubricant or ultrasound jelly) is placed between:
A. The rectal surface and the probe only, if the probe is not covered by a protective condom
B. Between the protective condom and the probe
C. Between the protective condom and the rectal surface
D. All are correct
D. All are correct
The TRUS without a biopsy has little utility in the evaluation of a patient for prostate cancer.
A. This is a TRUE statement. Prostate cancer sonologic characteristics are varied and do not have reliable and robust correlation with histopathologic results.
B. This is a FALSE statement. Prostate cancer is reliably detected as a hypoechoic nodular lesion of any size, most commonly found in the peripheral zone
A. This is a TRUE statement. Prostate cancer sonologic characteristics are varied and do not have reliable and robust correlation with histopathologic results.
After radical prostatectomy, which of the following TRUS findings are suspicious of local recurrence, and need further investigation:
A. A nodular appearance of the bladder neck - may represent purse string anastomosis
B. A nodule of tissue clearly anterior to the anastomosis - may represent dorsal vein
C. A hypoechoic of hyperechoic lesion that interrupts the retroanastomotic fat plane
D. All are indicative of recurrence
C. A hypoechoic of hyperechoic lesion that interrupts the retroanastomotic fat plane
The optimal brightness setting of the ultrasound probe results in a medium-gray image of this area, making it the gray-tone reference point when describing hypo-, iso-, or hyperechogenicity
A. Peripheral zone
B. Transition zone
C. Anterior fibromuscular stroma
D. Central zone
A. Peripheral zone
Adenoid cystic / basal cell carcinoma of the prostate is rare but potentially fatal. The following is the TRUS finding in this uncommon entity:
A. Irregular hypoechoic mass with an anechoic center indicating central necrosis
B. Numerous evenly distributed small anechoic cysts
C. Irregular anterior mass demonstrating relative hyperechogenicity
D. Extension from a primary bladder or urethral lesion
B. Numerous evenly distributed small anechoic cysts
Although the histopathologic zonal architecture of the prostate gland is not routinely visible as distinct entities via sonography, the following may be discernible particularly in glands with significant BPH:
A. The anterior fibromuscular stroma is discernible from the transition zone (TZ), and central zone (CZ) Missed correct answer
B. The transition zone is discernible from the PZ and CZ
C. Glands may appear as hypoechoic nodules distinct from surrounding fibromuscular stroma
D. Corpora amylacea highlight the plane between the anterior fibromuscular stroma and TZ
B. The transition zone is discernible from the PZ and CZ
