Our first month of delivering the prostate cancer diagnostic pathway within the limitations of COVID-19 using local anaesthesia transperineal biopsy.,BJU International

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Our first month of delivering the prostate cancer diagnostic pathway within the limitations of COVID-19 using local anaesthesia transperineal biopsy.
BJU International ( IF 3.7 ) Pub Date : 2020-05-26 , DOI: 10.1111/bju.15120
Rick Popert ₁ , Francesca Kum _{1,

2} , Findlay MacAskill ₁ , Luke Stroman ₁ , Grace Zisengwe ₁ , Jonah Rusere ₁ , Kate Haire ₃ , Ben Challacombe _{1,

2} , Paul Cathcart ₁

Affiliation

Introduction

The COVID‐19 pandemic is impacting all urological cancer services. On 19 March 2020, the BAUS provided pragmatic guidance for prostate cancer diagnostic services (Table 1) [1].

Table 1. BAUS guidance on the management of the prostate cancer diagnostic pathway during the COVID‐19 pandemic [1].

COVID‐19 policy recommendation 1: PSA >20 µg/mL (Category 1):

Patients with a PSA >20 ng/mLwith identified metastatic disease to initiate hormone therapy.

COVID‐19 policy recommendation 2: PSA <20 µg/mL, high PSAD (Category 2): Treat as normal pathway until services restricted.

Patients with PSA <20 µg/mL, but a high PSAD >0.15 µg/L/cc, with prostate volume determined on transabdominal ultrasonography or by estimated DRE, because of the presumed limited availability of MRI, should be offered a perineal prostate biopsy (potentially limited core numbers) if available in the outpatient setting. TRUS biopsy should be avoided if possible.

COVID‐19 policy recommendation 3: PSA <20 µg/mL, low PSAD (Category 3):

Where the PSAD (PSA/prostate volume) is low (<0.15 µg/L/cc), all patients should be reassured, discharged and have a repeat PSA test in the primary care setting in 6 months, with re‐referral if the repeat PSA test in 6 months provides a PSAD >0.15 µg/L/cc. This PSA value should be listed in hospital correspondence.

PSAD, PSA density.

On 16 March, Guy’s and St Thomas’ NHS Foundation Trust declared a major incident status and, in advance of the BAUS guidance, we suspended our transperineal (TP) biopsy service; however, a backlog of referrals remained. In February 2020, 101 MRIs were reviewed: 31 patients were discharged for PSA observation; 61 were listed for primary TP biopsy and nine were listed for active surveillance TP biopsy. Patients with evidence of metastatic bone disease were started on hormonal therapy immediately, without biopsy. By 30 March, 49 patients remained on the TP biopsy waiting list, so were stratified by priority, with 15 in the 'red' risk category, 15 in the 'amber' category, 10 in the 'green' category and nine on active surveillance (Table 2). Following careful risk assessment and case stratification, we decided to re‐start out prostate biopsy programme, but needed to carefully consider the logistics and how to proceed safely for both our patients and staff.

Table 2. Risk stratification for biopsies following PSA and MRI during the COVID‐19 pandemic.

Risk category	PSA density (ng/mL/cc)	MRI LIKERT score	Clinical stage	Management
Green (low risk)	<0.15	2–3 No lesion	T1c to T2a	Delay biopsy, repeat PSA within the next 4‐‐6 months Low priority
Amber (intermediate risk)	<0.2	3–4–5 Lesion	>T2b N0 M0	Early biopsy, within 3 months and within 1 month Intermediate priority
Red (high risk)	>0.2	3–4–5 Lesion	≥T2c N1 M0 T3a/b N0 M0	Urgent biopsy, within 1/12 High priority

Risk category

PSA density (ng/mL/cc)

MRI LIKERT score

Clinical stage

Management

Green (low risk)

<0.15

2–3

No lesion

T1c to T2a

Delay biopsy, repeat PSA within the next 4‐‐6 months

Low priority

Amber (intermediate risk)

<0.2

3–4–5

Lesion

>T2b N0 M0

Early biopsy, within 3 months and within 1 month

Intermediate priority

Red (high risk)

>0.2

3–4–5

Lesion

≥T2c N1 M0

T3a/b N0 M0

Urgent biopsy, within 1/12

High priority

中文翻译：

我们在 COVID-19 的限制范围内使用局部麻醉经会阴活检提供前列腺癌诊断途径的第一个月。

介绍

COVID-19 大流行正在影响所有泌尿外科癌症服务。2020 年 3 月 19 日，BAUS 为前列腺癌诊断服务提供了务实的指导（表 1）[ 1 ]。

表 1. BAUS 关于 COVID-19 大流行期间前列腺癌诊断途径管理的指南 [ 1 ]。

COVID‐19 政策建议 1：PSA >20 µg/mL （类别 1）：

PSA > 20 ng/mL 且已确定转移性疾病的患者开始激素治疗。

COVID-19 政策建议 2：PSA <20 µg/mL，PSAD 高（2 类）：在服务受限之前视为正常途径。

PSA <20 µg/mL，但PSAD >0.15 µg/L/cc，经腹超声或估计的DRE确定前列腺体积的患者，由于假定MRI的可用性有限，应提供会阴前列腺活检。可能有限的核心数量）（如果在门诊环境中可用）。如果可能，应避免进行 TRUS 活检。

COVID-19 政策建议 3：PSA <20 µg/mL，低 PSAD（第 3 类）：

如果PSAD（PSA/前列腺体积）低（<0.15 µg/L/cc），所有患者都应放心、出院，并在 6 个月内在初级保健机构进行重复 PSA 检测，如果重复则重新转诊6 个月内的 PSA 测试提供的 PSAD >0.15 µg/L/cc。该 PSA 值应列在医院信函中。

PSAD，PSA 密度。

3 月 16 日，Guy's 和 St Thomas' NHS Foundation Trust 宣布了重大事件状态，在 BAUS 指导之前，我们暂停了经会阴 (TP) 活检服务；但是，仍然有积压的转介。2020年2月复查MRI 101例：31例出院进行PSA观察；61 例被列为初级 TP 活检，9 例被列为主动监测 TP 活检。有转移性骨病证据的患者立即开始激素治疗，无需活检。到 3 月 30 日，仍有 49 名患者在 TP 活检等待名单上，因此按优先级进行了分层，其中 15 人处于“红色”风险类别，15 人处于“琥珀”风险类别，10 人处于“绿色”类别，9 人处于主动监测状态（表 2）。经过仔细的风险评估和病例分层，

表 2. COVID-19 大流行期间 PSA 和 MRI 后活检的风险分层。

风险类别	PSA 密度 (ng/mL/cc)	MRI LIKERT 评分	临床阶段	管理
绿色（低风险）	<0.15	2–3 无病变	T1c 至 T2a	延迟活检，在接下来的 4-6 个月内重复 PSA 低优先级
琥珀色（中等风险）	<0.2	3–4–5 病变	>T2b N0 M0	早期活检，3个月内和1个月内中级优先
红色（高风险）	>0.2	3–4–5 病变	≥T2c N1 M0 T3a/b N0 M0	紧急活检，1/12以内高优先级

风险类别

PSA 密度 (ng/mL/cc)

MRI LIKERT 评分

临床阶段

管理

绿色（低风险）

<0.15

2–3

无病变

T1c 至 T2a

延迟活检，在接下来的 4-6 个月内重复 PSA

低优先级