One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.     

Comparison of systematic sextant and lesion directed biopsies in prostate cancer detection

This study was designed to determine the value of performing separate lesion directed biopsies in addition to systematic random sextant biopsies for the detection, grading, and assessment of bilaterality of prostate cancer. A prospective study of 82 consecutive patients who had peripheral zone hypoechoic regions visualized on transrectal ultrasound was performed. All patients had either an abnormal prostate-specific antigen or an abnormal digital rectal examination and underwent random systematic and lesion directed biopsies. Cancer detection, laterality, and histologic grade of lesion directed biopsies were compared with those from systematic random biopsies. Prostate cancer was detected in 35 (40%) of 82 patients who had a hypoechoic lesion visualized. Three (9%) cancers would have been missed if only systematic biopsies had been performed, while nine (26%) cancers would have been missed if only lesion directed biopsies had been performed. In all but one patient, the Gleason score of the lesion directed biopsy was equal to or within one grade of the highest Gleason score determined from systematic biopsy. Systematic random biopsies detected cancer on the opposite side of a positive lesion directed biopsy in 48% of patients. In no case did a lesion directed biopsy add to the detection of bilateral disease. In conclusion, lesion directed biopsies increase the detection of prostate cancer when performed in addition to systematic random sextant biopsies. However, lesion directed biopsies alone would result in a substantial miss rate of prostate cancer. They do not add to the determination of bilateral disease, nor do they add to the pathologic grading of the detected cancer.     

Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer

PURPOSE: The standard sextant protocol for obtaining transrectal ultrasound guided biopsy of the prostate has been shown to underestimate the presence of prostate cancer. Studies have demonstrated an increased cancer detection rate with additional laterally directed biopsies. We compared the sensitivity of individual biopsy cores and evaluated combinations of these cores to identify an optimal biopsy strategy. MATERIALS AND METHODS: A total of 396 consecutive patients underwent biopsy of the lateral peripheral zone in addition to standard sextant biopsy. The cancer detection rate for each biopsy core was calculated. The sensitivity of different combinations of biopsy cores was compared with those of standard sextant biopsies and with a 12 core biopsy protocol that combined the standard sextant biopsy with a complete set of laterally directed cores. RESULTS: Cancer was detected in 160 of 396 (40.3%) patients. Of the possible combinations of biopsy cores a strategy that included laterally directed cores at the base, mid gland and apex of the prostate with mid lobar base and apical cores detected 98.5% of cancers. The detection rate of this 10 core biopsy regimen was significantly better than that of the standard sextant protocol (p < or =0.001), and was equivalent to that of the 12 core regional biopsy (p > or =0.302). CONCLUSIONS: The standard sextant protocol failed to detect a large proportion of cancers located laterally in the peripheral zone. A 10 core biopsy regimen that combined laterally directed cores at the base, mid gland and apex of the prostate with mid lobar biopsy cores at the base and apex maximizes the sensitivity of transrectal ultrasound guided systematic biopsy.     

Detection rate of clinically insignificant prostate cancer increases with repeat prostate biopsies

To analyze if clinically insignificant prostate cancer (CIPC) is more frequently detected with repeat prostate biopsies, we retrospectively analyzed the records of 2146 men diagnosed with prostate cancer after one or more prostate biopsies. The patients were divided into five groups according to the number of prostate biopsies obtained, e.g. group 1 had one biopsy, group 2 had two biopsies and group 3 had three biopsies. Of the 2146 patients diagnosed with prostate cancer, 1956 (91.1%), 142 (6.6%), 38 (1.8%), 9 (0.4%) and 1 (0.1%) men were in groups 1, 2, 3, 4 and 5, respectively. Groups 4 and 5 were excluded because of the small sample sizes. The remaining three groups (groups 1, 2 and 3) were statistically analyzed. There were no differences in age or prostate-specific antigen level among the three groups. CIPC was detected in 201 (10.3%), 28 (19.7%) and 9 (23.7%) patients in groups 1, 2 and 3, respectively (P<0.001). A multivariate analysis showed that the number of biopsies was an independent predictor to detect CIPC (OR=2.688 for group 2; OR=4.723 for group 3). In conclusion, patients undergoing multiple prostate biopsies are more likely to be diagnosed with CIPC than those who only undergo one biopsy. However, the risk still exists that the patient could have clinically significant prostate cancer. Therefore, when counseling patients with regard to serial repeat biopsies, the possibility of prostate cancer overdiagnosis and overtreatment must be balanced with the continued risk of clinically significant disease.     

Dutasteride prior to contrast-enhanced colour Doppler ultrasound prostate biopsy increases prostate cancer detection

OBJECTIVES: This study assessed the effect of premedication with dutasteride, a dual 5alpha-reductase inhibitor, on prostatic blood flow prior to prostate biopsy and its impact on prostate cancer detection. METHODS: Thirty-six patients, aged 52-74 yr, with elevated prostate-specific antigen (PSA) levels (>or=1.25 ng/ml and free-to-total ratio of <18%) were treated with dutasteride 14 d prior to prostate biopsy. Contrast-enhanced colour Doppler (CECD) ultrasound was performed before and 7 and 14 d after dutasteride treatment. Contrast-enhanced targeted biopsies (相似文献   

Detection rate of histologically insignificant prostate cancer with systematic sextant biopsies and fine needle aspiration cytology

PURPOSE: We evaluate the detection rate of insignificant prostate cancer and the rate of significant prostate cancer overlooked in the results of systematic sextant biopsy and fine needle aspiration biopsy of the prostate of asymptomatic men with serum prostate specific antigen concentrations less than 4.0 ng./ml. MATERIALS AND METHODS: We analyzed specimens from 133 consecutive patients with a mean age of 60 years undergoing cystoprostatectomy for bladder cancer. Six systematic biopsy specimens and 2 fine needle aspiration cytology samples were taken from the prostate immediately after cystoprostatectomy. The specimens were step sectioned and examined for prostate cancer. Insignificant prostate cancer was defined as any cancer with an aggregate volume 0.5 cm.3 or less. RESULTS: Incidental prostate cancer was found in 58 of the 133 patients (44%). Tumor volume was 0.5 cm.3 or less in 47 cases. Sextant biopsy detected 7 cancers, including 4 of 47 (9%) that were insignificant and 3 of 11 (27%) that were significant. Fine needle aspiration cytology also detected 7 cancers, including 3 (6%) and 4 (36%) that were insignificant and significant, respectively. CONCLUSIONS: Systematic sextant biopsy and fine needle aspiration cytology each diagnose prostate cancer in about 5% of asymptomatic men who have normal digital rectal examination and serum prostate specific antigen less than 4.0 ng./ml. However, many of the cancers thus detected are insignificant and most of the significant cancers are missed. Therefore, routine screening of such patients with sextant biopsy or aspiration cytology does not appear to be justified.     

Sextant prostate biopsies predict side and sextant site of extracapsular extension of prostate cancer

PURPOSE: We examined the ability of sextant prostate biopsies in combination with other preoperative data to predict side and sextant site of prostate cancer extracapsular extension in a large cohort of patients. MATERIALS AND METHODS: We examined 223 contemporary cases of prostate cancer managed by radical prostatectomy. Using logistic regression analysis, we determined whether patient age, Gleason score, clinical stage, prostate specific antigen, number of positive sextants, biopsy location or percent of biopsy cores positive for cancer in a sextant site, side and overall gland was predictive of location of pathological extracapsular extension into periprostatic tissue. RESULTS: Of 41 of the 223 (18%) patients with nonorgan confined disease extracapsular extension was localized to 45 sextant sites in 36 (apex 8, mid 22, base 15) while only side of extension was known in 5. In a multivariate analysis the best predictors of the risk of extracapsular extension on a side were average percent biopsy cores positive for cancer overall 15 or greater (odds ratio 8.4, p <0.0001) and average from 3 ipsilateral biopsies 15 or greater (odds ratio 7.4, p <0.0001). When used in combination these 2 factors yielded a model with a positive predictive value of 37% and a negative predictive value of 95%. Sextant specific percent biopsy cores positive for cancer was predictive of risk of extracapsular extension in a sextant (odds ratio 2.5, p = 0.020). CONCLUSIONS: Our data demonstrate that average overall and per side percent biopsy cores positive for cancer is a significant predictor of risk of extracapsular extension on a side. Sextant specific percent biopsy cores positive for cancer is predictive of sextant site of extension. The high negative predictive value of the side specific model identifies patients who are good candidates for nerve sparing surgery.     

Extensive biopsy protocol improves the detection rate of prostate cancer

PURPOSE: We evaluated improvement in the rate of prostate cancer detection when using an extensive biopsy protocol involving peripheral cores. MATERIALS AND METHODS: We prospectively evaluated 303 consecutive men who underwent transrectal ultrasound guided biopsy due to elevated prostate specific antigen (PSA) and/or abnormal digital rectal examination. Ten biopsies were performed, including at least 5 at the base and middle of each lobe. In addition to standard biopsy at a 45-degree angle, a more peripheral 30-degree angle biopsy was obtained. At the apex only 1 standard biopsy was done. However, when prostate volume was greater than 50 cm.3, an additional peripheral biopsy was obtained at the apex. RESULTS: The complication rate in this biopsy protocol was 1% (3 patients). Prostate cancer was detected in 118 of the 303 men (38. 9%). Overall this extensive protocol resulted in 6.6% improvement in the detection rate. Improvement was 6.5% in men with PSA 10 ng./ml. or less and 7% in those with PSA greater than 10 (not significant). CONCLUSIONS: Increasing the number of biopsy cores and improving prostate peripheral zone sampling resulted in a significant improvement in the detection of prostate cancer.     

Three-dimensional computer-simulated prostate models: lateral prostate biopsies increase the detection rate of prostate cancer

OBJECTIVES: Urologists routinely use the systematic sextant needle biopsy technique to detect prostate cancer. However, recent evidence suggests that this technique has a significant sampling error. We developed a novel three-dimensional (3D) computer-assisted prostate biopsy simulator based on whole-mounted step-sectioned radical prostatectomy specimens to compare the diagnostic accuracy of various prostate needle biopsy protocols. METHODS: We obtained digital images of 201 step-sectioned whole-mounted radical prostatectomy specimens. 3D computer simulation software was developed to accurately depict the anatomy of the prostate and all individual tumor foci. Additional peripheral devices were incorporated into the system to perform interactive prostate biopsies. We obtained 18 biopsies of each prostate model to determine the detection rates of various biopsy protocols. RESULTS: The 10- and 12-pattern biopsy protocols had a 99.0% detection rate; the traditional sextant biopsy protocol rate was only 72.6%. The 5-region biopsy protocol had a 90.5% detection rate and the 14-pattern, which includes all the biopsies used in the patterns above, only added 1 additional positive case (99.5%). Transitional zone and seminal vesicle biopsies did not result in a significantly increased detection rate when added to the patterns above. Only one positive model was obtained when the transitional zone biopsies were added. The lateral sextant pattern had a detection rate of 95.5%, and the 4-pattern lateral biopsy protocol had a 93.5% detection rate. CONCLUSIONS: Our results suggest that all the biopsy protocols that use laterally placed biopsies based on the 5-region anatomic model are superior to the routinely used sextant prostate biopsy pattern. Lateral biopsies in the mid and apical zones of the gland are the most important.     

Extensive repeat transrectal ultrasound guided prostate biopsy in patients with previous benign sextant biopsies

PURPOSE: Standard sextant prostate biopsy may underestimate cancer in men in whom clinical findings are suspicious for localized prostate cancer. We describe our experience with extensive transrectal ultrasound guided prostate biopsy in men in whom previous sextant biopsy was negative. MATERIALS AND METHODS: Between November 1997 and March 1999, 57 men 47 to 72 years old (mean age 61.4) underwent extensive transrectal ultrasound guided biopsy of the prostate using intravenous sedation at our institution. An average of 22.5 cores (range 15 to 31) were obtained depending on prostate size. Biopsies were obtained from each of 6 sagittal regions, including samples from the far lateral and mid transitional zones. Each patient had undergone at least 1 previous benign transrectal ultrasound guided sextant biopsy (mean 2.1, range 1 to 4). Indications for repeat biopsy were persistently elevated prostate specific antigen (PSA) in 89% of the cases, increased PSA velocity in 63%, suspicious free-to-total PSA in 39% and a previous suspicious biopsy finding in 32%. Clinical factors (PSA, PSA velocity, free-to-total PSA and previous suspicious biopsy) were analyzed for the ability to predict positive biopsy, and tumor parameters were assessed pathologically in patients undergoing radical prostatectomy. RESULTS: Adenocarcinoma was identified in 17 of the 57 men (30%). Biopsy revealed a Gleason score of 6 to 8 (mean 6.4). In 7 of the 17 patients (41%) in whom cancer was identified only 1 biopsy core was positive. Of the 15 patients in whom previous sextant biopsy had demonstrated high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation extensive biopsy revealed cancer in 7 (47%). Although serum PSA was higher and free-to-total PSA was lower in those with cancer, the only statistically significant predictor of positive biopsy was PSA velocity (p <0.001). Prostate cancer was noted in 64% of the men with PSA velocity 1 ng./ml. or greater. Of the 13 patients undergoing radical prostatectomy pathologically significant disease was identified in all but 1 (92%). Complications of extensive biopsy included urinary retention in 6 patients and limited rectal bleeding in 1. CONCLUSIONS: Extensive prostate biopsy identifies significant prostate cancer in many men in whom previous sextant biopsy was benign. This procedure should be considered when findings are suspicious for adenocarcinoma despite previously negative sextant biopsy.     

Transrectal ultrasound guided biopsy of the prostate: random sextant versus biopsies of sono-morphologically suspicious lesions

Transrectal ultrasound (TRUS) guided multiple systematic random biopsies are presently the method of choice for determining the presence or absence of prostate cancer. TRUS image information is only used to guide the biopsy needle into the prostate, but not to localize and target cancerous lesions. Our aim in this study was to evaluated the possible predictive value of tumor suspicious endosonographic lesions of the prostate for prostate biopsies. We prospectively compared six systematic biopsies with lesion guided biopsies in a consecutive series of 217 patients. All patients had a prostate specific antigen (PSA) level of >4 ng/ml without a history of prostate disease. In a subgroup of 145 men with sonomorphologic lesions suggestive for prostate cancer (hypoechoic areas or asymmetries predominantly in the peripheral zone), lesion-guided biopsies were taken in addition to the systematic biopsies. We evaluated the number of tumors which were diagnosed or missed by both of the biopsy strategies. Of the 217 evaluated patients, 64 (29%) had histology confirmed cancer. Four patients with negative sextant biopsies had a positive TRUS guided biopsy. Out of 145 patients with a normal TRUS, three were cancer positive by sextant biopsy. A total of 1,387 individual biopsy cores were evaluated. Of the 1,304 systematic biopsy cores, 182 (14%) were positive and 1,122 (86%) negative. Of the 329 TRUS lesion guided biopsy cores 139 (42%) were positive and 190 (58%) negative. Patients with tumor suggestive TRUS lesions have a considerably higher risk of being diagnosed with prostate cancer compared to patients without such lesions. Both systematic sextant and TRUS lesion guided biopsies missed detectable prostate cancer in a minority of patients. Taking the endosonographic morphology of the prostate gland into consideration for biopsy strategies may improve the quality of the biopsy and avoid unnecessary invasive procedures in selected cases.     

Screening of prostate cancer with PSA and transperineal six sextant biopsy]

OBJECT: The objectives of this study are to examine how many cancer patients we can detect among the outpatients whose PSA values are above 4.0 ng/ml, and to compare the usefulness of transperineal six sextant biopsy (ss-biopsy) with that of transrectal one. METHODS: All the male outpatients (above 50 years old) were inspected Tandem-R PSA levels and digital rectal examination (DRE). Among them, 129 patients showed more than 4.0 ng/ml of PSA values and/or positive finding of DRE, and underwent subsequent transperineal ss-biopsy. RESULTS: Cancers were detected in 52 patients (40.3%) without major complications. Among 64 gray zone (PSA 4.1-10.0 ng/ml) patients, 17 (26.6%) were found to be cancer by ss-biopsy, meanwhile only 2 cancer patients (8.9%) were detected from 23 gray zone ones by traditional directed biopsy. Application of PSA density could not be found practicable to eliminate unnecessary biopsies in the gray zone group. CONCLUSION: Prostate cancer could be found nearly a fourth in the gray zone group of the outpatients. To enhance the detection rate, obtaining at least 6 core samples are recommended from either perineal or rectal root.     

How to improve prostate biopsy detection of prostate cancer

The combination of serum prostate-specific antigen (PSA) testing and transrectal ultrasonography is a highly effective strategy to diagnose prostate cancer at an early curable stage. Even though PSA is the most useful serum biomarker to aid in prostate cancer detection, it has limited specificity: as many as 75% of men who undergo prostate biopsy because of an elevated PSA do not have prostate cancer. Additionally, sextant prostate biopsies miss prostate cancer at least 20% of the time. To reduce the number of false-negative biopsies, many have advocated obtaining 12 or more cores in a single biopsy session. Studies have shown that this practice is safe and can enhance cancer detection modestly. Although it is unlikely that prostate cancer imaging will replace prostate biopsy in the near future, many exciting new imaging technologies should eventually improve targeting of prostate needle biopsy and reduce false-negative biopsies. Some of the most exciting areas include power Doppler sonography, microbubble intravenous ultrasound contrast agents, and magnetic resonance spectroscopy. These functional imaging modalities can assess tumor blood flow and metabolic activity at a cellular level and can detect malignant changes that may not be detected by standard anatomic imaging.