Extensive biopsy using a combined transperineal and transrectal approach to improve prostate cancer detection

PURPOSE: Previous studies have indicated that 6-core transrectal prostate biopsy misses a considerable number of cancers. We performed an extensive biopsy protocol of 12-core sampling using both transperineal and transrectal approaches to determine the impact on the cancer detection rate. MATERIALS AND METHODS: We prospectively evaluated 402 men who underwent 6-core transperineal and 6-core transrectal biopsies simultaneously due to abnormal digital rectal examination (DRE) and/or elevated prostate-specific antigen (PSA) levels of 4.0 ng/mL or greater. Using the transperineal approach we obtained four cores from the bilateral peripheral zone targeting the lateral and parasagittal areas and two cores from the bilateral transition zone. The following transrectal biopsy was performed traditionally. We compared cancer detection rate between the extended 12-core procedure and conventional 6-core transperineal and transrectal groups in terms of total PSA and DRE findings. RESULTS: Using the extensive combined method, prostate cancer was detected in 195 cases (48.5%) and the detection rate significantly increased 7.2% and 8.5% compared to the transperineal and transrectal groups, respectively. According to PSA levels and DRE findings, the cancer detection rate by the combined method was significantly improved in patients with PSA levels of 4-10 ng/mL and negative DRE: 10.3% and 11.6% compared to the transperineal and transrectal groups, respectively. CONCLUSIONS: The extensive 12-core method significantly improved the overall cancer detection rate and was especially efficient for men with PSA levels of 4-10 ng/mL accompanied by a negative DRE finding.     

Optimal sampling sites for repeat prostate biopsy: a recursive partitioning analysis of three-dimensional 26-core systematic biopsy

OBJECTIVES: To explore an optimal combination of sampling sites to detect prostate cancer in a repeat biopsy setting. METHODS: A transrectal ultrasound-guided systematic three-dimensional 26-core biopsy (3D26PBx), a combination of transrectal 12 and transperineal 14 core biopsies, was performed in 235 Japanese men with prior negative biopsy. Using recursive partitioning, we evaluated cancer detection of all possible combinations of sampling sites and selected the combination that provides the highest cancer detection rate at a given number of biopsy cores. RESULTS: Prostate cancer was detected in 87 of the 235 (37%) men. The 3D26PBx improved cancer detection by 89% relative to the conventional transrectal sextant biopsy. Neither Gleason score nor percentage of Gleason 4/5 cancers differed between cancers with and without positive cores within the transrectal sextant-sampling sites. A three-dimensional combination of transrectal and transperineal approaches outperformed either transrectal or transperineal approach alone. Recursive partitioning revealed that a three-dimensional 16-core (transrectal eight cores plus transperineal eight cores) biopsy could detect all the cancers with the minimum number of cores. CONCLUSIONS: We propose a three-dimensional combination of transrectal eight cores taken from the far lateral peripheral zone and the parasagittal base, and transperineal eight cores taken from the anterior and posterior apex and the transition zone as an optimal set of sampling sites for repeat biopsy.     

Transperineal extended biopsy improves the clinically significant prostate cancer detection rate: A comparative study of 6 and 12 biopsy cores

BACKGROUND: We evaluated the improvement in the rate of prostate cancer detection when using a 12-core transperineal biopsy protocol including transitional zone biopsy. METHODS: Between April 2003 and November 2004, 247 consecutive men underwent transperineal systemic 12-core biopsy of the prostate. Six cores were obtained at the peripheral zone, four at the transitional zone and two at the apex. We examined the cancer detection rate in each of the 12 cores, and also determined the improvement of cancer detection resulting from the extensive 12-core versus standard 6-core biopsy. RESULTS: Using the extensive 12-core biopsy, prostate cancer was detected in 98 cases (39.7%). Prostate-specific antigen (PSA), PSA density, the positive rate in digital rectal examination and transrectal ultrasound findings were significantly higher in the prostate cancer group than in the non-prostate cancer group, and prostate volume was larger in non-prostate cancer group. Every site showed almost the same positive rate, between 17.8 and 21.5%. There were 20 cases which were positive in the extended biopsy, but negative in the sextant. The detection improved significantly (20.4%). The improvement of cancer detection in extended biopsy was better in men with PSA levels of 10 ng/mL or less (28.9%), PSA density 0.3 or less (25.8%), negative digital rectal examination (23.3%), and negative transrectal ultrasound (21.6%). Of these twenty patients, no cases with insignificant tumor were detected in the six prostatectomy cases. In particular, three cases of the six were transitional-zone-only cancer. CONCLUSION: Transperineal extended 12-core biopsy including 4 transitional zone cores is a more useful procedure than transperineal 6-core biopsy. Routine transitional zone biopsy, that is different from transrectal biopsy, might be useful for detecting biologically significant cancer.     

The utility of apical anterior horn biopsies in prostate cancer detection

We sought to determine the utility of adding apical anterior horn biopsies to systematic prostate sampling regimens in detecting cancer in men with measured prostate volume < or =50 cc. We reviewed the biopsy data of consecutive men referred for an abnormal digital rectal exam or PSA elevation > or =4.0 ng/mL. All of these patients underwent lesion directed biopsy as well as a systematic 12-core biopsy regimen consisting of the standard sextant, bilateral lateral mid- and lateral base-sites, and bilateral apical anterior horn sites. Overall cancer detection and unique cancer detection rates were calculated for each of the 12 sites, stratified by race, age, PSA, and findings on digital rectal exam. In addition, cancer detection rates of various biopsy schemes were calculated and compared. There were 255 men undergoing biopsy who had calculated prostate volume < or =50 cc, and the prostate cancer detection rate was 47%. The overall cancer detection rate of apical anterior horn biopsies ranged between 29% and 56%. The utility of these biopsies was greatest in men with normal rectal exam and PSA <10 ng/mL, with unique cancer detection rates of 6% and 4%, respectively. Including the apical anterior horn biopsies in an 8-biopsy scheme (anterior, apex, lateral mid, lateral base) yielded cancer detection rates greater than 91% in all subgroups that were not statistically different from extended 10- and 12-core biopsy regimens. Apical anterior horn prostate biopsies target cancers that are potentially in the anterior region of the prostate, a region under-sampled using traditional schemes. The use of these biopsies as part of an 8-core biopsy pattern provides high cancer detection in all groups of patients and may represent a new standard.     

Importance of peripheral biopsies in maximising the detection of early prostate cancer in repeat 12-core biopsy protocols

OBJECTIVE: To assess cancer-detection rates in repeat 12-core biopsy protocols, as extended multicore prostate biopsy protocols have become standard when investigating men with a raised prostate-specific antigen (PSA) level, but repeat prostate biopsy protocols are still developing. PATIENTS AND METHODS: During a 4.5-year period, 241 of 590 patients with persistently high age-specific PSA levels of 2.6-10 ng/mL and an initial benign biopsy were invited for repeat transrectal ultrasonography-guided 12-core prostatic biopsy. The protocol for repeat biopsy was identical to the first biopsy, and included a periprostatic nerve block. The first six biopsies were obtained from the periphery of the gland directed more laterally at the base, mid-zone and apices. The remainder were parasagittal sextant biopsies. Pathological findings were analysed on an individual core basis. RESULTS: The mean age of the 241 men was 63.4 years; cancer was diagnosed in 40 (16.6%) on repeat biopsy. Men with cancer were older and had a higher median PSA level. The median Gleason score was 6, with a median of two cores positive for cancer. Maximum cancer detection rates were from peripheral apices (37.5%), basal biopsies had the lowest detection rates (23.8% and 16.3%), and parasagittal biopsies missed 35% of detected cancers. Patients with cancer also had significantly lower prostate volumes and higher PSA densities (both P < 0.001). CONCLUSION: A low cancer yield from both peripheral basal and parasagittal basal specimens on repeat biopsy indicates adequate sampling at initial biopsy. The maximum cancer yield in the peripheral mid-zones and apical zones suggests the necessity for concentrated sampling of these zones in repeat biopsy protocols.     

Predictors of prostate cancer on extended biopsy in patients with high-grade prostatic intraepithelial neoplasia: a multivariate analysis model

OBJECTIVE: To define the importance of extended biopsy in patients with high-grade prostatic intraepithelial neoplasia (HGPIN) and to define predictors of cancer in extended biopsy in patients with HGPIN, using multivariate analysis. PATIENTS AND METHODS: In all, 83 patients with previous sextant biopsy of HGPIN had an extended 11-core biopsy taken. Patients with a negative biopsy for cancer were followed by serum prostate-specific antigen (PSA) and digital rectal examination (DRE) every 6 months. The extended biopsy was repeated in 21 patients. The criteria for second biopsy were an increase in PSA and/or abnormal changes on DRE. Overall, 49 patients had a transurethral resection of the prostate (TURP). The cancer-detection rate on extended biopsy was correlated with risk factors using the chi-square test and multivariate analysis. RESULTS: Extended biopsy detected prostate cancer in 30 of the 83 men (36%), with positive cores in only 20 sextant biopsy sites (67%), in only seven in additional sites (23%), and both in three (10%). Of the 21 patients who had repeat extended biopsy, four (19%) had cancers. There were two carcinomas in the 49 TURP specimens (4%). The PSA level, DRE and transrectal ultrasonography findings were not predictive of cancer in extended biopsies (chi-square test). Patient age, PSA density and the number of cores with HGPIN (all P < 0.001) had a significant effect on the cancer-detection rate, and multivariate analysis showed that all three were independent predictors of cancer. A logistic regression model was designed to predict the probability of cancer in extended biopsy, with an overall accuracy of 78%. CONCLUSION: Extended biopsy improved the cancer detection rate by 23% in patients with HGPIN. Patient age, PSA density and the number of cores with HGPIN were the only independent predictors of cancer.     

An extended 10-core transrectal ultrasonography guided prostate biopsy protocol improves the detection of prostate cancer

OBJECTIVE: To evaluate the efficacy of TRUS guided 10-core biopsy strategy for Turkish patients who had biopsy of the prostate for the first time. METHODS: Between February 2001 and May 2003, 303 consecutive men with suspected prostate cancer were included in the study. Indications for TRUS guided prostate biopsy were: abnormal digital rectal examination and/or a serum PSA over 2.5 ng/ml. All of the patients underwent a 10-core biopsy protocol with additional core from the each suspicious area detected by TRUS. Besides the sextant technique, 4 more biopsies were obtained from the lateral peripheral zone. We aimed to analyze whether cancer detection improved with the extended versus the standard sextant biopsy in our series overall and in each subgroup. RESULTS: Of 303 patients 94 (31%) were positive for prostate cancer. Median age and PSA of prostate cancer patients were significantly higher than of the non-cancer patients. Besides prostate volumes of the cancer patients were significantly lower than of the non-cancer ones. The cancer detection rates were 31% (94/303) and 23.1% (70/303) for the 10-core biopsy strategy and sextant biopsy strategies, respectively. Thus the 10-core biopsy technique increased cancer detection rate by 25.5% (24/94) for the whole group of patients. A statistically significant number of additional cancers were detected with 10-core biopsy strategy for all the subgroups of the patients. Furthermore 10-core biopsy protocol detected more cancers (at least 6.4%) than all the probable different combinations of 8-core biopsy protocols. Among the 94 cancer patients, biopsy from a suspicious area revealed cancer in 31.9% of them; however, in all of these patients cancer was already present in the 10-core biopsy. On the other hand, lesion biopsies revealed 5.7% additional cancers if sextant technique was used. There were only 3 (0.9%) serious complications requiring hospitalization and all 3 were infections controlled by appropriate antibiotics. CONCLUSION: Adding 4 lateral peripheral biopsies to the conventional sextant biopsy (10-core biopsy strategy) technique has increased the cancer detection rate by 25.5% without significant morbidity and without increasing the number of insignificant cancers. 10-core biopsy protocol was superior to all probable 8-core biopsy protocols in our study group. Additional biopsies from suspicious areas detected by transrectal ultrasonography revealed no further benefit if 10-core technique was used. We therefore suggest that 10-core biopsy protocol should be the preferred strategy in early detection of prostate cancer.     

Improved accuracy in predicting the presence of Gleason pattern 4/5 prostate cancer by three-dimensional 26-core systematic biopsy

OBJECTIVES: To evaluate whether three-dimensional 26-core (3D26) prostate biopsy improves the accuracy in predicting the presence of Gleason pattern 4/5 cancer compared with extended transrectal 12-core (TR12) or transperineal 14-core (TP14) biopsy schemes. METHODS: We studied 143 consecutive men in whom prostate cancer was diagnosed by the 3D26 biopsy and who underwent radical prostatectomy (RP) without neoadjuvant treatment. All histologic grading was reevaluated by a single pathologist according to the 2005 International Society of Urological Pathology Consensus Conference on Gleason Grading. Cancer grade was categorized into high grade (Gleason pattern 4/5 cancer present) and non-high grade (absent) in both biopsy and RP specimens. Since TR12 and TP14 biopsy schemes represent subsets of the 3D26 biopsy, we could compare these schemes directly in an identical patient cohort. RESULTS: There was a grade agreement between 3D26 biopsy and RP in 132 (92.3%) cancers. Grade concordance between biopsy and RP was significantly better in 3D26 biopsy than in TR12 (83.5%, p=0.025) biopsy. Risk of underestimation of cancer grade by 3D26 biopsy (26.5%) was significantly lower than that by TP14 (51.4%, p=0.034). Grade concordance between 3D26 biopsy and RP was not according to clinical variables including prostate volume, clinical stage, prostate-specific antigen (PSA), and PSA density. CONCLUSIONS: We demonstrated that the 3D26 biopsy can accurately predict the presence of Gleason pattern 4/5 cancer on RP specimens with a high concordance rate of 92.3%, a value significantly higher than that between extended TR12 biopsy and RP specimens.     

Transrectal ultrasound-guided transperineal 14-core systematic biopsy detects apico-anterior cancer foci of T1c prostate cancer

AIM: The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE). METHODS: In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers. RESULTS: Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers (n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers. CONCLUSIONS: TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers.     

Ultrasound-guided transrectal extended prostate biopsy： a prospective study

AIM: To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer. Methods: One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department. Results: Cancer detection rates were 27.6% (42/152) and 19.7% (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6% (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3% (34/116). When serum PSA was 4-10 ng/mL TRUS-guided biopsy detected cancer in 20.6%, while the detection rate was 32.4% and 47.0% when serum PSA was 10-20 ng/mL and above 20 ng/mL, respectively. Conclusion: The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6% when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer.     

Diagnostic performance of initial transperineal 14-core prostate biopsy to detect significant cancer

Purpose

To investigate cancers missed by extended transperineal (TP) 14-core biopsy (TP14PBx) and examined its diagnostic performance.

Methods

We evaluated 744 men with prostate-specific antigen (PSA) levels in the range 2.5–20 ng/mL or abnormal digital rectal examination underwent three-dimensional 26-core prostate biopsy (3D26PBx), a combination of TP14PBx and transrectal 12-core biopsy (TR12PBx), at initial biopsy. Of 269 patients diagnosed with cancer, 127 subsequently underwent radical prostatectomy (RP). Cancers were grouped into TP-positive cancers (detected through TP14PBx) and TP-negative cancers (those not detected through TP14PBx but detected through TR12PBx). Clinicopathological characteristics and cancer locations of TP-negative cancers were evaluated. For cancer location analysis, the prostate was divided into apex, midprostate, and base regions.

Results

Thirty-seven (14 %) TP-negative cancers were found in 269 biopsy-positive cancers. Median number of positive cores in TP-negative cancers was significantly lower than that in TP-positive cancers (1 vs. 5, p < 0.001). TP-negative cancers had biopsy Gleason score (GS) of 7 or less in 87 % of cases and had significantly lower biopsy GS than those of TP-positive cancers (p = 0.028). Of 20 TP-negative cancers treated with RP, 70 % (14/20) were insignificant cancers (GS <4+3, volume <0.5 cc, and organ-confined disease). Of all significant cancers treated with RP, 6 % (6/99) were missed by TP14PBx. TP-negative cancers treated with RP were located more frequently in the apex than in the base (85 vs. 20 %, p < 0.001).

Conclusions

Initial TP14PBx provides sufficient detectability of significant cancers despite a small risk of missing cancers located in the prostate apex.     

Clinical, biochemical and pathological features of initial and repeat transrectal ultrasonography prostate biopsy positive patients

BACKGROUND: Using sextant biopsy, 16-41% of prostate cancers were diagnosed on repeat biopsy. The objective of the present study was to compare the differences in the clinical, biochemical and pathological features between patients with positive results on initial and repeat biopsies, with an aim to identify factors that can be used to improve the detection rate of transrectal ultrasound (TRUS) biopsy of the prostate. METHODS: Between February 2000 and April 2001, 222 patients with a mean age of 64 years (range 38-85) underwent TRUS-guided 10-core prostate biopsy for either abnormal prostate specific antigen (PSA) levels (>4 ng/mL) and/or abnormal digital rectal examination (DRE). Of this number, 165 patients underwent their first biopsy, whereas 45 and 12 patients had had one or two previous biopsies, respectively. RESULTS: Prostate cancer detection rates for the initial biopsy group (n = 165), second biopsy group (n = 45) and third biopsy group (n = 12) were 29.7, 23.0 and 41.7%, respectively. Six patients who had a negative first 10-core biopsy underwent a second 10-core biopsy and one patient (16%) was found to have cancer. Apart from total prostate volume, there were no significant statistical differences between the patient age, mean total PSA, PSA density, PSA-transition zone density, DRE and TRUS findings between the initial and repeat biopsy groups of subjects who had cancer. Those who had cancer detected only on repeat biopsies had larger prostate glands (P = 0.041). CONCLUSION: Patients who had cancer detected only on repeat biopsies had bigger prostate glands, supporting the hypothesis that TRUS sextant biopsy as a technique suffers the error of under-sampling in a bigger prostate.     

Individualized prostate biopsy strategy for Chinese patients with different prostate-specific antigen levels

Aim： To evaluate the best individualized prostate biopsy strategies for Chinese patients with suspected prostate cancer. Methods： The present study included 221 Chinese patients who underwent transrectal ultrasound guided prostate biopsies for the first time. All patients underwent the same 10-core biopsy protocol. In addition to the Hodge sextant technique, four more biopsies were obtained from the base and middle regions of bilateral peripheral zones. The differences between 10-core and sextant strategies in cancer detection among patients with different prostate specific anitgen （PSA） levels were evaluated. The relationship between PSA level, number of positive biopsy cores and organ-confined cancer rate in prostate cancer patients was also analyzed. Results： The overall prostate cancer detection rate was 40.7% in the 221 patients. The 10-core strategy increased cancer detection by 6.67% （6/90） in our patients （P 〈 0.05）. The increased cancer detection rates decreased significantly when the patient PSA level increased from 0-20 ng/mL to 20.1-50 ng/mL and 〉 50 ng/mL （P 〈 0.01）. The number of positive biopsy cores in prostate cancer patients increased significantly with increasing patient PSA level （P 〈 0.01）. The rate of organ-confined prostate cancer decreased significantly with increasing patient PSA level （P 〈 0.01）. Conclusion： The extended 10- core strategy is recommended for Chinese patients with PSA 〈 20 ng/mL and the sextant strategy is recommended for those with PSA〉 50 ng/mL. For patients with PSA ranging from 20.1 ng/mL to 50 ng/mL, the 10-core strategy should be applied in patients with life expectancy 〉 10 years and the sextant strategy should be applied in those with life expectancy 〈 10 years. （Asian J Androl 2008 Mar; 10： 325-331）     

Saturation technique does not improve cancer detection as an initial prostate biopsy strategy

PURPOSE: We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS: Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS: Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS: Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.     

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.     

超声引导下经直肠前列腺饱和穿刺在首次活检阴性人群中的诊断价值

目的探讨超声引导下经直肠饱和穿刺在临床疑诊为前列腺癌但首次活检阴性患者中的诊断价值,评价其有效性和安全性。方法将120例因前列腺特异抗原（PSA）和（或）直肠指检异常而接受前列腺12针穿刺活检、且结果为阴性的患者纳入研究,随机分为扩大穿刺组（采用12针扩大穿刺法）和饱和穿刺组（采用24针饱和穿刺法）,行超声引导下经直肠重复穿刺活检。对两组患者均行前列腺周围神经阻滞术,穿刺活检过程中观察患者情况,并采用视觉模拟评分（VAS）评估疼痛程度。结果两组患者年龄、总PSA水平、PSA密度、前列腺总体积及移行区体积、首次穿刺病理、直肠指诊情况、穿刺活检过程中患者VAS和术后并发症差异均无统计学意义（P均＞O．05）。饱和穿刺组前列腺体积＞60ml者的穿刺阳性率高于扩大穿刺组（P-0．033）,其穿刺总体阳性率亦高于扩大穿刺组（31．67％VS15．00％,P-0．031）。结论经直肠饱和穿刺活检可以提高临床疑诊前列腺癌但首次活检阴性者的前列腺癌检出率,且不增加并发症发生率。     

Effect of peripheral biopsies in maximising early prostate cancer detection in 8-, 10- or 12-core biopsy regimens

OBJECTIVE: To assess the cancer detection rate per individual core biopsy in a 12-core protocol and develop an optimal biopsy regimen for detecting early prostate cancer. PATIENTS AND METHODS: The study included 445 new patients who had a 12-core transrectal ultrasonography (TRUS)-guided prostatic biopsy over a 40-month period. The 12- core biopsy protocol included parasagittal sextant and six peripheral biopsies. The cancer detection rate per individual core was evaluated to give an optimal biopsy protocol. RESULTS: Prostate cancer was detected in 142 patients (31.9%). Parasagittal sextant biopsy would have failed to detect 40 (28.2%) of the cancers. Among the various possible biopsy protocols, the optimum 10-core biopsy strategy excluding the parasagittal mid-zone biopsies from the 12-core protocol achieved a cancer detection rate of 98.6%. CONCLUSION: The cancer detection rate increased from 71.8% for parasagittal sextant biopsies to 88.7% by adding peripheral basal biopsies (8-biopsy protocol); 98.6% of cancers in the series would have been detected with a 10-biopsy strategy omitting the parasagittal mid-zone biopsies. Thus we recommend a 10-core protocol incorporating six peripheral biopsies in patients with elevated age- specific prostate-specific antigen levels (2.6-10.0 ng/mL) for maximising cancer detection.     

不同前列腺穿刺活检方案检出前列腺癌的比较

目的探讨理想的前列腺穿刺活检方案。方法临床表现怀疑前列腺癌患者214例，其中前列腺特异抗原〉4．0ng／ml 203例。均行13针前列腺穿刺活检术。年龄50～90岁，平均70岁；PSA水平0．8～112．3ng／ml，平均18．7ng／ml；前列腺体积12．3～182．5ml，平均61．3ml；直肠指诊阴性173例，阳性者41例。依穿刺结果，对比分析13针中6、8、10和13针穿刺阳性率。结果13针穿刺阳性率为36．0％（77／214）。在各种穿刺点组合中包含前列腺尖部、中部、底部、外侧中部、外侧底部的10针法能发现全部前列腺癌阳性病例的97．4％，与13针穿刺结果的差异无统计学意义（P=0．5）。结论对于初次前列腺活检的病例，包含尖部、中部、底部、外侧中部、外侧底部的10针法是较为合理的选择。     

How many cores are enough? Optimizing the transperineal prostate biopsy template

Introduction and ObjectiveMost urologists use a 10-12 core template during transrectal ultrasound guided prostate biopsy (TRUS-B). A similar consensus template does not exist for transperineal prostate biopsy (TP-B) including the optimal number and location of biopsy cores. We examined our institutional cohort to develop an optimal systematic template for TP-B.MethodsWe prospectively monitored our first 200 consecutive free-hand TP-B. These included men who were biopsy naïve (n = 117), had elevated PSA with prior negative biopsy (n = 18), and men on active surveillance (n = 65). All men underwent a 20 core TP-B with each core placed in a separate specimen container. This allowed the 20-core TP-B to be easily broken down as though fewer cores had been taken in each patient. Ten, 12, and 16 core templates were designed a priori and compared within each patient to the 20 core template. The highest Grade Group (GG) at pathologic analysis was assigned to each biopsy. Primary outcome was detection of clinically significant prostate cancer, defined as ≥GG2. Secondary outcome was detection of GG1 prostate cancer. We performed sub-group analyses of biopsy naïve men and biopsy naïve men stratified by PSA density (<0.15 vs. ≥0.15 ng/mL/cc). An historic institutional cohort of 10-12 core TRUS-B (n = 170) was used to compare prostate cancer detection between techniques. P value of ≤0.05 was considered statistically significant.ResultsClinically significant cancers were detected in 98 men (49%) using a 20 core TP-B technique. Had we sampled fewer cores we would have identified clinically significant cancers in 93 (47%, 16 core), 91 (46%, 12 core), and 82 (41%, 10 core) men. More clinically significant cancers were detected by the 20 core template compared to the 10 core template for both the whole cohort (49% vs. 41%, P = 0.02) and the biopsy naïve subset (48% vs. 40%, P = 0.05). Additional cores did not result in an increased detection of GG1 cancers (20-core: 35% vs. 10-core: 44%, P = 0.09). Less than one quarter of biopsy naïve men with a PSA density <0.15 were found to have clinically significant cancers. More clinically significant cancers were detected in the 12-core TP-B cohort compared to the 12-core TRUS-B series (46% vs. 38%, P < 0.001).ConclusionsA 20 core TP-B systematic biopsy template detected a greater number of clinically significant prostate cancers compared to a 10 core TP template. Cancer detection was similar for 12, 16, and 20 core templates. Higher core numbers did not result in greater detection of GG1 tumors reflecting increased detection of concomitant ≥GG2 with greater sampling. We propose a minimum 12 core systematic biopsy template for men undergoing TP-B.     

The Effect of Prior Biopsy Scheme on Prostate Cancer Detection for Repeat Biopsy Population: Results of the 14-core Prostate Biopsy Technique

OBJECTIVES: To evaluate the diagnostic performance of 14-core repeat biopsy protocol and the impact of prior biopsy scheme on repeat prostate biopsy group. METHODS: 211 patients had repeat biopsy using 14-core protocol consisting of 10-core peripheral zone (classical sextant+4 lateral peripheral cores) and 4-core transitional zone (TZ) biopsies. The diagnostic yield was determined both in patients who had previously undergone sextant or 10-core biopsy protocol. RESULTS: Overall cancer detection rate was 25.6%. 14-core biopsy technique detected cancer in 36.1 and 18.7% of the patients who had a previous sextant biopsy and 10-core biopsy protocol, respectively (P = 0.005). Patients with and without high-grade prostatic intraepithelial neoplasia (HGPIN) in the previous sextant biopsy had 56.5 and 28.3% cancer detection rates on the subsequent extended biopsy, respectively (P = 0.017) Patients who had previous 10-core biopsy with and without HGPIN revealed 22.9 and 17.2% cancer detection rates, respectively (P = 0.465) Additional four lateral peripheral cores detected 33% (3/30) and 17% (4/24) of cancers in patients with previous sextant and 10-core biopsy, respectively. 3.7% of the patients had tumor only in the TZ and none of them had prior extended biopsy. CONCLUSIONS: The yield of extended 14-core repeat biopsy protocol was higher in patients with previous negative sextant biopsy compared to the patients with previous negative 10-core biopsy. HGPIN history found on previous sextant biopsy was a strong cancer predictor on repeat biopsy; same was not true for the patients with previous 10-core biopsy. The yield of lateral peripheral cores and TZ biopsies were lower in patients with prior negative extended biopsy.