Clinicopathological Features of Prostate Cancer Detected by Transrectal Ultrasonography-Guided Systematic Six-Sextant Biopsy

Background :
The objectives of this study were to compare the efficacy of 3 modalities (prostate-specific antigen (PSA) assay, digital rectal examination (DRE), and transrectal ultrasonography (TRUS)) in detecting prostate cancer which was pathologically confirmed by TRUS-guided systematic six-sextant biopsy, and to investigate the relationship between the number of positive cores and several clinicopathological parameters.
Methods :
Between 1 992 and 1994, 297 males (155 from a mass screening program and 142 identified as outpatients) with a mean age of 71 years, underwent examinations including PSA determination, DRE, TRUS and systematic six-sextant biopsy, and/or additional directed biopsy.
Results :
Prostate cancer was detected in 93 men. The sensitivity level of the PSA assay was significantly higher (85%) than that of either DRE or TRUS. Patients with an abnormal DRE or TRUS, elevated PSA levels, and those in the T3-T4 category or with moderate to poorly-differentiated adenocarcinomas had more positive biopsy cores (P< 0.05). Also, the relationships of both the number of positive biopsy cores and tumor grade to bone metastasis were significant (P < 0.01). Of 209 hypoechoic areas identified by transrectal ultrasonography, 42% were cancerous, and of 427 isoechoic areas, 1 2% were cancerous. The percentage of positive biopsy cores with hypoechoic areas was 86% in the subjects with a PSA > 10 ng/mL, but low (9%) in subjects with a PSA < 4 ng/mL, and the percentage of negative biopsy cores with a normal TRUS was high (98%) in subjects with a PSA of < 4 ng/mL, but lower (67%) in subjects with a PSA > 10 ng/mL.
Conclusion :
The serum PSA assay was more useful than either DRE or TRUS in detecting prostate cancer. The percentage of bone metastasis increased concomitant with the number of positive biopsy cores, and the positive biopsy rate of hypoechoic areas positively correlated with the PSA level.     

Predictors of prostate cancer on repeat transrectal ultrasound-guided systematic prostate biopsy

BACKGROUND: We analyzed the outcome of repeated transrectal ultrasound (TRUS)-guided systematic prostate biopsy in Japanese men whose clinical findings were suspected of prostate cancer after previous negative biopsies. METHODS: Between January 1993 and March 2002, 1045 patients underwent TRUS-guided prostate biopsy. Among them, 104 patients underwent repeat biopsy due to indications of persistent elevated serum prostate-specific antigen (PSA), abnormal digital rectal examination (DRE) or TRUS, increased PSA velocity, and/or previous suspicious biopsy findings. Several clinicopathological factors were evaluated for their ability to predict the detection of prostate cancer on repeat biopsy. RESULTS: Prostate cancer was detected in 22 of 104 patients (21.2%) who underwent repeat biopsies. PSA concentration and PSA density at both the initial and repeat biopsies, and PSA velocity in men with positive repeat biopsy were significantly greater than those in men with negative repeat biopsy. The incidence of abnormal findings in DRE and TRUS at initial biopsy in men with positive repeat biopsy was also significantly higher than that in men with negative repeat biopsy. However, neither the presence of prostatic intraepithelial neoplasia nor number of biopsy cores at initial biopsy had a significant association with the results of the repeat biopsy. Furthermore, multivariate analysis revealed that PSA and PSA density at both the initial and repeat biopsies, PSA velocity, and DRE and TRUS findings at initial biopsy were independent predictors of malignant disease on repeat biopsy. CONCLUSION: Despite an initial negative biopsy, repeat TRUS-guided biopsy should be carried out to exclude prostate cancer in cases of suspicious clinical findings, such as elevated PSA or PSA-related parameters, or abnormal findings of DRE or TRUS.     

Clinical evaluation of transrectal power Doppler imaging in the detection of prostate cancer

To evaluate the clinical usefulness of power Doppler imaging (PDI), we compared this method to gray-scale transrectal ultrasound (TRUS) in the detection of prostate cancer. A total of 101 men with abnormally high serum prostate specific antigen (PSA) levels and/or abnormal digital rectal examination (DRE) findings were assessed using TRUS and PDI. Random systematic sextant and bilateral far lateral prostate biopsies were performed in all cases. In addition, when TRUS revealed a hypoechoic lesion or PDI revealed a hypervascular lesion (HVL), these lesions were directly biopsied. Of the 101 patients, 48 (47.5%), 42 (41.5%) and 42 (41.5%) were suspicious of having prostate cancer by DRE, TRUS and PDI, respectively. Prostate needle biopsy revealed prostate cancer in 39 patients (38.6%) and benign prostatic diseases in 62 patients (61.4%). If prostate needle biopsy was avoided when PDI was negative, then PDI eliminated the need for biopsy in 59 of the 101 patients (rate of biopsy procedures saved: 58.4%) and missed only 8 (13.6%) prostate cancers. Moreover, in 63 patients with intermediate PSA (3-10 ng/ml), the rate of biopsy procedures saved by DRE, TRUS, and PDI was 60.3%, 65.1%, and 68.3%, respectively, and the rate of cancers missed was 26.3%, 19.5%, and 14.0%, respectively. In a total of 826 specimens of TRUS-guided prostate biopsy, 126 (15.3%) specimens had adenocarcinoma. Site by site based analysis of the present series revealed 34.1% of prostate cancer sites were isoechoic and hypervascular. On a site by site basis, PDI had better sensitivity, specificity, positive predictive value and negative predictive value than TRUS. In 48 patients without abnormal DRE findings, on a site by site basis, the sensitivities of TRUS and PDI were 22.9% and 34.4%, respectively. Gleason score was associated with a positive rate of PDI on both a patient basis and site by site basis. From these results, on a patient basis, we conclude that PDI was helpful in the indication for prostate biopsy for all patients or patients with intermediate PSA level. On a site by site basis, PDI may be able to select prostate cancer sites at biopsy, in particular in patients without abnormal DRE findings.     

Detection of residual prostate cancer after radiotherapy by sonographically guided needle biopsy.

Detection of persistent or recurrent prostate cancer by digital rectal examination (DRE) after definitive radiotherapy is difficult. With the availability of transrectal ultrasonography (TRUS), the detection of prostate cancer has improved substantially. Since 1987 we have used TRUS to evaluate the prostate after definitive radiotherapy. A hypoechoic lesion suggestive of cancer was identified in 45 of 56 patients (80%) studied. Sonographically directed transrectal needle biopsies were performed in 27 of these (60%), and 16 (59%) were positive for cancer. The presence of a palpable nodule suggestive of cancer (present in 7 patients) was not predictive of a positive biopsy specimen. In 14 patients ultrasound-guided and digitally-guided biopsies were performed at the same time; 8 (57%) of the ultrasound-guided biopsy specimens were positive compared with only 4 (29%) of the digitally-guided biopsy specimens. In all 7 patients with an elevated serum level of prostate-specific antigen (PSA) an ultrasound-guided biopsy result was positive. Random biopsies of sonographically normal (isoechoic) areas of the prostate were performed in 8 patients, but only 2 specimens (25%) were positive for cancer. Ultrasound-guided transrectal biopsy of hypoechoic lesions was a safe and effective technique for identifying residual cancer in the irradiated prostate, regardless of the palpable findings. In the presence of an elevated PSA level, such biopsies invariably identified residual cancer. The use of TRUS, ultrasound-guided biopsy, and the measurement of PSA, in addition to DRE, may aid in the detection of residual cancer after definitive radiotherapy.     

Examination for indication of systematic biopsy for diagnosis of prostate cancer]

BACKGROUND: Systematic biopsy has been commonly used for detection of prostate cancer. Nevertheless, as this examination occasionally gives patients severe complications it is necessary to give careful consideration for application of this examination. Thus, we analyzed retrospectively 145 cases who underwent transrectal ultrasonography (TRUS) guided systematic biopsy to evaluate the application of systematic biopsy, correlating with the findings of digital rectal examination (DRE), prostate specific antigen (PSA), the findings of transrectal ultrasonography (TRUS) and the results of biopsies. METHODS: Between May, 1995 and May, 1997, 143 patients who were suspected to have prostate cancer with either of PSA and DRE, and 2 patients who received visual laser ablation of prostate (VLAP), underwent TRUS guided systematic biopsy of prostate. We evaluated diagnostic efficacy of PSA, DRE, TRUS, prostate-volume-specific PSA, and PSA density (PSAD). RESULTS: Sensitivity, specificity and positive predictive value (P.P.V.) are 78.4%, 62.8% and 53.5% for DRE, 100.0%, 4.4% and 41.8% for PSA, 88.2%, 60.0% and 52.9% for TRUS, 87.8%, 72.1% and 64.2% for prostate-volume-specific PSA, 100.0%, 30.6% and 45.4% for PSAD, respectively. Ten of 69 patients (14.5%) whose PSA levels were 4.0 to 10.0 ng/ml were diagnosed as cancer, and positive for both or either of DRE and TRUS. Twenty-seven who were negative for both of DRE and TRUS were not diagnosed as prostate cancer. Using the combination of prostate-volume-specific PSA, DRE and TRUS, we could eliminate 29 non-cancer men (21.5%) whose PSA level was greater than 4.0 ng/ml from systematic biopsy. CONCLUSION: On the diagnosis of prostate cancer, the combination of prostate-volume-specific PSA, DRE and TRUS is very useful to exclude unnecessary systematic biopsy, if an urologist could be used to and trained for DRE and TRUS.     

Evaluation of Prostate Specific Antigen Density and Transrectal Ultrasonography-Guided Biopsies in 100 Consecutive Patients with a Negative Digital Rectal Examination and Intermediate Serum Prostate Specific Antigen Levels

Background : This study was undertaken to assess the importance of prostate biopsies in patients with a negative digital rectal examination (DRE) and elevated prostate specific antigen (PSA) levels and to investigate the role of PSA density (PSAD) and hypoechoic lesions on transrectal ultrasound (TRUS) in increasing the diagnostic sensitivity and specificity for prostate cancer (PCa). Methods : One hundred patients with varied initial symptoms who had a negative DRE and a PSA level between 4 and 20ng/mL underwent TRUS-guided systematic and, if present, lesion-directed biopsies. Results : PCa was detected in 11 patients (11%). TRUS examinations revealed hypoechoic lesions in 31 patients. Lesion-directed biopsies revealed PCa in 1 3% (4/31) of patients with abnormal TRUS whereas, 7% (5/69) of patients with negative TRUS findings had PCa. Additional systematic biopsies detected PCa in 2 patients where lesion-directed biopsies were negative. None (0/19) of the lesions smaller than 0.2 ml on TRUS had PCa whereas, 33% (4/1 2) of patients with lesions greater than 0.2 ml had PCa. When the subgroup of patients with negative TRUS and PSA levels between 4 and 10ng/mL were considered, 25% (1/4) of cases with PCa would have been missed if 0.15 was used as the cut-off point for PSAD, however, this would save 61% (30/49) of unnecessary biopsies. The positive predictive value of PSA (cut-off level lOng/mL), PSAD (cut-off level 0.15), and hypoechoic lesions on TRUS were found to be 11.5%, 33%, and 13%, respectively. When hypoechoic lesions greater than 0.2 mL were taken as the positive finding, the positive predictive value and specificity rates of TRUS increased to 33% and 91 %, respectively, without any change in the sensitivity. Conclusions : In patients with a negative DRE and intermediate PSA levels, the application of PSAD would have saved 49% of study patients with BPH from a biopsy, but would have missed 27% of PCa cases. By ignoring lesions smaller than 0.2 mL on TRUS, a very high specificity of 91% was achieved with a sensitivity of 36%. Thus, further investigations aimed at defining a better mode of diagnosis of PCa are warranted.     

Diagnostic efficacy of transrectal ultrasound-guided biopsy of the prostatic fossa in patients with rising PSA following radical prostatectomy

To evaluate the diagnostic efficacy of transrectal ultrasound (TRUS)-guided biopsy of the prostatic fossa in men with biochemical relapse following radical retropubic prostatectomy (RP). Thirty patients, with detectable prostate specific antigen (PSA) and negative imaging for metastases after RP, were evaluated for local recurrence. All patients underwent TRUS-guided biopsies of the prostatic fossa, with at least six cores obtained. PSA and digital rectal examination (DRE) were correlated with biopsy results. Twelve patients (40%) were found with local recurrence. Sensitivities of TRUS and DRE were 75 and 50%, while specificities were 83 and 100%, respectively. Local recurrence was detected in 25% of the patients with PSA ≤ 1 ng/ml, and higher PSA levels were correlated with an increased positive biopsy rate. All patients with positive DRE had positive biopsy and positive TRUS as well. When both TRUS and DRE were positive it was more likely for the patient to have positive biopsy than when both TRUS and DRE were negative. TRUS-guided biopsy is an efficient tool in detecting local recurrence after RP and should be offered to all patients with biochemical relapse and absence of metastatic disease irrespective of the level of PSA.     

Elevated serum prostate specific antigen levels in conjunction with an initial prostatic biopsy negative for carcinoma: who should undergo a repeat biopsy?

OBJECTIVE: To determine the outcome of repeated prostatic biopsies in men attending with suspected prostate cancer but an initial negative biopsy. PATIENTS AND METHODS: Patients who had undergone two or more transrectal ultrasonography (TRUS)-guided prostate biopsies were identified from the Hospital Information Support System database. Indications for TRUS were a raised prostate-specific antigen (PSA) level (>4.0 ng/mL), with or without an abnormal digital rectal examination (DRE). Sextant prostate biopsies plus biopsies of any suspicious hypoechoic area or area of DRE abnormality were obtained for histology. Forty-eight patients underwent repeat TRUS-guided prostatic biopsies (mean age 67.5, sd 7. 25, range 53-82 years). RESULTS: The mean (sd, median, range) PSA level was 16.9 (13.5, 11.6, 5.2-61.8) ng/mL. Fifteen patients (31%) had carcinoma on repeat biopsy, 11 after the second and four after a third biopsy. The positive repeat biopsy rate was 24% where the PSA level was 4.0-9.9 ng/mL, 33% if the level was 10.0-19.9 ng/mL and 39% if it was >/=20.0 ng/mL. There was no significant difference in age or initial PSA concentration between those men with positive and those with negative repeat biopsies. However, patients with cancer had significantly higher PSA levels before repeat biopsy than at first biopsy (P=0.0043) and had greater PSA velocities than had patients with no diagnosis of cancer (P=0.0067). CONCLUSION: Where sufficient clinical suspicion exists, despite an initial negative biopsy, repeat TRUS-guided prostate biopsies should be carried out to exclude carcinoma of the prostate.     

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE: To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies. PATIENTS AND METHODS: Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population. RESULTS: Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE. CONCLUSION: There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.     

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.     

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.     

常规临床检查与PSA灰区患者前列腺癌检出率的关系

目的:探讨直肠指检(DRE)、影像学(TRUS、MRI)检查、血清游离与总前列腺特异性抗原(PSA)比值(f/t)与PSA在4～10μg/L之间患者前列腺癌检出率的关系。方法:回顾性分析365例PSA处于灰区的患者进行DRE、TRUS、MRI检查、游离PSA测定,并对这些患者行经直肠B超引导下的前列腺穿刺活检。评估其临床资料与前列腺穿刺病理结果的关系。结果:在365例患者中,穿刺病理为前列腺癌的患者共有87例(23.84%)。DRE阳性的患者共有128例,穿刺阳性40例,阳性率为31.25%,TRUS检查的患者共有257例,其中有异常回声结节的69例患者中穿刺阳性26例,阳性率为37.68%,MRI检查的患者共有191例,其中有异常信号结节的107例患者中穿刺阳性59例,阳性率为55.14%。198例患者行fPSA与tPSA比值分析,其中前列腺癌患者的平均f/t PSA明显低于穿刺阴性患者。f/t PSA受试者曲线(ROC)下的面积(0.725)高于患者PSA ROC的面积(0.542)。结论:结合临床DRE、影像学资料及f/t PSA比值可以有效提高前列腺癌检出率,从而减少不必要的穿刺给患者带来的痛苦。     

Multiple vesico-urethral biopsies following radical prostatectomy: the predictive roles of TRUS, DRE, PSA and the pathological stage

INTRODUCTION: The aim of this study is to verify the predictive role of transrectal ultrasound (TRUS) of prostatic fossa, digital rectal examination (DRE), prostate specific antigen (PSA) and pathological stage after radical prostectomy in the detection of a prostate tumor recurrence at the level of the vesico-urethral anastomosis by means of multiple TRUS biopsies (6-8 cores).MATERIAL AND METHODS: From October 1997, following a radical prostatectomy, 119 consecutive patients (median age: 67.9 years) with a PSA>or=0.2 ng/ml (median PSA: 0.9 ng/ml) underwent DRE and TRUS examinations with a 5.0-7.5 MHz variable frequency end-fire probe (Hitachi Medical System) and an EUB-525 machine. All patients received six TRUS-guided biopsies of the vesico-urethral anastomosis, and 1-2 additional biopsies directed to hypo-echoic or suspicious areas, if detected by TRUS.RESULTS: Biopsies revealed recurrent carcinoma in 50% of patients (60/119). TRUS proved more sensitive than DRE (75% vs. 50%; p=0.01) and, conversely, DRE proved more specific than a TRUS (85% vs. 66%; p=0.03). Cancer was detected in 45% of the 34 patients with a PSAor=2.0 ng/ml (24 patients), TRUS was able to detect every biopsy-proven local recurrence lesion (sensitivity: 100%). Conversely, all patients with a PSA>or=2.0 ng/ml and a negative TRUS had a negative biopsy (negative predictive value: 100%). In a multi-variable logistical analysis, the most predictive parameters determining a positive biopsy rate among those values studied (PSA, DRE, TRUS, positive surgical margins, pathological stage and time to PSA elevation) were TRUS and DRE findings (p=0.003, with an odds ratio of 4.6 and p=0.02, with an odds ratio of 4.1, respectively).CONCLUSION: TRUS and TRUS biopsies utilizing 6-8 cores are efficient tools in the detection of local recurrence after a radical prostatectomy, even with a PSAor=2.0 ng/ml and a negative TRUS, a biopsy of the vesico-urethral anastomosis could be avoided since the negative predictive value is 100%. Cancer recurrence detection seems to be predicted by TRUS and DRE findings, but not by PSA levels, pathological stage, status of the surgical margins or time to PSA elevation.     

Impact of additional sampling in the TRUS-guided biopsy for the diagnosis of prostate cancer

AIM: To evaluate the diagnostic value of 10+ systematic sampling technique when performing transrectal ultrasound-guided (TRUS) prostate biopsy, compared with the sextant biopsy technique for patients with suspected prostate cancer. METHODS: 286 patients with suspected prostate cancer were included in the study. Patients were eligible for the study if they had serum levels of prostate-specific antigen (PSA) >4 ng/ml or ratio PSA <0.25 and/or an abnormal digital rectal examination (DRE). The population sample was divided in three groups: (1) those with positive PSA, PSA ratio and DRE (70 patients); (2) those with positive PSA and PSA ratio but normal DRE (178 patients), and (3) those with positive PSA and PSA ratio, positive PSA velocity and a negative biopsy in the previous 6-month period (38 patients). In addition to the conventional sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone (10 core biopsy protocol). Additional cores (total of 12-14) were also randomly selected in case of larger prostates (>60 ml) or from suspicious foci revealed by transrectal ultrasound. All additional biopsy cores were submitted separately to the pathological department. RESULTS: Cancer was detected in 55.7% (39/70) and 69% (48/70) of the patients (for sextant core and for the extended biopsy protocols, respectively) in the first study group, 11% (20/178) and 23% (41/178) of the patients (for the sextant and the extended biopsy protocols, respectively) in the second study group, and 42% (16/38) and 63% (24/38) of the patients (for the sextant and the extended biopsy protocols, respectively) in the third study group. The addition of the lateral peripheral zone (PZ) of the prostate to the sextant biopsy showed a 23, 105 and 50% increase in the number of cancers diagnosed in the first, second and third study groups, respectively. The improvement of cancer detection rate (sensitivity) was statistically significant for all groups evaluated. CONCLUSION: The 10+ systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer compared to the sextant biopsy technique alone, especially when performed in men with positive PSA, PSA ratio, and negative DRE.     

Elevated prostate-specific antigen, abnormal prostate evaluation on digital rectal examination, and transrectal ultrasound and prostate biopsy

Prostate cancer screening for the early diagnosis of organ-confined, potentially curable prostate cancer has dramatically changed the practice of urology over the past 15 years. The introduction of prostate-specific antigen (PSA) testing, increased medical and public awareness for digital rectal examination (DRE), and transrectal ultrasound-assisted needle biopsy of the prostate (TRUS/PNBX) has been instrumental in these dramatic changes.     

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.     

Digital rectal examination, transrectal ultrasonography and prostate specific antigen for diagnosis of prostate cancer in clinical urological practice-detection of impalpable cancer]

OBJECTIVE: The clinical usefulness of multimodality detection for prostate cancer by digital rectal examination (DRE), transrectal ultrasonography (TRUS) and serum PSA determination (PSA) was evaluated in this retrospective study. PATIENTS AND METHODS: A total of 1344 symptomatic male patients who underwent DRE, TRUS and PSA in our outpatient clinic were studied. Prostate biopsies were performed when at least one diagnostic test was positive. RESULTS: Of 1344 patients, 436 (32.4%) had positive test results. Among 403 patients who underwent biopsy, 121 patients (30.0%) were found to have prostate cancer. The overall cancer detection rate was 9.0%. Among the 121 cancer patients, if examination had been carried out using only one or two tests, cancer would have not been detected in 22 patients (18.2%) by DRE alone, 27 patients (22.3%) by TRUS alone, 18 patients (14.9%) by PSA alone, 12 patients (9.9%) by a combination of DRE and TRUS, and 6 patients (5.0%) by a combination of DRE and PSA. Among the 121 patients with cancer, 22 (18.2%) had impalpable cancer. Impalpable cancer was more likely to be localized (77.3%) than palpable cancer (28.3%, p < 0.001) and more likely to be well or moderately differentiated (72.7%) than palpable cancer (41.4%, p = 0.008). CONCLUSION: This study confirmed the need for multimodality detection using DRE, TRUS and PSA as complementary methods in order to minimize decrease in cancer detection. In particular, impalbable cancers not detectable by DRE were detected and were revealed to be more likely to be localized and amenable to curative therapy. These results therefore underscore the importance of multimodality detection for early diagnosis of prostate cancer in urological practice.     

Contemporary impact of transrectal ultrasound lesions for prostate cancer detection

PURPOSE: Transrectal ultrasound (TRUS) guided systematic biopsy of the prostate is the gold standard diagnostic modality for prostate cancer. Consequently, the value of discrete hypoechoic lesions on TRUS lesions considered suspicious for cancer deserves meticulous reevaluation, specifically in the prostate specific antigen era when the majority of tumors diagnosed are nonpalpable. We studied whether the predictability of a biopsy core changes if the tissue comes from an isoechoic vs hypoechoic lesion. MATERIALS AND METHODS: Prospective data were collected on 3,912 consecutive patients referred to our medical center between 1993 and 1999 for biopsy of the prostate. A sextant technique (apex, mid gland and base) with an additional core biopsy from the transitional zone was used. If a hypoechoic lesion was identified, the biopsy was taken from the lesion. Correlation between hypoechoic lesions, isoechoic areas and cancer detection for each core was performed. RESULTS: A total of 31,296 cores were obtained from the cohort. Overall 2,642 (68%) cores had at least 1 hypoechoic lesion ultrasonographically. Cancer was detected in 675 (25.5%) and 323 (25.4%) patients with or without hypoechoic lesions (p = 0.97). The per core cancer detection was fairly uniform and averaged 9.3% and 10.4% for hypoechoic and isoechoic areas, respectively. The difference was not statistically significant (p = 0.3). Gleason scores were less than 7, 7 and greater than 7 in 46%, 34% and 20% of cases, respectively. CONCLUSIONS: Despite the higher prevalence of cancers discovered in prostates with hypoechoic areas, the hypoechoic lesion itself was not associated with increased cancer prevalence compared with biopsy cores from isoechoic areas. For impalpable tumors TRUS findings are not contributory for staging.     

血清PSA密度变化对前列腺癌高危人群的诊断价值

目的:探讨前列腺特异抗原(PSA)、前列腺特异抗原密度(PSAD)变化对前列腺癌高危人群的诊断价值。方法:对初次活检阴性的432例患者进行随访,其中79例重复穿刺活检,确诊前列腺癌27例(34.2%),消化道来源肿瘤1例,BPH25例,前列腺上皮内肿瘤(PIN)13例,慢性前列腺炎13例。对重复活检患者的PSA、PSAD等临床资料进行统计分析。结果:配对t检验显示,良性病变首末次穿刺前PSA、PSAD差异均无统计学意义,而前列腺癌末次穿刺前PSA、PSAD较首次穿刺前升高,差异有统计学意义。以PSA>4ng/ml筛选前列腺癌,其敏感性、特异性、阳性预测值分别为92.5%、17.6%、37.6%,PSA末-PSA首>0筛选前列腺癌的敏感性、特异性、阳性预测值分别为85.2%、41.2%、40.4%;而以PSAD末-PSAD首>0筛选前列腺癌的敏感性、特异性、阳性预测值分别为81.5%、54.9%、48.9%。结论:在前列腺癌高危人群中应该重复穿刺,以减少漏诊;以PSAD动态升高来指导穿刺,可以明显提高阳性率。     

General features and strategy in the diagnosis of prostatic carcinoma

Prostate cancer (PCa) is the most commonly diagnosed cancer in men as well as the second leading cause of cancer death. Age, family history and race are proved risk factors for developing a PCa. Prostate specific antigen (PSA) in combination with the digital rectal examination (DRE) has proven to be an essential element in early prostate cancer detection. Enthusiasm for using transrectal ultrasound (TRUS) alone to identify early prostate cancer has not been demonstrated with longer follow-up. The major role of TRUS today is to ensure accurate wide-area sampling of prostate tissue in men with PCa suspicion. This is best accomplished by targeted biopsy of TRUS-suspicious lesions and systematic biopsy of areas without hypoechoic lesions. Urologists recommend digital rectal examination and a PSA blood test annually starting at age 50.