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 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.     

经会阴前列腺24针饱和穿刺活检与14针活检在PSA＜20μg/L患者中筛检前列腺癌的对比性研究

目的:探讨超声引导下经会阴前列腺24针饱和穿刺活检与14针穿刺活检方案对PSA<20μg/L可疑前列腺癌患者的筛检阳性率及其相关并发症。方法:选取116例可疑前列腺癌患者行经会阴超声引导下14针穿刺活检(14针组),另136例患者,行经会阴24针饱和前列腺穿刺活检(24针饱和组),比较两组前列腺癌筛检阳性率、标本阳性率及穿刺后肉眼血尿、泌尿系感染、尿潴留等并发症的发生率。结果:两组患者平均年龄、穿刺前PSA水平、平均前列腺体积等指标均无统计学差异(P>0.05)。24针饱和组及14针组前列腺癌筛检总体阳性率分别为48.53%和17.24%,存在显著性差异(P<0.001),标本阳性率分别为8.09%和2.83%(P=0.012);其中24针饱和组前列腺尖部肿瘤的检出率(11.76%)显著高于14针组(1.72%,P<0.05)。两组穿刺后尿潴留、泌尿系感染和肉眼血尿等发生率均无统计学差异(P>0.05)。结论:24针经会阴前列腺饱和穿刺活检方法显著提高PSA<20μg/L患者中前列腺癌的筛检阳性率,尤其是增加了前列腺尖部区域的肿瘤筛检阳性率,而并未增加相关并发症。     

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.     

Effect of dimensions and volume of the prostate on cancer detection rate of 12 core prostate biopsy

Purpose To evaluate if volume or any of the three dimensions of prostate influences cancer detection rate by 12-core transrectal ultrasound (TRUS) guided prostate biopsy. Materials and methods We have searched our database for patients who underwent 12 core TRUS guided prostate biopsy with PSA values between 4.0 and 9.9 ng/ml, benign digital exam and no suspicious lesions at TRUS. The measurements of three dimensions and volume of the prostate of 99 patients were correlated with cancer detection rates of biopsy. Results There were no statistically significant differences between patients with prostate cancer or with benign histopathologic result for mean age, PSA and % PSA. Patients without cancer had a significantly higher mean prostate volume (58.88 cc) than patients with cancer (48.85 cc) (P = 0.038). A volume of 48.5 cc was determined as a cut-off value above which cancer detection rate decreases. Of the three dimensions, only the difference for the craniocaudal dimension between benign and malignant groups was marginally significant (P = 0.052). Conclusions With 12 core biopsy, cancer detection rate is lower in patients with prostates larger than 48.5 cc. Further studies comparing biopsy results with prostatectomy specimens can clarify whether these results necessitates higher number of cores for such patients.     

Direct comparison between transrectal and transperineal extended prostate biopsy for the detection of cancer

AIM: To establish whether extended transrectal (TR) and extended transperineal (TP) biopsies are equivalent in detecting prostate cancer. METHODS: Due to an elevated prostate-specific antigen (PSA) greater than 2.5 ng/mL or abnormal digital rectal examination findings, 783 men underwent a transrectal ultrasound-guided three-dimensional 26-core biopsy, a combination of TR 12-core and TP 14-core biopsies. Using recursive partitioning, the best combination of sampling sites that gave the highest cancer detection rate at a given number of biopsy cores was selected either with a TR or a TP approach. The cancer detection rate and characteristics of detected cancers were compared between the TP 14-core and the TR 12-core biopsies and between selected subset biopsy schemes. RESULTS: Prostate cancer was detected in 283 of the 783 men (36%). There was no statistical difference in cancer detection rate or in the characteristics of detected cancers between TP 14-core and TR 12-core biopsies. As far as the best combination of sampling sites was selected, there was no statistical difference in cancer detection rates or in the characteristics of detected cancers between the TP and the TR subset biopsy schemes up to 12 cores. TP and TR biopsies performed equally, regardless of a history of negative biopsy, a digital rectal examination finding, the PSA level or the prostate volume. CONCLUSIONS: We demonstrated for the first time that extended TP biopsy is as effective as its TR counterpart in detecting cancer and the characteristics of detected cancers, as far as sampling sites are selected to maximize the cancer detection rate.     

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.     

Comparison of prostate biopsy schemes by computer simulation

OBJECTIVES: To compare the ability of different biopsy schemes to detect cancer and predict tumor volume using our previously described prostate biopsy simulation system. In addition, we used the simulation system to evaluate the optimal location of transition zone biopsies. METHODS: Digital reconstructions of 180 radical prostatectomy specimens were used. Forty simulations were performed on each prostate for 10 biopsy schemes, including a previously reported five-region peripheral zone biopsy pattern and a new 11-core multisite-directed scheme consisting of sextant, two transition zone, one midline, and two anterior horn biopsies. For simulation of the transition zone biopsies, paired near-midline biopsies were simulated, with needle insertion points from the apex to the base of the prostate and with needle advances of 1 to 4 cm before firing. A total of 1,180,800 individual biopsy tracks were simulated. RESULTS: The 11-core multisite-directed biopsy scheme had the highest detection rate for cancers greater than 0.5 cc. This scheme reliably detected cancer in 94% (138 of 147) of the cases. These results were significantly better than those of the sextant biopsy scheme (P <0.001) and the five-region 18-core peripheral zone scheme (P = 0.03). Compared with other schemes, there were increases in small-volume (0.5 cc or less) cancer detection by both the 11-core multisite-directed and five-region schemes, but they were not statistically significant. The multisite and the sextant plus four transition zone biopsy schemes had the best correlation of mean total core cancer length with total cancer volume. In the simulation of the transition zone biopsies, the highest detection rate was observed when the biopsies were initiated at the most apical section and inserted for a depth of 3 cm before firing. CONCLUSIONS: Our simulation results suggest that the detection rate of prostate biopsies is not related solely to the number of cores taken. Core placement (the regions of the prostate from which samples are taken) is also important. The 11-core multisite-directed biopsy scheme performed the best, with improved cancer detection rates and tumor volume correlation over other schemes. On the basis of our simulations, this scheme has been chosen for clinical evaluation.     

The 20-core prostate biopsy as an initial strategy: impact on the detection of prostatic cancer

Introduction:

To increase the detection rate of prostate cancer in recent years, we examined the increase in the number of cores taken at initial prostate biopsy. We hypothesized that an increasing number of cores may undermine the accuracy of models predicting the presence of prostate cancer at initial biopsy in patients submitted to 20-core initial biopsy.

Methods:

A total of 232 consecutive patients with prostate-specific antigen (PSA) between 4 and 20 ng/mL and/or abnormal digital rectal examination (DRE) underwent 12-core prostate biopsy protocol (group 1) or 20-core prostate biopsy protocol (group 2). The patients were divided into subgroups according to the results of their serum PSA and prostate volume. We evaluated the cancer detection rate overall and in each subgroup. Clinical data were analyzed using chi-square analysis and the unpaired t-test or 1-way ANOVA with significance considered at 0.05.

Results:

The 2 groups of patients were not significantly different with regard to parameters (age, abnormal DRE and serum PSA), although median prostate volume in group 1 (57.76 ± 26.94 cc) were slighter greater than in group 2. Cancer detection rate for patients submitted to 20 prostate biopsy was higher than patients submitted to 12 prostate biopsy (35.2% vs. 25%, p = 0.095). Breakdown to PSA level showed a benefit to 20 prostate biopsy for PSA <6 ng/mL (37.1% vs. 12.9%, p = 0.005). Stratifying results by prostate volume, we found that the improvement of cancer detection rate with 20 prostate biopsy was significant in patients with a prostate volume greater than 60 cc (55% in 20 prostate biopsy vs. 11.3% p < 0.05). Morbidity rates were identical in groups 1 and 2 with no statistically significant difference. There appeared to be no greater risk of infection and bleeding with 20 prostate biopsy protocol.

Conclusion:

The 20-core biopsy protocol was more efficient than the 12-core biopsy protocol, especially in patients with prostate specific antigen <6 ng/mL and prostate volume greater than 60 cc.     

Transperineal 12-core systematic biopsy in the detection of prostate cancer

BACKGROUND: The present study was designed to determine the clinical value of transperineal 12-core systematic prostate biopsy guided by transrectal ultrasonography (TRUS) in the detection of prostate cancer. METHODS: A total of 679 consecutive patients underwent systematic prostate biopsies because of abnormal results on digital rectal examination and/or TRUS and/or an elevated serum prostate-specific antigen level. Systematic six- and 12-core biopsies were taken in 138 patients between April 1994 and February 1995 and in the remaining 541 between March 1995 and February 2000, respectively. Twelve-core biopsy included two samples from the lateral portion of the peripheral zone and four from the anterior portion of the transition zone in addition to the conventional six-core biopsy. RESULTS: In the series overall, systematic biopsy revealed 156 cases of prostate cancer (23.0%). The detection rate increased by 5.2%, although this was statistically not significant, from 18.8% (26/138) by six-core biopsy to 24.0% (130/541) by 12-core biopsy. Out of 130 patients in whom prostate cancer was detected by 12-core biopsy, it was supposed that conventional six-core biopsy would have missed 18 cases (13.8%). CONCLUSIONS: Systematic 12-core biopsy might improve the detection rate for prostate cancer. However, further studies are needed to determine its clinical value in the diagnosis of the disease.     

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.     

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.     

Individualization of the biopsy protocol according to the prostate gland volume for prostate cancer detection

PURPOSE: In this study we assessed the relative yield of 10 core biopsy, and the whole range of alternative 8 and 6 core biopsy protocols over that of the classic sextant biopsy protocol. We determined the optimum number of cores per biopsy according to prostate volume in patients who experienced prostate biopsy for the first time. MATERIALS AND METHODS: A total of 503 men with the indications of abnormal digital rectal examination and/or serum prostate specific antigen greater than 2.5 ng/ml were included in the study. All patients underwent a 10 core biopsy protocol with an additional 1 core from each suspicious area detected by transrectal ultrasound. Prostate volume was divided into quartiles, namely 14.9 to 35, 35.1 to 50, 50.1 to 65 and 65.1 to 150 cc. The optimum number of biopsy cores was determined in patients with different prostate volumes. RESULTS: Median age was 63 years and prostate specific antigen was 7.4 ng/ml in the whole group. Of 503 patients 159 (31.6%) were positive for prostate cancer. Cancer detection rates decreased significantly from 49.6% to 20.8% as prostate volume increased in preset quartiles. Lesion biopsies revealed the lowest unique cancer detection rates for all prostate volume quartiles (0% to 3%). There was an obvious positive trend in cancer detection rates in favor of the 10 core biopsy protocol over sextant biopsies in all patient groups. Classic sextant biopsy protocol proved to be inadequate for all prostate volumes. Among sextant biopsy protocols laterally placed cores including the apex, lateral mid gland and lateral base had the best cancer detection rates (81% to 95%). The 8 core biopsy scheme consisting of the apex, mid gland, lateral mid gland and lateral base resulted in an only 1% lower detection rate (97%) than the 10 core biopsy protocol in the lowest quartile. The yield of the 10 core biopsy protocol in patients with a prostate volume of between 35.1 and 150 cc outscored that of the optimal 8 core biopsy scheme including the apex, base, lateral mid gland and lateral base with 3% to 8% differences in the cancer detection rate. CONCLUSIONS: The 10 core biopsy protocol must be used in all group of patients except patients with a prostate volume of 14.9 to 35 cc. In patients with a prostate volume of 14.9 to 35 cc the 8 core biopsy protocol consisting of the apex, mid gland, lateral mid gland and lateral base can be used since it revealed results similar to those of the 10 core biopsy protocol. The classic sextant biopsy protocol seemed inadequate for all prostate volumes. Patients with a larger prostate had lower cancer detection rates. Transrectal ultrasound directed lesion biopsies may be omitted when using 10 core biopsy protocols since the yield of these biopsies was less than 2%.     

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.     

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.     

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.     

Sensitivity and detection rate of a 12-core trans-perineal prostate biopsy: preliminary report

OBJECTIVES: The various prostate biopsy methods are usually compared in terms of the diagnosis rate of prostate cancer. However, the prevalence of cancer in patients with a negative prostatic biopsy is not usually known. We determined the sensitivity and detection rate of 12-core transperineal biopsies in patients not previously investigated for prostate cancer. METHODS: We performed prostate biopsy in 63 patients (median age 67 years) before radical cystoprostatectomy for high-grade bladder cancer. We then assessed the relationships between biopsy result, prostate cancer in the surgical specimen, and other variables. RESULTS: 17.2% of patients had a positive biopsy and 54% had prostate cancer on definitive histology. Biopsy sensitivity was 32.3% overall, 75% for clinically significant cancers, and 11% for non-significant cancers. Median PSA was 1.2ng/ml, PSA levels did not correlate with the presence of prostate cancer, the presence of clinically significant cancer, bioptic diagnosis, or prostate volume. Age correlated with risk of cancer. CONCLUSIONS: According to autopsy series, the prevalence of prostate cancer is greater than 50% in males older than 60, yet low PSA levels do not reliably indicate disease absence. The sensitivity of double sextant biopsy is unsatisfactory overall (32%), but acceptable (75%) for diagnosing clinically significant cancer.     

Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review

PURPOSE: Several new extended prostate biopsy schemes (greater than 6 cores) have been proposed. We compared the cancer detection rates and complications of different extended prostate biopsy schemes for diagnostic evaluation in men scheduled for biopsy to identify the optimal scheme. MATERIALS AND METHODS: In a systematic review we searched 13 electronic databases, screened relevant urological journals and the reference lists of included studies, and contacted experts. We included studies that compared different systematic prostate biopsy methods using sequential sampling or a randomized design in men scheduled for biopsy due to suspected prostate cancer. We pooled data using a random effects model when appropriate. RESULTS: We analyzed 87 studies with a total of 20,698 patients. We pooled data from 68 studies comparing a total of 94 extended schemes with the standard sextant scheme. An increasing number of cores were significantly associated with the cancer yield. Laterally directed cores increased the yield significantly (p = 0.003), whereas centrally directed cores did not. Schemes with 12 cores that took additional laterally directed cores detected 31% more cancers (95% CI 25 to 37) than the sextant scheme. Schemes with 18 to 24 cores did not detect significantly more cancers. Adverse events for schemes up to 12 cores were similar to those for the sextant pattern. Adverse event reporting was poor for schemes with 18 to 24 cores. CONCLUSIONS: Prostate biopsy schemes consisting of 12 cores that add laterally directed cores to the standard sextant scheme strike the balance between the cancer detection rate and adverse events. Taking more than 12 cores added no significant benefit.     

Extended 21-sample needle biopsy protocol for diagnosis of prostate cancer in 1000 consecutive patients

OBJECTIVE: To prospectively evaluate the diagnostic yield of a 21-sample ultrasound-guided needle biopsy protocol as the initial diagnostic strategy for detection of prostate cancer. MATERIALS AND METHODS: Between December 2001 and October 2005, 1000 consecutive patients underwent 21-sample needle biopsies under local anesthesia, comprising sextant biopsies, 3 additional posterolateral biopsies in each peripheral zone, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Each prostate core was numbered and analyzed separately. The patients were divided into subgroups according to the result of digital rectal examination (DRE), serum prostate-specific antigen (PSA), and prostate volume. We evaluated the cancer detection rate overall and in each subgroup. We compared the results of our biopsy protocol to those from 6-, 12-, and 18-core biopsy protocols by analyzing only those cores from our protocol that would correspond to these biopsy schemes. RESULTS: Cancer detection rates using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant, lateral, and TZ biopsies), and 21 samples (sextant, lateral, TZ, plus midline biopsies) were 31.7%, 38.7%, 41.5%, and 42.5%, respectively. The 12-sample procedure improved the cancer detection rate by 22% compared with the 6-sample procedure (p=0.0001). The improvement in the diagnostic yield was most marked in patients with a prostate volume > or =55 ml (36.9%), in patients with normal DRE (26.6%), and in patients with PSA<4 (37.5%). The addition of TZ biopsies to a 12-biopsy scheme increased the diagnostic yield by 7.2% overall (p=0.023). Only 10 of 425 (2.3%) patients were diagnosed on the sole basis of midline biopsies. CONCLUSIONS: Patients with suspected localized prostate cancer should be offered at least 12 biopsies in the peripheral zone and far lateral peripheral zone (statistically significant). TZ biopsies have to be considered, because these biopsies improve the diagnostic yield. For patients with abnormal DRE and/or PSA> or =20 ng/ml, the 6-biopsy scheme seems sufficient (statistically), but 6 far lateral peripheral zone biopsies as well as the TZ biopsies add little incremental value (not significant). Evidence does not support the use of routine midline peripheral zone needle biopsies in the initial biopsy to enhance the detection of prostate cancer.     

Cancer detection rates of different prostate biopsy regimens in patients with renal failure

We aimed to evaluate the cancer detection rates of 6-, 10-, 12-core biopsy regimens and the optimal biopsy protocol for prostate cancer diagnosis in patients with renal failure. A total of 122 consecutive patients with renal failure underwent biopsy with age-specific prostate-specific antigen (PSA) levels up to 20?ng/mL. The 12-core biopsy technique (sextant biopsy?+?lateral base, lateral mid-zone, lateral apex, bilaterally) performed to all patients. Pathology results were examined separately for each sextant, 10-core that exclude parasagittal mid-zones from 12-cores (10a), 10-core that exclude apex zones from 12-cores (10b) and 12-core biopsy regimens. Of 122 patients, 37 (30.3%) were positive for prostate cancer. The cancer detection rates for sextant, 10a, 10b and 12 cores were 17.2%, 29%, 23.7% and 30.7%, respectively. Biopsy techniques of 10a, 10b and 12 cores increased the cancer detection rates by 40%, 27.5% and 43.2% among the sextant technique, respectively. Biopsy techniques of 10a and 12 cores increased the cancer detection rates by 17.1% and 21.6% among 10b biopsy technique, respectively. There were no statistical differences between 12 core and 10a core about cancer detection rate. Adding lateral cores to sextant biopsy improves the cancer detection rates. In our study, 12-core biopsy technique increases the cancer detection rate by 5.4% among 10a core but that was not statistically different. On the other hand, 12-core biopsy technique includes all biopsy regimens. We therefore suggest 12-core biopsy or minimum 10-core strategy incorporating six peripheral biopsies with elevated age- specific PSA levels up to 20?ng/mL in patients with renal failure.