Improving prostate cancer detection with an extended‐core transrectal ultrasonography‐guided prostate biopsy protocol

Abstract

Objective To investigate whether taking two transition zone (TZ) and four lateral peripheral zone (PZ) biopsies in addition to routine parasaggital sextant biopsies would improve detection rates in men with suspected prostate cancer. Patients and methods The study included 493 consecutive men (mean age 68.7 years, sd 8.2) with elevated serum prostate‐specific antigen (PSA) levels and/or abnormal findings on a digital rectal examination who underwent transrectal ultrasonography‐guided prostate biopsy. In addition to sextant biopsies, six further biopsies were obtained, two from the TZ (mid‐gland) and four from the lateral PZ (base and mid‐gland). Pathological findings for the additional biopsies were compared with those of the sextant regions. Results Prostatic adenocarcinoma was diagnosed in 164 of the 493 (33%) men biopsied. Men with cancer were older, had smaller prostates and higher median PSA levels than men with negative biopsies. Sextant biopsies were positive for cancer in 133 of 164 (81%) men. All three sets of biopsies were positive in 53 (32%) cases. In 50 (30%) men both the sextant and lateral PZ biopsies were positive, while in six (4%) men, both sextant and TZ biopsies were positive. Thirty‐one (19%) tumours were not detected by sextant biopsies, 10 (6%) where the lateral PZ biopsies alone were positive, 17 (10%) where the TZ biopsies alone were positive and four (3%) where both the TZ and lateral PZ together were positive. There were no differences in median PSA concentration, total prostate volume or TZ volume between men with an isolated TZ cancer and men with cancer elsewhere in the prostate. However, 77% of men with TZ cancer had a PSA of > 10 ng/mL, compared with 60% of men with cancer at other sites within the prostate (P = 0.015). Conclusion An extended‐core biopsy protocol significantly improves the detection rate for prostate cancer when compared with the standard sextant biopsy protocol alone. Routine TZ biopsies should be considered for men with serum PSA levels of >10 ng/mL.

A prospective randomized comparison of diagnostic efficacy between transperineal and transrectal 12-core prostate biopsy

“…2 Protocols proposed to improve the cancer detection rate have included increasing the number of specimen cores and sampling extended fields of the prostate. 3,4 These studies indicated that useful sites to add to sextant biopsy included far lateral and anterior horn. However, Durkan et al 3 reported that 31 of 164 cancer cases (19%) were not detected by sextant biopsies, and in 17 of these 31 cases, the transition zone (TZ) biopsies alone were positive.…”

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

“…This is not surprising, as mathematical models have shown that sextant biopsy misses 27% of tumors, and the probability of identifying a fixed volume of prostate cancer increases by taking more cores [16] . Results from clinical studies have shown that the sextant protocol for TRUS-guided prostate biopsy can miss cancer in 19%-31% of cases [17,18] . To overcome these diagnostic shortcomings, several extended biopsy policies have been advocated.…”

“…To overcome these diagnostic shortcomings, several extended biopsy policies have been advocated. Increasing the number of cores from six to eight, with extra cores targeted along the post-lateral margins of the gland, identifies up to 20% more tumors [19] , but even an eight-core biopsy may miss cancer, and others have advocated [16,18] more biopsies per gland [20][21][22] . However, trying to improve the diagnostic accuracy should not be at the expense of the increased complication rate that may accompany more core biopsies, particularly bleeding, as occurred in our patient, especially when the prostate and surrounding rectal tissue are supplied by a rich vascular bed that consists of branches of the inferior vesicular artery and the middle and inferior rectal arteries.…”

CUA guidelines on prostate biopsy methodology

“…39 Several groups have published results showing higher cancer detection rates with the 5-region prostate biopsy scheme compared to standard sextant technique for primary biopsy (cores ranged from 10 to 13). 39,[43][44][45][46][47] An exhaustive systematic review of the literature of cancer detection rates with different extended prostate biopsy schemes compared to the standard sextant scheme was published by Eichler and colleagues 48 (Level 1 evidence). Eighty-seven studies were reviewed with a total of 20 698 patients.…”