Increased accuracy of biopsy Gleason score obtained by extended needle biopsy

Initial outcomes of local anaesthetic freehand transperineal prostate biopsies in the outpatient setting

OBJECTIVES

To evaluate the histopathological outcomes, morbidity and tolerability of freehand transperineal (TP) prostate biopsies using the PrecisionPoint™ access system (Perineologic, Cumberland, MD, USA) under local anaesthetic (LA) in the day surgery and outpatient environments, as systematic and targeted biopsies can be taken with the potential for reduced morbidity, particularly sepsis.

PATIENTS AND METHODS

In all, 176 patients underwent freehand TP prostate biopsies from May 2016 to November 2017. The procedure was carried out either under LA alone or with the addition of sedation. Magnetic resonance imaging (MRI) scans were reported using the Prostate Imaging-Reporting and Data System (PI-RADS), version 2. Tolerability was assessed using a visual analogue scale pain score for each procedural stage. Histopathological outcomes and complications were recorded.

RESULTS

The mean (range) age was 65 (36-83) years, median (range) prostate-specific antigen level was 7.9 (0.7-1374) ng/mL, and the mean (range) prostate volume 45 (15-157) mL. Biopsies were taken under LA alone (160 patients, 90%) or under LA with sedation (16, 9%). The main indication for biopsy was primary diagnosis (88.6%). In all, 91 (52%) patients underwent systematic TP biopsies (mean 24.2 cores). Cognitive MRI-targeted biopsies alone were performed in 45 patients (26%; mean 6.8 cores), and 40 (23%) had both systematic and target biopsies (mean 27.9 cores). Of the 75 patients who had primary systematic biopsies alone, 46 (61%) were positive, and 28/46 (60.9%) were diagnosed with clinically significant disease (Gleason ≥3+4). VAS pain scores were greatest during LA administration. There were five complications (2.8%, Clavien-Dindo Grade I/II). No patients developed urosepsis.

CONCLUSIONS

Freehand TP biopsies using the PrecisionPoint access system is a safe, tolerable and effective method for systematic and targeted biopsies under LA in the outpatient setting. It has replaced transrectal biopsies in our centre and has potential to transform practice.

Radical Prostatectomy for High-risk Localized or Node-Positive Prostate Cancer: Removing the Primary

PURPOSE OF REVIEW

We reviewed the literature to determine what role, if any, radical prostatectomy should play in the treatment of high-risk and/or node-positive prostate cancer.

RECENT FINDINGS

The AUA, NCCN, and EAU all include radical prostatectomy as a treatment option for high-risk prostate cancer based on evidence that has shown improvements in biochemical-free and disease-specific survival. Lymph node-positive patients may also derive benefit from radical prostatectomy with lymph node dissection, however, only retrospective studies with high risk of selection bias have been published to date. High-risk prostate cancer is a heterogeneous disease representing a wide range of disease characteristics. Radical surgery, historically avoided in such patients, may now be considered a valid treatment option for select cases. The adverse effects of surgery using modern techniques lead to similar quality of life outcomes as radiation therapy, and treatment of the primary tumor is likely beneficial when compared to ADT alone.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound (TRUS) or transperineal template (TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increased number of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

Untreated Gleason Grade Progression on Serial Biopsies during Prostate Cancer Active Surveillance: Clinical Course and Pathological Outcomes

PURPOSE

We describe the outcomes of patients with low risk localized prostate cancer who were upgraded on a surveillance biopsy while on active surveillance and evaluated whether delayed treatment was associated with adverse outcome.

MATERIALS AND METHODS

We included men in the study with lower risk disease managed initially with active surveillance and upgraded to Gleason score 3+4 or greater. Patient demographics and disease characteristics were compared. Kaplan-Meier curve was used to estimate the treatment-free probability stratified by initial upgrade (3+4 vs 4+3 or greater), Cox regression analysis was used to examine factors associated with treatment and multivariate logistic regression analysis was used to evaluate the factors associated with adverse outcome at surgery.

RESULTS

The final cohort comprised 219 men, with 150 (68%) upgraded to 3+4 and 69 (32%) to 4+3 or greater. Median time to upgrade was 23 months (IQR 11-49). A total of 163 men (74%) sought treatment, the majority (69%) with radical prostatectomy. The treatment-free survival rate at 5 years was 22% for 3+4 and 10% for 4+3 or greater upgrade. Upgrade to 4+3 or greater, higher prostate specific antigen density at diagnosis and shorter time to initial upgrade were associated with treatment. At surgical pathology 34% of cancers were downgraded while 6% were upgraded. Cancer volume at initial upgrade was associated with adverse pathological outcome at surgery (OR 3.33, 95% CI 1.19-9.29, p=0.02).

CONCLUSIONS

After Gleason score upgrade most patients elected treatment with radical prostatectomy. Among men who deferred definitive intervention, few experienced additional upgrading. At radical prostatectomy only 6% of cases were upgraded further and only tumor volume at initial upgrade was significantly associated with adverse pathological outcome.

Concordance between transrectal ultrasound guided biopsy results and radical prostatectomy final pathology: Are we getting better at predicting final pathology?

INTRODUCTION

Inaccuracy in biopsy Gleason scoring poses a risk to men who may then receive inappropriate treatment. We assess whether there was a change in discordance rates between biopsy and radical prostatectomy at our institution in recent years, while considering the implementation of active surveillance and the shift in biopsy scores caused by the 2005 International Society of Urologic Pathology update to the Gleason scoring protocol.

METHODS

We reviewed patients who underwent radical prostatectomy at our institution between May 2004 and April 2011. We analyzed clinical and pathological correlates of upgrading in 3 subgroups: Gleason sum (GS) 6/6, GS6/7 and GS7/7, where the sum preceding the dash was determined from biopsy and the subsequent sum was determined from the radical prostatectomy specimen. We applied the log-rank test and Cox model to a Kaplan Meier analysis of biochemical recurrence in the subgroups, and also mapped GS6/7 discordance over time.

RESULTS

In total, 1717 patients met our inclusion criteria. The 3 subgroups had significantly different mean prostate-specific antigen, patient age, tumour volume, margin status, pathologic stage, prostate weight, transrectal ultrasound volume and rate of progression (p < 0.05). We noted a multiphasic trend with a fall in discordance after 2005. However, there was no sustained trend over the study period taken as a whole (p = 0.06).

CONCLUSIONS

Although no sustained trend was observed, the falling discordance after 2005 may reflect the accommodation to the Gleason scoring update, while the gradual adoption of active surveillance may have led to the otherwise increasing trends. However, our observations may also be spurious biopsy sampling errors.

Improving the Gleason grading accuracy of transrectal ultrasound-guided biopsy

BACKGROUND

Transrectal ultrasound (TRUS)-guided prostate biopsy is the technique of choice for the assessment of clinical suspicion of prostate cancer (PC) based on abnormal digital rectal examination (DRE) and/or elevated or rising levels of prostate-specific antigen (PSA).

PURPOSE

To identify factors involved in TRUS-guided prostate biopsy, which can be modified by radiologists in order to improve Gleason score (GS) accuracy, and to assess the influence of clinical variables.

MATERIAL AND METHODS

We carried out a retrospective review of the records of 185 patients with PC treated surgically at our hospital between 2005 and 2008. Biopsy schemes were classified according to the number of cores (≤7, 8-9, 10-11, 12-15) and the needle length (11, 16, 20 mm). Clinical characteristics - age, family history of PC, DRE, PSA levels, and sonographic data - and prostatectomy GS (pGS) were collected.

RESULTS

Non-random concordance between biopsy Gleason score (bGS) and pGS was obtained for 36% of patients (P < 0.001). Under- and over-staging were 30% and 4%, respectively. Concordance was correlated with the core number (45% for ≤7, 54% for 8-9, 85% for 10-11, and 80% for 12-15; P < 0.001), but not with the needle length. The concordance rate showed a seven-fold increase when 10-11 cores were obtained (95% CI, 2-18; P < 0.001) compared to those cases in which the core number obtained was ≤7. Among clinical variables, only PSA correlated with concordance, showing an inverse relationship.

CONCLUSION

The Gleason correlation values were not improved when 12 or more cores were collected. These values reached a plateau beyond that number of samples. Therefore, when determining treatment strategies, physicians must consider the biopsy scheme used since it has proven to be a predictor of the accuracy of the PC grading system.

Needle biopsy size and pathological Gleason Score diagnosis: No evidence for a link

BACKGROUND

Biopsy Gleason score (GS), in combination with other clinical parameters, is important to take a therapeutic decision for patients with diagnosis of localized prostate cancer. However, preoperative GS is often upgraded after a radical prostatectomy. Increasing the amount of tissue in prostate biopsy may be a way to avoid this issue. We evaluate the influence of a larger biopsy needle size on the concordance between biopsy and pathological GS.

METHODS

We analyzed paired biopsies and prostatectomy specimens from 104 cases of men with clinically localized prostate cancer. At the time of prostate biopsy, the patients were prospectively randomized into two needle groups (16-Gauge [G] and 18G) using a 1:1 ratio. GS concordance was estimated performing kappa statistic testing, overall concordance rate and risk to under grade biopsy GS=6. A logistic regression analysis was performed to evaluate the patients' characteristics as possible risk factors.

RESULTS

The overall concordance between prostate biopsy and pathological GS was 76.9% and 75.6% (p = 0.875) and the k values were 0.821 and 0.811 (p = 0.424), respectively, for 16G and 18G needle study groups. The risk to undergrade a biopsy GS=6 was 21.1% and 15.4% (p = 0.709) using a 16G and 18G needle, respectively. Age, prostate-specific antigen, prostate volume and needle calibre were not independently associated with a higher risk of GS discordance.

CONCLUSIONS

Needle size does not affect the concordance between biopsy and pathological GS. Although GS is not the only way to determine treatment, it is still an unresolved urological issue.

Transperineal biopsy of the prostate--is this the future?

Transperineal prostate biopsy is re-emerging after decades of being an underused alternative to transrectal biopsy guided by transrectal ultrasonography (TRUS). Factors driving this change include possible improved cancer detection rates, improved sampling of the anteroapical regions of the prostate, a reduced risk of false negative results and a reduced risk of underestimating disease volume and grade. The increasing incidence of antimicrobial resistance and patients with diabetes mellitus who are at high risk of sepsis also favours transperineal biopsy as a sterile alternative to standard TRUS-guided biopsy. Factors limiting its use include increased time, training and financial constraints as well as the need for high-grade anaesthesia. Furthermore, the necessary equipment for transperineal biopsy is not widely available. However, the expansion of transperineal biopsy has been propagated by the increase in multiparametric MRI-guided biopsies, which often use the transperineal approach. Used with MRI imaging, transperineal biopsy has led to improvements in cancer detection rates, more-accurate grading of cancer severity and reduced risk of diagnosing clinically insignificant disease. Targeted biopsy under MRI guidance can reduce the number of cores required, reducing the risk of complications from needle biopsy.

Frequency and determinants of disagreement and error in gleason scores: a population-based study of prostate cancer

BACKGROUND

To examine factors that affect accuracy and reliability of prostate cancer grade we compared Gleason scores documented in pathology reports and those assigned by urologic pathologists in a population-based study.

METHODS

A stratified random sample of 318 prostate cancer cases was selected to ensure representation of whites and African-Americans and to include facilities of various types. The slides borrowed from reporting facilities were scanned and the resulting digital images were re-reviewed by two urologic pathologists. If the two urologic pathologists disagreed, a third urologic pathologist was asked to help arrive at a final "gold standard" result. The agreements between reviewers and between the pathology reports and the "gold standard" were examined by calculating kappa statistics. The determinants of discordance in Gleason scores were evaluated using multivariate models with results expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The kappa values (95% CI) reflecting agreement between the pathology reports and the "gold standard," were 0.61 (95% CI: 0.54, 0.68) for biopsies, and 0.37 (0.23, 0.51) for prostatectomies. Sixty three percent of discordant biopsies and 72% of discordant prostatectomies showed only minimal differences. Using freestanding laboratories as reference, the likelihood of discordance between pathology reports and expert-assigned biopsy Gleason scores was particularly elevated for small community hospitals (OR = 2.98; 95% CI: 1.73, 5.14).

CONCLUSIONS

The level of agreement between pathology reports and expert review depends on the type of diagnosing facility, but may also depend on the level of expertise and specialization of individual pathologists.

Prostate saturation biopsy following a first negative biopsy: state of the art

INTRODUCTION

Saturation prostate biopsy (SPBx) has been initially introduced to improve prostate cancer (PCa) detection rate (DR) in the repeat setting. Nevertheless, the optimal number and the most appropriate location of the cores, together with the timing to perform a second PBx and the eventual modification of the PBx protocols according to the different clinical situations, are matters of debate. The aim of this review is to perform a critical analysis of the literature about the actual role of SPBx in the repeat setting.

MATERIALS AND METHODS

We performed a systematic review of the literature since 1995 up to 2011. Electronic searches were limited to the English language, using the MEDLINE database. The key words 'saturation prostate biopsy' and 'repeated prostate biopsy' were used.

RESULTS

SPBx improves PCa DR if clinical suspicion persists after previous biopsy with negative findings and provides an accurate prediction of prostate tumor volume and grade, even if the issue about the number and locations of the cores is still a matter of debate.

CONCLUSIONS

At present, SPBx seems to be really necessary in men with persistent suspicion of PCa after negative initial biopsy and probably in patients with a multifocal high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. In the remaining situations, adopting an individualized scheme is preferable.

pT3 Predictive Factors in Patients with a Gleason Score of 6 in Prostate Biopsies

Purpose

Often, a diagnosis of pT3 is made on the basis of radical retropubic prostatectomy specimens, despite a Gleason score of 6 on the preoperative prostate biopsy. Thus, we investigated the preoperative variables in patients displaying these characteristics.

Materials and Methods

Study subjects comprised patients at our institute from 1996 to July 2010 who had exhibited a Gleason score of 6 on their prostate biopsies and had undergone a radical retropubic prostatectomy. Through univariate and multivariate analysis, we investigated pT3 predictive factors including age, preoperative prostate-specific antigen (PSA) levels, transrectal ultrasonography (TRUS)-weighted prostate volume, digital rectal examination findings, bilaterality via prostate biopsy, prostatic cancer in prostate base cores via prostate biopsy, maximum length and percent of prostatic cancer, and number of cores detected in prostatic cancer via prostate biopsy.

Results

In the univariate logistic regression mode, a PSA value of 7.4 ng/ml or higher, TRUS-weighted PSA density of 0.2 ng/ml/cc or higher, prostate cancer detected in the basal core, and prostate cancer detected in 2 or more cores out of 12 were predictive factors for extraprostatic extension. Independent predictive factors for stage pT3 were a PSA of 7.4 ng/ml or higher and prostate cancer detected in 2 or more cores out of 12.

Conclusions

In the case of patients with the foregoing risk factors, it is advisable not to perform nerve-sparing surgery but to prepare for the possibility of a pT3 stage.

Changes in prostate cancer grade on serial biopsy in men undergoing active surveillance

PURPOSE

Active surveillance is now considered a viable treatment option for men with low-risk prostate cancer. However, little is known regarding changes in Gleason grade on serial biopsies over an extended period of time.

PATIENTS AND METHODS

Men diagnosed with prostate cancer between 1998 and 2009 who elected active surveillance as initial treatment, with 6 or more months of follow-up and a minimum of six cores at biopsy, were included in analysis. Upgrading and downgrading were defined as an increase or decrease in primary or secondary Gleason score. Means and frequency tables were used to describe patient characteristics, and treatment-free survival rates were determined by life-table product limit estimates.

RESULTS

Three hundred seventy-seven men met inclusion criteria. Mean age at diagnosis was 61.9 years. Fifty-three percent of men had prostate-specific antigen of 6 ng/mL or less, and 94% had Gleason score of 6 or less. A majority of men were cT1 (62%), had less than 33% of biopsy cores involved (80%), and were low risk (77%) at diagnosis. Median number of cores taken at diagnostic biopsy was 13, mean time to follow-up was 18.5 months, and 29% of men had three or more repeat biopsies. Overall, 34% (129 men) were found to have an increase in Gleason grade. The majority of men who experienced an upgrade (81%) did so by their second repeat biopsy.

CONCLUSION

A proportion of men experience an upgrade in Gleason score while undergoing active surveillance. Men who experience early upgrading likely represent initial sampling error, whereas later upgrading may reflect tumor dedifferentiation.

Upgrading of Gleason score on radical prostatectomy specimen compared to the pre-operative needle core biopsy: an Indian experience

Objectives:

To assess the accuracy of Gleason grading/scoring on preoperative needle core biopsy (NCB) compared to the radical prostatectomy (RP) specimen.

Materials and Methods:

Data of NCB and RP specimens was analyzed in 193 cases. Gleason grade/scoring was done on both NCB and RP specimens. Sixteen cases were excluded for various reasons. The Gleason scores of the two sets of matched specimens were compared and also correlated with the PSA, age, and number of needle biopsy cores. The overall change was also correlated with the initial score on NCB.

Results:

The mean age and PSA were 63.3±2(5.27) years and 18.48±2(28.42) ng/ml, respectively. The average Gleason score increased from 5.51 ± 2(1.52) to 6.2 ± 2(1.42) (P<0.02). The primary grade increased in 57 (32.2%) cases. Overall, 97 (54.8%) cases had an increase in Gleason score. Five other cases had a change from 3 + 4 = 7 to 4 + 3 = 7. Change in Gleason score was significantly more if the score on NCB was ≤6 or number of needle cores was ≤6. Besides, 28 cases had perineural invasion, 16 had capsular invasion (pT3_a), and 4 had vascular invasion on RP specimen.

Conclusions:

There is a significant upgrading of Gleason score on RP specimens when compared with NCB. This trend may be correlated positively with lower initial Gleason score on preoperative biopsy and the lower number of cores taken.

Effect of the number of biopsy cores on prostate cancer detection and staging

Digital rectal examination, serum concentration of prostate cancer-specific antigen and transrectal ultrasound-guided biopsies are currently the main diagnostic tools to detect evidence of prostate cancer. Different prostatic biopsy strategies have been proposed in order to achieve an optimal prostate cancer detection rate and an accurate characterization of prostate cancer stage and grade. We examined the role of the number of biopsy cores on prostate cancer detection rates at initial and repeat biopsies. Moreover, we examined the relationship between the number of biopsy cores and the detection of insignificant prostate cancer. Finally, we reviewed the ability of biopsy cores in predicting prostate cancer stage and grade at radical prostatectomy. We relied on a PubMed systematic review of the contemporary English language literature using the terms ‘prostate cancer’, ‘diagnosis’, ‘transrectal ultrasound’ and ‘prostate biopsy’.

Current Perspectives on the Gleason Grading of Prostate Cancer

Context.—Since its description in 1966 by Donald Gleason, the Gleason grading has remained a cornerstone in the diagnosis and management of prostate cancer. With widespread use of the prostate specific antigen screening, the diagnosis and management patterns of prostate cancers have dramatically changed. In addition, better understanding of the morphologic spectrum of prostate cancer and its subsequent outcome have prompted the refinement of the grading criteria and reporting practices applicable to contemporary practice management.

Objective.—To present contemporary perspectives and approaches to the Gleason grading of prostate cancer.

Data Sources.—Personal practice experience, review of medical literature, and excerpts from the 2005 International Society of Urological Pathology Consensus Statement on Gleason Grading of Prostate Cancer.

Conclusions.—This review addresses the trend in contemporary practice toward a grading shift, with rare utilization of Gleason patterns 1 and 2, and discusses the refinement of histologic criteria for Gleason patterns 3 and 4; approaches to Gleason grading in the setting of unusual variant morphologies of prostate cancer; significance of higher tertiary pattern 5; and practice recommendations for reporting in the setting of extended multiple core biopsies and multifocal prostate cancers in radical prostatectomy. Finally, the impact of consensus recommendations in current practice, its limitations and pitfalls, are also addressed.

Watchful waiting versus active surveillance: appropriate patient selection

The prostate-specific antigen (PSA) screening era has seen dramatic stage and age migration in patients with newly diagnosed prostate cancer. The average serum PSA level of newly diagnosed patients is about 6 ng/dL, and 60% of patients are diagnosed with clinical stage T1c disease. There is evidence that many low-grade and low-stage prostate cancers have a slow growth rate and protracted clinical course, with a very low threat of metastasis or death over a prolonged interval. Many men are also appropriately concerned about the impact of prostate cancer treatment on sexual and urinary function. Therefore, delaying therapy in favor of careful surveillance, with the expectation of delivering curative treatment upon evidence of progression, is an attractive concept. In this review, we discuss active surveillance, contrast it to watchful waiting, and define common inclusion criteria. We compare follow-up regimens and discuss indications and intervention outcomes after active surveillance. Finally, we support well-designed prospective clinical trials that evaluate active surveillance compared with immediate definitive treatment.

Biopsies performed at tertiary care centers are superior to referral biopsies in predicting pathologic Gleason sum

OBJECTIVE

Biopsy grading at tertiary care centers may or may not be superior to biopsies performed at referral institutions.

METHODS

Referral biopsy and tertiary care center biopsy Gleason sums were studied in 758 men treated with radical prostatectomy (RP) at a tertiary care center between 1992 and 2004. Grade agreement was calculated using the Cohen kappa (ê). Logistic regression models predicting high-grade prostate cancer at RP were fitted using either referral or tertiary care center biopsies. Comparison of bootstrap-corrected predictive accuracy estimates were performed using the Mantel-Haenszel test.

RESULTS

Grade agreement between biopsy and RP Gleason sum was higher (P = 0.003) for tertiary care center biopsies v referral biopsies (55.5% v 47.9%; P = 0.003). Upgrading occurred in 39.8% of referral biopsies v 32.6% of tertiary care center biopsies (P = 0.03). Tertiary care center biopsies were more accurate in determining RP Gleason sum than referral biopsies (71.5% v 65.6%, P = 0.04).

CONCLUSION

More accurate prediction of RP Gleason grade may be achieved if biopsy is performed and graded at tertiary care centers.

The association between prostate size and Gleason score upgrading depends on the number of biopsy cores obtained: results from the Shared Equal Access Regional Cancer Hospital Database

OBJECTIVE

To test the hypothesis that the association between prostate size and risk of Gleason grade upgrading varies as a function of sampling.

PATIENTS AND METHODS

We examined the association between pathological prostate weight, prostate biopsy scheme and Gleason upgrading (Gleason > or =7 at radical prostatectomy, RP) among 646 men with biopsy Gleason 2-6 disease treated with RP between 1995 and 2007 within the Shared Equal Access Regional Cancer Hospital Database using logistic regression. In all, 204 and 442 men had a sextant (six or seven cores) or extended-core biopsy (eight or more cores), respectively. Analyses were adjusted for centre, age, surgery, preoperative prostate-specific antigen level, clinical stage, body mass index, race, and percentage of cores positive for cancer.

RESULTS

In all, 281 men (44%) were upgraded; a smaller prostate was positively associated with the risk of upgrading in men who had an extended-core biopsy (P < 0.001), but not among men who had a sextant biopsy (P = 0.22). The interaction between biopsy scheme and prostate size was significant (P interaction = 0.01).

CONCLUSIONS

These data support the hypothesis that the risk of upgrading is a function of two opposing contributions: (i) a more aggressive phenotype in smaller prostates and thus increased risk of upgrading; and (ii) more thorough sampling in smaller prostates and thus decreased risk of upgrading. When sampled more thoroughly, the phenotype association dominates and smaller prostates are linked with an increased risk of upgrading. In less thoroughly sampled prostates, these opposing factors nullify, resulting in no association between prostate size and risk of upgrading. These findings help to explain previously published disparate results of the importance of prostate size as a predictor of Gleason upgrading.

Active surveillance for the management of prostate cancer in a contemporary cohort

BACKGROUND

Active surveillance followed by selective treatment for men who have evidence of disease progression may be an option for select patients with early-stage prostate cancer. In this article, the authors report their experience in a contemporary cohort of men with prostate cancer who were managed with active surveillance.

METHODS

All men who were managed initially with active surveillance were identified through the authors' institutional database. Selection criteria for active surveillance included: prostate-specific antigen (PSA)<10 ng/mL, biopsy Gleason sum </=6 with no pattern 4 or 5, cancer involvement of <33% of biopsy cores, and clinical stage T1/T2a tumor. Patients were followed with PSA measurements and digital rectal examination every 3 to 6 months and with transrectal ultrasound at 6- to 12-month intervals. Beginning in 2003, patients also underwent repeat prostate biopsy at 12 to 24 months. The primary outcome measured was active treatment. Evidence of disease progression, defined as an increase in rebiopsy Gleason sum or significant PSA velocity changes (>0.75 ng/mL per year), was a secondary outcome. Chi-square and log-rank tests were used to compare groups. The association between clinical characteristics and receipt of active treatment was analyzed by using Cox proportional hazards regression.

RESULTS

Three hundred twenty-one men (mean age [+/-standard deviation]: 63.4+/-8.5 years) selected active surveillance as their initial management. The overall median follow-up was 3.6 years (range, 1-17 years). The initial mean PSA level was 6.5+/-3.9 ng/mL. One hundred twenty men (37%) met at least 1 criterion for progression. Overall, 38% of men had higher grade on repeat biopsy, and 26% of men had a PSA velocity>0.75 ng/mL per year. Seventy-eight men (24%) received secondary treatment at a median 3 years (range, 1-17 years) after diagnosis. Approximately 13% of patients with no disease progression elected to obtain treatment. PSA density at diagnosis and rise in Gleason score on repeat biopsy were associated significantly with receipt of secondary treatment. The disease-specific survival rate was 100%.

CONCLUSIONS

Selected individuals with early-stage prostate cancer may be candidates for active surveillance. Specific criteria can be and need to be developed to select the most appropriate individuals for this form of management and to monitor disease progression. A small attrition rate can be expected because of men who are unable or unwilling to tolerate surveillance.

The effect of the number of biopsy cores on the concordance between prostate biopsy and prostatectomy Gleason score: a prostate volume-controlled study

CONTEXT

Studies analyzing the concordance of biopsy and radical prostatectomy (RP) Gleason scores have limitations. Some included 2 or more centers, used historical controls from the early prostate specific antigen era or lacked a clear definition of the biopsy schemes. Furthermore, most did not control the results for prostate volume.

OBJECTIVE

To confirm whether prediction of RP Gleason score can be optimized by taking more biopsy cores in a contemporary series of patients, with pathologic samples analyzed by the same pathologist, and controlling these results for prostate volume.

DESIGN

The study comprised a retrospective case-control analysis of 393 patients with prostate cancer treated with RP. Patients were divided into 3 groups: those in group 1 underwent a 6-core biopsy; group 2, an 8-core biopsy; and group 3, a 10 or more-core biopsy. Concordance rates between biopsy and RP Gleason scores, as well as the rates of undergrading and overgrading, were determined for each biopsy scheme.

RESULTS

Concordance rates were 60.9%, 58.3%, and 64.6% for patients from groups 1, 2, and 3, respectively (P = .18). When we analyzed patients with prostate volumes of less than 50 cm(3), concordance rates were 58.3%, 58.3%, and 65.1% for each group, respectively (P = .03). Among patients with prostate volumes of 50 cm(3) or more, concordance rates were 70%, 58.1%, and 63.6%, respectively (P = .66).

CONCLUSIONS

Taking 10 or more cores can improve the prediction of RP Gleason score in patients with prostate volumes of less than 50 cm(3). For patients with prostate volumes of 50 cm(3) or more, increasing the biopsy cores to 10 or more did not improve prediction of RP Gleason score.

Significant discrepancies between diagnostic and pathologic Gleason sums in prostate cancer: the predictive role of age and prostate-specific antigen

OBJECTIVES

To assess the discrepancies between diagnostic and pathologic Gleason sums and the predictive role of age and prostate-specific antigen (PSA) level on Gleason sum discrepancies.

METHODS

A total of 2963 patients receiving radical prostatectomy at Duke University from 1988 to 2006 were divided into two groups according to year of diagnosis: 1988 to 1999 and 2000 to 2006. The Gleason sum discrepancies were evaluated in the above groups. The predictive roles of diagnostic age (less than 50, 50 to 60, 60.1 to 70, and greater than 70 years), PSA level (less than 10, 10 to 20, and greater than 20 ng/mL), race, body mass index, and prostate weight on the discrepancies were analyzed.

RESULTS

Overall, 55.8% of diagnostic Gleason sums differed from those on final surgical pathology (58.6% in the 1988 to 1999 and 49.3% in the 2000 to 2006 groups). Diagnostic Gleason sums were undergraded in 41.2% of cases and overgraded in 12.8% of cases. Men older than 60 years were more likely to have their diagnostic Gleason sums undergraded than men younger than 50 (odds ratio in age groups less than 50, 50 to 60, 60.1 to 70, and greater than 70 years: 1.00, 2.30, 4.03, and 3.96, respectively). Biopsy Gleason sums in men with a high PSA level were more likely to be undergraded compared with the PSA group less than 10 ng/mL (odds ratio in PSA groups less than 10, 10 to 20, and greater than 20 ng/mL: 1.00, 2.11, and 3.64, respectively).

CONCLUSIONS

Significant discrepancies between diagnostic and pathologic Gleason sums remain in recent years. The rate of diagnostic Gleason sum undergrading was 3.2-fold that of overgrading. Advanced age and high PSA level were predictive of diagnostic Gleason sum undergrading, and caution should be exercised when recommending active surveillance in older men.

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.

Trans-rectal ultrasound guided biopsy of the prostate: nationwide diversity in practice and training in the United Kingdom

INTRODUCTION

TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. However the practice is highly variable across the United Kingdom. We survey the standard approaches to TRUS biopsy of prostate, highlighting the nationwide diversity of practice and training.

METHODS

One hundred and eighty questionnaires were sent out to specialist registrars, investigating the number of prostate biopsy cores taken, the use of prophylactic antibiotics, rectal preparation and local analgesia in TRUS biopsy of the prostate. One hundred and fourteen trainees (63%) returned the questionnaires. Twenty-three percent reported sextant biopsy as standard, 36% taking eight-core and 26% taking 10 or more cores. There is no standard regime for antibiotic prophylaxis. Eighteen percent also reported rectal preparation as routine. Thirty-eight percent of the patients receive local anaesthesia prior to the biopsy. Overall, 42% of the TRUS biopsies are carried out by urologists, 29% by radiologists and 21% by both. Six percents have nurse practitioners' involvement. Fifty-six percent of trainees are involve in the TRUS biopsy, 68% do not think they received enough training to carry out the procedure.

CONCLUSIONS

TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. Our survey highlights nationwide diversity in practice in the UK with respect of the number of cores taken, antibiotic prophylaxis and local anaesthesia utilisation. This raised the issue of standardising the practice. More urologists are also actively taking part in this procedure, making the structured training increasingly important.

Prostate biopsy patterns in the CaPSURE database: evolution with time and impact on outcome after prostatectomy

PURPOSE

Significant variability exists in the urological community regarding the number of cores that should be taken during prostate biopsy. Using CaPSURE we determined trends in prostate biopsy patterns during the last decade and assessed whether changes in biopsy number have had an impact on outcomes after radical prostatectomy.

MATERIALS AND METHODS

In CaPSURE between 1995 and 2004 we identified 6,450 men with newly diagnosed prostate cancer who underwent biopsy with 6 cores or greater. The number of cores removed, number of cores positive for cancer and percent of cores containing cancer were analyzed by year of diagnosis. For 1,757 men who underwent radical prostatectomy these variables were entered into Cox proportional hazards models controlling for preoperative prostate specific antigen, biopsy Gleason sum and clinical stage to predict recurrence-free survival.

RESULTS

The mean number of removed cores increased from 6.9 in 1995 to 10.2 in 2004 (p <0.0001). The mean number of positive cores remained unchanged from 2.9 in 1995 to 3.2 in 2004 (p = 0.40). The percent of positive cores decreased from 42.6% in 1995 to 32.1% in 2004 (p <0.0001). The number and percent of positive cores were associated with recurrence-free survival after radical prostatectomy throughout the study period (each p <0.001).

CONCLUSIONS

The percent of positive cores is an independent predictor of disease recurrence after radical prostatectomy. The total number of tissue cores sampled increased during the last decade, thereby driving down the mean percent of positive cores from 42.6% to 32.1%. The trend toward an increasing number of removed cores may have contributed indirectly to improved outcomes after radical prostatectomy in the last decade.

Increasing the number of biopsies increases the concordance of Gleason scores of needle biopsies and prostatectomy specimens

PURPOSE

To determine the importance of increasing the number of biopsy cores to decrease the discrepancy of Gleason scores of needle biopsy and radical prostatectomy specimens.

MATERIALS AND METHODS

Between May 1998 and July 2005, 392 patients with clinically localized prostate cancer diagnosed by 18-gauge transrectal needle biopsy underwent radical prostatectomy. We categorized the cohort into 2 groups according to the number of the cores. Group 1 consisted of 206 patients diagnosed by extended biopsies (> or =10 cores, range 10-14, median 11). The remaining 186 patients who were diagnosed by sextant biopsies were categorized as being in group 2. Preoperative clinical variables, including patient age, digital rectal examination findings, serum prostate-specific antigen, and the number of cores positive for cancer the parameters, were assessed in both groups. The concordance of Gleason scores in both groups were analyzed by both individual Gleason scores and clinical subgroups of Gleason scores: 2-4 (well differentiated), 5-6 (moderately differentiated), 7 (intermediate), and 8-10 (poorly differentiated).

RESULTS

Needle biopsies revealed moderately differentiated tumors (Gleason 5-6) for the 2 groups (55.3% and 60.2%). Gleason scores of the needle biopsies were identical to that of the prostatectomy specimen in 116 (56.31%) and 76 cases (40.86%) for each group (kappa: 0.432 and 0.216 for each group, respectively). Gleason score of the needle biopsy differed by 1 grade in 56 (27.18%) and 84 cases (45.16%), and by > or =2 units in 34 (16.50%) and 26 cases (15.05%) for each group, respectively. Of the specimens, 34% were undergraded, and 10% were overgraded in group 1. These rates were 38% and 22% in group 2, respectively. A total of 70% in group 1 and 56% in group 2 remained in the same categorical group, 28% and 32% of the specimens were undergraded, and 4% and 12% were overgraded in groups 1 and 2, respectively. In group 1, the number of patients with Gleason scores of 2-4, 5-6, 7, and 8 were 9.7%, 55.3%, 21.4%, 13.6%, and 1.9%, 47.6%, 32%, 18.4%, graded by needle biopsies and radical prostatectomy specimens, respectively. However, in the sextant group, the change was the number of patients with Gleason scores of 2-4, 5-6, 7, and 8-10 was 5.4% 60.2%, 24.7%, and 9.7%, detected by needle biopsies, respectively. Radical prostatectomy specimens revealed the same Gleason categories in 4.3%, 41.9%, 38.7%, and 15.1%, respectively. There was no correlation between categorized prostate-specific antigen levels and concordance of the Gleason grade. Age and digital rectal examination results did not affect Gleason correlation.

CONCLUSIONS

We have shown that an extended biopsy scheme beyond its superior diagnostic capability also improves the concordance of Gleason scores of needle biopsies and radical prostatectomy specimens.

Extended and saturation prostatic biopsy in the diagnosis and characterisation of prostate cancer: a critical analysis of the literature

OBJECTIVE

To review and critically analyse all the recent literature on the detection and characterisation of prostate cancer by means of extended and saturation protocols.

METHODS

A systematic review of the literature was performed by searching MedLine from January 1995 to April 2007. Electronic searches were limited to the English language, and the key words "prostate cancer," "diagnosis," "transrectal ultrasound (TRUS)," "prostate biopsy," and "prognosis" were used.

RESULTS

The prostate biopsy technique has changed significantly since the original Hodge sextant biopsy protocol. Several types of local anaesthesia are now available, but periprostatic nerve block (PPNB) has proved to be the most effective method to reduce pain during TRUS biopsy. It remains controversial whether PPNB should be associated with other medications. The optimal extended protocol (sextant template with at least four additional cores) should include six standard sextant biopsies, with additional biopsies (up to 12 cores) taken more laterally (anterior horn) to the base and medially to the apex. Repeat biopsies should be based on saturation biopsies (number of cores >/= 20) and should include the transition zone, especially in a patient with an initial negative biopsy. As a means of increasing accuracy of prostatic biopsy and reducing unnecessary prostate biopsy, colour and power Doppler imaging, with or without contrast enhancement, and elastography now can be successfully adopted, but their routine use is still controversial.

CONCLUSION

Extended and saturation biopsy schemes should be performed at first and repeat biopsy, respectively. The widespread use of local anaesthesia makes the procedures more comfortable.

Clinical predictors of gleason score upgrading

BACKGROUND

Brachytherapy, active surveillance, and watchful waiting are increasingly being offered to men with low-risk prostate cancer. However, many of these men harbor undetected high-grade disease (Gleason pattern > or =4). The ability to identify those individuals with occult high-grade disease may help guide treatment decisions in this patient cohort.

METHODS

The authors identified 175 cases of low-risk prostate cancer treated with radical prostatectomy. By using logistic regression analysis, 11 a priori-defined preoperative risk factors were evaluated for their ability to predict upgrading from Gleason 6 at biopsy to Gleason > or =7 at radical prostatectomy. An internally validated nomogram using all clinical variables was subsequently created to help physicians identify patients who had undetected high-grade disease.

RESULTS

A total of 60 (34%) patients were upgraded to high-grade disease. On multivariate analyses, both prostate-specific antigen (PSA) level (P = .02) and the level of pathologist expertise (P = .007) were predictive of upgrading. The predictive nomogram contained these variables plus age, digital rectal examination, transrectal ultrasound results, biopsy scheme applied (sextant vs extended), presence of prostatic intraepithelial neoplasia, prostate gland volume, and percentage of cancer in the biopsy. The nomogram provided acceptable discrimination (C statistic 0.71).

CONCLUSIONS

The authors identified significant predictors of upgrading for patients diagnosed with low-risk prostate cancer. A nomogram based on these study findings could help physicians further risk-stratify patients with low-risk prostate cancer before embarking on treatment. Caution should be exercised in recommending nonradical therapy to individuals with a high probability of undetected high-grade disease.

Diagnosis of prostate cancer

The contemporary challenge of prostate cancer diagnosis has been changed in the past decade from the endeavor to increase detection to that of detecting only those tumors that are clinically significant. Better interpretation of the role of prostate-specific antigen (PSA) and its kinetics as a diagnostic tool, the adoption of extended prostate biopsy schemes, and perhaps implementation of new transrectal ultrasound (TRUS) technologies promote the achievement of this clinical mission. This chapter reviews these issues as well as the change in practice of patient preparation for TRUS-biopsy and analgesia during it, the role of repeat and saturation prostate biopsies, and the interpretation of an incidental prostate cancer finding. Currently, the lifetime risk of a diagnosis of prostate cancer for North American men is 16%, compared to the lifetime risk of death from prostate cancer, which is 3% (Carter 2004). The advent of prostate-specific antigen (PSA) screening and transrectal ultrasonography (TRUS) has significantly impacted the detection of prostate cancer over the last 20 years. The mean age at diagnosis has decreased (Hankey et al. 1999; Stamey et al. 2004) and the most common stage at diagnosis is now localized disease (Newcomer et al. 1997; Stamey et al. 2004). The goal of prostate cancer screening is to detect only those men at risk for death from the disease at an early curable phase. The ambiguous natural history of this most common malignancy in men, being latent with questionable life-threatening potential in a large number of cases on the one hand, with only a relatively small number (though not negligible) of highly malignant cases on the other, propels many doubts about whether this is possible. This was famously phrased more than 20 years ago by Whitmore who asked: "Is cure possible for those in whom it is necessary; and is it necessary for those in whom it is possible?" This is probably even more relevant nowadays. During the past decade two factors influenced significantly the increased detection rate of prostate cancer in general and that of clinically insignificant prostate cancers in particular: the widespread use of serum PSA as a screening tool to a large extent and to a lesser though significant extent the application of extended multiple core biopsy schemes (Master et al. 2005). In fact, 75% of men in the United States aged 50 years and older have been screened with the PSA test (Sirovich et al. 2003). Outside of the screening context, which is dealt with in depth in Chap. 5, clinical suspicion of prostate cancer is raised usually by abnormal digital rectal examination (DRE) and/or by abnormal levels of serum PSA. Final diagnosis is achieved only based on positive prostate biopsies.

Validation of a prediction model for low volume/low grade cancer: application in selecting patients for active surveillance

PURPOSE

We previously demonstrated that assessment of the number of positive cores, tumor length in a core, Gleason score and prostate volume significantly enhanced the accuracy of a prediction model for low volume/low grade cancer in men who had undergone extended biopsy. To determine the validity of the model, we applied it to an independent population of men with prostate cancer.

MATERIALS AND METHODS

The study group included 170 men who had undergone radical prostatectomy without neoadjuvant therapy. In all cases, prostate cancer was diagnosed on only 1 positive core of a 10-core extended biopsy. We assessed the accuracy of the model, which consists of tumor length less than 2 mm, Gleason score 3+4 or less and prostate gland volume greater than 50 cc in predicting the occurrence of low volume/low grade cancer (defined as tumor volume less than 0.5 cc, no Gleason grade 4 or 5 disease, and organ confined disease).

RESULTS

Of the patients 101 (59.4%) had low volume/low grade cancer. Our model using all 3 previously mentioned variables had the highest performance, demonstrating a positive predictive value of 70.4% (88 of 125), a negative predictive value of 71.1% (32 of 45) and a diagnostic accuracy of 70.6% (120 of 170). This model performed better than a model based on tumor length only (positive predictive value, negative predictive value and diagnostic accuracy 68.1%, 57.9% and 64.7%, respectively) or a model based on tumor length and Gleason score (positive predictive value, negative predictive value and diagnostic accuracy 70.0%, 60.0% and 66.5%, respectively).

CONCLUSIONS

This study validates that our model with a combination of tumor length, Gleason score and prostate volume is predictive for low volume/low grade cancer in an independent population of men who demonstrated only 1 positive core in an extended biopsy. This model can be used as a tool for selecting men for active surveillance.

Free/total PSA ratio can help in the prediction of high gleason score prostate cancer in men with total serum prostate specific antigen (PSA) of 3–10 ng/ml

PURPOSE

We evaluate the use of free/total prostate specific antigen (PSA) ratio in improving the prediction of cancers of higher Gleason scores.

PATIENTS AND METHODS

A total of 164 patients with total serum PSA of 3.0-10.0 ng/ml underwent extended TRUS-guided core biopsy. In each man serum free PSA was measured and the free/total (F/T) PSA ratio was calculated. Out of the 164 patients who underwent TRUS-biopsy, cancer was detected in 62 (37.8%) patients. The mean age for the 62 patients with histologically proven prostate cancer was 62.3+/-5.5 years (49-73). The histological findings were compared with the free/total PSA ratio. Pearson Correlation Coefficient test and Chi-Square test (chi2-test) were used for statistical analysis and p<0.05 was considered statistically significant.

RESULTS

Of the 62 patients, 37 (59.7%) patients had cancers of low Gleason scores (score 2-6) and 25 (40.3%) patients had cancers of high Gleason scores (score 7-10). Free PSA<0.15% was found in 19 (30.6%) patients, from 15 to 20% in 23 (37.1%) patients and >20% in 20 (32.3%) patients. There was a significant positive correlation between total PSA and Gleason score (Pearson Correlation Coefficient test, r=0.328, p<0.01). Also, there was a significant increase in Gleason score with lower F/T PSA ratio (r=-0.668, p<0.001). Among the 19 patients with free PSA ratio<15%, 14 (73.7%) patients had cancers of high Gleason score while 5 (26.3%) patients had cancers of low Gleason score. In patients (n=23) with free PSA ratio15-20%, 10 (43.5%) had cancers of high Gleason score and 13 (56.5%) had cancers of low Gleason score. In the 20 patients with free PSA ratio>20%, 1 patient (5%), had prostate cancer of high Gleason score and the remaining 19 (95%) patients had low Gleason scores. There was a significant relation between lower F/T PSA ratios and higher Gleason scores, Chi-Square test, chi2=19.3, p<0.01.

CONCLUSIONS

In this study, men with prostate cancer and lower F/T PSA ratio were at a higher risk of having higher Gleason scores (7-10) and those with higher F/T PSA ratio were more likely to have lower Gleason scores.

What's new in prostate cancer disease assessment in 2006?

PURPOSE OF REVIEW

Issues relating to the disease are critical in the diagnosis, management, and prognostication of prostate cancer.

RECENT FINDINGS

New data have emerged regarding the disease of prostate cancer and its precursors. The diagnosis of prostate cancer on needle biopsy has been refined because of the recent discovery of alpha-methylacyl-CoA racemase, which preferentially labels adenocarcinoma of the prostate. Modifications and additions to the Gleason grading system were published based on a consensus conference of urological pathologists. Various models have been proposed using Gleason score, clinical findings, as well as measurements of tumor volume on needle biopsy to enhance the prediction in men undergoing radical prostatectomy and to predict "insignificance". Several studies have confirmed that certain findings in radical prostatectomy are adverse, yet conflicting studies were published as to the independent prognosis of tumor volume. The risk of cancer following a diagnosis of high-grade prostatic intraepithelial neoplasia on needle biopsy has decreased to the point at which this author does not recommend a routine repeat needle biopsy within the first year following the diagnosis of high-grade prostatic intraepithelial neoplasia.

SUMMARY

This review summarizes developments over the last year in the disease of prostate cancer and its precursors.

Prostate Cancers Scored as Gleason 6 on Prostate Biopsy are Frequently Gleason 7 Tumors at Radical Prostatectomy: Implication on Outcome

PURPOSE

Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery.

MATERIALS AND METHODS

We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy.

RESULTS

Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66).

CONCLUSIONS

Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.

Impact of increased number of biopsies on the nature of prostate cancer identified

PURPOSE

Increasing the number of cores obtained at the time of transrectal ultrasound guided prostate biopsy has increased the number of cancers identified. However, there is increasing recognition that many men with prostate cancer may not benefit from early, aggressive intervention and that over detection of prostate cancer has resulted in over treatment. We determined the impact of the greater number of prostate biopsies on the nature of cancer identified.

MATERIALS AND METHODS

In the Cancer of the Prostate Strategic Urologic Research Endeavor database, a longitudinal disease registry of men with prostate cancer, we identified those men diagnosed between 1999 and 2002 with complete data on serum prostate specific antigen, Gleason score, clinical T stage, number of biopsies obtained and number involved with cancer.

RESULTS

We identified 4,072 men with 6 or more prostate biopsies obtained at initial diagnosis. Of the men 30%, 47% and 24% underwent 6, 7 to 11, and more than 12 biopsies, respectively. The number of biopsies correlated significantly with numerous sociodemographic and clinical variables including prostate specific antigen, comorbidities and income. There did not appear to be differences in disease characteristics as assessed by Kattan and Cancer of the Prostate Risk Assessment scores among men with a biopsy number between 6 and 17. In the subset of 1,548 men undergoing radical prostatectomy, no differences in biochemical-free survival were observed among the various biopsy groups at a median followup of 2.2 years.

CONCLUSIONS

The increasing number of prostate biopsies obtained at diagnosis increases cancer detection but the impact on disease characteristics remains unclear. Our data suggest that the risk stratification of prostate cancers is independent of biopsy number (6 or greater) in a contemporary cohort of men.

Should Men with Serum Prostate-Specific Antigen ≤4 ng/ml and Normal Digital Rectal Examination Undergo a Prostate Biopsy?

The clinical significance of a prostate cancer (PCa) cannot be determined solely by tumor volume (< or =0.5 cm(3)), as small tumors of higher Gleason grade and tumors occurring in younger men may become clinically significant even though the initial volume at diagnosis is small. A certain number of these minimal cancers are likely to remain clinically insignificant; however, it is unpredictable how many can progress beyond the curable stage by the time there is a rise in serum prostate-specific antigen (PSA) values. Compared to clinically detected PCa, PCa detected exclusively by PSA screening (clinical stage T1c) are less likely to be advanced but no more likely to be insignificant in terms of volume, pathologic stage, and Gleason pattern. Only 10-15% of PSA-detected cancers have the features of PCa found at autopsy or in cystoprostatectomy specimens. Actually, 25-30% of PCa are detected with PSA values between 2.5 and 4 ng/ml, and most of these cancers are clinically significant. Evidence from both retrospective and longitudinal studies has shown that the risk of a PCa is dependent on the patient's age and the initial serum PSA. This allows an individualized approach to PCa screening programs, and PSA cutoff values for biopsy indication may be lowered in selected patients.

Extended 12-core prostate biopsy increases both the detection of prostate cancer and the accuracy of Gleason score

OBJECTIVE

To evaluate the effect of extended 12-core prostate biopsy in improving the detection rate of prostate cancer and increasing the accuracy of Gleason score.

METHODS

This study included 113 patients who underwent TRUS-guided lateral sextant biopsy (group I) and 176 patients who underwent extended 12-core biopsy (group II). Inclusion criteria for prostate biopsy were elevated serum PSA levels (>3.0 ng/ml) and/or suspicious digital rectal examination (DRE).

RESULTS

Clinical characteristics were similar in both groups. Cancer was detected in 28 (24.8%) and 64 (36.4%) patients in group I and II respectively, chi2=4.26, p=0.039. Among patients with cancer in group I, 14 were treated by radical prostatectomy (RP). The median Gleason sum was 6 (range 3-8) and 7 (range 5-9) for needle and prostatectomy specimens respectively. There was an agreement between the biopsy and prostatectomy Gleason sum in 7 (50%) patients while the biopsy Gleason sum was lower in 7 (50%) cases. Among patients with cancer in group II, 27 were treated by RP. The median and the range of Gleason sum was the same for needle and prostatectomy specimen (median 6, range 4-9). There was an agreement between the biopsy and prostatectomy specimen in 23 (85.2%) patients while the biopsy sum was lower than prostatectomy in 4 (14.8%) patients. The agreement between the biopsy and prostatectomy specimen was significantly higher in group II (82.5%) than group I (50%), Fisher's Exact Test, p=0.026.

CONCLUSION

Extended 12-core prostate biopsy significantly increases both the detection rate of prostate cancer and the accuracy of biopsy Gleason score.