Anterior prostate cancer: is it more difficult to diagnose?

Abstract

Objective To determine whether anterior prostatic tumours are adequately sampled using the Stamey sextant protocol, as a fifth of prostate cancers are anterior in distribution at radical prostatectomy. Materials and methods All tumours (62) with an anterior distribution (75% of the tumour anterior to the urethra) on radical prostatectomy whole‐mounts, and in which the number and results of the sextant biopsies were available, were extracted from a prostate cancer database. Sixty‐one posterior tumours (75% of the malignant tissue posterior to the urethra) and their corresponding sextant biopsies were also retrieved for comparison. The number of biopsy sessions, the number of cores involved and the summated tumour length were recorded, together with the prostate gland weight, the tumour volume and the site of 75% of tumour in the superior‐inferior axis. Results Anterior tumours required significantly more biopsy sessions to diagnose prostate cancer than posterior neoplasms (anterior, one set 47; > one set 15; posterior, one set 57; > one set, four, P=0.007). Anterior tumours had fewer cores with tumour involvement and less summated tumour length than had posterior cancers. The mean (sd) number of positive cores was; anterior 1.8 (1.01), posterior 2.50 (1.30) (P=0.001); the summated tumour length was; anterior 5.05 (4.10) mm, posterior 9.25 (7.80) mm (P<0.001). There was no significant difference in gland weight (mean anterior 43.8 g; posterior 48.3 g, P=0.3) or tumour volume (mean anterior 1.85 mL; posterior 1.49 mL, P=0.11) between the groups. There was no significant difference between the incidence of anterior and posterior neoplasms with respect to their position in the superior‐inferior axis (P=0.96). Conclusions Anterior prostate tumours account for 21% of all prostate cancers. They more often require multiple sets of sextant biopsies for diagnosis, and yield smaller areas of cancer on core biopsies than do posterior tumours in glands of similar weight and tumour volume. If prostate cancer is suspected clinically but biopsies are negative, targeting the anterior gland at subsequent prostatic biopsy should be considered.

Direct Comparison of Targeted MRI-Guided Biopsy with Systematic Transrectal Ultrasound-Guided Biopsy in Patients with Previous Negative Prostate Biopsies

“…The apical region of the prostate is underrepresented in systematic transrectal biopsies due to the angulation of the probe guidance. It has been shown that localization in the anterior aspect and the apex of the prostate require significantly more biopsy sessions than posterior tumors until detection of PC [21]. In a previous MR-GB series we reported similar predominant tumor localizations, with tumors in the transitional zone in around 33% [22].…”

Transition zone and anterior stromal prostate cancers: Zone of origin and intraprostatic patterns of spread at histopathology

“…These cancers are undersampled by 10-12-core random posterior biopsies protocols and tend to be detected at more advanced stage [1,17,18]. TRUS imaging is not sensitive, whereas DCE MRI allows to identify them and to guide biopsies at earlier stage.…”

Detection Rate of Anterior Prostate Cancer in 226 Patients Submitted to Initial and Repeat Transperineal Biopsy

“…However, recently Sundi et al [21] reported a higher prevalence of AZ cancers in African American men with very low-risk PCa who underwent radical prostatectomy; still today no data are available regarding the incidence and clinical significance of AZ PCa diagnosed in case of initial prostate biopsy. Bott et al [8] showed that about one fifth of all index cancers were located anterior to the prostatic urethra, highlighting the need for better understanding of the clinicopathologic features of these lesions. Recently, Al-Ahmadie et al [14] in 1,312 radical prostatectomies demonstrated that 197 (15%) PCa were located in the AZ of the gland and characterized by a superimposable grading and staging in comparison with PZ PCa; Iremashvili et al [22] reported a higher rate of positive surgical margin in the presence of TZ cancer in comparison with PZ PCa in 1,141 men submitted to radical prostatectomy.…”

“…In this respect, to reduce the number of unnecessary definitive treatment, an active surveillance program has been introduced in clinical practice, but still today the risk of understaging and/or undergrading PCa is equal to 30% [3,4], and certain criteria to assess the aggressiveness of PCa in the early stage are still missing. Although magnetic resonance imaging [5] and targeted magnetic resonance imaging/ultrasound fusion-guided biopsy [6,7] have improved extended and saturation biopsy schemes' accuracy in detecting significant PCa, the rate of repeat prostate biopsy is equal to 30-40%, with an high percentage of cancer detected in the anterior zone (AZ) of the gland (about 20% of cases) [5,8]. …”