Prospective evaluation of systematic sextant transition zone biopsies in large prostates for cancer detection

Chang, James J.; Shinohara, Katsuto; Hovey, Regina M.; Montgomery, Carolyn K.; Presti, Joseph C.

doi:10.1016/s0090-4295(98)00116-2

Cited by 54 publications

(27 citation statements)

References 12 publications

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“…Given the difficulties in detecting anterior prostatic tumors on clinical examination, imaging studies and needle biopsy (4, 29, 46, 48), a number of investigators have examined the value of transition zone-directed needle biopsies (NB) in prostate cancer detection, with conflicting results. While some have found utility for such biopsies in patients with previous negative NB sessions or ‘gray-zone’ PSA levels (13-14, 22, 26, 31-32), with few exceptions (5-6), most authors have argued against using TZ-directed NB in routine protocols (2, 8, 27, 41, 43, 47). Surprisingly however, few studies have correlated the cancer seen in these NB with that seen in RP specimens and/or the clinical relevance of these tumors.…”

Section: Discussionmentioning

confidence: 99%

Do Prostatic Transition Zone Tumors Have a Distinct Morphology?

García¹,

Al‐Ahmadie²,

Gopalan³

et al. 2008

American Journal of Surgical Pathology

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Previous studies have proposed that the morphologic spectrum of prostatic glands of variable size with tall columnar cells displaying basally-oriented nuclei and clear to pale pink cytoplasm (TZ-LOOK) is characteristic of the well-to moderately-differentiated component of transition zone (TZ) tumors. However, the specificity of these findings has not been well studied. In a recent report, we identified dominant peripheral zone (PZ) and TZ tumors situated anterior to the prostatic urethra. Currently, we evaluate the histopathologic features of 215 dominant tumors, including 63 TZ and 73 anterior PZ lesions and an additional cohort of 79 posterior PZ tumors, in radical prostatectomy specimens, to identify the prevalence of this morphology in tumors of different zonal origin. Each dominant tumor was assigned a TZ-LOOK extent score of 0 to 4, with 0 = no such morphology, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, and 4 = >75%. Overall, 121/215 (56%) tumors showed some degree of this histology, including 56 of 63 (89%) TZ tumors and 65 of 152 (43%) PZ tumors (p< 0.0001). 37 of 215 (17%) lesions had scores of 3-4, with 31 (84%) of these being of TZ origin. However, only 31/63 (49%) TZ tumors had >50% TZ-LOOK. Among PZ tumors, 6/152 (4%) had predominant (>50%) TZ-LOOK morphology, yet 23/152 (15%) of all PZ tumors and 23/65 (35%) of PZ tumors displaying any degree of TZ-LOOK had scores of 2-3 (>25%; non-focal). In tumors of both zones with predominant (scores 3-4; > 50%) TZ-LOOK histology, darker glands of usual acinar adenocarcinoma were often seen at the periphery. Conversely, in tumors with non-predominant TZ-LOOK (scores 1-2; ≤ 50%), these glands were frequently admixed with small glands bearing dark cytoplasm. In this series, we demonstrate that some degree of TZ-LOOK morphology is twice as frequent in dominant TZ tumors than in PZ tumors. Tumors demonstrating > 50% of this histology are very likely of TZ origin, but this scenario occurs in only half of TZ tumors. Importantly, the TZ-LOOK is non-focal in up to 35% of PZ tumors exhibiting any degree of this morphology. Given this lack of specificity, caution should be exercised in assigning zone of origin based on this histologic appearance, especially in limited samples such as prostate needle biopsy.

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Section: Discussionmentioning

confidence: 99%

Do Prostatic Transition Zone Tumors Have a Distinct Morphology?

García¹,

Al‐Ahmadie²,

Gopalan³

et al. 2008

American Journal of Surgical Pathology

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“…However, due to the noncharacteristic echogenic appearance of prostate malignancies at ultrasound and to the relatively low cancer detection (when sampling was limited only in ultrasonographically visible lesions), the ideal sampling method in TRUS guided biopsies was a point of debate. Because biopsy sites limited to either hypoechoic lesions, or areas of palpable abnormality tended to miss many malignancies, Hodge et al [1] proposed the use of the random sextant core biopsy technique (a method of obtaining spatially separated biopsies from each sextant of the prostate) which showed a significantly higher cancer detection rate and was at the time considered to be the standard or routine biopsy method [7,[12][13][14] . According to this technique, three biopsy cores are taken from each side (right and left) of the prostate, 1 cm apart along the parasagittal area.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, many clinics perform even more extended prostate biopsy protocols, consisting of 10+ cores, with even more prostate cancers detected than with the sextant biopsy cores. In fact, the additional cancers detected by the extra lateral PZ biopsies would have remained undetected by the sextant method [14,21,22] . Similarly, the cancer detection rates for the extended 10+ field protocols are better than those for sextant biopsies [23,24] .…”

Section: Discussionmentioning

confidence: 99%

Impact of Additional Sampling in the TRUS-Guided Biopsy for the Diagnosis of Prostate Cancer

Stamatiou

Alevizos

Karanasiou³

et al. 2007

Urol Int

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

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“…The transition zone and seminal vesicles are not routinely sampled because these regions have been shown to have consistently low yields for cancer detection at initial biopsy, but transition zone and anteriorly directed biopsies may occasionally prove necessary to diagnose prostate cancer in those patients with persistently elevated PSA levels and prior negative biopsies [ 45,[58][59][60][61] . Furthermore, there may be a role for transition zone biopsies in men with a gland size greater than 50 cm 3 , with an additional yield of 15% cancer detection in these larger prostates [ 62 ] . Seminal vesicle biopsy is not routinely performed unless there is a palpable abnormality or, as some suggest, when the PSA value is greater than 30 ng/mL or if brachytherapy is being considered [ 63 ] .…”

Section: Techniquementioning

confidence: 99%