Elsevier

European Urology

Volume 58, Issue 6, December 2010, Pages 851-864
European Urology

Collaborative Review – Prostate Cancer
Optimizing Performance and Interpretation of Prostate Biopsy: A Critical Analysis of the Literature

https://doi.org/10.1016/j.eururo.2010.08.041Get rights and content

Abstract

Context

The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate.

Objective

Our aim was to review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy.

Evidence acquisition

A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Results were restricted to the English language, with preference given to those published within the last 3 yr.

Evidence synthesis

At initial biopsy, a minimum of 10 but not >18 systematic cores are recommended, with 14–18 cores in glands ≥50 cm3. Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (≥20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3–6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound–guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative.

Conclusions

The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.

Introduction

The early detection of prostate cancer (PCa) should be aimed at diagnosing significant disease at a curable state. Within the past 2 decades, substantial improvements in early detection have been achieved [1], [2]. For example, the increased use of prostate-specific antigen (PSA) has resulted in so-called stage migration, shifting the proportion of pathologically localized curable disease from 20% to 30% in the pre-PSA era to about 70–80% currently [3].

Despite this significant shift toward curable stages, early PCa detection remains limited in several ways. First, a PSA cut-off level such as 4.0 ng/ml for biopsy indication is characterized by a limited PCa specificity due to the effect on PSA of other underlying prostatic diseases such as inflammation or benign prostatic hyperplasia. Therefore, PSA represents only a surrogate marker of PCa. Additionally, as clearly demonstrated in the Prostate Cancer Prevention Trial (PCPT), instead of cut-off levels, PSA values represent a continuum of PCa risk. Thus single PSA measurements are unable to rule out the presence of disease [4]. In fact, it may be anticipated that the principal early detection driving force, that is, PSA, will weaken its association to PCa because a significant proportion of men who present for prostatic evaluation already have PSA values below specific cut-off levels such as 4.0 ng/ml. Consequently, the benefits of PSA-driven early detection, especially in the light of the most recent data from the European and American PCa screening trials, must be carefully balanced and may also be perceived controversially [1], [2].

Second, except for palpable lesions, clinical symptoms on which a urologist may identify early disease are practically absent [5]. Third, despite substantial technological progress, neither visualization nor molecular characterization is currently advanced enough to indicate reliably the presence or absence of underlying malignant disease [6].

Therefore, the significant research effort based on established clinical prebiopsy risk factors such as age, PSA, percentage of free prostate-specific antigen (%fPSA), digital rectal examination (DRE), prostate volume, and the consideration of novel markers such as urinary prostate cancer antigen 3 (PCA3) [7], [8], [9], [10], [11], [12] has resulted in multifactorial statistical models to individualize biopsy indication and thus to subject only those men with the highest risk to further prostatic evaluation. In addition to identifying those individuals at high risk for harboring PCa, the combined proper use of prebiopsy clinical risk predictors reduces the proportion of unnecessary biopsies, biopsy-related side effects, and patient anxiety [8], [13].

Prostate biopsy represents a “hot-spot area” on different levels [14]. For example, the determination of the optimal number of cores and prostate sampling sites stratified according to biopsy session, the systematic versus targeted prostate biopsy approach, the need to quantify certain histologic patterns such as high-grade prostatic intraepithelial neoplasia (HGPIN), the optimal pathologic processing of the biopsy cores, and the expertise-dependent pathologic interpretation are controversial.

Beyond these ongoing debates, it is important to note that “typical” clinical biopsy studies carry a so-called verification bias that makes it difficult to truly assess, for example, the influence of different biopsy schemes due to the unknown proportion of “falsely biopsy-negative” men [15]. Consequently, identification of a prostate biopsy gold standard is almost impossible.

Taken together, these different activities potentially add to the current uncertainty of how to perform and how to interpret a prostatic biopsy. To address this significant and competitive interdisciplinary field, this review considers the current clinical evidence investigating risk factors including novel markers, performance of prostate biopsy in different clinical settings, and pathologic interpretation of prostate biopsy.

Section snippets

Evidence acquisition

A systematic review of the literature was performed in December 2009 using the Medline database. The Medline search used a complex search strategy including both Medical Subject Heading (MeSH) search terms and free-text protocols. Specifically, the MeSH search was conducted by combining the following terms retrieved from the MeSH browser provided by Medline: prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Subsequently, the search results were

Risk stratification models as clinical decision aids for biopsy indication

Risk estimation, patient counseling, and decision making are based on clinical judgment. The major limitation is that clinical judgment is biased at all of these stages of patient management [16], [17], [18], [19]. Specifically, PCa risk depends on multiple clinical risk factors. In fact, it is difficult to adequately consider the multitude of these clinical variables followed by weighing each factor’s relative importance and to formulate a PCa risk estimation [20], [21], [22]. Therefore,

Conclusions

Review of the most relevant biopsy studies reveals that current questions such as how many cores to take at which biopsy session or where to direct biopsy cores have attracted the attention of urologists for the past 20 yr. Currently, a minimum of 10 but not >18 systematic cores at initial biopsy are recommended, with 14–18 cores in glands ≥50 cm3. Biopsies should be directed laterally, and TZ cores are not recommended in the initial biopsy setting. Further biopsy sets either as an extended

References (128)

  • F. Chun et al.

    Development and external validation of an extended repeat biopsy nomogram

    J Urol

    (2007)
  • F.K.-H. Chun et al.

    Initial biopsy outcome prediction—head-to-head comparison of a logistic regression-based nomogram versus artificial neural network

    Eur Urol

    (2007)
  • J.S. Jones

    Prostate cancer: are we over-diagnosing—or under-thinking?

    Eur Urol

    (2008)
  • M.W. Kattan et al.

    The ultimate prostate cancer biopsy decision support tool

    Eur Urol

    (2010)
  • R.G. Uzzo et al.

    The influence of prostate size on cancer detection

    Urology

    (1995)
  • F.K.-H. Chun et al.

    Development and external validation of an extended 10-core biopsy nomogram

    Eur Urol

    (2007)
  • F.K. Chun et al.

    Development and external validation of an extended repeat biopsy nomogram

    J Urol

    (2007)
  • A. Briganti et al.

    Prostate volume and adverse prostate cancer features: fact not artifact

    Eur J Cancer

    (2007)
  • K.K. Hodge et al.

    Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate

    J Urol

    (1989)
  • W. Siu et al.

    Use of extended pattern technique for initial prostate biopsy

    J Urol

    (2005)
  • J.L. Gore et al.

    Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer

    J Urol

    (2001)
  • G. Guichard et al.

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

    Eur Urol

    (2007)
  • V. Ravery et al.

    The 20-core prostate biopsy protocol—a new gold standard?

    J Urol

    (2008)
  • V. Scattoni et al.

    Initial extended transrectal prostate biopsy—are more prostate cancers detected with 18 cores than with 12 cores?

    J Urol

    (2008)
  • V. Scattoni et al.

    Biopsy schemes with the fewest cores for detecting 95% of the prostate cancers detected by a 24-core biopsy

    Eur Urol

    (2010)
  • K. Eichler et al.

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

    J Urol

    (2006)
  • A. de la Taille et al.

    Prospective evaluation of a 21-sample needle biopsy procedure designed to improve the prostate cancer detection rate

    Urology

    (2003)
  • V. Ficarra et al.

    The potential impact of prostate volume in the planning of optimal number of cores in the systematic transperineal prostate biopsy

    Eur Urol

    (2005)
  • M. Inahara et al.

    Improved prostate cancer detection using systematic 14-core biopsy for large prostate glands with normal digital rectal examination findings

    Urology

    (2006)
  • V. Ravery et al.

    Extensive biopsy protocol improves the detection rate of prostate cancer

    J Urol

    (2000)
  • T.A. Stamey

    Making the most out of six systematic sextant biopsies

    Urology

    (1995)
  • H. Singh et al.

    Six additional systematic lateral cores enhance sextant biopsy prediction of pathological features at radical prostatectomy

    J Urol

    (2004)
  • J.C. Presti et al.

    Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study

    J Urol

    (2003)
  • R. Takashima et al.

    Anterior distribution of stage T1c nonpalpable tumors in radical prostatectomy specimens

    Urology

    (2002)
  • A.R. Patel et al.

    Parasagittal biopsies add minimal information in repeat saturation prostate biopsy

    Urology

    (2004)
  • J.C. Applewhite et al.

    Results of the 5 region prostate biopsy method: the repeat biopsy population

    J Urol

    (2002)
  • B. Djavan et al.

    Prospective evaluation of prostate cancer detected on biopsies 1, 2, 3 and 4: when should we stop?

    J Urol

    (2001)
  • C.G. Roehrborn et al.

    Diagnostic yield of repeated transrectal ultrasound-guided biopsies stratified by specific histopathologic diagnoses and prostate specific antigen levels

    Urology

    (1996)
  • D.W. Keetch et al.

    Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values

    J Urol

    (1994)
  • J.B. Rietbergen et al.

    Repeat screening for prostate cancer after 1-year followup in 984 biopsied men: clinical and pathological features of detected cancer

    J Urol

    (1998)
  • J.L. Letran et al.

    Repeat ultrasound guided prostate needle biopsy: use of free-to-total prostate specific antigen ratio in predicting prostatic carcinoma

    J Urol

    (1998)
  • P.G. Borboroglu et al.

    Extensive repeat transrectal ultrasound guided prostate biopsy in patients with previous benign sextant biopsies

    J Urol

    (2000)
  • Y.M. Hong et al.

    Impact of prior biopsy scheme on pathologic features of cancers detected on repeat biopsies

    Urol Oncol

    (2004)
  • H. Singh et al.

    Predictors of prostate cancer after initial negative systematic 12 core biopsy

    J Urol

    (2004)
  • J.L. Campos-Fernandes et al.

    Prostate cancer detection rate in patients with repeated extended 21-sample needle biopsy

    Eur Urol

    (2009)
  • V. Scattoni

    Systematic prostate biopsies are more and more often becoming saturation biopsies

    Eur Urol

    (2006)
  • A.E. Pelzer et al.

    Are transition zone biopsies still necessary to improve prostate cancer detection? Results from the Tyrol screening project

    Eur Urol

    (2005)
  • J.L. Wright et al.

    Improved prostate cancer detection with anterior apical prostate biopsies

    Urol Oncol

    (2006)
  • J.I. Epstein et al.

    Prostate needle biopsies containing prostatic intraepithelial neoplasia or atypical foci suspicious for carcinoma: implications for patient care

    J Urol

    (2006)
  • D.G. Bostwick et al.

    Prostatic intraepithelial neoplasia and the origins of prostatic carcinoma

    Pathol Res Pract

    (1995)
  • Cited by (0)

    View full text