698 INITIAL EXTENDED TRANSRECTAL PROSTATIC BIOPSY: DO 18 CORES DETECT MORE PROSTATIC CANCERS THAN 12 CORES?

697

Extended 24-sample TRUS prostatic needle biopsy protocol for prostate cancer detection as initial diagnostic strategy

Raber M., Scattoni V., Roscigno M., Dehò F., Suardi N., Salonia A., Briganti A., Gallina A., Rigatti P., Montorsi F.

Introduction & Objectives: To prospectively evaluate the optimal number of cores and the most accurate scheme of prostatic biopsies on the basis of 24 core TRUS prostatic biopsy scheme as the initial diagnostic strategy. Material & Methods: Between December 2005 and October 2006, 260 consecutive patients (mean age 65 years) underwent initial 24-sample needle biopsies under local anesthesia, including sextant biopsies (classic Hodge)(S1), 6 more lateral biopsies (classic Stamey)(S2), 8 extremely lateral in each peripheral zone (S3), and 4 biopsies in the transition zone (TZ). Every single core was numbered, inked and analyzed separately. The patients were divided into subgroups according to the result of digital rectal examination (DRE) which was suspicious for cancer in 26% of cases, serum PSA (mean: 9,2±15,8 ng/ml) and prostate volume (mean: 54,3±26,7 cc). We evaluated the cancer detection rate overall and in each subgroup stratified by PSA, prostate volume and DRE. We compared the results of our biopsy protocols to those obtained from a 6, 12, 14 and 18-core biopsy protocols. Categorical data obtained were compared with chi-square test assuming P<0,05 to exclude the null hypothesis. Results: The overall 24 cores cancer detection rate was 38% (99/260). Cancer detection rates in S1 (6 cores), S2 (6 cores), S3 (8 cores), S1+S2 (12 cores), S1+S3 (14 cores), S2+S3 (14 cores), S1+S2+S3 (20 cores), were 25,8%, 26,2%, 31,9%, 32,3%, 35,8%, 35,4% and 37,7% respectively. The 24 biopsy procedure improved the cancer detection rate by 0,4% (P=0,98), 5,7% (P=0,38), 11,9%(P=0,04) compared to the 18, 12 and 6 sample procedure respectively. Compared with sextant biopsies, the improvement in the diagnostic yield was most marked in patients with a prostate volume ≥50 ml (8,1% P=0,02), in patients with normal DRE (11,2% P=0,01) and in patients with PSA<10 (9,6% P=0,05). The addition of TZ biopsies to a 12 and 20 biopsies scheme increases the diagnostic yield by 0,4% and 0,4% overall (P=0,98). The number of cancer missed with each scheme, stratified by total PSA, prostate volume and DRE results, are reported in the following table: N

S1

S2

S3

S1+S2

S1+S3

S2+S3

S1+S2+S3

19 80 53 46 25 74

3 28 11 20 2 30

5 25 10 19 2 31

0 15 7 9 4 13

1 11 3 11 1 12

0 6 3 3 0 6

0 7 2 5 0 6

0 1 1 1 0 1

Conclusions: A 24-sample needle biopsy procedure increased significantly the prostate cancer detection rate compared to a 6 sample procedure but not to a 12 and 18-sample. TZ biopsies increased cancer detection of only 0,4%. The improvement in the diagnostic yield was most marked in patients with a prostate volume ≥50 ml, PSA<10 ng/ml and negative DRE.



699

Pathological and biochemical features of cancers detected on saturation biopsies in men with PSA levels 2.5 - 10ng/ml and negative initial biopsies: A multiinstitutional European study

Djavan B.1, Rocco B.2, Ravery V.3, Zlotta A.4, Pushkar D.5, Hammerer P.6, Anagnostou T.7, Dobronski P.8, Herwig R.1, Margreiter M.1, Borkowski A.8, Schulman C.4, Marberger M.1 Medical University of Vienna, Department of Urology, Vienna, Austria, Medical University of Milan, Department of Urology, Milan, Italy, 3Medical University of Paris, Department of Urology, Paris, France, 4Medical University of Brussels, Department of Urology, Brussels, Belgium, 5Medical University of Moscow, Department of Urology, Moscow, Russia, 6Medical University of Hamburg, Department of Urology, Hamburg, Germany, 7Medical University of Athens, Department of Urology, Athens, Greece, 8 Medical University of Warsaw, Department of Urology, Warsaw, Poland 1

2

Introduction & Objectives: To evaluate the pathological and biochemical features of prostate cancer detected on saturation biopsy following a negative initial biopsy as compared to cancers detected on first and standard repeat biopsy. Material & Methods: In this prospective study 377 men with a total PSA between 2.5 and 10 ng/ml underwent transrectal ultrasound (TRUS) guided sextant biopsies. Patients being negative on the initial biopsy underwent either standard repeat biopsy or a saturation repeat biopsy (22-24 cores). Those with clinically localized cancers underwent radical prostatectomy. Pathological and clinical features of patients diagnosed with cancer and clinically organ confined disease who agreed to undergo radical prostatectomy were compared. Results: Out of the patients with clinically localized disease (83% of cancers detected), 84% underwent radical prostatectomy, 14% opted for radiation therapy and 2% opted for watchful waiting. Statistical significant differences were observed with respect to cancer location (cancers on repeat biopsy overall showing a more dorsal (p=0.0004) and apical location (p = 0.003)). This was true irrespective of the repeat biopsy protocol employed. Overall, 86.6%, 88.4% and 91.8% had organ confined disease (p = 0.002), respectively. No differences were noted with respect to extracapsular extension (ECE) (p = 0.32) and seminal vesicle invasion (SVI) (p = 0.18) between cancers on first and repeat standard biopsies. However, cancers on saturation repeat biopsy had a significant lower rate with respect to ECE (p = 0.005) and SV (p = 0.0001) invasion. Positive margins were noted in 17%, 15% and 8%, respectively (p = 0.006). Although there were no differences with respect to final pathological stage (p = 0.3), Gleason score (p = 0.2) and percentage Gleason grade 4/5 (p = 0.3) between first and repeat standard biopsies, repeat saturation biopsies had significant higher pathological stages (p=0.02), lower biopsy (p=0.001) and specimen Gleason scores (p=0.002) and lower percentage Gleason grade 4/5 (p=0.001). PSA

1st Biopsy

SD

Gleason Score Biopsy Gleason Score (RPE) % Gleason Grade 4/5 multifocality (n of foci) Cancer volume

6.5 6.2

SD

SATURATION (n=118)

SD

0.6

standard repeat Biopsy (n=259) 5.7

0.2

4.9

0.3

0.22

0.3

6.6

0.5

5.7

0.4

0.38

24.2%

21.6%

14.4%

698

Initial extended transrectal prostatic biopsy: do 18 cores detect more prostatic cancers than 12 cores?

Scattoni V.1, Roscigno M.1, Zanoni M.1, Riva M.1, Raber M.1, Dehò F.1, Mazzoccoli B.1, Nava L.1, Suardi N.1, Freschi M.2, Montorsi F.1, Guazzoni G.1, Rigatti P.1 University Vita-Salute, Scientific Institute San Raffaele, Urology, Milan, Italy, 2University Vita-Salute, Scientific Institute San Raffaele, Pathology, Milan, Italy

1

University Vita-Salute, Scientific Institute San Raffaele, Urology, Milan, Italy

PSA≥10 PSA<10 PV≤50 ml PV>50 ml DRE+ DRE-



2.6-3.0

p-value

0.10

1.9

0.3

2.0

0.2

2.2

0.3

0.01

1.8

0.5

1.4

0.4

0.9

0.2

0.24

Conclusions: Biochemical and pathological features of cancers detected on initial and repeat biopsy using the standard and saturation biopsy were not comparable in terms of grade, stage and cancer volume. Cancers detected on first and standard repeat biopsy had significantly lower stage and higher Gleason scores and grades (incl. percent of Gleason grades 4/5) as compared to cancers detected on saturation biopsies. Although saturation biopsies are known to improve cancer detection rates upon standard repeat biopsies, the trade off is a significant increase in detection of potentially insignificant cancers.

Introduction & Objectives: Although the optimal extent of prostate biopsy (PBx) is controversial, there is a trend to increase the number of cores taken to increase cancer (PCa) detection. We investigated PCa, high-grade prostatic intraprostatic neoplasia (HGPIN) and atypical glands suspicious for carcinoma (ATYP) detection rate by initial 18-core PBx (18PBx) compared with that of 12-core PBx (12PBx). Material & Methods: A total of 3463 consecutive patients referred to our Institution (two different departments of Urology) with a PSA between 2.5 and 15 ng/ml were submitted either to 12PBx or to 18PBx with local anesthesia in the outpatient setting. In one department two urologists performed a 12PBx in 1684 patients and, in the other department during the same period, two different urologists performed a 18PBx in 1776 cases. Biopsies were evenly distributed throughout the prostate in 6 sectors, apex (2), lateral (2) and base (2) for group 12Bx. Group 18Bx had one more core taken from each sector. Results: The two groups of patients were not significantly different according to PSA, %FPSA, prostate volume and DRE. Cancer detection rate for patients submitted to 18Bx was not significantly higher than patients submitted to 12Bx (39.9% vs 38.4%, p=0.37) even if 18Bx was able to detect more patients with HGPIN (25.0% vs 18.7%, p=0.001). ATYP was present with similar proportion in both groups (2.9% vs 3.3%, p=0.33). Breakdown to PSA level failed to show benefit to 18Bx for any degree PSA increase. The improvement of cancer detection rate with 18Bx was obtained only in patients with a prostate volume > 55 cc (31.5% vs 24.8%, p=0.01) than patients with a prostate < 55 cc (54.3% vs 53.0%, p=0.7) and in patients with a TZ volume > 30 cc (27.2% vs 21.1%, p= 0.03) than in patients with a TZ volume < 30 cc (53.15 vs 47.6%, p= 0.09). Moreover, we showed that patients with a positive DRE do not need a 18PBx over a 12PBx scheme. Conclusions: The overall cancer detection rate by initial 18 PBx is only slightly higher than that of 12PBx biopsy while 18PBx detects significantly more patients with HGPIN. 18PBx is definitely more sensitive in cancer detection rate than 12 PBX in patients with a prostate > 55 cc or a TZ volume > 30 cc. Patients with positive DRE do not need a 18PBx over a 12PBx scheme.



700

Indications for saturation biopsies of the prostate: Where do we stand?

Djavan B.1, Rocco B.2, Zlotta A.3, Herwig R.1, Margreiter M.1, Harik M.1, Kuehhas F.1, Brausi M.4, Pushkar D.5, Ravery V.6, Anagnostou T.7, Kaisary A.8, Marberger M.1 Medical University of Vienna, Department of Urology, Vienna, Austria, 2Medical University of Milan, Department of Urology, Milan, Italy, 3Medical University of Brussels, Department of Urology, Brussels, Belgium, 4Medical University of Modena, Department of Urology, Modena, Italy, 5Medical University of Moscow, Department of Urology, Moscow, Russia, 6Medical University of Paris, Department of Urology, Paris, France, 7Medical University of Athens, Department of Urology, Athens, Greece, 8University of London, Department of Urology, London, United Kingdom 1

Introduction & Objectives: Recent results of the European Prostate Cancer Detection study (EPCDS) and the 3 dimensional reconstruction of cancers detected on first and repeat biopsy suggested that cancers detected on repeat biopsy were located in more dorso-lateral (para-rectal) and apical location. The Vienna nomograms further identified the optimal number of cores required. The purpose of this study was to evaluate the value and legacy of saturation biopsies (22 cores) versus a novel modified biopsy protocol. Material & Methods: A total of 593 patients were evaluated in 8 European University centers. 212 patients with a total PSA (2.5-10 ng/mL) and an initial negative biopsy underwent a repeat saturation biopsy. A second group of 382 consecutive patients underwent repeat biopsy with a novel modified biopsy protocol using the Vienna nomograms and aiming at the apical and dorso-lateral regions. Uniand multivariate statistical analysis using the SAS system (CARY, North Carolina) and ROC curves were performed to compare cancer detection rates and distribution. Results: Cancer detection rate on first biopsy was 28.7%. Cancer detection rate on saturation repeat biopsy was 22.8%. Using the novel biopsy protocol, cancer detection rate upon repeat biopsy was 18.7%. As compared to patients diagnosed with PCa after the first set of biopsies, patients diagnosed after the second set had larger total prostate (tot vol.) and transition zone volumes (TZ vol.) (45.2 ± 11.0cc vs 33.7 ± 9.6cc, p = 0.0001 and 22.0 ± 6.5cc vs. 11.8 ± 8.3cc, p = 0.0001). These findings were identical to cancers detected on first and repeat biopsy with the saturation and modified protocol (p = 0.33). Morbidity of both the saturation and modified protocol biopsies were identical (p = 0.12), however significantly higher than with the standard octant biopsy protocol (p = 0.003). Using the cumulative logistic plot analysis the probability of a positive first/repeat biopsy core was analyzed. The dorsolateral biopsy cores (p = 0.001), followed by the apical (p = 0.02) and transition zone biopsy cores (p = 0.04) were the most common sites of cancer on repeat biopsy. On multivariate analysis, patients with HG-PIN on first biopsy, PSA > 8 ng/mL, tot vol. >50 cc, TZ vol 20-40cc, TZ/PZ ratio < 0.4 and a negative prior history of biopsies had a significantly higher detection rate on saturation biopsy. Conclusions: Saturation biopsy and modified biopsy protocols using volume/age charts resulted in a 69-78% improvement of the cancer detection rate on repeat biopsy as compared to standard repeat biopsies technique. However, saturation biopsies were not necessary in all patients with negative initial biopsies. Saturation biopsies were beneficial in patients with HG-PIN on first biopsy, PSA > 8 ng/mL, tot Vol >50 cc, TZ vol 20-40cc, TZ/PZ ratio < 0.4 and a negative prior history of biopsies resulting in a further 37% increase in detection rates.

Eur Urol Suppl 2007;6(2):197