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Extended sector biopsy for detection of carcinoma of the prostate
Urologic Oncology 6 (2001) 91–93
Original article
Extended sector biopsy for detection of carcinoma of the prostate Paul M. Arnold M.D., Theodore H. Niemann, M.D., Robert R. Bahnson, M.D.* Division of Urology, The Ohio State University, 456 W. 10th Ave., 4841 UHC, Columbus, OH 43210, USA Received 26 April 2000; revised 5 July 2000; accepted 9 November 2000
Abstract Purpose: To determine whether an extended sector biopsy of the prostate will increase the detection of prostate cancer, without causing an increase in morbidity. Materials and Methods: A total of 74 men with a mean age of 62.3 years (46–98 years) who either had an elevated PSA or an abnormal digital rectal exam underwent a transrectal ultrasound guided needle biopsy. Beginning on 7/1/98, an extended sector biopsy technique was performed on 74 patients by one urologist (RRB). Each transrectal ultrasound guided needle biopsy included 12 total cores (normal sextant biopsy, 2 in each peripheral zone, and 2 in the transition zone). We retrospectively reviewed the biopsy results for the location of cancer. PSA data and morbidity of the procedures were reviewed. Results: Of 74 total patients, 40 (54.1%) were positive for adenocarcinoma of the prostate. There were 10 positive results detected only in the additional zones. If one looks at the total number of cancers detected (40), then 10/40 (25%) of the cancers detected were found in the additional regions only or in 13.5% of all patients biopsied. Of the 10 patients with sector only prostate cancer, 8 were detected in the peripheral zone, 1 in the transition zone and 1 in both zones. All 10 patients had a Gleason pattern score 3⫹3⫽6 or 4⫹3⫽7. There were no atypical or PIN cores found in the sector zones only. PSA ranged from 1.2–142 (median 6.0 ng/ml). The median PSA was 6.2 ng/ml in all patients found to have cancer, and 6.0 ng/ml in the cancers detected only in the additional zones. There was 1 (1.4%) complication of urinary retention and fever. Conclusion: Our study suggests that an extensive sector biopsy may increase the detection of prostate cancer by 13.5% over a routine sextant biopsy, without demonstrable serious morbidity. © 2001 Elsevier Science Inc. All rights reserved. Keywords: Extended sector biopsy; Prostate cancer; Cancer detection
1. Introduction The most commonly used technique for a prostatic biopsy is a transrectal ultrasound guided sextant biopsy. There is controversy whether a sextant biopsy is the ideal biopsy technique. Eskew et al. reported an increase of 35% in the detection of prostate cancer with a 5 region biopsy technique [1]. Stimulated by this report, we elected to change from a standard sextant to an extended biopsy in July of 1998. We report our experience with the extended sector biopsy technique to determine if it increases the detection of prostate cancer without increasing morbidity. 2. Materials and methods Beginning on July 1, 1998, a 5 sector biopsy technique was performed on consecutive patients, with one exception, by one urologist. A patient with a highly suspicious nodule on Coumadin had only one core of tissue. A total of 78 men
* Corresponding author. Tel.: ⫹1-614-293-3646; Fax: ⫹1-614-293-5363. E-mail address: [email protected] (R. Bahnson).
with a mean age of 62.3 years (46–98 years) underwent a transrectal ultrasound guided needle biopsy. Biopsies were performed because of an elevated PSA (greater than 4.0 ng/ ml) and/or an abnormal digital rectal exam (DRE). Two biopsies were performed because of an increase in PSA velocity with a PSA less than 4.0 ng/ml. There were 4 patients excluded from the study because we were unable to obtain a pre-biopsy PSA. Patients were given periprocedural antibiotics lasting for 24 hours after the biopsy. A Bruel and Kjaar ultrasound probe or a General Electric unit with digital imaging was used to perform the biopsy. Patients were placed in the left lateral decubitus position on the examining table. Two of the 74 patients received local anesthetic with 1% lidocaine administered transrectally via a spinal needle. The rest of the patients did not receive an anesthetic. Each patient underwent a transrectal ultrasound and evaluation of the prostate in both the transverse and longitudinal views. Notations of hypoechoic foci, presence or absence of capsular disruption, or identification of abnormal seminal vesicles were noted. The transrectal ultrasound guided needle biopsy included 12 total cores (normal sextant biopsy, 2 in each peripheral zone, and 2 in the transition zone) (Fig.1).
1078-1439/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S1078-1439(00)00 1 1 1 - 3
92
P.M. Arnold et al. / Urologic Oncology 6 (2001) 91–93 Table 2 Correlation of location of cancer and PSA with sector zone positive biopsy
Fig. 1. Posterior view of prostate as seen through rectal wall, modified from McCullough, showing the 5 sector technique.
The sextant biopsy, peripheral zones and transition zones were collected and processed individually. Four levels of each biopsy were examined. Immunohistochemical staining for high molecular weight cytokeratin was performed on selected cases. Biopsy cores were interpreted by staff pathologists as malignant, atypical, prostatic intraepithelial neoplasia (PIN), chronic inflammation or benign. We retrospectively reviewed all biopsy results for location of cancer. PSA data and morbidity of the procedure were reviewed. 3. Results Of 74 patients who underwent transrectal ultrasound guided needle biopsy, 40 (54.1%) were positive for adenocarcinoma of the prostate. There were 10 positive results detected only in the additional zones. If one looks at the total number of cancers detected (40), then 10/40 (25%) of the cancers detected were found in the additional regions only or in 13.5% of the patients biopsied (Table 1). Of the 10 patients with sector only prostate cancer, 8 were detected in the peripheral zone, 1 in the transition zone, and 1 in both zones (Table 2). All 10 patients had a cancer with a Gleason pattern score of 3⫹3⫽6 or 4⫹3⫽7. There were no atypical or prostatic intraepithelial neoplasia (PIN) cores found in the sector zones only. Therapeutic follow up was available on 9 of the 10 patients whose cancer was diagnosed in the sector biopsies only. Three patients underwent a radical retropubic prostatectomy, 3 patients had external beam radiation, 2 patients had brachytherapy with Palladium seeds, and 1 patient
Patient
Location of cancer
PSA (ng/ml)
1 2 3 4 5 6 7 8 9 10
Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral & Transition Transition zone
3.1 3.4 3.9 5.4 6.0 6.2 6.3 6.5 7.6 26.2
who was 77 years old opted for androgen deprivation. PSA ranged from 1.2–142.0 (median 6.0 ng/ml). The 34 patients with benign biopsies had a median PSA 5.5 ng/ml (1.3– 27.9). The median PSA was 6.2 ng/ml in all patients found to have cancer (n⫽40), and 6.0 ng/ml (3.1–26.2) in the 10 cancers detected only in the sector zones (Table 3). PSA values (ng/ml) of the 10 additional cancers were 3.1, 3.4, 3.9, 5.4, 6.0, 6.2, 6.3, 6.5, 7.6, 26.2 (Table 2). All 9 of the cancers detected in the lateral peripheral zones had a PSA ⬍ 10 ng/ml, while the one detected in the transitional zone had a PSA of 26.2 ng/ml. PSA of the 9 patients who had prostate cancer in the normal sextant biopsy zones was 4.1 ng/ml (1.2–14.7), while the 21 patients with cancer in both the sextant and sector zones had a median PSA of 7.5 ng/ml (Table 3). Both patients who were biopsied secondary to an increase in the PSA velocity with PSA less than 4 ng/ml were negative for a malignancy. There was 1 (1.4%) patient who developed urinary retention and fever. This patient was admitted overnight 48 hours after his biopsy for observation, parenteral antibiotics, and placement of a Foley. There were no known complications of prostatitis. 4. Discussion Prostate specific antigen (PSA) measurement has lead to a tremendous increase in the number of transrectal ultrasound guided needle biopsies performed each year. There has also been a shift to an earlier age and stage at diagnosis. Age at diagnosis has decreased significantly from 71.3 years in the pre-PSA era to 66.8 years in the late-PSA era. Also the number of organ confined cancers has risen from 13% to 30% since the advent of PSA [2]. Table 3 Mean PSA values of patients who underwent 5 sector biopsy
Table 1 Percentage of patients with positive and benign biopsies Total (%) CaP (n ⫽ 40) Benign (n ⫽ 34) Sector zones only (n ⫽ 10) Sextant only (n ⫽ 9) Sextant & Sector (n ⫽ 21) ⫹ Sector only/⫹ CaP
40/74 (54.1) 34/74 (46.0) 10/74 (13.5) 9/74 (12.2) 21/74 (28.4) 10/40 (25.0)
All patients in study Benign All cancers Sector zones only Sextant zones only Sextant and sector zones
Totals
Median PSA (ng/ml)
Mean PSA (ng/ml)
Range (ng/ml)
74 34 40 10 9 21
6.0 5.5 6.2 6.0 4.1 7.5
12.1 7.9 15.4 7.4 5.0 23.9
1.2–142 1.3–27.9 1.2–142 3.1–26.2 1.2–14.7 3.0–142
P.M. Arnold et al. / Urologic Oncology 6 (2001) 91–93
Sextant biopsies are the most commonly employed technique for diagnosis of carcinoma of the prostate. However, the question remains whether sextant biopsies are the optimal number and sites of samples for early detection. McCullough et al. demonstrated that a 5 region biopsy with 13–18 cores increases the chance of diagnosing prostate cancer by 35% [1]. Our results indicate a 13.5% increase in carcinoma of the prostate detection when using a 5 region biopsy technique. It had been suggested that PSA testing leads to the diagnosis of insignificant cancers. However in our study, all 10 patients who were diagnosed in the sector zones only had a Gleason pattern score of 3⫹3⫽6 or 4⫹3⫽7. We believe that the 10 additional cancers detected by our technique are significant cancers. We also believe they have been detected at a low stage when chances for cure are improved. In one series of 500 patients, 50% of moderately differentiated cancers (Gleason score 5 to 6) were organ confined. Other series found that 60–69% of Gleason score 5–6 tumors were confined to the prostate [3–5]. McCullough concluded that the 5 region technique is superior to sextant biopsies in diagnosing prostate cancer in patients with a PSA level of less than 10 [1]. In our study, the median PSA in the 10 sector only cancers was 6.0 ng/ ml, ranging from 3.1–26.2 ng/ml. We believe that the 5 region biopsy technique can be used for all patients regardless of the PSA. There are morbidities seen with transrectal ultrasound needle guided biopsies, such as hematuria, hematachezia, pain, hematospermia, urinary retention, prostatitis, and sepsis. Only one patient in our study (1.3%) had a complication
93
of urinary retention and fever, which included an admission for observation. There were no other serious complications seen in our patients secondary to the more extensive biopsy performed. 5. Conclusion Our study suggests that extended sector biopsy may increase the detection of prostate cancer by 13.5% over routine sextant biopsy, without demonstrable serious morbidity. We believe that the 5 region biopsy technique is safe, easy and superior to routine sextant biopsies regardless of the PSA value.
References [1] Eskew LA, Bare RL, McCullough DL. Systematic 5 region prostate is superior to sextant method for diagnosing carcinoma of the prostate. J Urol 1997;157:199–203. [2] Roberts RO, Bergstrahl EJ, Katusicc SK, Lieber MM, Jacobsen SJ. Decline in Prostate Cancer from 1980 to 1997, and an update on incidence trends in Olmsted County, Minnesota. J Urol 1999;161:529–33. [3] Ohori M, Goad JR, Wheeler TM. Can radical prostatectomy alter the progression of poorly differentiated prostate cancer? J Urol 1994;152: 1843–9. [4] Partin AW, Yoo J, Carter HB. The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 1993;150:110–4. [5] Tefilli MV, Gheiler EL, Tiguert R, et al. Should Gleason score 7 prostate cancer be considered a unique grade category. Urology 1999;53: 372–7.
Original article
Extended sector biopsy for detection of carcinoma of the prostate Paul M. Arnold M.D., Theodore H. Niemann, M.D., Robert R. Bahnson, M.D.* Division of Urology, The Ohio State University, 456 W. 10th Ave., 4841 UHC, Columbus, OH 43210, USA Received 26 April 2000; revised 5 July 2000; accepted 9 November 2000
Abstract Purpose: To determine whether an extended sector biopsy of the prostate will increase the detection of prostate cancer, without causing an increase in morbidity. Materials and Methods: A total of 74 men with a mean age of 62.3 years (46–98 years) who either had an elevated PSA or an abnormal digital rectal exam underwent a transrectal ultrasound guided needle biopsy. Beginning on 7/1/98, an extended sector biopsy technique was performed on 74 patients by one urologist (RRB). Each transrectal ultrasound guided needle biopsy included 12 total cores (normal sextant biopsy, 2 in each peripheral zone, and 2 in the transition zone). We retrospectively reviewed the biopsy results for the location of cancer. PSA data and morbidity of the procedures were reviewed. Results: Of 74 total patients, 40 (54.1%) were positive for adenocarcinoma of the prostate. There were 10 positive results detected only in the additional zones. If one looks at the total number of cancers detected (40), then 10/40 (25%) of the cancers detected were found in the additional regions only or in 13.5% of all patients biopsied. Of the 10 patients with sector only prostate cancer, 8 were detected in the peripheral zone, 1 in the transition zone and 1 in both zones. All 10 patients had a Gleason pattern score 3⫹3⫽6 or 4⫹3⫽7. There were no atypical or PIN cores found in the sector zones only. PSA ranged from 1.2–142 (median 6.0 ng/ml). The median PSA was 6.2 ng/ml in all patients found to have cancer, and 6.0 ng/ml in the cancers detected only in the additional zones. There was 1 (1.4%) complication of urinary retention and fever. Conclusion: Our study suggests that an extensive sector biopsy may increase the detection of prostate cancer by 13.5% over a routine sextant biopsy, without demonstrable serious morbidity. © 2001 Elsevier Science Inc. All rights reserved. Keywords: Extended sector biopsy; Prostate cancer; Cancer detection
1. Introduction The most commonly used technique for a prostatic biopsy is a transrectal ultrasound guided sextant biopsy. There is controversy whether a sextant biopsy is the ideal biopsy technique. Eskew et al. reported an increase of 35% in the detection of prostate cancer with a 5 region biopsy technique [1]. Stimulated by this report, we elected to change from a standard sextant to an extended biopsy in July of 1998. We report our experience with the extended sector biopsy technique to determine if it increases the detection of prostate cancer without increasing morbidity. 2. Materials and methods Beginning on July 1, 1998, a 5 sector biopsy technique was performed on consecutive patients, with one exception, by one urologist. A patient with a highly suspicious nodule on Coumadin had only one core of tissue. A total of 78 men
* Corresponding author. Tel.: ⫹1-614-293-3646; Fax: ⫹1-614-293-5363. E-mail address: [email protected] (R. Bahnson).
with a mean age of 62.3 years (46–98 years) underwent a transrectal ultrasound guided needle biopsy. Biopsies were performed because of an elevated PSA (greater than 4.0 ng/ ml) and/or an abnormal digital rectal exam (DRE). Two biopsies were performed because of an increase in PSA velocity with a PSA less than 4.0 ng/ml. There were 4 patients excluded from the study because we were unable to obtain a pre-biopsy PSA. Patients were given periprocedural antibiotics lasting for 24 hours after the biopsy. A Bruel and Kjaar ultrasound probe or a General Electric unit with digital imaging was used to perform the biopsy. Patients were placed in the left lateral decubitus position on the examining table. Two of the 74 patients received local anesthetic with 1% lidocaine administered transrectally via a spinal needle. The rest of the patients did not receive an anesthetic. Each patient underwent a transrectal ultrasound and evaluation of the prostate in both the transverse and longitudinal views. Notations of hypoechoic foci, presence or absence of capsular disruption, or identification of abnormal seminal vesicles were noted. The transrectal ultrasound guided needle biopsy included 12 total cores (normal sextant biopsy, 2 in each peripheral zone, and 2 in the transition zone) (Fig.1).
1078-1439/01/$ – see front matter © 2001 Elsevier Science Inc. All rights reserved. PII: S1078-1439(00)00 1 1 1 - 3
92
P.M. Arnold et al. / Urologic Oncology 6 (2001) 91–93 Table 2 Correlation of location of cancer and PSA with sector zone positive biopsy
Fig. 1. Posterior view of prostate as seen through rectal wall, modified from McCullough, showing the 5 sector technique.
The sextant biopsy, peripheral zones and transition zones were collected and processed individually. Four levels of each biopsy were examined. Immunohistochemical staining for high molecular weight cytokeratin was performed on selected cases. Biopsy cores were interpreted by staff pathologists as malignant, atypical, prostatic intraepithelial neoplasia (PIN), chronic inflammation or benign. We retrospectively reviewed all biopsy results for location of cancer. PSA data and morbidity of the procedure were reviewed. 3. Results Of 74 patients who underwent transrectal ultrasound guided needle biopsy, 40 (54.1%) were positive for adenocarcinoma of the prostate. There were 10 positive results detected only in the additional zones. If one looks at the total number of cancers detected (40), then 10/40 (25%) of the cancers detected were found in the additional regions only or in 13.5% of the patients biopsied (Table 1). Of the 10 patients with sector only prostate cancer, 8 were detected in the peripheral zone, 1 in the transition zone, and 1 in both zones (Table 2). All 10 patients had a cancer with a Gleason pattern score of 3⫹3⫽6 or 4⫹3⫽7. There were no atypical or prostatic intraepithelial neoplasia (PIN) cores found in the sector zones only. Therapeutic follow up was available on 9 of the 10 patients whose cancer was diagnosed in the sector biopsies only. Three patients underwent a radical retropubic prostatectomy, 3 patients had external beam radiation, 2 patients had brachytherapy with Palladium seeds, and 1 patient
Patient
Location of cancer
PSA (ng/ml)
1 2 3 4 5 6 7 8 9 10
Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral zone Peripheral & Transition Transition zone
3.1 3.4 3.9 5.4 6.0 6.2 6.3 6.5 7.6 26.2
who was 77 years old opted for androgen deprivation. PSA ranged from 1.2–142.0 (median 6.0 ng/ml). The 34 patients with benign biopsies had a median PSA 5.5 ng/ml (1.3– 27.9). The median PSA was 6.2 ng/ml in all patients found to have cancer (n⫽40), and 6.0 ng/ml (3.1–26.2) in the 10 cancers detected only in the sector zones (Table 3). PSA values (ng/ml) of the 10 additional cancers were 3.1, 3.4, 3.9, 5.4, 6.0, 6.2, 6.3, 6.5, 7.6, 26.2 (Table 2). All 9 of the cancers detected in the lateral peripheral zones had a PSA ⬍ 10 ng/ml, while the one detected in the transitional zone had a PSA of 26.2 ng/ml. PSA of the 9 patients who had prostate cancer in the normal sextant biopsy zones was 4.1 ng/ml (1.2–14.7), while the 21 patients with cancer in both the sextant and sector zones had a median PSA of 7.5 ng/ml (Table 3). Both patients who were biopsied secondary to an increase in the PSA velocity with PSA less than 4 ng/ml were negative for a malignancy. There was 1 (1.4%) patient who developed urinary retention and fever. This patient was admitted overnight 48 hours after his biopsy for observation, parenteral antibiotics, and placement of a Foley. There were no known complications of prostatitis. 4. Discussion Prostate specific antigen (PSA) measurement has lead to a tremendous increase in the number of transrectal ultrasound guided needle biopsies performed each year. There has also been a shift to an earlier age and stage at diagnosis. Age at diagnosis has decreased significantly from 71.3 years in the pre-PSA era to 66.8 years in the late-PSA era. Also the number of organ confined cancers has risen from 13% to 30% since the advent of PSA [2]. Table 3 Mean PSA values of patients who underwent 5 sector biopsy
Table 1 Percentage of patients with positive and benign biopsies Total (%) CaP (n ⫽ 40) Benign (n ⫽ 34) Sector zones only (n ⫽ 10) Sextant only (n ⫽ 9) Sextant & Sector (n ⫽ 21) ⫹ Sector only/⫹ CaP
40/74 (54.1) 34/74 (46.0) 10/74 (13.5) 9/74 (12.2) 21/74 (28.4) 10/40 (25.0)
All patients in study Benign All cancers Sector zones only Sextant zones only Sextant and sector zones
Totals
Median PSA (ng/ml)
Mean PSA (ng/ml)
Range (ng/ml)
74 34 40 10 9 21
6.0 5.5 6.2 6.0 4.1 7.5
12.1 7.9 15.4 7.4 5.0 23.9
1.2–142 1.3–27.9 1.2–142 3.1–26.2 1.2–14.7 3.0–142
P.M. Arnold et al. / Urologic Oncology 6 (2001) 91–93
Sextant biopsies are the most commonly employed technique for diagnosis of carcinoma of the prostate. However, the question remains whether sextant biopsies are the optimal number and sites of samples for early detection. McCullough et al. demonstrated that a 5 region biopsy with 13–18 cores increases the chance of diagnosing prostate cancer by 35% [1]. Our results indicate a 13.5% increase in carcinoma of the prostate detection when using a 5 region biopsy technique. It had been suggested that PSA testing leads to the diagnosis of insignificant cancers. However in our study, all 10 patients who were diagnosed in the sector zones only had a Gleason pattern score of 3⫹3⫽6 or 4⫹3⫽7. We believe that the 10 additional cancers detected by our technique are significant cancers. We also believe they have been detected at a low stage when chances for cure are improved. In one series of 500 patients, 50% of moderately differentiated cancers (Gleason score 5 to 6) were organ confined. Other series found that 60–69% of Gleason score 5–6 tumors were confined to the prostate [3–5]. McCullough concluded that the 5 region technique is superior to sextant biopsies in diagnosing prostate cancer in patients with a PSA level of less than 10 [1]. In our study, the median PSA in the 10 sector only cancers was 6.0 ng/ ml, ranging from 3.1–26.2 ng/ml. We believe that the 5 region biopsy technique can be used for all patients regardless of the PSA. There are morbidities seen with transrectal ultrasound needle guided biopsies, such as hematuria, hematachezia, pain, hematospermia, urinary retention, prostatitis, and sepsis. Only one patient in our study (1.3%) had a complication
93
of urinary retention and fever, which included an admission for observation. There were no other serious complications seen in our patients secondary to the more extensive biopsy performed. 5. Conclusion Our study suggests that extended sector biopsy may increase the detection of prostate cancer by 13.5% over routine sextant biopsy, without demonstrable serious morbidity. We believe that the 5 region biopsy technique is safe, easy and superior to routine sextant biopsies regardless of the PSA value.
References [1] Eskew LA, Bare RL, McCullough DL. Systematic 5 region prostate is superior to sextant method for diagnosing carcinoma of the prostate. J Urol 1997;157:199–203. [2] Roberts RO, Bergstrahl EJ, Katusicc SK, Lieber MM, Jacobsen SJ. Decline in Prostate Cancer from 1980 to 1997, and an update on incidence trends in Olmsted County, Minnesota. J Urol 1999;161:529–33. [3] Ohori M, Goad JR, Wheeler TM. Can radical prostatectomy alter the progression of poorly differentiated prostate cancer? J Urol 1994;152: 1843–9. [4] Partin AW, Yoo J, Carter HB. The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol 1993;150:110–4. [5] Tefilli MV, Gheiler EL, Tiguert R, et al. Should Gleason score 7 prostate cancer be considered a unique grade category. Urology 1999;53: 372–7.