Abstract
BackgroundThe prostatic anterior zone (AZ) is not targeted routinely by TRUS guided prostate biopsy (TRUS-Pbx). MRI is an accurate diagnostic tool for AZ tumors, but is often unavailable due to cost or system restrictions. We examined the diagnostic yield of office based AZ TRUS-Pbx.Methods127 men at risk for AZ tumors were studied: Patients with elevated PSA and previous extended negative TRUS-Pbx (group 1, n = 78) and actively surveyed low risk prostate cancer patients (group 2, n = 49). None of the participants had a previous AZ biopsy. Biopsy template included suspicious ultrasonic areas, 16 peripheral zone (PZ), 4 transitional zone (TZ) and 6 AZ cores. All biopsies were performed by a single urologist under local peri-prostatic anaesthetic, using the B-K Medical US System, an end-firing probe 4-12 MHZ and 18 ga/25 cm needle. All samples were reviewed by a single specialized uro-pathologist. Multivariate analysis was used to detect predictors for AZ tumors accounting for age, PSA, PSA density, prostate volume, BMI, and number of previous biopsies.ResultsMedian PSA was 10.4 (group 1) and 7.3 (group 2). Age (63.9, 64.5), number of previous biopsies (1.5) and cores (17.8, 21.3) and prostate volume (56.4 cc, 51 cc) were similar for both groups. The overall diagnostic yield was 34.6% (group 1) and 85.7% (group 2). AZ cancers were detected in 21.8% (group 1) and 34.7% (group 2) but were rarely the only zone involved (1.3% and 4.1% respectively). Gleason ≥ 7 AZ cancers were often accompanied by equal grade PZ tumors. In multivariate analysis only prostate volume predicted for AZ tumors. Patients detected with AZ tumors had significantly smaller prostates (36.9 cc vs. 61.1 cc p < 0.001). Suspicious AZ ultrasonic findings were uncommon (6.3%).ConclusionsTRUS-Pbx AZ sampling rarely improves the diagnostic yield of extended PZ sampling in patients with elevated PSA and previous negative biopsies. In low risk prostate cancer patients who are followed by active surveillance, AZ sampling changes risk stratification in 6% but larger studies are needed to define the role of AZ sampling in this population and its correlation with prostatectomy final pathological specimens.
Highlights
The prostatic anterior zone (AZ) is not targeted routinely by trans-rectal ultrasound (TRUS) guided prostate biopsy (TRUS-Pbx)
While the majority of prostate cancers are detected in the peripheral zone (PZ) [1], recent Magnetic resonance imaging (MRI) data suggest that the anterior zone (AZ) of the prostate, an area that is not palpable on digital rectal examination (DRE) and not targeted routinely by extended or saturated TRUS guided prostate biopsy protocols, can harbor clinically significant cancer [2,3]
Given the potential multi-focal nature of PC, and evidence that saturation biopsy can improve the risk stratification of patients enrolled to active surveillance (AS) [5], we hypothesize that clinical benefit of additional AZ sampling may be larger in the AS cohort who were already diagnosed with peripheral zone prostate cancer than among those with previous negative biopsies
Summary
The prostatic anterior zone (AZ) is not targeted routinely by TRUS guided prostate biopsy (TRUS-Pbx). We examined the diagnostic yield of office based AZ TRUS-Pbx. While the majority of prostate cancers are detected in the peripheral zone (PZ) [1], recent MRI data suggest that the anterior zone (AZ) of the prostate, an area that is not palpable on digital rectal examination (DRE) and not targeted routinely by extended or saturated TRUS guided prostate biopsy protocols, can harbor clinically significant cancer [2,3]. Given the potential multi-focal nature of PC, and evidence that saturation biopsy can improve the risk stratification of patients enrolled to AS [5], we hypothesize that clinical benefit of additional AZ sampling may be larger in the AS cohort who were already diagnosed with peripheral zone prostate cancer than among those with previous negative biopsies
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