Abstract
Transrectal ultrasound (TRUS) evaluation of the prostate gland should be reserved for men with a suspected result of digital rectal examination (DRE) or prostate-specific antigen (PSA). However, we questioned the recent emphasis of linking suspected screening parameters with automatic biopsy of all patients without regard for TRUS diagnostic criteria. Beyond hypoechoic patterns of intraglandular tumor spread, TRUS assists in cancer risk evaluation through gland volume adjustments of moderate elevations in PSA. Gland volume has minimal longitudinal measurement variation (less than 5 cc) for men with prostate volume less than 50 cc, thereby producing less relative variability over time than PSA. The optimal decision level for PSA density (ng/ml/cc) is 0.12 ng/ml/cc and is a stronger risk parameter than the subjective results of DRE or TRUS. Therefore, a biopsy approach tailored to patients with positive predictive values greater than 10% was developed, and it included patients with PSA density greater than 0.12 ng/ml/cc or concurrently suspicious DRE and TRUS. Significant reductions in low-risk biopsy (that is, a positive predictive value less than 10%) thus can be achieved, even beyond those attainable using age-related criteria and with comparable sensitivity. The rationale for performing a modified sextant biopsy technique in the axial projection and possibilities for directed staging biopsies are presented. Cancer 1995 ;75 :1805-13.
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