Transrectal Ultrasound-guided Sextant Biopsy Research Articles

Reduction in Hospital Admission Rates Due to Post-Prostate Biopsy Infections After Augmenting Standard Antibiotic Prophylaxis

We evaluated the incidence of infectious complications requiring hospitalization after transrectal ultrasound guided prostate biopsy, comparing an augmented regimen of antibiotic prophylaxis to the standard regimen, and established cost-effectiveness at our center. Our standard antibiotic prophylaxis regimen consisted of 3 days of ciprofloxacin or Bactrim™ DS in the perioperative period. An increase in hospital admissions related to infection after transrectal ultrasound guided biopsy from January 2010 through December 2010 led us to initiate an augmented regimen of 3 days of ciprofloxacin or Bactrim DS in addition to 1 dose of intramuscular gentamicin before biopsy from January 2011 to December 2011. Urine and blood cultures along with bacterial susceptibilities were obtained at admission and compared between the 2 groups. Cost analysis was done to determine the cost-effectiveness of standard and augmented regimens. The rate of hospitalization due to post-biopsy infections was 3.8% (11 patients among 290 biopsies) in 2010, which decreased to 0.6% (2 patients among 310 biopsies) in 2011 (p <0.001). Of the admitted patients who received standard prophylaxis, 73% had fluoroquinolone resistant Escherichia coli urinary infection and/or bacteremia and only 9% had strains resistant to gentamicin. Multivariate analysis showed that the standard regimen was significantly associated with hospital admission due to post-biopsy infection (HR 2.078 ± 0.84, p = 0.013). The augmented regimen resulted in a cost savings of $15,700 per 100 patients compared to the standard regimen. The addition of gentamicin to current prophylactic regimens significantly reduced the rate of hospitalization for post-biopsy infectious complications and was shown to be cost-effective.

Endorectal MRI after radiation therapy: Questioning the sextant analysis

To evaluate whether the information gained by three coregistration systems (sextant, hemi-prostate, and whole gland) differs significantly, suggesting that one approach should be routinely favored over the others. Despite its known limitations, sextant is the generally accepted standard for magnetic resonance imaging (MRI) and biopsy coregistration; nevertheless, depending on the magnitude of localization errors, other options may be adequate. Institutional Review Board approval was obtained and the study was Health Insurance Portability and Accountability Act (HIPAA)-compliant. We identified 70 patients who underwent 1.5 T endorectal MRI of the prostate between 1999 and 2008 after external beam radiotherapy for prostate cancer. A single reader reviewed all T2-weighted images for the presence or absence of tumor. The performance of each approach was quantified using receiver operating characteristic (ROC) curve analysis. Transrectal ultrasound-guided sextant biopsies were used as a standard of reference. The areas under the ROC curve indicating accuracy for each MRI approach were 0.63 (sextant), 0.68 (hemi-prostate), and 0.71 (whole gland). There was no statistically significant difference among these approaches. As expected, the point estimate was higher for the whole-gland approach, but not significantly. Reliable assessment of locally recurrent prostate cancer after external beam radiotherapy by endorectal MRI may be made using a sextant, hemi-prostate, or whole gland approach. The option for one or another approach should not be solely based on estimations of imaging accuracy, but on the purpose of the procedure.

Consequences of Switching 5α-Reductase Inhibitors on Prostate Specific Antigen Velocity

The 5alpha-reductase inhibitors improve urinary symptoms related to benign prostatic hyperplasia, deter benign prostatic hyperplasia progression and provide prostate cancer chemoprevention. Currently there are a number of 5alpha-reductase inhibitor formularies, including Proscar, generic finasteride and dutasteride. While all formularies decrease serum prostate specific antigen (a proxy for prostate volume), they may not accomplish this to the same degree, which may have dramatic effects on prostate specific antigen kinetics in men changing 5alpha-reductase inhibitor formularies. We examined prostate specific antigen velocity after changes in 5alpha-reductase inhibitor formularies. We identified patients treated with 2 or more 5alpha-reductase inhibitor formularies who had sufficient prostate specific antigen values to calculate prostate specific antigen velocity during each 5alpha-reductase inhibitor treatment. Patient data were grouped depending on the formularies received. Statistical analysis was done to compare prostate specific antigen velocity at various time points while on different 5alpha-reductase inhibitors. Eight men changed from dutasteride to generic finasteride (group 1), 21 changed from dutasteride to Proscar (group 2), 49 changed from Proscar to dutasteride (group 3) and 77 changed from Proscar to generic finasteride (group 4). We noted a significant increase in prostate specific antigen velocity in groups 1 and 2 (p <0.05), and 4 (p <0.005). The increase was greater than 0.35 ng/ml per year, the common cutoff for prostate biopsy recommendations, in more than a third of patients. Results confirm that changing 5alpha-reductase inhibitors drugs can be associated with a clinically significant change in prostate specific antigen velocity. These prostate specific antigen velocity changes could place patients at risk for unnecessary prostate biopsy. Additional prospective studies are warranted.

Importance of prostate volume for detection of prostate cancer by first sextant biopsy in high-risk patients

The aim of this study was to evaluate the relevance of prostate gland volume, transitional zone volume, and transitional zone index for the detection of prostate cancer by the first sextant biopsy. A total of 121 men with high risk of prostate cancer were included in our study (prostate-specific antigen level higher than 4 ng/mL and/or pathological digital rectal examination). We consulted the patients in Outpatient Department of Kaunas University of Medicine Hospital during 2003-2006. Total prostate volume and transition zone volume were measured, and all patients underwent transrectal ultrasound-guided sextant biopsy of the prostate. According to histological results of prostate biopsy, patients were divided into two groups: benign group (benign prostate hyperplasia and high-grade intraepithelial neoplasia) and prostate cancer group. Statistical analysis was made by SPSS (Statistical Package for Social Sciences) 12.0.1 for Windows. After histological examination, prostate cancer was detected in 20.7% of patients (n=25). Prostate cancer was found in 24.6% of patients with a total prostate volume of less than 60 cm3 and only in 8.2% of patients with a total prostate volume greater than 60 cm3 (P=0.026). Prostate cancer was found in 27.1% of patients with transition zone volume smaller than 30 cm3 and only in 7.5% of patients with transition zone volume greater than 30 cm3 (P=0.007). A statistically significant difference was found when patients were divided into the groups according to transition zone index: when transition zone index was lower than 0.45, prostate cancer was detected in 37.1% of patients, and when transition zone index was higher than 0.45, prostate cancer was observed in 9.1% of patients (P=0.001). The possibility to detect prostate cancer was 5.9 times higher in patients with transition zone index lower than 0.45. Prostate cancer detection rate by first sextant prostate biopsy in patients with elevated prostate-specific antigen level and/or pathological digital rectal examination was higher when total prostate volume was less than 60 cm3, transition zone was less than 30 cm3, and transition zone index was less than 0.45.

The Continuing Importance of Transrectal Ultrasound Identification of Prostatic Lesions

In light of a recent tendency toward systematic nontargeted biopsy we reassessed whether identification and biopsy of ultrasonographically suspicious lesions contribute to the detection of prostate cancer. We reviewed prospectively gathered data on 7,426 transrectal ultrasound directed prostatic biopsies performed at our institution between June 16, 2000 and September 1, 2005. Patients underwent systematic biopsy (6 to 10 cores on initial biopsy and 13 to 15 on rebiopsy) with additional sampling of visible suspicious lesions. The RR for finding cancer in transrectal ultrasound positive and negative patients was calculated for likely independent prognostic variables. A total of 3,828 biopsies (51.5%) were transrectal ultrasound negative and 3,598 (48.5%) were transrectal ultrasound positive. Prostate cancer was detected in 3,258 biopsies (43.9%). For each independent variable the RR for prostate cancer was higher if a sonographic lesion was present. A lesion increased the likelihood of cancer detection (57.8% vs 30.8%, RR 1.8). Biopsies from lesions identified by transrectal ultrasound had a greater median percent of the core involved with cancer (50% vs 10%, p <0.001) and they were more likely to have Gleason score 7 or greater (69.3% vs 28.3%, p <0.001). Biopsies taken when a prostatic lesion is identified by transrectal ultrasound are almost twice as likely to show cancer than when no lesion is visible. These cancers are of higher grade and volume and, therefore, they are more clinically significant. The search for and targeted biopsy of suspicious lesions seen on transrectal ultrasound remains important for prostate cancer diagnosis.

CONTROVERSIES IN PROSTATE CANCER SCREENING

Prostate cancer is the most common cancer in men and the second most common cause of cancer death in men, and yet controversy continues to surround the practice of prostate cancer screening. Despite recent studies that have cast doubt over the true efficacy of breast cancer screening programs, the National Cancer Institute continues to support breast cancer screening and it has withheld endorsement of widespread prostate cancer screening. Criticisms of prostate cancer screening include the financial burden of screening, the morbidity of prostate biopsy, the low positive predictive value of screening, the over treatment of an indolent disease and the lack of evidence demonstrating a mortality benefit due to screening. We formulated a comprehensive discussion addressing the criticisms of prostate cancer screening. In an effort to highlight the importance of prostate cancer screening we noted how concerns regarding cost, morbidity and low positive predictive value are common to widely accepted screening programs for other common malignancies. We also draw attention to the danger of abandoning prostate cancer screening, a practice that is called into question by watchful waiting series and Markov modeling of prostate cancer treatment. Finally, we observed how the implementation of prostate cancer screening in the United States has led to the phenomenon of stage migration and paralleled the decrease in the prostate cancer mortality rate. The prostate specific antigen era has brought great promise for improving the prognosis of prostate cancer. We must continue to seek support for widespread prostate cancer screening.

Influence of transrectal ultrasound probe on prostate cancer detection in transrectal ultrasound-guided sextant biopsy of prostate

Objectives To determine whether end-fire probes increase the prostate cancer (PCa) detection rate. Enhancing the PCa detection rate is the main goal of biopsy protocols. Prostate biopsy is limited by side-fire probes to a longitudinal axis, but end-fire probes allow biopsy cores to also be taken in the transverse section. Methods A total of 2625 patients underwent systematic sextant biopsy in three institutions using the same protocol. Three different ultrasound probes were used—the Kretz Combisone and Bruel & Kjaer side-fire probes and the ATL HDI end-fire probe. We retrospectively evaluated the influence of the probe on the PCa detection rate. Results The Kretz probe was used in 384 men, the Bruel & Kjaer probe in 598 men, and the ATL probe in 1643 men. Overall, 35.2% had PCa detected. Analyzing all patients, no statistically significant difference ( P = 0.73) was found for the probes, but the subgroup with a prostate-specific antigen level of 4 to 10 ng/mL demonstrated a statistically significant improvement in the detection rate using the end-fire probe (31.3% versus 24.5% and 21.5% for the side-fire probes, P = 0.01). Patients with nonpalpable PCa also demonstrated a statistically significant increase in detection with the end-fire probe ( P = 0.004). Multivariate analysis confirmed that the ultrasound probe is an independent parameter to enhance the PCa detection rate. Conclusions Our results showed that end-fire probes provide a statistically significant improvement in the PCa detection rate compared with side-fire probes in patients with a prostate-specific antigen level of 4 to 10 ng/mL and nonpalpable disease. The reason could be the facilitated sampling in the most lateral part of the peripheral zone. Our results suggest that the widespread use of end-fire probes for prostate biopsy could enhance the PCa detection rate.

Ethnic differences in distribution of serum prostate-specific antigen: a study in a healthy chinese male population

Objectives To evaluate the normal distribution of serum prostate-specific antigen (PSA) levels in healthy Chinese men, because, until recently, studies conducted to establish normal serum PSA values have not involved a Chinese population. Methods Between September 1999 and December 2001, 1096 healthy Chinese men aged 23 to 85 years, who had undergone a routine health examination, were recruited to this study. All underwent detailed clinical examinations, including serum PSA determination and digital rectal examination. All men with abnormal digital rectal examination findings and/or an abnormal serum PSA level (greater than 4.0 ng/mL) underwent transrectal ultrasound-guided sextant biopsy. Results The median serum PSA concentration was 0.50 ng/mL (95th percentile 1.20) for men 23 to 29 years old (n = 77); 0.55 ng/mL (95th percentile 1.21) for men 30 to 39 years old (n = 189); 0.54 ng/mL (95th percentile 1.23) for men 40 to 49 years old (n = 233); 0.82 ng/mL (95th percentile 2.35) for men 50 to 59 years old (n = 177); 0.93 ng/mL (95th percentile 3.20) for men 60 to 69 years old (n = 265); and 1.17 ng/mL (95th percentile 3.39) for men 70 years old or older (n = 155). The serum PSA concentration correlated with age ( P <0.001), with an increase of approximately 1.1% annually. No change occurred in the median serum PSA value and 95th percentile in men younger than 50 years old; a gradual increase was observed in men older than 50 years. In those 50 years old or older, the median and 95th percentile serum PSA values for Chinese men were significantly lower than those for other races and even for other Asian men. Conclusions These findings further confirm that the serum PSA level correlates with age. Moreover, the distribution and cutoff value of the serum PSA level differs along ethnic lines. In addition, our findings raise the question of whether lowering the PSA cutoff may enhance the detection of cancer in Chinese men who have the lowest prostate cancer rate.

Complication Rates and Risk Factors of 5802 Transrectal Ultrasound-guided Sextant Biopsies of the Prostate Within A Population-based Screening Program

Complication Rates and Risk Factors of 5802 Transrectal Ultrasound-guided Sextant Biopsies of the Prostate Within A Population-based Screening Program

Complication rates and risk factors of 5802 transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program

Objectives To evaluate the complication rates and possible risk factors of biopsy of the prostate, with the aim of improving patient counseling and the safety of the procedure. Biopsy of the prostate has to be a relatively safe procedure and the participants have to be well informed about the possible complications. Methods Within the biopsy protocol of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer, we evaluated 5802 transrectal ultrasound-guided systematic sextant biopsies. All participants received prophylactic antibiotic therapy. Results We performed 5802 biopsies. Hematuria lasting longer than 3 days and hematospermia were present after 22.6% and 50.4% of the procedures, respectively. More severe complications were far less frequent. Two hundred participants (3.5%) developed fever after biopsy. Urinary retention was seen 20 times (0.4%), and hospitalization was needed in 27 cases (0.5%). Twenty-five of these men were admitted because of signs of prostatitis and/or urosepsis. Risk factor analyses revealed that an earlier episode of prostatitis was significantly associated with hospital admission and pain after biopsy. Characteristics of prostatic hyperplasia, such as prostate volume, transition zone volume/total prostate volume ratio, and a higher International Prostate Symptom Score, were all predictors of urinary retention. Conclusions Minor complications are frequently seen but major complications are rare after prostate biopsy. Assessment of the risk factors before biopsy can help to improve the adequacy of counseling, and precautionary measures can be taken to minimize the risk of complications after the procedure. Transrectal ultrasound-guided sextant biopsy remains a safe procedure for the diagnosis of prostate cancer within the general population.

Distribution of serum prostate-specific antigen in healthy korean men: influence of ethnicity

Objectives. To evaluate the normal distribution of serum prostate-specific antigen (PSA) levels in healthy Korean men. The subjects included men younger than 40 years of age, because information on serum PSA levels in younger men is scarce. Methods. Between January 1997 and December 1998, the serum PSA levels of the subjects who visited our hospital for a routine health checkup were determined. All men who were older than 50 years with abnormal digital rectal examination findings and/or an abnormal serum PSA level (greater than 4.0 ng/mL) underwent transrectal ultrasound-guided sextant biopsy. Two men who were found to have cancer were excluded from the analysis. The detection rate of prostate cancer for men with abnormal digital rectal examination findings and/or an abnormal serum PSA level was 2.0% for men 50 to 59 years old; 0.0% for men 60 to 69 years old; and 11.1% for men 70 to 79 years old. A total of 8297 men (aged 20 to 79 years) were included in the study. Results. The median serum PSA level (5th to 95th percentile range) was 0.90 ng/mL (0.33 to 2.25) for men 20 to 29 years old; 0.89 ng/mL (0.30 to 2.35) for men 30 to 39 years old; 0.89 ng/mL (0.30 to 2.36) for men 40 to 49 years old; 0.96 ng/mL (0.32 to 2.96) for men 50 to 59 years old; 1.22 ng/mL (0.33 to 3.78) for men 60 to 69 years old; and 1.25 ng/mL (0.30 to 7.49) for men 70 to 79 years old. The median and 95th percentile serum PSA levels of Korean men younger than 50 years were higher, but those for men 50 years old or older were lower than in other races. In our study cohort, the serum PSA level weakly correlated with age ( r = 0.088, P <0.001). The serum PSA level weakly correlated with age in men 50 years old or older ( r = 0.116, P <0.001) but in men younger than 50 years, it did not correlate ( r = 0.000, P = 0.987). Conclusions. These results suggest that the distribution and cutoff value of the serum PSA level in Korean men differ from those in other races. In addition, our findings raise the question of whether lowering the PSA cutoff may enhance the detection of cancer in this population with low prostate cancer rates.

Computer Simulation of Prostate Biopsies

Objectives: Prostate specific antigen or an abnormal digital rectal exam can indicate a statistical risk of prostate cancer in a defined population. However, the definitive diagnosis can only be made by prostate biopsy, typically guided by transrectal ultrasound (TRUS). The optimization of these prostate biopsies is therefore, of great importance. Systematic TRUS guided sextant biopsies have been demonstrated to be effective in detecting prostate cancer. It is not certain, however, whether other biopsy patterns may be more sensitive or specific in detecting the cancer. Therefore, computer simulation of prostate biopsies has many attractions. Methods: A Medline literature search on prostatic biopsy was performed and relevant articles were reviewed. Results: A variety of biopsy schemes can be rapidly tested prior to clinical evaluation in patients. Such schemes can be optimized to detect the maximum number of significant prostate cancers while minimizing the detection of insignificant cancers. Furthermore, research is ongoing to develop computer simulation models that utilize additional subvisual ultrasound information in order to demonstrate improved prostate biopsy detection rates and staging information. Conclusions: It is likely that properly constructed prostate biopsy simulations will have clinical relevance. It must be emphasized that prostate biopsy simulations are not a means in and of themselves. They are tools to “experiment” with, and refine, prostate biopsy schemes for clinical testing.

PAIN AND MORBIDITY OF AN EXTENSIVE PROSTATE 10-BIOPSY PROTOCOL: A PROSPECTIVE STUDY IN 289 PATIENTS

Some studies imply that increasing the number of prostate biopsy cores may improve the cancer detection rate. We performed a prospective study to evaluate pain and morbidity after an extensive transrectal ultrasound guided 10-core biopsy protocol. A total of 289 consecutive men with abnormal digital rectal examination findings and/or increased prostate specific antigen underwent extensive prostate biopsy involving 6 sextant and 4 peripheral biopsies. Each received an information leaflet a few days before the procedure. A single dose of fluoroquinolone and a rectal enema were administered before biopsy. In no case was the procedure performed using anesthesia. Immediately after biopsy patients were asked to complete a self-administered nonvalidated questionnaire evaluating the degree of pain and/or discomfort using a visual analog scale. In another questionnaire they listed the side effects noticed during month 1 after biopsy. Although 48% of the 275 men who completed the initial questionnaire reported anxiety before the procedure, 78.8% of them were completely reassured by the information brochure. Of the 275 patients 47.6% described the procedure as painful, including only slightly painful (analog visual scale 3 or less) in 67.9%, while 33.8% described it as uncomfortable but not painful and 18.6% thought that it was neither painful nor uncomfortable. Of the 115 patients who engaged in sexual intercourse during month 1 after the procedure 78.3% noticed hematospermia an average of 10.9 days in duration. Of the 164 men who completed questionnaire 2, 74.4% noticed hematuria an average of 2.7 days in duration, 3.7% noticed pyrexia and 1.2% noticed acute prostatitis. In the 59 patients (36%) who reported delayed perineal pain it was slight in 64.4%, moderate in 30.5% and severe in 5.1%. No patient required hospitalization. Although minor complications are common, the extensive 10-core prostate biopsy protocol is associated with few major complications. The occurrence and intensity of pain and discomfort are in the range reported after the standard 6-core biopsy protocol.

PROSTATE CANCER DIAGNOSIS USING A SATURATION NEEDLE BIOPSY TECHNIQUE AFTER PREVIOUS NEGATIVE SEXTANT BIOPSIES

We hypothesized that markedly increasing the number of cores obtained during prostate needle biopsy may improve the cancer detection rate in men with persistent indications for repeat biopsy. We performed saturation ultrasound guided transrectal prostate needle biopsy in 224 men under anesthesia in an outpatient surgical setting in whom previous negative biopsies had been performed in the office. The mean number of previous sextant biopsy sessions plus or minus standard deviation before saturation biopsy was 1.8 (range 1 to 7). A mean of 23 saturation biopsy cores (range 14 to 45) were distributed throughout the whole prostate, including the peripheral, medial and anterior regions. Indications for repeat biopsy were persistent elevated serum prostate specific antigen (PSA) in 108 cases, persistent elevated PSA and abnormal rectal examination in 27, persistent abnormal rectal examination in 4, high grade prostatic intraepithelial neoplasia in the previous biopsy in 64 and atypia in the previous biopsy in 21. Cancer was detected in 77 of 224 patients (34%). The number of previous negative sextant biopsies was not predictive of subsequent cancer detection by saturation biopsy. Median PSA was 8.7 ng./ml. and median PSA velocity was 0.63 ng./ml. yearly. Of the 77 patients in whom cancer was detected radical prostatectomy was performed in 52. Pathological stage was pT2 in 48 patients and pT3 in 4, while Gleason score was 4 to 5, 6 to 7 and 8 in 5, 46 and 1, respectively. At prostatectomy median cancer volume was 1.04 cc and 85.7% of removed tumors were clinically significant, assuming a 3-year doubling time. The overall complication rate for saturation needle biopsy was 12% and hematuria requiring hospital admission was the most common event. Saturation needle biopsy of the prostate is a useful diagnostic technique in men at risk for prostate cancer with previous negative office biopsies. This technique allows adequate sampling of the whole prostate gland and has a detection rate of 34% in this cohort of patients.

Results of a screening program for prostate cancer in patients scheduled for abdominoperineal resection for colorectal pathologic findings

Objectives. Because of the difficulty of accessing the prostate for tissue sampling after surgical removal of the rectum and obliteration of the anus, we started an early detection program for prostate cancer in all men scheduled for abdominoperineal resection. Methods. Twenty consecutive men were screened for prostatic adenocarcinoma before planned abdominoperineal resection for colorectal pathologic findings. Patients were 48 to 77 years old (mean 66.9). Screening included serum prostate-specific antigen determination and digital rectal examination. Those patients with suspicious findings underwent transrectal ultrasound-guided sextant biopsies of the prostate. Results. One patient was excluded because of a prior history of prostate cancer. Six (31.6%) of the remaining 19 patients demonstrated elevated prostate-specific antigen levels (greater than 4.0 ng/mL); two of these patients also had an abnormal digital rectal examination. Transrectal ultrasound and prostate biopsies in these 6 patients revealed prostatic adenocarcinoma in 3 patients (50% of those undergoing biopsies or 15.8% of those screened). The 13 patients who did not undergo prostate biopsies had prostate-specific antigen levels from 0.4 to 2.4 ng/mL (mean 0.9) and normal prostate glands according to the digital rectal examinations. Conclusions. Screening for prostate cancer in men 50 years old or older with 10 years or longer life expectancy before they undergo abdominoperineal resection detects a significant number of prostatic malignancies and should be encouraged.

Lymphatic drainage of prostatic transition and peripheral zones visualized on a three-dimensional workstation

Objectives. To determine whether the prostate has lymphatic/lymph node drainage that is not sampled by conventional lymphadenectomy and whether the transition and peripheral zones of the prostate have a different lymphatic drainage, because up to one quarter of lymph-node-negative patients who undergo radical prostatectomy will develop distant metastases. Methods. Ten patients (mean age 62.3 years, range 50 to 76) scheduled for transrectal ultrasound-guided sextant biopsy because of an elevated serum prostate-specific antigen level of 4 to 10 ng/mL and a normal digital rectal examination were included in this study. All patients underwent ultrasound-guided sextant biopsies. Subsequently, an oily contrast medium was injected into the transition zone (group A, n = 5) or peripheral zone (group B, n = 5) of the prostate under transrectal ultrasound guidance and fluoroscopy. Immediately, 1 hour, and 24 hours after the procedure, anteroposterior and lateral radiographs were obtained. In addition, spiral computed tomography of the abdomen was performed 10 minutes after the procedure and analyzed on a three-dimensional workstation. Results. No difference in the lymphatic drainage system between the transition and peripheral zones of the prostate was found. In all patients (n = 10), the lymphatic drainage comprised three major routes: (1) the prostate to the lymph nodes along the lateral bony wall of the pelvis to the angle of internal/external iliac lymph nodes to the common iliac lymph nodes, (2) the prostate to the perineal floor to the pudenda internal lymph nodes to the angle of the internal/external iliac lymph nodes to the common iliac lymph nodes, and (3) the prostate to the sacral lymph nodes. In all 10 patients, main contrast medium enhancement was seen immediately after procedure indicating drainage from the prostate to the lymph nodes along the lateral bony wall of the pelvis. Presacral lymph node enhancement was seen in all patients only in the late (24 hours after contrast injection) radiograph. Conclusions. Our data suggest that the main lymphatic drainage, irrespective of the prostatic region (transition or peripheral zone), runs to the pelvic regions that are mostly removed by standard lymphadenectomy techniques. However, one has to bear in mind that the prostate has some lymphatic drainage that is not covered by standard lymphadenectomy and therefore carries the risk of metastatic tumor spread.

Ethnic differences in the age-related distribution of serum prostate-specific antigen values: a study in a healthy Korean male population

Objectives. To further improve the use of prostate-specific antigen (PSA) as a screening test for prostate cancer in Asian countries, we sought to establish the normal distribution of serum PSA values in Korean men, because, until recently, studies conducted to establish normal serum PSA values have involved few Asian populations. Methods. Between May 1995 and June 1997, 5805 healthy Korean men 30 to 79 years old who visited our hospital for a routine health checkup were entered into a prospective study of early screening for prostate cancer. All men underwent detailed clinical examinations, including a digital rectal examination and serum PSA determination. All men who were more than 50 years old with abnormal digital rectal examination findings and/or an elevated serum PSA level (greater than 4.0 ng/mL) also underwent transrectal ultrasound-guided sextant biopsy. Four were found to have cancer and were excluded from the analysis. Results. The median serum PSA concentration (5th to 95th percentile range) was 0.8 ng/mL (0.2 to 1.8) for patients 30 to 39 years old (n = 1382); 0.8 ng/mL (0.2 to 2.0) for patients 40 to 49 years old (n = 1776); 0.9 ng/mL (0.2 to 2.4) for those 50 to 59 years old (n = 1775); 1.0 ng/mL (0.2 to 3.9) for men 60 to 69 years old (n = 746); and 1.3 ng/mL (0.5 to 6.3) for patients 70 to 79 years old (n = 122). The serum PSA concentration correlated with age ( P <0.001), with an increase by approximately 1.2% annually, although the statistical correlation was weak ( r = 0.16). Almost no change occurred in the median serum PSA value in patients 50 years old or younger; a gradual increase was observed in patients older than 50. In those 50 years old or older, the median and 95th percentile serum PSA values for Korean men were lower than those for white men. Conclusions. Contrary to earlier observations that the serum PSA level strongly correlates with age, the influence of age on serum PSA was found to be weaker in this study. Moreover, the results also demonstrated that the distribution of the serum PSA level differs along ethnic lines. The cutoff value for serum PSA in mass screening for prostate cancer should be adjusted in nonwhite races.

EXAMINATION OF THE 3 MOLECULAR FORMS OF SERUM PROSTATE SPECIFIC ANTIGEN FOR DISTINGUISHING NEGATIVE FROM POSITIVE BIOPSY: RELATIONSHIP TO TRANSITION ZONE VOLUME

We evaluated the relative usefulness of total, free and complexed serum prostate specific antigen (PSA), and their ratios for distinguishing positive from negative biopsy of prostates in a university referral practice. We compared 90 consecutive men who had 2 sets of 6 negative systematic biopsies with 70 who had at least 5 mm. of prostate cancer in systematic biopsies during the same period at our institution. Total prostate and transition zone volumes were determined by transrectal ultrasound. The Bayer, DPC and Hybritech assays were performed to measure total, free and complexed serum PSA. Receiver operating characteristics curves were constructed for all forms of serum PSA and their ratios as well as prostate size to distinguish true positive (sensitivity) from false-positive (1 minus specificity) fractions. Complexed PSA was only marginally better than total serum PSA. Free-to-total, complexed-to-total and prostate size had highly significant areas under the curves of greater than 80%. Free PSA only was better than complexed or total PSA. When factored by prostate volume, total PSA performed as well as the PSA ratios, and transition zone volume was consistently better than total prostate volume. DPC free-to-total ratios were equivalent to Hybritech ratios in all respects. Complexed PSA is only marginally better than total PSA for distinguishing negative from positive biopsy of prostates. It is inferior to free PSA and far less useful than free-to-total or complexed-to-total ratios. Prostate size is a decisive variable in men in whom we avoided the expected 25% false-negative biopsy rate in terms of specificity and hopefully avoided insignificant cancer in terms of sensitivity. In the future the performance of PSA serum markers should be related to a transition zone volume of less than 20, 20 to 60 and greater than 60 gm. when comparing assays to each other.

Comparative Study of Two Different TRUS–Guided Sextant Biopsy Techniques in Detecting Prostate Cancer in One Biopsy Session

Objective: The aim of this study was to compare a transrectal ultrasound (TRUS)–guided sextant biopsy technique, which puts more emphasis on the apical region of the prostate where most prostate carcinomas (PCs) develop, with the standard sextant biopsy technique.Methods: A total of 280 patients with suspected PC were included in this analysis. Twelve biopsy cores were obtained from all patients. Six biopsy cores were taken within a lateral parasagittal plane from each lobe at the apex, middle and basis, with an angle of approximately 45° (technique A), and 6 further biopsy cores were taken from the left to the right lateral margin always penetrating the prostate in the apex with the same angle (socalled fan–shaped technique, technique B). Technique A predominantly samples in the sagittal and technique B samples more in the transversal plane with emphasis on the apical region where most PCs develop. The sensitivity in detecting PCs for both techniques was calculated and correlated to the serum prostate–specific antigen (PSA) levels.Results: A total of 72 PCs (25.7%) were diagnosed. We subsequently performed subgroup analysis depending on the serum PSA levels: in patients with a PSA of ≤10 ng/ml (n = 27) technique A has a PC sensitivity of 88.8% (p = 0.037) and technique B 96.2% (p = 0.326) as compared to our reference standard of 100% by sampling 12 biopsy cores in the same prostate. The number of positive biopsy cores using technique B was superior in 12 cases as compared to 3 cases with technique A (p = 0.04). In 12 patients the number of positive biopsy cores was identically. In patients with a PSA of >10 ng/ml (n = 45) technique A has a PC sensitivity of 93.3% (p = 0.083) and technique B 88.8% (p = 0.023) as compared to our reference standard. The number of positive core biopsies using technique A was superior in 14 cases as compared to 12 with technique B (p = 0.154). In 19 patients the number of positive biopsies was identical.Conclusion: Our data suggest that in patients with PSA of ≤10 ng/ml technique B bring significant benefit with regard to the number of positive core biopsies, as well as an enhanced PC detection rate which is near the 12–core biopsy. Due to the fact that technique B samples more in the apical region where most cancers develop, it should be performed in suspected early stage cancers of the prostate (PSA≤10 ng/ml).

Differences in Prostate Size Between Patients From University and Veterans Affairs Medical Center Populations

BACKGROUND Numerous studies on prostatic disease have been performed at Veterans Affairs (VA) Medical Centers. Recent investigations evaluating early detection of prostate cancer provide insight that the average prostate volume may be different between patients with similar clinical findings who are from different hospital settings. The objective of this study was to compare prostate size between men from University and VA Medical Centers. METHODS Patients were enrolled retrospectively from 1989–1996 from the Urology Clinics at a University and a VA Medical Center. All men underwent transrectal ultrasound-guided sextant biopsy of the prostate owing to either an elevated prostate-specific antigen (PSA) level and/or abnormal digital rectal examination (DRE) detected prior to biopsy. Prostate volume was calculated using the ellipsoid three-diameter formula based on transrectal ultrasound measurements. RESULTS There were 1,311 men included in the analysis: 717 were from the VA, and 594 were from the University. The average prostate volume was significantly smaller among VA patients both for men with cancer (P = 0.0004) and for men with no evidence of malignancy (P < 0.0001). Overall, the average prostate volume was 38.5 cm3 (median, 32.5 cm3) among men from the VA compared to 46.8 cm3 (median, 39.3 cm3) among men from the University Medical Center. Men from the VA were older (mean ± SD = 68 ± 7.3) than men from the University (mean ± SD = 66 ± 7.7) (P = 0.004) and there was no significant difference in PSA levels between the two groups of patients (P = 0.11). Intriguingly, the incidence of cancer was significantly lower at the VA (24.5%) compared to the University (35.9%) (P < 0.0001). CONCLUSIONS The variance in prostate size suggests that there are significant differences between the two patient populations. Proposed factors leading to this discrepancy include differences in socioeconomic factors, environmental factors, and changes in hormonal milieu related to alcohol and tobacco use. These results may have significant implications regarding the interpretation and extrapolation of results from previous studies performed at a single hospital setting. Prostate 38:144–150, 1999. © 1999 Wiley-Liss, Inc.