UROLOGICAL ONCOLOGY

Prostate cancer detection rate in patients with repeated extended 21-sample needle biopsy
Campos-Fernandes JL, Bastien L, Nicolaiew N, Robert G, Terry S, Vacherot F, Salomon L, Allory Y, Vordos D, Hoznek A, Yiou R, Patard JJ, Abbou CC, de la Taille A
Department of Urology, CHU Mondor, Créteil, France
Eur Urol. 2009; 55: 600-6

• Background: Prevalence of prostate cancer (PCa) after a negative first extended prostate needle biopsy protocol is unknown.
  Objective: To evaluate the prevalence of significant PCa in patients who have had a negative first extended prostate biopsy protocol.
  Design, Setting, and Participants: Between March 2001 and May 2007, 2500 consecutive patients underwent an extended protocol of 21 biopsies. Of 953 patients who had a negative first extended prostate biopsy procedure, 231 patients underwent a second or more set of 21-core biopsies. Indications for repeated biopsies were persistently elevated prostate-specific antigen (PSA), PSA increase during the follow-up, or prior prostatic intraepithelial neoplasia (PIN), or atypical small acinar proliferation (ASAP).
  Intervention: All participants underwent at least two extended prostate needle biopsy protocols.
  Measurements: Clinical and pathologic factors (age, PSA, PSA doubling time, PIN, ASAP, digital rectal exam [DRE]) were analyzed for their ability to predict positive biopsy, and tumour parameters were assessed in patients undergoing radical prostatectomy.
  Results and Limitations: Second, third, and fourth extended 21-sample biopsy procedures yielded a diagnosis of PCa in 18%, 17%, and 14% of patients respectively. Patients with prior PIN had 16% risk of prostate cancer; patients with ASAP had a 42% risk. The mean number of positive cores was 2.19. Prostate volume and PSA density were statistically significant predictors of positive biopsy (p<0.05). For the 43 patients who underwent radical prostatectomy, pathologic findings revealed mean Gleason score of 6.7 (6-8), pT2a-c in 72%, pT3a in16%, and pT4 in 7%. Mean cancer volume was 1.15 cc and 85.2% of tumours were clinically significant (tumour volume > 0.5 cc, Gleason > or = 7 and/or pT3).
  Conclusions: Negative first extended biopsies should not reassure a patient of not having PCa. However, prostate cancers detected after two or more sets of extended procedures, appear to be localized (intracapsular disease) and well-differentiated prostate cancers, although they are still clinically significant.

• Editorial Comment
  The authors report on a large series of extended 21-sample needle biopsies in 2500 consecutive patients with suspect prostate cancer.
  There are several interesting issues for the clinician. First, this procedure was done in an outpatient 2-hour setting with local anesthesia. Next, the results show that with each new round of biopsies roughly 15% of cancers are detected (18%, 17%, 14% for the second, third and forth biopsy procedure, respectively). This leads to the conclusion that in case of continued suspicion the urologist and his/her patient should not give up. Notably, most of these cancers were significant (82.5%). Of the 58 cancers diagnosed, 65% had PSA levels between 4 and 10 ng/ml. Seventy-six percent and 10% had biopsy Gleason sum 6 and 7a (3+4), respectively. Interestingly, of those 43 patients from this group who underwent radical prostatectomy 30% had Gleason sum score 6 and roughly 60% had Gleason sum score 7a, again suggesting an undergrading in core biopsies.
  There are much more details and I recommend the paper for reading.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de