Fred Lee

The American Cancer Society National Prostate Cancer Detection Project. Findings on the detection of early prostate cancer in 2425 men.

The American Cancer Society National Prostate Cancer Detection Project (ACS‐NPCDP) is a multidisciplinary, multicenter effort to assess the feasibility of early prostate cancer detection by digital rectal examination (DRE), transrectal ultrasound (TRUS), and prostate specific antigen (PSA) assay. By June 1990, 2425 men not previously suspected of having prostate cancer had been examined in ten participating clinical centers according to the project protocol. Three hundred ninety‐six men (16.3%) were recommended for biopsy on the basis of TRUS or DRE. An analysis of the results of 330 completed biopsies showed 52 cancers detected by DRE and/or TRUS. Forty‐four (84.6%) of the men with cancer had positive TRUS examination results compared with 33 (63.5%) with positive DRE. Five additional cancers were discovered as a result of elevated PSA levels. The overall detection rate was 2.4% and this rate varied by age. The detection rate in men 55 to 60 years of age was 1.3% and this rose to 3.3% in men older than 65 years of age. The estimated sensitivity was significantly greater for TRUS compared with DRE (77.2% versus 57.9%; P < 0.05). The estimated specificity of DRE was greater than that of TRUS (96.3% versus 89.4%; P < 0.01). The positive predictive value (PPV) for the tests varied as a function of patient and disease characteristics. The overall PPV was 28.0% for DRE and 15.2% for TRUS. The occurrence of elevated PSA levels significantly increased the PPV of both TRUS and DRE. The majority of cancers detected were at early stages. These preliminary data suggest the feasibility of using these techniques to promote cancer control, but additional data and follow‐up are needed to assess the significance of the results.

Prostate cancer: Transrectal ultrasound and pathology comparison. A preliminary study of outer gland (peripheral and central zones) and inner gland (transition zone) cancer

A study was conducted to compare results of transrectal ultrasound with pathologic findings on 116 patients who underwent radical prostatectomy for treatment of prostate cancer. In 96% (111 of 116), transrectal ultrasound guided biopsies of a hypoechoic lesion proved cancer; seven patients had known Stage A cancer; one patient had cancer detected by palpation and not detected by ultrasound. Cancers in the outer gland (peripheral and central zones) were compared with cancers in the inner gland (transition zone) by both ultrasound and pathology. Forty‐eight percent (52 of 108) of cancers originating in the outer gland showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the outer gland were the prostatic capsule (38%), anterior fibromuscular stroma (5%), seminal vesicle (18%), the base of the gland at the neurovascular bundle (21%), and the apex (31%). Twenty‐two percent (17 of 54) of cancers originating in the inner gland (transition zone) showed extraprostatic extension (Stage C disease). The primary sites of tumor escape from the inner gland were the anterior fibromuscular stroma (6%) and apex (11%). Both histologic and biologic differences between outer and inner gland cancers were found when tumor size was controlled. Gleason scores were significantly different for inner and outer gland cancers, with mean scores of 6.2 ± 1.6 and 7.4 ± 0.9, respectively. An odds ratio of 8.6 confirmed the increased risk of extraprostatic extension for outer gland cancer. Outer gland cancers showed increased aggressive behavior of both histologic and biologic nature. The difference in biologic aggressiveness of outer and inner gland cancers has definite implications for treatment options. Use of other diagnostic parameters, such as DNA ploidy, may help to determine which cancers to treat and when to treat them; this may have more relevance for cancers originating in the inner gland. Strategic transrectal ultrasound guided biopsy affords accurate tumor mapping and staging when modes of internal spread and escape of cancer from both outer and inner gland are known. Thus, transrectal ultrasound may be our “window of observation” through which additional research may explain the histologic and biologic discrepancies between outer and inner gland cancers.

American cancer society–national prostate cancer detection project. Results from multiple examinations using transrectal ultrasound, digital rectal examination, and prostate specific antigen

Background. The American Cancer Society–National Prostate Cancer Detection Project is a prospective study of the feasibility of early prostate cancer detection by digital rectal examination (DRE), transrectal ultrasound (TRUS), and prostate specific antigen (PSA). Two thousand nine hundred ninety‐nine men not previously suspected of having prostate cancer have been entered on study in ten participating clinical centers.

Use of transrectal ultrasound in diagnosis, guided biopsy, staging, and screening of prostate cancer.

TRUS allows visualization of the internal anatomy of the prostate gland. Knowledge of zonal prostate anatomy allows more accurate staging of prostate cancer by use of strategic TRUS-guided biopsy of sites of possible tumor extension. These biopsies may be facilitated via the transrectal route using an automatic Biopsy system. TRUS is twice as sensitive as DRE and is capable of detecting nonpalpable prostate cancer. TRUS can detect nonpalpable tumors with average dimensions as small as 1.0 cm. This size is considered to be clinically significant.

Transrectal ultrasound: diagnosis and staging of prostatic carcinoma

Transrectal ultrasound has developed into a sophisticated technology since its first clinical application, and ultrasound imaging is now widely accepted. When 7 MHz scanning was introduced in 1986, improved resolution depicted an infrastructure of the prostate that corresponded to McNeals 1968 concept of zonal prostate anatomy. McNeals definition of three glandular zones (i.e., transition, central, and peripheral) and one nonglandular region (i.e., anterior fibromuscular stroma) has allowed us to identify areas of anatomic weakness through which cancer may escape the prostate. These glandular zones have sites of anatomic weakness through which cancer may easily extend to the extraprostatic space, thus affecting eventual staging. Highly accurate, easy to perform, and readily accepted by patients, strategic ultrasound-guided transrectal biopsy can accurately sample all areas within the prostate, including areas of anatomic weakness.

Panel I: Detection and screening for prostate cancer

The group agreed on the following statements. First, there is no current evidence to support that early diagnosis or screening will reduce mortality or morbidity from prostate cancer. Second, digital rectal examination (DRE), serum prostate specific antigen (PSA), transrectal ultrasound (TRUS), and prostatic biopsy (PBx) are currently useful in the detection of prostate cancer (PSA, along with DRE in men older than 50 years of age has increased the detection rate of prostatic cancer). Given the current state of medical knowledge, sufficient information to establish guidelines for their specific use does not exist. The appropriate use of these diagnostic tests must therefore be the decision of the physician for each individual patient’s situation. TRUS should be reserved for cases with an abnormal DRE result or elevated serum PSA. The committee subsequently agreed that some mention of PSA in relation to DRE should be incorporated into

Transrectal ultrasound. A case report related to the natural history of prostate cancer

This is a case report of a man with prostate cancer diagnosed 10 years ago by digital rectal examination and prostatic biopsy. He was followed with serial transrectal ultrasound examinations for the last 22 months. Transrectal ultrasound enabled us to observe the natural history of his cancer. Because of accelerated tumor growth, a radical prostatectomy was performed. The tumor was confined within the prostate capsule and thus considered a “cure.” Transrectal ultrasound is an invaluable tool for continuous monitoring of patients with prostate cancer.