Joseph C. Presti

EXTENDED PERIPHERAL ZONE BIOPSY SCHEMES INCREASE CANCER DETECTION RATES AND MINIMIZE VARIANCE IN PROSTATE SPECIFIC ANTIGEN AND AGE RELATED CANCER RATES: RESULTS OF A COMMUNITY MULTI-PRACTICE STUDY

PURPOSE We assessed the impact of age and prostate specific antigen (PSA) on extended systematic biopsy schemes for detecting prostate carcinoma and better characterized these tumors as a function of patient age and PSA. MATERIALS AND METHODS We retrospectively reviewed the records of 2,299 consecutive patients who underwent initial systematic biopsy performed by 167 community based urologists. A total of 12 systematic biopsies of the peripheral zone were obtained in all patients. Various biopsy schemes were then created and cancer detection rates were calculated. Data analyses were stratified by patient age and PSA. RESULTS On biopsy 1,020 patients (44.4%) had cancer. Detection rates increased with increasing patient age. Increasing age and PSA were associated with larger, higher grade tumors. Overall and unique site specific cancer detection rates were highest for laterally directed biopsies and the apical biopsy of the standard sextant scheme. The 12 site biopsy scheme outperformed all other schemes in patients with PSA 7 ng./ml. or less and in those 60 years or younger. The variation in age related and PSA related detection rates was greatest for the standard sextant scheme and this variability decreased for extended biopsy schemes. CONCLUSIONS This multi-practice community based study confirms the inadequacy of sextant biopsies and emphasizes the need for extended peripheral zone sampling of the lateral aspect of the prostate. Generally increasing patient age and PSA were associated with larger, higher grade tumors. Extended biopsy schemes minimize PSA and age related detection rates.

The Impact of Tumor Volume on Outcomes after Radical Prostatectomy: Implications for Prostate Cancer Screening

Purpose: For screening to make an impact on prostate cancer mortality, detection of potentially lethal cancers at an early stage when they are low volume should result in improved recurrence and death rates after treatment. Patients and Methods: The effect of tumor volume on prostate cancer recurrence and death was evaluated in 764 men who underwent radical prostatectomy between 1984 and 2004, with particular attention focused on patients with moderate and high risk features. Results: Tumor volume was a powerful predictor of recurrence in men after radical prostatectomy with moderate and high risk features, even after accounting for the effects of percentage Gleason pattern 4/5 cancer, extracapsular extension, seminal vesicle invasion, lymph node metastasis, pre-operative PSA, and surgical margin involvement. In a subset of 159 patients for whom pre-operative PSA velocity was available, tumor volume predicted recurrence in those in the highest risk category (PSAV > 2 ng/ml/yr). Tumor volume, along with percent grade 4/5 and positive surgical margins, was sig- nificantly associated with prostate cancer specific death. Conclusions: The association of volume with outcome after radical prostatectomy, particularly in high risk patients, sug- gests that screening has made a positive impact on prostate cancer mortality. Future screening efforts should be directed at finding cancers with moderate and high risk features at low volume.

Repeat Prostate Biopsy Strategies: How Many and Where?

Patients with a negative prior prostate biopsy yet a persistently elevated or rising PSA level represent a challenge to the practicing urologist. Anxiety often exists in the patient, the family, and the referring primary care physician. Tremendous variation exists among physicians in the approach to these patients. Controversy exists with respect to the use of various markers to determine the need for additional biopsy, specific biopsy technique used, and significance of cancers found in this setting. Each of these will be addressed in this chapter. This chapter will not address patients who have either high-grade prostatic intraepithelial neoplasia (HGPIN) or atypical small acinar proliferation (ASAP) on their prior biopsy as this is covered elsewhere in this book.