Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature

UROLOGICAL SURVEY

Pathology

Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature

Chun FK, Epstein JI, Ficarra V, Freedland SJ, Montironi R, Montorsi F, Shariat SF, Schröder FH, Scattoni V

Department of Urology, University Hospital Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany

Eur Urol. 2010 Sep 4. [Epub ahead of print]

Context: The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate.

Objective: Our aim was to review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy.

Evidence Acquisition: A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Results were restricted to the English language, with preference given to those published within the last 3 yr.

Evidence Synthesis: At initial biopsy, a minimum of 10 but not > 18 systematic cores are recommended, with 14-18 cores in glands = 50cm(3). Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (= 20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3-6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound-guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative.

Conclusions: The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.

Editorial Comment

The article is from a selected group of uropathologists giving several recommendations for optimizing performance and interpretation of prostate biopsies. The highlights are:

a) At initial biopsy, a minimum of 10 but not more than 18 systematic cores;

b) In cases of glands iqual or larger than 50 cm3, 14-18 cores;

c) Transition zone cores are not recommended in the initial biopsy setting;

d) An immediate repeat biopsy is not indicated for prior high-grade intraepithelial neoplasia (HGPIN) given an adequate extended initial biopsy;

e) Biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3-6 months.

Note that the authors do not use the term ASAP but "suspicious but not diagnostic of cancer". The term ASAP for "atypical small acinar proliferation" was coined by Iczkowski et al. in 1997 (1), however is not recommended by uropathologists. In a consensus meeting in 2004 sponsored by the World Health Organization (2), the committee members recommended designating ASAP as either suspicious or highly suspicious for cancer. The reasons for this include the equation by some urologists of the term ASAP with HGPIN, and because all of the atypical foci are not always "small" acinar but may include glands with a larger diameter (such as pseudohyperplastic pattern of cancer or adenocarcinoma with ductal features).

Dr. Athanase Billis

Full-Professor of Pathology

State University of Campinas, Unicamp

Campinas, São Paulo, Brazil

E-mail: [e-mail]

• 1. Iczkowski KA, MacLennan GT, Bostwick DG: Atypical small acinar proliferation suspicious for malignancy in prostate needle biopsies: clinical significance in 33 cases. Am J Surg Pathol. 1997; 21: 1489-95.
• 2. Amin M, Boccon-Gibod L, Egevad L, Epstein JI, Humphrey PA, Mikuz G, Newling D, Nilsson S, Sakr W, Srigley JR, Wheeler TM, Montironi R: Prognostic and predictive factors and reporting of prostate carcinoma in prostate needle biopsy specimens. Scand J Urol Nephrol Suppl. 2005; 216: 20-33.

Publication Dates

• Publication in this collection
  06 Dec 2010
• Date of issue
  Oct 2010