Pathological Features Of Prostate Biopsy When To Stop

Little was reported on the differences in pathological stage, grade and cancer behavior of cancers detected on initial and repeat prostate biopsy. Although optimal predictors of cancer detection on repeat biopsy are crucial, one can spare or delay a repeat biopsy if the cancers detected are 'insignificant'. Certainly the dilemma of prostate cancer is that only a small proportion of men with untreated cancer will die from it, especially if these are small in volume, well differentiated and detected on repeat biopsy.

In a recent study, Djavan etal. showed that of cancers detected on initial (n = 231) and repeat biopsy (n = 83), 148 out of 231 (64%) and 56 out of 83 (67.5%) had clinically localized disease, respectively, and were offered radical prostatectomy or radiation therapy.25 Watchful waiting was not offered as a primary option. Ten out of 148 (6.7%) and 3 out of 56 (5.3%), respectively, opted for radiation therapy, and thus 138 out of 148 (93.2%) and 53 out of 56 (94.6%), respectively, underwent radical retropubic prostatectomy. All specimen underwent histopathological evaluation by a single pathologist. Overall, 58.0% and 60.9% had organ-confined disease in both groups, respectively. No differences were noted with respect to organ confinement (P=0.15), extracapsular extension (P=0.22) and seminal vesical invasion (P=0.28). Positive margins were noted in 23% and 18%, respectively (P=0.23). No differences were noted between both cancer groups (initial vs. repeat) in the biopsy Gleason score (6.0 vs. 5.7; P=0.252) as well as in Gleason score of the surgical specimen (5.3 vs. 4.9; P = 0.358). The same accounted for the % Gleason grade 4/5 (31.1% vs. 29.8%; P=0.10). In contrast, cancers detected on initial biopsy expressed a higher rate of multifocality (P=0.009), whereas overall cancer volume was identical (p=0.271) in both groups.25

Recently, Stamey etal. challenged the 'traditional' predictors of cancer progression, such as stage, capsular penetration and surgical margins.40 In a retrospective analysis of 379 men treated by radical prostatectomy only, eight morphologic variables were analyzed and associated with cancer progression, defined by an increasing PSA level (^0.07 ng/ml). They identified % Gleason score 4/5, cancer volume, positive lymph node findings and intraprostatic vascular invasions as independent predictors of cancer progression.40

In contrast, cancers detected on initial biopsy expressed a higher rate of multifocality (P = 0.0009), whereas overall cancer volume was identical (P=0.271) in both groups. Based on these findings, Djavan et al. concluded that cancers detected on repeat biopsy exhibit similar characteristics as cancers detected initially.25 Thus, repeat biopsies do detect significant cancers and a repeat biopsy policy should be advocated in case of a negative initial biopsy. This conclusion, however, is limited to cases in which initial and repeat biopsies are performed in a similar fashion, as was done in the current study. If the biopsy technique is modified, cancers detected may differ and the conclusion may differ as well.

In a recent study, Djavan et al. presented the results of a prospective study of the pathological features find in first, second, third and fourth prostate biopsy. Of those with benign prostatic tissue on the first, second and third biopsy, 820 out of 829, 737 out of 756 and 94 out of 101 agreed to undergo repeat biopsy. Cancer detection rates on first, second, third and fourth biopsy were 22% (231 out of 1051), 10% (83 out of 820), 5% (36 out of 737) and 4% (4 out of 94), respectively. Overall, of patients with clinically localized disease (67% of cancers detected), 86% underwent radical prostatectomy and 14% opted for watchful waiting or radiation therapy. Of cancers detected on initial (n = 231), repeat (n = 83), third (n = 36) and fourth biopsy (n = 4), 148 out of 231 (64%), 56 out of 83 (67.5%), 33 out of 36 (91.6%) and 4/4 (100%) had a clinically localized disease, respectively, and were offered radical prostatectomy or radiation therapy. Watchful waiting was not offered as a primary option. Ten out of 148 (6.7%), 3 out of 56 (5.3%), 1 out of 33 (3%) and 0 out of 4 (0%), respectively, opted for radiation therapy, and thus 138 out of 148 (93.3%), 53 out of 56 (94.7%), 32 out of 33 (97%) and 4 out of 4 (100%), respectively, underwent radical retropubic prostatectomy. All specimens underwent histopathological evaluation by a single pathologist at each institution. Overall, 58.0%, 60.9%, 86.3% and 100% had organ-confined disease on first, repeat, third and fourth biopsy, respectively. No differences were noted with respect to organ confinement (OC) (P=0.15), extracapsular extension (ECE) (P=0.22) and seminal vesical invasion (SV) (P=0.28) between first and repeat biopsy, whereas the same parameters were significantly different (higher values for organ confinement and lower for all other parameters) for cancers on third versus first biopsy (P = 0.001, P=0.02, P = 0.01, respectively) as well as cancers on fourth versus first biopsy (p = 0.001, P = 0.01, P=0.001, respectively). Positive margins (M+) were noted in 23%, 18% (P = 0.23), 8% (P=0.03) and 0%, respectively. No differences were noted between cancers detected on initial versus repeat biopsy in the biopsy Gleason score (6.0 vs. 5.7; P = 0.252) as well as in Gleason score of the surgical specimen (5.3 vs. 4.9; P=0.358). The same accounted for the % Gleason grade 4/5 (31.1% vs. 29.8%; P=0.10). Cancers detected on initial biopsy expressed a higher

Table 9.2. Cancer characteristics and grading of prostate cancers detected on first, second, third and fourth repeat biopsy.

First biopsy

Second biopsy

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