title: Prostate cancer diagnosis: should patients with prostate specific antigen >10ng/mL have stratified prostate biopsy protocols?
abstract: BACKGROUND
  Trans-rectal ultrasound (TRUS) guided systematic prostate biopsy is a standard tool in prostate cancer (CaP) diagnosis. Extended biopsy techniques using 10-12 cores are the norm. Controversy exists on extended TRUS biopsy in men with PSA>10ng/mL. We evaluated cancer detection rates on an individual core basis, to stratify prostate biopsy protocols based on PSA levels.
  
  
  METHODS
  Over a five-year period, 1036 patients underwent TRUS guided prostate biopsy for raised serum PSA (>2.5ng/mL). 436 patients had PSA>10ng/mL. Patients with PSA<50ng/mL underwent a 12-core TRUS guided prostate biopsy including six peripheral biopsies. The six peripheral biopsies were directed laterally towards the base, mid-zone and apices. Remainder were standard para-sagittal sextant biopsies. Patients were stratified into three groups (PSA 10-20ng/mL, 20-50ng/mL and >50ng/mL).
  
  
  RESULTS
  Mean age of 436 patients with PSA>10ng/mL was 70.3years. 270 (62%) men had cancer. Cancer detection rates for different PSA levels were 46% (10-20ng/mL), 76% (20-50ng/mL) and 93% (>50ng/mL). Higher PSA levels and advanced clinical stage were associated with increased cancer detection rates. All patients with clinical T3 and T4 disease had biopsy diagnosed CaP.
  
  
  CONCLUSIONS
  TRUS guided prostate biopsy in patients with PSA>10ng/mL did not require 12 cores to diagnose CaP. CaP diagnosis required 8 cores in men with PSA 10-20ng/mL. These cores were right and left peripheral basal and apical, and right and left para-sagittal basal and apical biopsy. Only 6 cores were necessary to diagnose CaP in men with PSA>20ng/mL which were right and left peripheral basal and apical, and para-sagittal apical biopsies. We suggest limited TRUS prostate biopsy protocols for men with PSA>10ng/mL.
authors.affiliation: Department of Urology, Leighton Hospital, Crewe, Cheshire, CW1 4QJ UK. indianajoe@gmail.com
authors.forename: Joe
authors.initials: J
authors.lastname: Philip
authors.forename: Ramaswamy
authors.initials: R
authors.lastname: Manikandan
authors.forename: Pradip
authors.initials: P
authors.lastname: Javlé
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Foster
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000379:methods; D002985:Clinical Protocols; D055088:Early Detection of Cancer; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011467:Prostate / Q000000981:diagnostic imaging* / Q000473:pathology*; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology; D014463:Ultrasonography
chemical_list: D017430:Prostate-Specific Antigen