title: Regular transition zone biopsy during active surveillance for prostate cancer may improve detection of pathological progression.
abstract: OBJECTIVE
  We investigated the frequency of cancer and pathological progression in transition zone biopsies in men undergoing multiple rebiopsies while on active surveillance.
  
  
  METHODS
  Eligibility criteria of the active surveillance prostate cancer database (1997 to 2012) at our tertiary center includes prostate specific antigen 10 ng/ml or less, cT2 or less, no Gleason grade 4 or 5, 3 or fewer positive cores, no core with greater than 50% involvement, patient age 75 years or less and 1 or more biopsies after initial diagnostic biopsy. We excluded from analysis men with fewer than 10 cores at diagnostic biopsy and/or confirmatory biopsy greater than 24 months after diagnostic biopsy. Multiparametric magnetic resonance imaging was performed selectively to investigate incongruity between prostate specific antigen and biopsy findings. Pathological progression was defined by grade and/or volume (greater than 50% of core involved). Transition zone progression was subdivided into exclusively transition zone and combined transition zone (transition and peripheral zones). A multivariate Cox proportional hazards model was used to determine predictors of transition zone progression.
  
  
  RESULTS
  A total of 392 men were considered in analysis. Median followup was 45.5 months. At each biopsy during active surveillance (confirmatory biopsy to biopsy 5+) there were transition zone positive cores in 18.6% to 26.7% of cases, all transition zone progression in 5.9% to 11.1% and exclusively transition zone progression in 2.7% to 6.7%. Volume related progression was noted more frequently than grade related progression (24 vs 9 cases). Predictors of only transition zone progression were the maximum percent in a single core (HR 1.99, 95% CI 1.30-3.04, p = 0.002) and cancer on magnetic resonance imaging (HR 3.19, 95% CI 1.23-8.27, p = 0.02).
  
  
  CONCLUSIONS
  Across multiple active surveillance biopsies 2.7% to 6.7% of men had only transition zone progression. We recommend that transition zone biopsy be considered in all men at confirmatory biopsy. Positive magnetic resonance imaging findings or a high percent of core involvement may subsequently be useful to identify patients at risk.
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia. Electronic address: lihmingwong@gmail.com.
authors.forename: Lih-Ming
authors.initials: LM
authors.lastname: Wong
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Ants
authors.initials: A
authors.lastname: Toi
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Theodorus
authors.initials: T
authors.lastname: Van der Kwast
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Greg
authors.initials: G
authors.lastname: Trottier
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Shabbir M H
authors.initials: SM
authors.lastname: Alibhai
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Narhari
authors.initials: N
authors.lastname: Timilshina
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Evans
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Zlotta
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Neil
authors.initials: N
authors.lastname: Fleshner
authors.affiliation: Division of Surgical Oncology, Department of Uro-oncology, Princess Margaret Cancer Center, University Health Network; Department of Radiology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Pathology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia.
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
mesh_terms: D000368:Aged; D001706:Biopsy / Q000379:methods* / Q000592:standards; D003937:Diagnosis, Differential; D018450:Disease Progression; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D060787:Neoplasm Grading; D011467:Prostate / Q000473:pathology*; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013997:Time Factors; D057832:Watchful Waiting / Q000379:methods*
chemical_list: D017430:Prostate-Specific Antigen
keywords: biopsy; magnetic resonance imaging; neoplasm progression; prostate; prostatic neoplasms