Contemporary Role of Systematic Prostate Biopsies: Indications, Techniques, and Implications for Patient Care

• Published in: European Urology Vol. 63; no. 2; pp. 214 - 230
• Main Authors: Ukimura, Osamu, Coleman, Jonathan A., de la Taille, Alex, Emberton, Mark, Epstein, Jonathan I., Freedland, Stephen J., Giannarini, Gianluca, Kibel, Adam S., Montironi, Rodolfo, Ploussard, Guillaume, Roobol, Monique J., Scattoni, Vincenzo, Jones, J. Stephen
• Format: Journal Article
• Language: English
• Published: Kidlington Elsevier B.V 01.02.2013; Elsevier BV; Elsevier
• Subjects: Biological and medical sciences; Biopsy, Large-Core Needle; Biopsy, Large-Core Needle - methods; Biopsy, Large-Core Needle - statistics & numerical data; Detection; Diagnosis; Digital Rectal Examination; Digital Rectal Examination - statistics & numerical data; Early Detection of Cancer; Early Detection of Cancer - methods; Early Detection of Cancer - statistics & numerical data; EMC MM-03-49-01; Gynecology. Andrology. Obstetrics; Humans; Image-Guided Biopsy; Image-Guided Biopsy - methods; Image-Guided Biopsy - statistics & numerical data; Kallikreins; Kallikreins - blood; Male; Male genital diseases; Medical sciences; Nephrology. Urinary tract diseases; Patient Selection; Prostate; Prostate - diagnostic imaging; Prostate - pathology; Prostate biopsy; Prostate cancer; Prostate-Specific Antigen; Prostate-Specific Antigen - blood; Prostatic Neoplasms; Prostatic Neoplasms - pathology; SDG 3 - Good Health and Well-being; Sensitivity and Specificity; Significant cancer; Tumors; Tumors of the urinary system; Ultrasonography; Urinary tract. Prostate gland; Urology; Diagnosis; Prostate biopsy; Detection; Prostate cancer; Significant cancer; Human; Nephrology; Urinary system disease; Prostate disease; Indication; Malignant tumor; Care; Urology; Anatomic pathology; Biopsy; Technique; Urogenital system; Male genital diseases; Prostate; Cancer
• ISSN: 0302-2838; 1873-7560; 1873-7560
• DOI: 10.1016/j.eururo.2012.09.033

Prostate cancer (PCa) screening to detect early stage PCa has resulted in increased identification of small-volume, low-grade PCa, many of which meet criteria for clinically indolent disease. Nevertheless, there remains some degree of underdetection of high-risk PCa in substantial numbers of men despite current diagnostic strategies. To discuss the contemporary role of prostate biopsy (PB), focusing on the indications, techniques, and limitations of current PB techniques and evolving techniques affecting patient care. A comprehensive Medline search was performed using the medical subject heading search terms prostate cancer, detection, prostate biopsy, significant cancer, and diagnosis, with restriction to the English language. Emphasis was given to publications within the past 5 yr. Because abnormal digital rectal examination (DRE) and prostate-specific antigen (PSA) tests alone lack specificity for cancer, there is no universal indication for PB. This lack has inspired exploration for a cancer-specific biomarker and prediction tools such as risk calculators. Indication for biopsy should involve a balance between the underdiagnosis of high-risk cancers and the potential risks for the overdetection of clinically insignificant cancers as well as biopsy-related morbidity. Evidence supports the inclusion of laterally directed cores during transrectal ultrasound (TRUS) PB in addition to the traditional sextant pattern, which significantly improves cancer detection without a demonstrable increase in morbidity. These data indicate that such PB templates, typically 12 cores, represent the optimal template in initial PB. Optimised techniques and templates for repeat PB remain controversial. However, debate continues regarding indications, sampling number, and location as well as on the potential of modern image-guided approaches or three-dimensional (3D) mapping biopsy in this unique setting. Additional limitations of repeat PB techniques include associated procedural risks if general anaesthesia is required and inherent sampling errors of template-based techniques that are not targeted to the specific tumour site. Current data support the utility of extended PB templates for initial TRUS PB intended to detect clinically significant PCa. Repeat PB in the setting of prior negative PB on the grounds of clinical suspicion or for risk-stratified approaches to management of low risk PCa requires balancing overdetection of low-risk cancer with the potential to miss significant cancer. Several options, including modern image-guided targeting, biomarker development, transrectal saturation PB, and 3D template mapping PB, are changing the clinical paradigms for evaluation and management. Evidence to support adopting approaches other than the current established standards should be tested through appropriately designed prospective studies. To improve prostate cancer diagnosis and management, this review identifies the importance of considering individual risk factors and patient-specific goals at various points in the patient's care to determine the indication for and technique used in prostate biopsy.