To evaluate whether core length impacts biopsy accuracy and Gleason score underestimation compared to radical prostatectomy (RP) specimens.
From 2010 to 2011, 8,928 cores were trans-rectal obtained from 744 consecutive patients (178 RP, 24 %), 557 by an experienced performer (>250/year) and 187 (25 %) by in-training urology residents. Prospectively analyzed variables were core length, age, prostate volume, free and total prostate-specific antigen (PSA), PSA density and free/total PSA ratio.
Mean core length for Gleason upgrading on RP (42.7 %, n = 76) was 11.61 (±2.5, median 11.40) compared to 13.52 (±3.2, median 13.70), p < 0.001 for perfect biopsy-RP Gleason agreement (57.3 %, n = 102). In multivariate analysis, for each unit of core length increment in millimeter, the Gleason upgrading risk decreased 89.9 %, p = 0.049 [odds ratio (OR) 0.10, 95 % confidence interval (CI) 0.01–0.99]. Biopsy positivity between experienced (35.5 %) and in-training performer (30.1 %) was not significantly different (p = 0.20), with comparable mean patient age (65.1 vs. 64.1), prostate volume (52.3 vs. 50.7) and median PSA (5.2 vs. 5.1), respectively. Denoting wider variability in terms of core length, in-training performers obtained significantly larger cores for positive biopsies (11.33 ± 3.42 vs. 10.83 ± 3.68), p = 0.043, compared to experienced performer (11.39 ± 3.36 vs. 11.37 ± 3.64), p = 0.30. In multivariate analysis, PSA density (OR 1.14, 95 % CI 1.02–1.28) and age (OR 1.04, 95 % CI 1.01–1.07) were significantly associated with biopsy positivity, p = 0.021 and p = 0.011, respectively.
While core length on trans-rectal biopsy independently affects Gleason upgrading on RP specimens, performer experience has minor impact on Gleason discordance or biopsy positivity due to a sharp learning curve.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
American urological association
European association of urology
International society of urological pathology
European randomized study of screening for prostate cancer
Digital rectal examination
Bjurlin MA, Carter HB, Schellhammer P et al (2013) Optimization of initial prostate biopsy in clinical practice: sampling, labeling, and specimen processing. J Urol 189(6):2039–2046
Reis LO, Reinato JA, Silva DC et al (2010) The impact of core biopsy fragmentation in prostate cancer. Int Urol Nephrol 42(4):965–969
Ukimura O, Coleman JA, de la Taille A et al (2013) Contemporary role of systematic prostate biopsies: indications, techniques, and implications for patient care. Eur Urol 63(2):214–230
Van der Kwast T, Bubendorf L, Mazerolles C et al (2013) Guidelines on processing and reporting of prostate biopsies: the 2013 update of the pathology committee of the European randomized study of screening for prostate cancer (ERSPC). Virchows Arch 463(3):367–377
Billis A, Quintal MM, Meirelles L et al (2014) The value of the 2005 international society of urological pathology (ISUP) modified Gleason grading system as a predictor of biochemical recurrence after radical prostatectomy. Int Urol Nephrol 46(5):935–940
Ficarra V, Martignoni G, Novella G et al (2006) Needle core length is a quality indicator of systematic transperineal prostate biopsy. Eur Urol 50(2):266–271
Cormio L, Scattoni V, Lorusso F et al (2014) Prostate cancer detection rates in different biopsy schemes. Which cores for which patients? World J Urol 32(2):341–346
Durmus T, Goldmann U, Baur AD et al (2013) MR-guided biopsy of the prostate: comparison of diagnostic specimen quality with 18 G and 16 G biopsy needles. Eur J Radiol 82(12):e749–e754
Reis LO, Zani EL, Freitas LL et al (2013) Higher prostate weight is inversely associated with Gleason score upgrading in radical prostatectomy specimens. Adv Urol. 2013:710421
Colleselli D, Pelzer AE, Steiner E et al (2010) Upgrading of Gleason score 6 prostate cancers on biopsy after prostatectomy in the low and intermediate PSA range. Prostate Cancer Prostatic Dis. 13(2):182–185
Helpap B, Köllermann J (2012) Combined histoarchitectural and cytological biopsy grading improves grading accuracy in low-grade prostate cancer. Int J Urol 19(2):126–133
Descazeaud A, Rubin MA, Allory Y et al (2005) What information are urologists extracting from prostate needle biopsy reports and what do they need for clinical management of prostate cancer? Eur Urol 48(6):911–915
Berney DM, Algaba F, Camparo P et al (2014) Variation in reporting of cancer extent and benign histology in prostate biopsies among European pathologists. Virchows Arch 464(5):583–587
Kanao K, Eastham JA, Scardino PT et al (2013) Can transrectal needle biopsy be optimised to detect nearly all prostate cancer with a volume of ≥0.5 mL? A three-dimensional analysis. BJU Int. 112(7):898–904
Lawrentschuk N, Toi A, Lockwood GA et al (2009) Operator is an independent predictor of detecting prostate cancer at transrectal ultrasound guided prostate biopsy. J Urol 182(6):2659–2663
Hori S, Fuge O, Trabucchi K et al (2013) Can a trained non-physician provider perform transrectal ultrasound-guided prostatic biopsies as effectively as an experienced urologist? BJU Int. 111(5):739–744
Benchikh El Fegoun A, El Atat R, Choudat L et al (2013) The learning curve of transrectal ultrasound guided prostate biopsies implications for training programs. Urology 81(1):12–15
Han M, Chang D, Kim C et al (2012) Geometric evaluation of systematic transrectal ultrasound guided prostate biopsy. J Urol 188(6):2404–2409
Bostwick DG, Qian J, Drewnowska K et al (2010) Prostate needle biopsy quality in reduction by dutasteride of prostate cancer events study: worldwide comparison of improvement with investigator training and centralized laboratory processing. Urology. 75(6):1406–1410
Öbek C, Doğanca T, Erdal S et al (2012) Core length in prostate biopsy: size matters. J Urol 187(6):2051–2055
Fiset PO, Aprikian A, Brimo F (2013) Length of prostate biopsy cores: does it impact cancer detection? Can J Urol. 20(4):6848–6853
Siadat F, Sykes J, Van der Kwast TH (2013) Length matters in prostate cancer. Can J Urol. 20(4):6854
Iczkowski KA, Casella G, Seppala RJ et al (2002) Needle core length in sextant biopsy influences prostate cancer detection rate. Urology 59(5):698–703
We would like to thank Wagner França for help with data collection.
Conflict of interest
The authors declare that they have no conflict of interest.
Performed in accordance with the institutional ethical guidelines ethical standards laid down in the 1964 Declaration of Helsinki its later amendments.
About this article
Cite this article
Reis, L.O., Sanches, B.C.F., de Mendonça, G.B. et al. Gleason underestimation is predicted by prostate biopsy core length. World J Urol 33, 821–826 (2015). https://doi.org/10.1007/s00345-014-1371-9
- Trans-rectal biopsy
- Technique optimization
- Pathology report
- Radical prostatectomy
- Learning curve