Biopsy Strategies—How Many and Where?

  • Joseph C. PrestiJr.
Part of the Current Clinical Urology book series (CCU)


Definitive prostate cancer diagnosis can only be made through histologic evaluation of prostate tissue. Transrectal ultrasound—guided, 10- to 12-core biopsy is the gold standard for practicing urologists and should be routinely used in initial evaluation because this examination contributes significantly to risk stratification models for men with localized cancer. Anterior biopsies may be less significant than other samples in extended biopsy schemes. A greater number of lateral and transition zone—directed needle biopsies may be recommended in men with critical risk factors such as advanced age, substantially elevated prostate-specific antigen (PSA) level, or prostate volume >50 cc. PSA density and PSA transition zone density are also useful in distinguishing prostate cancer from benign prostatic hyperplasia.

The diagnostic value of needle cores is greatly increased if the cores are divided into separate sample bottles, thus pathologic results would be more informative and useful in determining the prognosis of prostate cancer. Simply separating cores into two bottles by laterality has important clinical significance, serving as a guide for repeat biopsy and/or focal therapy if its role becomes established. However, many clinicians do not practice these measures because they increase the cost of biopsy screening.


prostate biopsy biopsy strategy repeat biopsy extended core biopsy PSA density 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Hodge KK, McNeal JE, Terris MK, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 1989;142:71–75.PubMedGoogle Scholar
  2. 2.
    McNeal JE, Redwine EA, Freiha FS, Stamey TA. Zonal distribution of prostatic adenocarcinoma: correlation with histologic pattern and direction of spread. Am J Surg Pathol 1988;12:897–906.PubMedCrossRefGoogle Scholar
  3. 3.
    Stamey TA. Making the most out of six systematic sextant biopsies. Urology 1995;45:2–12.CrossRefPubMedGoogle Scholar
  4. 4.
    Eskew LA, Bare RL, McCullough DL. Systematic 5 region prostate biopsy is superior to sextant method for diagnosing carcinoma of the prostate. J Urol 1997;157:199–203.CrossRefPubMedGoogle Scholar
  5. 5.
    Presti JC Jr, Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial. J Urol 2000;163:163–166.CrossRefPubMedGoogle Scholar
  6. 6.
    Babaian RJ, Toi A, Kamoi K, et al. A comparative analysis of sextant and an extended 11-core multisite directed biopsy strategy. J Urol 2000; 163:152–157.CrossRefPubMedGoogle Scholar
  7. 7.
    Gore JL, Shariat SF, Miles BJ, et al. Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer. J Urol 2001;165:1554–1559.CrossRefPubMedGoogle Scholar
  8. 8.
    Presti JC Jr, O’Dowd G, Miller MC, Mattu R, Veltri RW. Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific antigen and age related cancer rates: results of a community multi-practice study. J Urol 2003;169:125–129.CrossRefPubMedGoogle Scholar
  9. 9.
    Karakiewicz PI, Bazinet M, Aprikian AG, et al. Outcome of sextant biopsy according to gland volume. Urology 1997;49:55–59.CrossRefPubMedGoogle Scholar
  10. 10.
    Rabbani F, Stroumbakis N, Kava BR, Cookson MS, Fair WR. Incidence and clinical significance of false-negative sextant prostate biopsies. J Urol 1998;159:1247–1250.CrossRefPubMedGoogle Scholar
  11. 11.
    Norberg M, Egevad L, Holmberg L, Sparén P, Norlén BJ, Busch C. The sextant protocol for ultrasound-guided core biopsies of the prostate underestimates the presence of cancer. Urology 1997;50:562–566.CrossRefPubMedGoogle Scholar
  12. 12.
    Levine MA, Ittman M, Melamed J, Lepor H. Two consecutive sets of transrectal ultrasound guided sextant biopsies of the prostate for the detection of prostate cancer. J Urol 1998;159:471–476.CrossRefPubMedGoogle Scholar
  13. 13.
    Hong YM, Lai FC, Chon CH, McNeal JE, Presti JC Jr. Impact of prior biopsy scheme on pathologic features of cancers detected on repeat biopsies. Urol Oncol 2004;22:7–10.PubMedGoogle Scholar
  14. 14.
    D’Amico AV, Whittington R, Malkowicz SB, et al. Clinical utility of the percentage of positive prostate biopsies in defining biochemical outcome after radical prostatectomy for patients with clinically localized prostate cancer. J Clin Oncol 2000;18:1164.PubMedGoogle Scholar
  15. 15.
    Freedland SJ, Aronson WJ, Csathy GS, et al. Comparison of percent of total prostate needle biopsy tissue with cancer to percent of cores with cancer for predicting PSA recurrence following radical prostatectomy: results from the SEARCH database. Urology 2003;61:742–747.CrossRefPubMedGoogle Scholar
  16. 16.
    Freedland SJ, Presti JC Jr, Terris MK, et al. Improved clinical staging system combining biopsy laterality and TNM stage for men with T1c and T2 prostate cancer: results from the SEARCH database. J Urol 2003;169:2129–2136.CrossRefPubMedGoogle Scholar
  17. 17.
    Freedland SJ, Aronson WJ, Terris MK, et al. Percent of prostate needle biopsy cores with cancer is a significant independent predictor of PSA recurrence following radical prostatectomy: results from the SEARCH database. J Urol 2003;169:2136–2141.CrossRefPubMedGoogle Scholar
  18. 18.
    King CR, McNeal JE, Gill HR, Presti JC Jr. Extended prostate biopsy scheme improves reliability of Gleason grading: implications for radiotherapy patients. Int J Radiat Oncol 2004;59:386–391.CrossRefGoogle Scholar
  19. 19.
    Benson MC, Whang IS, Olsson CA, et al. The use of prostate-specific antigen density to enhance the predictive value of intermediate levels of serum prostatespecific antigen. J Urol 1992;147:817–821.PubMedGoogle Scholar
  20. 20.
    Benson MC, Whang IS, Pantuck A, et al. Prostate-specific antigen density: a means of distinguishing benign prostatic hypertrophy and prostate cancer. J Urol 1992;147:815–816.PubMedGoogle Scholar
  21. 21.
    Djavan B, Zlotta AR, Remzi M, et al. Total and transition zone prostate volume and age: how do they affect the utility of PSA-based diagnostic parameters for early prostate cancer detection? Urology 1999;54:846–852.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press, a part of Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Joseph C. PrestiJr.
    • 1
  1. 1.Stanford Cancer CenterStanford University School of MedicineStanford

Personalised recommendations