Critical evaluation of the current indications for transition zone biopsies

Objectives. Two primary indications for the performance of anteriorly direc ted transition zone (TZ) biopsies are (a) an elevated prostate-specific ant igen (PSA) level and an enlarged, non-nodular prostate and (b) prior negati ve sextant biopsies of the prostate. These indications are, however, based on a study population evaluated early in the PSA era (1989 to 1992). The cu rrent analysis targeted a more contemporary series of patients (1995 to 200 0) presenting with these two indications for TZ biopsies, who underwent ult rasound scanning and biopsies by the same examiner and with the same equipm ent as in the earlier series. Methods. We evaluated 390 men, 274 (70.3%) of whom underwent sextant plus T Z biopsies for elevated PSA levels and an enlarged, non-nodular prostate; 1 16 (28.7%) underwent this biopsy strategy because of an elevated or rising PSA in whom prior sextant biopsies had not revealed cancer. Results. Of the 274 patients who underwent initial sextant biopsies plus an terior biopsies for an enlarged, non-nodular prostate, 49 (17.9%) were foun d to have adenocarcinoma and in only 4 (1.5%) did only the TZ biopsies reve al cancer. Of the 116 patients who underwent TZ biopsies after prior negati ve sextant biopsies, 36 (31.0%) were found to have prostate cancer and in 1 1 (9.5%) only the TZ biopsies demonstrated cancer. Conclusions. The cancer detection rate for sextant plus TZ biopsies in this contemporary series of patients presenting with enlarged, non-nodular pros tates was substantially lower than the rate in earlier reports (1.5% compar ed with 36.9%), despite the consistency in the equipment and examining phys ician. This may have been due to the stage migration of prostate cancer, wh ich has been observed as a result of the widespread use of PSA measurement for early detection. Sextant plus TZ biopsies are more productive in patien ts with prior negative biopsies who have a persistent clinical suspicion fo r prostate cancer on the basis of an elevated and/or rising PSA level. UROL OGY 57: 1117-1120, 2001. (C) 2001, Elsevier Science Inc.