Critical evaluation of the current indications for transition zone biopsies

Objectives. Two primary indications for the performance of anteriorly directed transition zone (TZ) biopsies are (a) an elevated prostate-specific antigen (PSA) level and an enlarged, non-nodular prostate and (b) prior negative sextant biopsies of the prostate. These indications are, however, based on a study population evaluated early in the PSA era (1989 to 1992). The current analysis targeted a more contemporary series of patients (1995 to 2000) presenting with these two indications for TZ biopsies, who underwent ultrasound scanning and biopsies by the same examiner and with the same equipment as in the earlier series. Methods. We evaluated 390 men, 274 (70.3%) of whom underwent sextant plus TZ biopsies for elevated PSA levels and an enlarged, non-nodular prostate; 116 (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 anterior biopsies for an enlarged, non-nodular prostate, 49 (17.9%) were found to have adenocarcinoma and in only 4 (1.5%) did only the TZ biopsies reveal cancer. Of the 116 patients who underwent TZ biopsies after prior negative sextant biopsies, 36 (31.0%) were found to have prostate cancer and in 11 (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 prostates was substantially lower than the rate in earlier reports (1.5% compared with 36.9%), despite the consistency in the equipment and examining physician. This may have been due to the stage migration of prostate cancer, which has been observed as a result of the widespread use of PSA measurement for early detection. Sextant plus TZ biopsies are more productive in patients with prior negative biopsies who have a persistent clinical suspicion for prostate cancer on the basis of an elevated and/or rising PSA level.