Coninne

H. Dyke,

Value Prostate

MD

#{149} Ants

Toi,

of Random Biopsy’

One hundred sixty-four men underwent ultrasound-guided transrectal biopsy of a hypoechoic prostatic nodule suspicious for malignancy, and random biopsy of normal-appearing areas of the gland. The contribution of random biopsy to diagnosis, staging, and management of prostatic carcinoma was evaluated. A diagnosis of carcinoma was made in 71 patients (43.3%). Carcinoma was diagnosed at biopsy of only the nodule in 56 of these patients (79%), at both the nodule and random biopsy site in 10 (14%), and only at the random biopsy site in five (7%). Random biopsy did not result in significant alteration of clinical staging. However, management was altered in five patients with positive results at random biopsy only, four of whom underwent surgery. The additional yield from random prostatic biopsy was small but distinct and had clinical relevance. The authors conclude that random biopsy is a useful procedure in the evaluation of patients with prostatic nodules. Index terms: tate, neoplasms, 844.1298

Prostate, 844.32

#{149} Ultrasound

Radiology

1990;

biopsy, 844.126 #{149} ProsProstate, US studies,

#{149}

(US)

guidance,

844.126

176:345-349

MD,

FRCP

#{149} Joan

M. Sweet,

US-guided

P

ROSTATE

with slow

is the

third

of cancer death it is a common

a potentially to manifest

dire clinical

lead-

in men disease

outcome, signs.

estimated that 30% of men over the age of 45 years harbor latent prostate cancer (1). In many of these men it will remain latent until death. However, it is further estimated that approximately 1% of latent disease is clinically

diagnosed

each

method

prostate trasound

year

(1).

biopsy have opsy to the

expanded diagnosis

cancer (5-7). It has that this may result

Transrectal TRUS-guided

the role of biof nonpalpable

been suggested in earlier diagno-

sis of prostate cancer at curable stages (7). Prostate carcinoma at TRUS has several characteristics. It is most commonly located in the peripheral portion of the gland (8), and it is generally seen as a hypoechoic nodule

suggested but this common

(12,13). specimens

of pathologic that 24%-39%

US

normal

evaluation has shown

prostate

important cates that

a hyis now

(14-16).

also

often

(17).

These

dude (C.H.D., A.T.) ty of Toronto, Elizabeth Received

January cepted

and Pathology Toronto General

St. Toronto, December

AT. 1990

(J.M.S.), Hospital,

Ont, Canada 8, 1989; revision

29, 1990; revision April 20. Address

RSNA,

of Radiology

received reprint

Universi200

M5G 2C4. requested

April requests

10; acto

This

is an

bilateral

random

facts

palpable carcinoma

and

multifocal

prompted

biopsy

or lais

us to in-

in men

going biopsy of a clinically sonically suspicious nodule.

underor ultra-

In performing this study, we questioned whether TRUS-guided random prostatic biopsies altered (a) the detection of prostate carcinoma, (b) the staging of prostate carcinoma,

nodule

METHODS

consisted

with

of 164 con-

a solitary

visible

referred

hypoechoic

at TRUS.

for TRUS

(69.5%),

stage

A carcinoma

transurethral (TURP) (n

They

and TRUS-guided

needle biopsy between January June 1989. Reasons for referral palpable nodule or abnormality

1988 and included a (n 114)

detected

resection

of the

at

prostate

= 14) (8.5%), prostatism (n 10) (6.1%), elevated prostatic enzymes (n 8) (4.9%), a nodule detected at TRUS examination at another institution (n = 5) (3.0%), hematospermia (n = 3) (1.8%), other (n 4) (2.4%), and reason for referral not available (n 6) (3.7%).

We examined transducers Naerum,

patients

(1850 Denmark)

sagittal normalities

and

planes.

with

7.0-MHz

8537; Bruel in the transverse

abnormalities

All patients

received

Two tablets sulfamethoxazole

abfor

at TRUS.

antibiotic

prophy-

containing 400 mg of and 80 mg of trimetho-

laxis.

prim each were administered 1 hour before biopsy and for 36 hours eight tablets. sulfa drugs

& Kjaer, and

Patients with palpable examined carefully

were

corresponding

by every

mouth 12 hours

after biopsy, for a total of Patients with allergies to were given 200 mg of trimeth-

by mouth 12 hours

The

from

group

men

oprim every

finding because it mdiTRUS may not enable de-

tection of all clinically tent disease. Prostate

the Departments

At

AND

study

were

in a mehypoechoic

examination.

PATIENTS

prostatic

ul-

(9-li). Earlier studies penechoic appearance, accepted as much less

at TRUS

Our

of diagnosing

cancer (2-4). (TRUS) and

nodules

secutive

diagnosis, prostate cancer has often spread beyond the limits of the gland, which means it is incurable (1). Transrectab pnostatic biopsy is an important

or (c) patient management femred population with

it is It is

of prostate carcinoma is isoechoic and therefore indistinguishable

‘From

FRCP

Transrectal

cancer

ing cause (1). Although

MD,

for

1 hour before biopsy and 36 hours after biopsy.

spring-loaded

Biopty

gun

and

an

18-gauge needle sion, Covington, TRUS guidance

(Bard Urological DiviGa) were used with to obtain 1.5-cm core biopsy samples from the hypoechoic nodule (average of three samples), as well as biopsy samples from random sites of normal-appearing prostate (average of two samples). When the hypoechoic nodule was

confined

random the

to one-half

biopsy

opposite

from

the

side,

PSA

transrectal resection

at the

peripheral

Abbreviations: tion,

DRE =

of the

samples

ultrasound, of the

obtained

apex

and

zone.

When

digital

prostate-specific

rectal antigen,

TURP

gland,

were

=

on

base,

the

nod-

examinaTRUS

transurethral

prostate.

345

Table

Table

1

Carcinoma Hypoechoic Nodules Random Sites

at Biopsy of and Isoechoic

Prostatic

and

in 10 PatIents

Isoechoic

Random

with

random

Diameter of TRUS Nodule (mm)

Clinical Stage Al Al A2 Bi Bi

93(56.7)

positive, random negative Nodule positive, random site positive Nodule negative, random site positive

56(34.2) 10 (6.i)

Bi 164

Note-Percentages

in parentheses. S

Nodul#{149}Po Random Po

Nodsils Random

Tumor

length

in core biopsy

Clinical Stage

Nodule

Random

1.

Gleason

score

Random

of

Neg

biopsy

findings

negative,

=

Bi B2 Bi 0 Bi Note-ND

ule was located in the midline (eight patients), random biopsy samples were obtamed from more lateral aspects of the gland on either side, midway between the apex and the base, at least 5 mm from the hypoechoic nodule. The biopsy specimens were graded according to the Gleason histopathologic pattern score on a scale of 2 to 10 (18). It was not possible to determine from the biopsy specimens whether lesions originated in the peripheral zone or the transitional zone, but because biopsies began at the capsule and the Biopty gun was angled cephalad, most of a core biopsy specimen contained peripheral-zone tissue. The length of carcinoma from the core specimen

was

measured

with

necessarily

tumor

measured,

diameter

foci

specimen,

may

since

not

of cancer

were

be

346

stage,

in

measured

TRUS

Radiology

#{149}

Tumor Length*

Bi B2 B2 Bi Bi C C Bi C C

3 4 4 7 8 6 15 5 15 13

stage,

specimen

Biopsy

Gleason Score

Tumor Length#{176}

Gleason Score

6 8 8 6 6 6 6 4 6 6

1 1 2 1 1 2 8 11 5 1

5 4 8 4 6 4 6 4 2 2

in millimeters.

with

Prostatic

Carcinoma

at Isoechoic

TRUS Stage

Stage after Biopsy

Bi Bi Bi Bi Bi

A A A A Bl

a single

and

biopsy

individually

modifications

and Follow-up Sites Only

Random

PSA Level

Age Patient

(y)

1 2 3 4 5

77 73 66 58 62

in Patients

Random

Sites

Pathologic Stage ND ND Bi C C

with

Prostatic

(jig/L)

at

Carcinoma

Gleason Tumor

Score

Length

at Biopsy

8.2 1.2 4.2 14.5 i.5

(mm)

Biopsy

3 3 NA 4 3

Pathologict

3 2 6 4 4

.

Treatment

Observation Orchiectomy Prostatectomy Prostatectomy Prostatectomy

. .

. .

.

5 7 4

Note-NA = not available. S Normal level is 2.25 og/L. t Pathologic score after prostatectomy.

after

prostatic

biopsy,

pathologic

stage.

and, Clinical

where stag-

ing was as follows: Al represented prostate cancer on less than three chips, or

maximum

sampled

Isoechoic

possible,

and their lengths summed. The third pattern, specimens with interspersed normal and abnormal tissue, was measured to indude the entire length of abnormal tissue. For each patient, we recorded clinical tumor

Random

not done.

-

Table 4 Clinical Findings

stage

core tissue can undergo distortion during handling. Also, we noted three basic patterns of tumor involvement, each requir. ing a different measurement technique. The first pattern, a solitary discrete focus of cancer, was measured from one end to another. In the second pattern, multiple discrete

Biopsy

a mi-

crometer. Several pitfalls in tumor measurement, however, must be recognized. The maximum diameter of the lesion is not

at

and

Pos

positive.

biopsy

Nodules

(Mg Pon

Table 3 Staging in Five Patients Only

and range).

Nodule

TRUS Stage

12 20 19 9 11 14 18 10 29 13

Bi B2 C C

5(3.0)

Total

(mean

in Hypoechoic

site

Nodule site

Figure

Carcinoma TRUS

negative

-

Prostatic

Sites

Mean

No. of Patients

Category Nodule

2

Findings

of

less than 5% of a TURP specimen; A2 represented three or more chips, or more than 5% of a TURP specimen; Bi was a

mean

tumor

invasive

volume,

on the other system acteristics,

on

hand,

of size and invasive

staging

as follows:

gland; beyond

C represented the prostate

having

stage

seminal

vesicles;

static

tumor

palpable capsule

and

invasion or into the

D represented

meta-

used

a classification

method

been discussed We modified

system

based

on

equal

his classification

et al translated staging on the

clinibasis

characteristics

(22). A

staging

has

but not established (23). clinical staging for TRUS Patients

A cancer

previous TURP if no hypoechoic ameter

Watanabe,

and invasive charconsidering apparent

of TRUS

classified

on

remained lesions

was a hypoechoic

(19).

Although attempts have been made to establish a staging system based on TRUS, there has been marked variance in approach (20-22). Sugiyama and Kitagawa

based

(21). Lee to TRUS

palpable nodule equal to or less than 1.5 cm in diameter; B2 was a palpable nodule more than 1.5 cm in diameter, involving one side of the gland; B3 was a single palpable nodule involving both sides of the

considering

(20).

asymmetry without

tumor size cal staging

uniform

without

characteristics

the

as of a

in that category were seen; Bi

nodule

to or less

basis

with than

a mean

di-

1.5 cm; B2

was a hypoechoic

nodule

ameter more than side of the gland; nodule involving

1.5 cm, involving one B3 was a hypoechoic both sides of the gland;

with

a mean

August

di-

1990

ban atypia, now also called prostatic intraepithelial neoplasia. In this group, eight patients (47%) had atypia in the biopsy specimen obtained from the nodule, five patients (29%) with carcinoma in the nodule had atypia

a.

b.

Figure

2.

defined

Sagittal

(a) and

transverse

nodule

(arrow,

hypoechoic

the gland pearing

demonstrated peripheral

between

nodular zone

midway

(b) images

of the prostate

cursors)

hyperplasia

in the

at biopsy.

between

the

apex

and

in a 66-year-old peripheral

Random base

on the

zone

biopsy left

man. at the

A wellapex of

of the normal-apside

yielded

carcinoma.

RESULTS

D represented metastatic tumor. The mean diameter of a TRUS nodule was calculated by adding the length, width, and

Of the 164 men who underwent biopsy of a hypoechoic prostatic nodule and random biopsy of normal-appeaning areas of the gland, 71 (43.3%) had biopsy results positive for adenocarcinoma. Carcinoma was diagnosed on the basis of biopsy directed at the suspicious hypoechoic nodule alone in 56 patients (79%), on the basis of both the directed and random biopsy in 10 patients (14%), and on random biopsy alone in five patients (7%) (Table 1). Thus, random biopsy mesuits confirmed the presence of multifocal prostate carcinoma in 14% of patients and was the only method of diagnosing malignancy in 7%. Of the 56 patients with carcinoma discovered at biopsy of a hypoechoic nodule, 49 had a palpable nodule that corresponded to the TRUS nodule. The mean diameter of the hypoechoic nodules in this group was 1.4 cm; the diameter was greater than 2.0 cm in only six patients. Of the 10 patients with carcinoma discovered at

height

biopsy

Figure

3. Transverse in a 62-year-old man.

in the peripheral

zone

rows) was benign normal-appearing

right

side

revealed

capsule

visible

(ar-

of the on the

invasion seminal

lesion

results

Biopsy zone

carcinoma.

or into

of the

three. Biopsy

prostate nodule

on the left side

at biopsy. peripheral

C represented the

image of the A hypoechoic

and could

through vesicles;

dividing modify

and

by staging

by

either confirming the presence of tumor in a suspected nodule or demonstrating benign disease. When a palpable or visible nodule was benign at biopsy, staging reverted to stage 0. However, if tumor was detected in samples from random, nonpalpable isoechoic sites, this was

sidered

stage

A

disease.

When

con-

biopsy

samples nodules

showed cancer in and random sites,

both TRUS staging re-

mained involved nonpalpable

unchanged, but the cancer multiple sites or represented isoechoic extension.

now

Follow-up treatment by the referring urologist was noted for those patients

who

had positive

Volume

176

random

#{149} Number

biopsy 2

results.

of the

hypoechoic

nodule

and

random sites, palpable abnormalities were detected in seven, all comesponding to the TRUS nodule. The mean diameter cf the hypoechoic nodules in this group was 1.5 cm, with only one patient having a nodule more than 2.0 cm in diameter. Of the five patients with carcinoma found at random biopsy alone, four had palpable lesions. Three had corresponding TRUS nodules; the fourth patient had a vague abnormality, felt by the referring urologist, on the side opposite the TRUS nodule. A total of 17 patients (10.4%) had biopsy results demonstrating gbandu-

in specimens

from

random

bi-

opsy sites, and four patients (24%) with negative biopsy results in the nodule had atypia in specimens from random biopsy sites. This last group is being followed up with repeat biopsies and prostate tumor markers. Gleason histologic pattern scones for cancer in visible hypoechoic nodubes were generally higher than for cancer in isoechoic random sites in the same patients. The mean scones were 6.3 in the nodule and 4.9 in mandom sites, statistically significant at P < .05 (t test, 13 degrees of freedom). Gleason scones in patients with positive random biopsy results alone were the lowest (mean, 3.8). The difference between these latter scores and nodule scores was statistically significant at P < .01 (t test, 8 degrees of freedom). The difference in scones between the two groups of random biopsies was not statistically significant (Fig 1). In the cases in which multiple biopsy

samples,

from

the

nodule

and

random sites, revealed prostate carcinoma, random biopsy results did not alter staging. Four Bi and two B2 nodules at TRUS remained as such after biopsy. Random biopsies proved the presence of either multifocal or bilateral tumor, since contiguity of the lesions could not be established from biopsy results. Four cases of stage C disease clinically on at TRUS were presumed to remain stage C when random biopsy results were positive. Other data on tumor size and Gleason score from biopsy of the nodules and random sites are listed in Table 2. In the five patients in whom nodule biopsy results were negative and random biopsy results were positive for carcinoma, staging was lowered in four from stage Bi or B2 by TRUS or digital rectal examination (DRE) to stage A after biopsy. This was because the prostatic nodule was no longer considered malignant and the cancer detected was neither visible nor palpable. One patient’s tumor remained stage Bi when his hypoechoic nodule was negative but random biopsy

results

were

positive

on

the

opposite side, which had a palpable abnormality. Pathologic staging of prostatectomy specimens from three of these five patients resulted in an increase to at least stage B. Thus, ranRadiology

#{149} 347

dom prostatic biopsy actually lowered the clinical stage in four patients, although in three of these patients it was raised again after surgery (Table 3). The clinical findings and outcomes in the five patients with negative nodule and positive random biopsy results are listed in Table 4. Patient 1 is being followed up clinically in view of his age. Patient 2 underwent bilateral orchiectomy. The three memaining patients underwent radical prostatectomy. Patient 3 had a cancerous nodule in the peripheral zone (Gleason scone, 5), measuring 10 X 8 mm in transverse dimensions at pathologic examination (Fig 2). Patient 4 had cancer involving 35% of the gland (Gleason scone, 7), including a peripheral zone nodule measuring 5 X 4 mm and a transitional zone nodule measuring 18 X 10 mm. Unfortunately, the urethral resection margin became involved from the small peripheral zone tumor. Patient 5 had

cancer

involving

only

5% of

the gland (Gleason scone, 4), a nodule measuring 7 X 5 mm in transverse dimensions, but there was perineural involvement at the bladder resection margin (Fig 3). Because of the presence of residual tumor in patients 4 and 5, they are being treated as haying stage C disease. Owing to the manner of sectioning of prostatectomy specimens, tumor measurements were obtained in only two dimensions. The third dimension was estimated by averaging the other two dimensions. Estimated tumon volume was calculated and multiplied by a factor of 1 .5 to account for shrinkage in processing (24). Thus, patient 3 had a 1.1-mL tumor, patient 4 had 0.15- and 3.8-mL tumors, and patient 5 had a 0.32-mL tumor. Prostate-specific antigen (PSA) 1evels (as determined by nadioimmunoassay [Diagnostic Products, Los Angeles] [normal mange, 0-2.25 g/L]) in the five patients with carcinoma found only at random biopsy sites were normal in two patients, marginally elevated in one, and more significantly elevated in two (Table 4). DISCUSSION Random TRUS-guided prostatic biopsy is a technique that may be of value in the diagnosis, staging, and management of prostate cancer. Although in theory, random digitally directed prostatic biopsy could provide similar information, such an approach cannot hope to match the precise needle localization possible with 348

#{149} Radiology

TRUS (25). The additional two to three random biopsies are simple to perform, require only a few extra minutes, and have not caused significant morbidity (26). In our department, no hospitalizations or deaths have occurred as a result of this procedune; 3.6% of patients experienced mild

fever,

and

none

had

any

clini-

cally significant bleeding. The complication mate did not increase when the number of biopsies per patient was increased from three to eight, although some patients noted increased discomfort (27). In our study, random biopsy was responsible for an increased cancer yield of 3.0% (five of 164 men with hypoechoic prostatic nodules), or 7% of the 71 men with prostate cancer detected at prostate biopsy. This increased yield is small compared with the 30% frequency of unsuspected carcinoma found at autopsy in men over 50 years of age (3,8,24,28). However, the majority of these men with latent carcinoma have only small foci of disease: 62% less than 0.1 mL in volume and 24% between 0.1 and 1.0 mL (8). If we want to find tumors that have not yet penetrated the capsule, we should aim at detecting tumoms less than 1.5 mL in volume (24). On the other hand, it is probably not desirable to detect very small tumors that may never cause symptoms or premature mortality in individual patients. Nevertheless, the study of McNeal et al showed that even small tumors

less

than

1.5 mL

in volume

can invade the capsule. Of 14 tumors between 0.45 and 1.5 mL in volume, two had penetrated the capsule and invaded peniprostatic tissue and six involved the capsule within two to three cell diameters of the outer capsular margin (24). The present study demonstrates that random TRUS-guided biopsy can enable detection of small tumors. Of the five patients with cancer detected at random biopsy only, three patients showed pathologic evidence of clinically significant lesions. Pathologic evidence is not available for the other two patients, and only clinical follow-up will determine if they had significant lesions. Additional data (eg, Gleason score, tumor size at biopsy, serum PSA levels) may aid

in determining

the

clinical

im-

portance of small tumors detected at random biopsy. We do not advocate random transrectal prostatic biopsy as a screening method. Our study group consisted of patients who had clear indications for prostatic biopsy. The lack of a

nodule-free

allow

control

group

us to address

the

screening. However, addressing screening sy, has been performed.

performed

not

of

such a study, DRE and biopGuinan et al

a battery

tests, including 50 years of age

does

issue

of screening

DRE, in 300 with symptoms

men

over of un-

nary obstruction (29). Biopsies were performed in all patients whether they opsy

had palpable nodules or not. enabled detection of prostate

Bi-

cancer in 69 patients. DRE demonstrated a palpable nodule in only 48 of the patients with cancer. In 227 men without palpable nodules, 21 (9.3%) had cancer at biopsy. Other

the

workers

role

have

of random

prostatic

biopsies.

formed

random

mapping

with

Hodge six

of 136 men

ules

(25).

mas.

the

core

biopsy

cancino-

in 79 patients

sampling

hypoechoic

site.

their sample to ours. These did

nodule, at the prostatic

positive nodule

Thus,

a

sites, 22 (73%) had in both the nodule

their

by the

and five at random

additional

from

random

biopsy was higher 7%). This discrepancy

plained

include

as well as biopnodule. Of 30 pacarcinoma, three

at random sites, positive results

carcinoma

system-

not

results for cancinoand negative me-

sults at random positive results

only.

a

a subset

random

that

hypoechoic sies directed tients with

included

Therefore,

underwent

biopsies

(58%),

also

of 57 patients from group is comparable

and had

nod-

systematic

However,

(10%) had ma in the

in

palpable

94% of all detected

random

atic

prostate biopsies

with

Random

patients

et al pen-

systematic

each revealed

investigated

TRUS-guided

yield

of

systematic

than

larger

(17%) sites

ours (17% may be ex-

number

vs

of ran-

dom samples they obtained. The Gleason scores for our biopsy specimens add interesting information. In patients with carcinoma in

both

directed

nodule

and

random

bi-

opsy specimens, the score for random biopsy specimens was lower than that for specimens from the visible nodule (P < .05). All of the scores for which only random biopsy results

were either ately suggests tumors

recent

positive were well-differentiated well-differentiated

found

with or modemtumors. This

that poorly differentiated are more visible at TRUS.

study

by Shinohana

paring the TRUS mom with histologic

radical

associated

prostatectomy that

isoechoic

appearance examination

of tuof

specimens tumors

A

et al com-

also had

a

significantly lower Gleason score than hypoechoic tumors (16). At final August

1990

ran-

placed). Also, three patients had dinically significant carcinoma at radical prostatectomy. The numbers in both of these studies are small. We agree with the suggestion of Hodge et al (25) that a mepeat biopsy be performed if the come tumor length is small (ie, less than 2

had

or 3 mm),

pathologic examination (after prostatectomy) in three patients, Gleason scores were virtually unchanged from those determined at random biopsy in two patients and were elevated in one patient. Clinical staging of patients in our study

was

not

dom

biopsy

carcinoma

greatly

affected

results.

by

Patients

in both

the

who

nodule

and

random sites remained stage B on C. Patients who had carcinoma only at random biopsy sites went from stage B to A in four of five cases, since their clinically or TRUS-detected nodule was benign. Stage A disease constitutes

23%

of prostate

cancer

at

presentation and is important to detect. Stage Al cancer progresses in 16% of men by 8 years and becomes a higher stage cancer in 7%; it is managed by clinical follow-up or radical prostatectomy. Stage A2 cancer progresses

in 33%

of men

becomes a higher 40%; it is usually prostatectomy

ing sis

of random

4 years

and

stage cancer in managed by radical (30,31).

of tumors

by

as Al biopsy

Although

or A2 on the has,

stag-

ba-

to our

knowledge, not been described, the diagnosis of stage A prostate cancer does have an impact on patient management and prognosis. When elevated, PSA levels were helpful ble and

in the detection of nonpalpanonvisible carcinoma. How-

ever, only two of our five patients with cancer found only at random biopsy had a significantly elevated PSA level. One of two patients with a positive resection margin had a normal PSA level. Guinan et al reported that a normal PSA level does not rule out invasive carcinoma (32). Thus, PSA levels must be interpreted in bight of other information. Finally, we wanted to know how random biopsy results altered patient management. Four of five patients with carcinoma detected only at random biopsy were treated by means of prostatectomy. This is in contrast to the results of Hodge et a! (25). In their comparable subset of 57 patients, five had cancer diagnosed at random biopsy only. In all of these, the cancer occupied 2 mm or less of the 1.5-cm-long biopsy cone. One of these patients underwent radical prostatectomy and had a 0.92-mL tumor. A follow-up biopsy in one other patient had negative results. Outcomes in the other three patients were not described. Four of our five patients had tumors that occupied more than 2 mm of the core biopsy (the tumor could not be measured in one specimen that had been misVolume

176

Number

#{149}

2

to distinguish

significant

from

important

sults

also

clinical

!3.

14.

15.

that

this

17.

in the prostatic

evaluation nodules.

20.

21.

22.

23.

of U 24.

Acknow!edgment: We thank John Trachtenberg, MD, Department of Urology, Toronto General Hospital, for his assistance and advice.

References Coffey

DS, Resnick

MI, Dorr

A multidisciplinary

2.

analysis

FA, Karr

JP, eds.

of controversies

in the management of prostate cancer. New York: Plenum Press, 1988; 1-16. Astraldi A. Diagnosis of cancer of the prostate: biopsy by rectal 1937; 41:421-427.

route.

Urol

Cutan

Rev

3.

Emmett JL, Barber KW, Jackman rectal biopsy to detect prostatic review and report of 203 cases.

RJ. Transcarcinoma: a J Urol 1962;

4.

Esposti PL. Cytologic diagnosis of prostatic tumors with the aid of transrectal aspiration biopsy. Acta Cytol 1966; 10:182-186. Holm H, Cammelgaard J. Ultrasonically guided precise needle p!acement in the prostate and the seminal vesicles. J Urol 198!;

87:85-99.

5.

6.

125:385-387. Rifkin MD, Kurtz

biopsy

7.

utilizing

AB,

Goldberg

transrectal

BB.

ultrasound

ance: diagnosis of non-palpable trasound Med 1983; 2:165-167. Lee F, Torp-Pederson ST. Siders

cancers.

Prostate

guidJ Ui-

27.

28.

30.

31.

prostectomy

sections.

Prostate

Philadelphia:

and cliniIn: Tanthe

Lea & Febiger.

1977;

part II, 171-!98. Whitmore WF Jr. Interstitial radiation therapy for carcinoma of the prostate. Prostate 1980; 1:157-168. Sugiyama Y, Kitagawa R. Ultrasound staging of prostatic cancer according to cancer volume. In: Resnick M, Watanabe H, Karr J, eds. Diagnostic ultrasound of the prostate. New York: Elsevier, 1989; 36-40. Watanabe H. The Japanese staging system. In: Resnick M, Watanabe H, Karr J, eds. Diagnostic ultrasound of the prostate. New York: Elsevier, !989; 4-12. Lee F, Littrup PJ. Kumasaka CH, Borlaza CS, McLeary RD. The use of transrectal ultrasound in the diagnosis, guided biopsy, staging and screening of prostate cancer. RadioGraphics 1987; 7:627-644. Watanabe H, Catalona W, Scardino P. Pollack H. Staging committee report. In: Resnick M, Watanabe H, Karr J, eds. Diagnostic ultrasound of the prostate. New York: Elsevier, 1989; 204-207. McNeal JE. Kindrachuk RA, Freiha FS, et al. Patterns of progression in prostate cancer.

1986;

1:60-63.

Hodge KK, McNeal JE, Terris MK, Stamey TA. Random-systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 1989; 142:7!-75. Hodge KK, McNeal JE, Stamey TA. Ultrasound guided transrectal core biopsies of the palpably abnormal prostate. J Urol 1989; ! 42:66-70 Toi A, Wilson SR. Safety of ultrasound-guided transrectal prostate biopsy in outpatients

(abstr).

Radiology

Franks

LM.

1989;

Latent

Bacteriol

173(P):82.

carcinoma

of the

prostate.

1954; 68:603-616.

Cuinan P. Bush I, Ray V. Vieth R, Rao R, Bhatti R. The accuracy of the rectal examination in the diagnosis of prostate carcinoma. N Engl J Med 1980; 303:499-503. Cantrell BB, Deklerk DP, Eggleston JC, Boltnott JK, Walsh PC. Pathological factors that influence prognosis in stage A prostatic cancer: the influence of extent versus grade. Urol 1981; 125:516-520. Coffey DS. Resnick MI. Dorr FA. Karr JP. eds. A multidisciplinary analysis of controversies in the management of prostate cancer. New

York: 32.

of the

AIR 1987;

1972; 30:5-13.

J Pathol 29.

sonography

implications.

Gleason DF. Histological grading cal staging of prostatic carcinoma. nenbaum M, ed. Urologic pathology:

Lancet 25.

26.

1.

on radical

prostate. 19.

Endorectal

clinical

1987; 10:1-9. Shinohara K, Wheeler TM, Scardino PT. The appearance of prostate cancer on transrectal ultrasonography: correlation of imaging and pathological examinations. J Urol !989; 142:76-82. Byar DP, Mostofi FK. Carcinoma of the prostate: prognostic evaluation of certain pathologic features in 208 radical prostatectomies.

Cancer 18.

ap-

proach enables detection of clinically significant carcinoma. Because the additional cost in terms of time and morbidity to the patient is minimal, we believe that the ongoing use of random TRUS-guided prostatic biop-

MD.

148:1137-1142. Rifkin MD, Friedland CW, Shortiiffe L. Prostatic evaluation by transrectai endosonography: detection of carcinoma. Radiology 1986; 158:85-90. Abu-Yousef MM, Narayama A. Prostatic carcinoma: detection and staging using suprapubic ultrasound. Radiology 1985; 156:175-180. Dahnert WF, Hamper UM. Eggleston JC, et a!. Prostatic evaluation by transrectal sonography with histopathologic correlation: the echopenic appearance of early carcinoma. Radiology 1986; 158:97-102. Salo JO, Rannikko S. Makinen J, Lehtonen 1. Echogenic structure of prostatic cancer im-

aged 16.

implications.

demonstrate

sy is warranted patients with

12.

insignifi-

Our results suggest that tumors not visible at TRUS are of a lower grade than visible ones. Although random biopsy did not significantly alter clinical staging, it did change patient management in cases in which it was the sole method of diagnosis. Our me-

Rifkin

prostate:

clinically

carcinoma

cant small-volume disease. A repeat biopsy may not be necessary in the presence of high-risk factors such as a high Gleason score at biopsy, large tumor size in the cone specimen, or a significantly elevated serum PSA 1evel. In conclusion, the additional yield of carcinoma found at random prostatic biopsy is small but distinct and has

11.

Plenum,

1988; 41-55.

Cuinan

P. Bhatti

R, Ray

prostate

specific

antigen

Urol

1987;

P.

An

evaluation

in prostatic

of

cancer.

137:686-689.

DB, et a!.

Transrectal ultrasound in the diagnosis and staging of prostatic carcinoma. Radiology 1989; 170:609-615.

8. 9.

10.

McNeal JE. Origin and development of carcinoma in the prostate. Cancer !969; 23:24-34. Lee F, Cray JM, McLeary RD. et a!. Transrectal ultrasound in the diagnosis of prostate cancer: location, echogenicity, histopathoiogy. and staging. Prostate 1985; 7:117-129. Lee F, Cray JM, McLeary RD. et al. Prostatic

evaluation by transrectal sonography: criteria for diagnosis of early carcinoma. Radiology 1986; 158:91-95.

Radiology

349

#{149}