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Epidemiology, diagnosis and treatment of anterior prostate cancer

Nature Reviews Urology volume 22, pages 439–446 (2025)Cite this article

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Abstract

Anterior prostate cancers (APCs) are a group of impalpable neoplasms located in regions anterior to the urethra, which comprise the transition zone, apical peripheral zone and anterior fibromuscular stroma. These regions are typically undersampled using conventional biopsy schemes, leading to a low detection rate for APC and a high rate of false negatives. Radical prostatectomy series suggest prevalence rates of at least 10–30%, but transperineal systematic biopsy is ideal for diagnosis, particularly where multiparametric MRI is unavailable. Combined MRI-targeted and systematic biopsies demonstrate high concordance with final histopathology and lead to the fewest incidences of upgrading and upstaging at radical prostatectomy. Thus, the use of combined biopsy techniques has important implications for preoperative work-up and surgical planning, as APCs are associated with larger cancer volumes and a higher rate of positive surgical margins than posterior prostate cancer. Nevertheless, anterior tumour ___location might confer a relative resistance to stage progression, as APCs exhibit lower rates of extraprostatic extension, seminal vesical invasion and lymph node metastases than the more commonly seen posterior neoplasms. Few studies have examined the long-term outcomes of partial gland approaches to APCs, but MRI-targeted techniques have the potential to provide real-time intraoperative guidance and maximize the oncological safety of anterior focal treatment options in patients with APC.

Key points

  • Anterior prostate cancer (APC) accounts for 10–30% of all prostate cancers at radical prostatectomy.

  • APCs are a heterogenous group from a histological perspective, comprising tumours found in the transition zone, the anterior peripheral zone and the anterior fibromuscular stroma.

  • APCs are generally larger than posterior prostate cancers and are associated with higher rates of positive surgical margins, but are rarely associated with extraprostatic extension or lymph node metastasis.

  • Transrectal ultrasonography-guided biopsy has poor sensitivity for APCs; anterior lesions are better sampled through the transperineal approach.

  • Multi-parametric MRI ± prostate-specific membrane antigen-PET are essential for preoperative staging and surgical planning.

  • The choice of the most appropriate focal therapy for localized prostate cancer can be influenced by tumour ___location.

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Fig. 1: Template diagram of the prostate, illustrating the anatomy and surgical approach for anterior prostate cancer.

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  1. Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

    Sammy Gharbieh, Joshua Mullin, Ata Jaffer, Daniel Chia & Ben Challacombe

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Gharbieh, S., Mullin, J., Jaffer, A. et al. Epidemiology, diagnosis and treatment of anterior prostate cancer. Nat Rev Urol 22, 439–446 (2025). https://doi.org/10.1038/s41585-024-00992-7

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