D-1) Persistently raised PSA and single negative prostate biopsy:
The first step is to assess adequacy of initial biopsy –
which depends on:
what next = repeat biopsy.
D-2) Role of new biochemical marker:
Aim is to reduce unnecessary Repeat biopsy.
NCCN guideline (EAU 2013)
|%fPSA ( in pt with total PSA 4-10 ng/ml)||Prostate Biopsy (PB)|
|.>10 - ≤25%||Intermediate|
Progensa PCA3 assay
D-3) Dilemma if initial bx showed HGPIN (15-20%):
What next ?
D-4) Dilemma if initial bx showed - ASAP (5%):
D-5) Dilemma in techniques / no of cores / sampling location during initial bx:
Sextant? / 10 cores? / 12 cores? / more?
10-12 core extended PB scheme, with additional cores from suspected area on DRE/TRUS is the most accepted method.
(some authors recommend adding a core from extreme apex on each side, because this is the m/c site where CA is missed during initial bx)
What is extended PB scheme?
sextant template + at least 4 & up to 8 laterally directed sampling from PZ.
Usually 12 cores.
Superior detection rate.
Vienna nomogram suggested (8-18) cores, based on pt age & gland volume, in PSA 2-10 ng/ml to ensure 90% certainty.
(for example= prostate size of 50-60 ml in pt <50yrs, 50s, 60s, 70s- 16, 14, 12 or 10 cores were prescribed respectively)
Most initial bx shown = further increase in no of bx core >12 has no significant benefit.
D-6) Repeat PB – what’s the optimal technique?
Recently Scattoni et al developed some model,
|Pt with previous ASAP||Pt with %fPSA <10%||Pt with %fPSA>10% but no ASAP|
|14 core without TZ sampling||14 core bx with 4 TZ core||20 core bx with 4 TZ core|
Algorithm for pt with prior negative biopsy (AUA updates 2012-1)
Assessing the adequacy of initial biopsy.
F/T PSA is currently the most useful for predicting cancer on repeat biopsy.
(Newer marker such as PCA-3 and %(-2) proPSA are promising)
Repeat bx include a minimum of 14 cores
(12 cores recommended for initial biopsy plus 2 additional core from right and left anterior apex)
(The yeild from transition zone is low)
Fail to identify CA
Saturation biopsy (>20 cores) is warranted
mp-MRI – (Multiparametric-MRI) for Prostate-malignancy
Includes T1 and T2 weighted sequences with at least 2 functional parameters–
dynamic contrast enhancement (DCE),
diffusion-weighted imaging (DWI),
apparent diffusion coefficient (ADC) mapping
Q) Does mpMRI have a role in ruling-in and ruling-out clinically significant prostate cancer in men at risk prior to biopsy ?
MRI may rule out significant cancer and avoid a second biopsy series in case of persistent elevated PSA.
Pt had high PSA & negative TRUS–bx. Later Cancer confirmed on MR-bx
MRI for the Detection, Localisation, and Characterisation of Prostate Cancer:
Recommendations from a European Consensus Meeting–
TRUS (Trans Rectal Ultrasonography):
D-7) Diagnostic dilemma in histopathology report following robot assisted laparoscopic prostatectomy:
D-8)Diagnostic dilemma in histopathology report following radical prostatectomy:
TRUS biopsy showing adenocarcinoma prostate Gleason Score 3 + 3 = 6
Final histopathology slides of radical prostatectomy
specimen of same patient showing no tumor.
Negative AMACR staining