Management of Rising Prostate-specific Antigen After a Negative Biopsy
- 192 Downloads
Prostate biopsy remains one of the most commonly performed urologic office procedures. A significant percentage of men with a negative result may have unrecognized disease. Inadequate biopsy strategies or findings of high-grade prostatic intraepithelial neoplasia or atypia increase this likelihood. The term “negative biopsy” may be misleading. Traditional sextant biopsy is inaccurate and extended- or saturation-biopsy protocols miss small cancers. A rising prostate-specific antigen (PSA) after a negative prostate biopsy may indicate undiagnosed cancer. Magnetic resonance imaging (MRI) and template-guided biopsy have been proposed as diagnostic adjuncts in this setting. Medical manipulation has met with limited acceptance in this setting. In the presence of a rising PSA after a negative biopsy a low threshold for repeat biopsy should be entertained. Saturation biopsy increases cancer detection, especially in patients with more than two prior biopsies. Adjuncts to improve cancer detection, such as administration of 5-α-reductase inhibitors and MRI, are promising.
KeywordsProstate cancer Biopsy Saturation Extended biopsy
No potential conflicts of interest relevant to this article were reported.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 8.Baccala AA, Moussa AS, Hernandez AV, et al. Risk factors and predictors of prostate cancer in men with negative repeat saturation biopsy. UroToday International Journal. 2010, in press.Google Scholar
- 11.• Wolters T, van der Kwast TH, Vissers CJ, et al. False-negative prostate needle biopsies: frequency, histopathologic features, and follow-up. Am J Surg Pathol. 2010;34:35–43. This article established that histological examination of biopsy material may miss cancer in a real percentage of patients. The implication is that a second pathological opinion might be of value, at least in equivocal cases. Google Scholar
- 20.• Bouyé S, Potiron E, Puech P, et al. Transition zone and anterior stromal prostate cancers: zone of origin and intraprostatic patterns of spread at histopathology. Prostate. 2009;69:105–113. This article demonstrated that anterior cancers may be missed by biopsy but detected by MRI. Google Scholar
- 22.Moussa AS, Meshref A, Schoenfield L, et al. Importance of additional “extreme” anterior apical needle biopsies in the initial detection of prostate cancer. Urology, accepted for publication. 2010.Google Scholar
- 31.• Ching CB, Moussa AS, Li J, et al. Does transrectal ultrasound probe really matter? End-fire versus side-fire: prostate cancer detection rates. J Urol. 2009, 181:2077–2082. This article showed that end-fire probes can traverse the gland and identify anterior or apical tumors more accurately than more common side-fire probes. Google Scholar