I screen men that present to my practice with a total prostatic specific antigen (tPSA) as well as a free and % free PSA,especially so if they are of African American heritage or have a family history of prostate cancer. If the tPSA or % free PSA are abnormal (in the absence of influencing factors such as urinary infections etc) I will repeat the test to exclude spurious laboratory results. If the level is still elevated I recommend the standard 12 core needle biopsy of the prostate in the office under a periprostatic nerve block.
While about 70% of men with an elevated PSA greater than 4ng/ml will have a so called negative biopsy ( and about 20% of men with a PSA under 4 will have a clinically significant prostate cancer), this negative biopsy result should be viewed somewhat cautiously for the following reasons:
1) technique
if the biopsy is not performed adequately information may be missing. For example,there should be proper sextant sampling in addition to biopsying hypoechoic areas where there may be about a 20% incidence of cancer. Also, each core sample should be intact and measure about 12mm.
A single 12 core sextant biopsy may miss small volume cancers but with careful follow up with periodic PSA’s,% free PSA’s and PCA3′s and a low threshold for a second biopsy,clinically significant prostate cancers will be picked up. These localized prostate cancers are treated ideally, with non surgical non radiation HIFU.
The use of 5 alpha reductase inhibitors like proscar/avodart may improve prostate cancer detection,especially if the PSA continues to rise or fails to drop appropriately after administration of these medications.
2) pathology
and assuming appropriate biopsy technique. Since the majority of prostate biopsies are read by general pathologists it is imperative to have your slides forwarded to a prostate reference laboratory for validation of your findings and report.
a) benign histology report.
monitor with tPSA and % free PSA and PCA3 and consider a second biopsy at some time within the following 12 months.
b) high grade prostatic intra epithelial neoplasia (HGPIN)
this is thought to be a precursor lesion but the incidence with which this may progress towards prostate cancer is controversial. Another biopsy within the 12 month follow up period is advisable.
b) atypical small acinar proliferation (ASAP)
this is also considered a precursor lesion of prostate cancer and rebiopsy ,especially of the involved zones may be reasonable a few months later after the diagnosis.
c) microfocus or less of prostate cancer (5% of a Gleason 6 or less in one zone only)
rebiopsy, especially of the zones where a micro focus of prostate cancer was identified previously is recommended within a few months of the initial diagnosis. Only if more substantial prostatic cancer disease is documented should there be consideration for a treatment option such as HIFU. In the absence of significant disease,active surveillance is called for.