Determining variables for repeat prostate biopsy

Abstract

During the evaluation of prostate cancer, men who have undergone transrectal ultrasound-guided biopsy with negative results present a dilemma as to what further follow-up is required. Multiple variables have been proposed throughout the literature to improve cancer detection rates not only in initial biopsy results, but also on repeat evaluation. These variables include prostate-specific antigen (PSA) velocity, PSA density, free-percent PSA, and histological findings, each of which may singly or collectively dictate the need for further biopsy. After performing a Medline literature search using specific Medical Subject Headings (prostate biopsy, repeat prostate biopsy, PSA velocity, PSA density, free-percent PSA, prostate inflammation), we critically evaluated pertinent articles. Using this accumulated data and information, we composed an algorithm to assist in the decision process for repeat biopsy.

Strategies for repeat prostate biopsies

“…For repeat prostate biopsies after an initial set has been free of cancer, a PSA greater than 10 ng/mL is agreed upon as a clear indication for the need for repeat biopsies, although repeat biopsies are not felt to be strongly indicated for a PSA less than 4 ng/mL [2][3][4]. A PSA level over 4 ng/mL is generally accepted as an indication for initial biopsy, whereas some urologists will biopsy for a PSA over 2.5 ng/mL or adjust the acceptable upper limit of normal PSA for the patient's age.…”

“…This calculation targets the problem of PSA elevation caused by benign prostatic hyperplasia and, when elevated, has been shown to correlate with the existence of cancer. Calculating the PSAD-TZ has the potential for a high rate of error due to the need for high-resolution ultrasound equipment and an experienced sonographer because the margins of the transition zone are not as clearly demarcated as those of the entire prostate [3]. Using a value of 0.15 ng/mL/cm 3 , they reported missing 35% of the cancers.…”

“…Keetch et al [7] determined that using only PSAV greater than 0.75 ng/mL/y would miss a large number of cancers and recommended combining the PSAV other parameters. Busby and Evans [3] recommend a combination of total PSA, percent free PSA, PSAD, and PSAV based on analysis of the published data on each of these parameters. Busby and Evans [3] recommend a combination of total PSA, percent free PSA, PSAD, and PSAV based on analysis of the published data on each of these parameters.…”

“…Djavan et al [2] recommend the combination of a percent free PSA of less than 30% and/or a PSAD-TZ ≥ 0.26 ng/mL/cm 3 as the most accurate predictor of a positive repeat biopsy result in patients with PSA levels between 4 and 10 ng/mL. Both Djavan et al [2] and Busby and Evans [3] recommend repeat biopsy in any patient with a PSA greater than 10 ng/mL regardless of the other parameters. Their recommended PSAbased indications for repeat biopsy include any patient with a PSA in the 4 to 10 ng/mL range and a percent free PSA less than 25%.…”

Can the Effect of Antibiotherapy and Anti-Inflammatory Therapy on Serum PSA Levels Discriminate between Benign and Malign Prostatic Pathologies?

“…On the contrary of some investigators denying the contribution of this condition to PSA rise [7,9] , there are some other investigators advocating this relationship due to its impact on diagnostic strategies [10][11][12][13] . Some of them take the fact of prostatic infl ammation into consideration only during the interpretation of the biopsy or for the decision on re-biopsy [2,6,8,14] , while some others suggest this evaluation in concert with PSA screening or even before the fi rst sampling [12,15,16] .…”