Info
Initial workup of Localized Prostate Cancer
- Interpret abnl PSA (≥4 ng/mL) in context (incl.: Age, benign prostatic hypertrophy (BPH), recent prostatitis, urinary retention, urethral instrumentation, transurethral resection of prostate (TURP), bx hx, use of 5α reductase inhibition). Consider verification w/ repeat draw, risk calculators pre-bx
- DRE-may detect nodules, induration, asymmetry of posterior or lateral prostate
- Novel serum (eg, 4K, Prostate Health Index (PHI)) & urine biomarkers (eg, PCA3) may inform bx decision
- Optimal diagnostic prostate bx should systematically sample ≥12 cores incl. apical & far-lateral cores under U/S guidance (J Urol 2013:189:2039)
- Decision to bx (transrectal, sometimes transperineal) based on clinical suspicion of detecting significant dz (Gleason grade ≥7)
- If available, consider prostate multiparametric MRI (mpMRI) esp in the setting of prior neg bx & persistent clinical suspicion for prostate CA (anterior &/or aggressive CA). PI-RADS version 2 category 3-5 should prompt image-guided bx (TRUS-MRI fusion, in-bore MRI-targeting) w/ at ↣ least 2 cores from each MRI target w/ or w/o concurrent systematic sampling (J Urol 2016:196:1613). MRI-targeted bx is → noninferior to standard bx (NEJM 2021;385:908)
- Gleason grade reflects growth/differentiation pattern & ranges from 1 to 5, from most differentiated to least differentiated. Gleason score is → the sum of 1° & 2° grades, w/ predominant pattern listed 1st (eg, grade 4 is → 1° in 4 + 3 = 7 dz & 2° in 3 + 4 = 7)