1. What would you recommend?
Case History:
55 yr-old with no FHx CaP, Neg. DRE, and PSA = 5.4 ng/mL
Nonspecific TRUS
10 Bx cores
Result: NEM, but High Grade PIN
What would you recommend?

2. Rising PSA with Negative Prostate Biopsies
Neil F. Wasserman, M.D.
University of Minnesota
Minneapolis, MN

3. What next? Case History (Cont.) Follow-up PSA in 3 months = 6.9 ng/mL
Extended 12 core [2nd Set of Bxs] incl.
Bilateral Anterior PZ
Bilateral TZ
Result: All cores negative for malignancy
High grade PIN (HGPIN)
What next?

4. Options: Repeat w/Extended Bxs Saturation Bxs MRI, MRS
FU PSA for stability or↓

5. Indications for Repeat Bx
Rising PSA
Esp. > ng/mL
Abn. PSA Velocity
≥ 0.75 ng/mL rise in 1 Yr.
2.0 ng/mL rise/yr. assoc. with high risk of dying of prostate cancer*
High Grade PIN
D’Amico A, Chen MH, Roehl K, Catalona WJ. NEJM 2004; 351:

6. Extended Biopsies Variably Defined
Sextant (6) + Lateral (2-6)=Total 8-12
Sextant (6) + TZ (2-4)=Total 8-10
Sextant (6) + Lateral (2-6) + TZ (2—4)=Total10-16

7. Case History (Cont.) Options? 6 mo. Follow-up PSA=10.2
Rx with antibiotics → No change in PSA
Summary of Case to This Point:
High Risk Pt. (HGPIN, Rising PSA)
22 neg. biopsies (2 courses/biopsies)
Options?

8. Options: Repeat Biopsies [3rd set] ? Saturation Biopsies ? MRI/MRS ?
Focusing only on TZ/anterior lateral PZ
Saturation Biopsies ?
MRI/MRS ?
Followed by MR-based guided Bx
Diagnostic TURP ?
Stop ?

9. 3rd & 4th Repeat Biopsies Diagnosis of CaP on 2nd Bx = 12-20%✝
Options
3rd & 4th Repeat Biopsies
Diagnosis of CaP on 2nd Bx = 12-20%✝
Pos. Result is low on Subsequent Biopsies *
5% on 3rd
4% on 4th
Conclusion:
Biopsies 3 & 4 are not mandatory in pts. with PSA 4-10 ng/mL
✝Djavan B, Remzi M, Marberger M. Eur Urol Suppl. 2002; 1:52-59
Djavan B, Ravery V, Zlotta A, et.al. J Urol 2001;166:

10. 3rd & 4th Repeat Biopsies (cont.)
Options
3rd & 4th Repeat Biopsies (cont.)
However, additional rounds of biopsy may be indicated in patients with
PSA > 10 ng/mL
PSA rapidly accelerating (Abn. Velocity) *
Raja J, Ramachandran N, Munneke G, Patel U. Clinical Radiology. 2006;61:

11. Saturation Biopsy Definition of “Saturation Bx” ? Methods
Options
Saturation Biopsy
Definition of “Saturation Bx” ?
Usually cores
Methods
Transrectal
Transperinial using BrachyRx Template Grid
Positive Result
Transrectal = 30-34%
Transperineal = 37% (single study)
Template

12. Saturation Bx Options n=102 Mean of 2 prior neg. Bxs Perineal Template
Merrick GS, et. al. European Urol. 2007; 52:
Saturation Bx
n=102
Mean of 2 prior neg. Bxs
Perineal Template
43(42%) positive
282 pos. sites
105 anterior ½ of prostate(69%)
Example: 24 Core Saturation Biopsy Scheme

13. Saturation Biopsy (cont.)
Options
Saturation Biopsy (cont.)
Comparison of Saturation Bx Studies in Pts. Undergoing Rebiopsy
Scattoni V, Z.otta A, Montironi R, et. al. Euroopean Urology 2007; 52:

14. Multiparametric MRI Protocols Conventional T2
Options
Multiparametric MRI
Protocols
Conventional T2
Phased array abdominal coil
Endorectal
Both
Diffusion Weighted Imaging (DWI)
Dynamic Enhanced Imaging
MR Spectroscopy

15. Multiparametric Features of TZ CaP on T2 Imaging
Options
Multiparametric
Features of TZ CaP on T2 Imaging
Poorly circumscribed margin compared to sharp with BPH
Uniform Low Signal
Lenticular shape
Invasion of Ant. FM Layer

16. Options
Multiparametric MRI
Metabolic Character of TZ CaP is nonspecific✝
Only 1 Study Applied to Multiple Previous BX situation*
MRS
n=42
Mean PSA=7.6 ng/mL, Neg. DRE, neg. prev. Bx ≥ x2
MRS-based TRUS-guided biopsies from location of suspicious voxels + extended TRUS-guided biopsies
Results: Sens.=0.85, Spec.=0.89
✝Zakian K, Eberhardt S, et.al. Radiology 2003;229:
Prando A, Kurhanewicz J, et. al. Radiology 2005; 236:

17. Diagnostic TURP Retrospective study 1189 prostatectomy pts.
Options
Diagnostic TURP
Minimal Data for Multiple Bx Situation
Retrospective study 1189 prostatectomy pts.
445 post TUR Pts. with at least 1 previous neg. Bx
↑ PSA
Abn. DRE
CaP found on TUR in 35 Pts. (7.9%) overall.
5.5% in those with ↑PSA alone
16.5% in pts. With Abn. DRE
c/w incidence of 6.4% in pts. w/normal DRE & PSA
Concluded that “TURP for diagnostic purposes only, in general, cannot be recommended.”
Zigeuner R, Schips L, Lipsky K, et. al. Urology. 2003; 62:
Ito H, Yamaguchi K, Kotake T, et.al. Int. Urol Nephrol. 1995; 27:93-100

18. Other Options Watchful Waiting
Not a good choice for most patients when risk of CaP is high and increasing.
Therapy Based on Presumptive Diagnosis of CaP
Usually radiation