Diagnosis and staging of prostate cancer.

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This paper reviews current concepts and recent advances in the diagnosis and staging of carcinoma of the prostate (CaP). Open perineal biopsy is seldom performed because of unnecessary morbidity and a substantial risk of impotence. Transurethral biopsy is inaccurate in detecting both early CaP and residual Cap following transurethral resection of the prostate. Transrectal needle biopsy is contraindicated because of a high rate of sepsis. Transperineal needle biopsy is accurate, has a low risk of complications, and can be performed in an out-patient setting. Transrectal needle aspiration of the prostate appears very accurate with even less morbidity and may replace core needle biopsy in the future. The staging of CaP includes measurement of prostatic acid phosphatase (PAP), radionuclide bone scan, and pelvic lymphadenectomy. PAP should be measured enzymatically using thymolphthalein monophosphate as the substrate. Patients with elevated serum levels of PAP (0.8 IU/L) generally have advanced disease and are not candidates for radical prostatectomy. Radioimmunoassay measurements of PAP have not proved useful because of low specificity. Prostate specific-antigen (PSA) levels are similar in CaP and BPH, and PSA does not appear useful in either the diagnosis or staging of CaP. PSA is, however, extremely sensitive in detecting residual disease after radical prostatectomy. Alkaline phosphate and other biochemical markers have not been reliable because of low specificity. Flow cytometry is a new technique that may be useful in selecting patients for radical prostatectomy. The value of transrectal ultrasound both in diagnosis and staging remains uncertain. Radionuclide bone scan is extremely accurate in detecting osseous metastasis with a false negative rate of two percent. Pelvic lymphadenectomy with frozen section diagnosis is highly accurate in detecting lymphnode metastases with a false negative rate of three point five percent.