Abstract
Urologists are routinely faced with the dilemma of a persistently worrisome clinical picture for prostate cancer in patients who have undergone prior negative ultrasound-guided prostate biopsies. Indications for repeat biopsy include sustained or worsening of the findings that prompted the initial biopsy; various derivations of prostate-specific antigen; and the histology from the initial biopsy (ie, high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation is identified). Large prostate volume or inflammation can confound the decision to perform repeat biopsies. Repeat biopsies should include a combination of standard sextant, lateral, anterior apical, and possibly transition zone biopsies. Repeat biopsies should consist of at least 14 cores but may include more than 36 samples. In patients who are not at high risk for prostate cancer, more than two sets of repeat biopsies have a very low yield.
Highlights
Despite urologists increasingly employing more extended prostate biopsy schemes for initial biopsies, the rate of repeat biopsies continues to rise [1]
A PSA level over 4.0ng/ml is generally accepted as an indication for initial biopsy while some urologists will biopsy for a PSA over 2.5ng/ml or adjust the acceptable upper limit of normal PSA for the patient’s age
Zhou et al affirmed these findings with the report that of patients diagnosed with atypical small acinar proliferation (ASAP), 51.0% were diagnosed with prostate cancer on repeat biopsy (56)
Summary
Despite urologists increasingly employing more extended prostate biopsy schemes for initial biopsies, the rate of repeat biopsies continues to rise [1]. The histology from the initial biopsy may encourage repeat biopsy if high grade prostatic intraepithelial neoplasia (HGPIN) or atypical small acinar proliferation (ASAP) are identified. Risk factors such as family history of prostate cancer and African American race have not been evaluated as potential indications for repeat biopsy but often impact urologists attitudes toward encouraging patients to undergo repeat biopsy. Patient anxiety about the possibility of prostate cancer is another common but difficult to quantitate indication for repeat biopsy. Other PSA parameters can facilitate the decision to perform repeat biopsies These include the percent-free PSA, PSA velocity (PSAV), PSA density (PSAD), and PSA density of the transition zone (PSAD-TZ)
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