Ca prostate,how to move forward in management?

60 years old gentleman,just retired on health chech up, have  two psa of 9, n,14 with no urinary symptoms.on examination all normal DRE- normal

All blood reports,urine reports r normal.
usg  abdomen normal.
He read in Google that raised psa is cancer..
He is advised for radical prostectomy by some , asking for the operation.
How to proceed for investigationg this patient??
Without going for mri   prostate ,can we directly do trus guided biopsy for this case?

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  • Prabir Basu
    Prabir Basu
    16 Apr 2020 05:26:10 PM

    This is so typical of an index asymptomatic man undergoing PSA based screening with a repeat rising PSA, whose standard of care is a TRUS guided 12 core biopsy.

    But, here I shall prefer a mpMRI prior to  or with biopsy  as he is a fit man , very motivated for radical prostatectomy, hopefully will enable more precise targetting of suspected areas, so as to increase the accuracy of biopsy.

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    16 Apr 2020 08:01:52 PM

    Thank u sir reply...

    sir I'm eager to know whether we can decide on trus guided biopsy based on  this level of PSA value or we we need specification of value by PHI or 4K .
    What is your opinion about use of risk calculator for decision on Bx?

  • Prabir Basu
    Prabir Basu
    16 Apr 2020 11:03:25 PM

    I am not aware of them, let our seniors comment.

  • Utsav Shah
    Utsav Shah
    17 Apr 2020 08:23:00 AM

    Dear Dr Mazumdar,

    I recently attended a webinar by uro-oncology experts where they discussed the role of risk calculators like PHI, 4K, HK-2 and others. It was a joint opinion of the panel that the use of such indicators just enhance or help us in moving further when the diagnosis is doubtful. So this case does qualify for the same. Availability in India is a concern. 

    However these tests have limited specificities. Mp-mri is a well tested non invasive investigation already in mainstream and radiologists are used to it. Hence, as Basu sir mentioned, we can go ahead with a multiparametric MRI f/b biopsy in case of a doubtful lesion. However, if the patient is fairly anxious and opts for a biopsy ANYWAYS, then we can always do the biopsy irrespective of the mri findings. He does fall in the risk age group and one indication for biopsy is ‘patient choice’. 

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    18 Apr 2020 09:47:48 AM

    I agree with Dr Basu that this is a common clinical situation with normal DRE and slowly rising PSA. 

    I decide based on:
    1. Patients fitness and probable life expectancy
    2. PSA density (anything more than 0.11 should looked at seriously)
    3. PSA velocity is also important
    4. MpMRI would be very vital
    5. What patient wants; he needs to be involved in decision making.
    A recent article in NEJM (have attached the article) even suggested that the cut-off of 10 should be considered. In our country where a lot of patients and families may not accept active surveillance, we need to be very cautious before suggesting biopsy. For them the word cancer is more dangerous than the disease itself. 
    In this patient who is young and fit, appears to have a high PSA velocity (not clear based on history provided) and appears to be health conscious, i would suggest MpMRI and take it forward based on that. 

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  • Altaf Khan
    Altaf Khan
    18 Apr 2020 10:43:29 PM

    In this case, I would first like to do a mpMRI and if the PIRADS score is 3 or more then go ahead with TRUS guided biopsy.

    Since PSA is more than 10, if it turns out to be Carcinoma prostate it will be intermediate risk, and has to be dealt accordingly.
    You haven't mentioned the duration between the two PSA tests.

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