Role of formal 12 core Prostatic biopsy as a routine following CAP diagnosed on biopsy of TUR chips

• 11 Mar 2020 10:27:51 AM
• |Onco Urology

57 yr old healthy male with normal DRE undergoes TURP after failing medical management on alpha blockers for 35g Prostate. 

Comments(12)

• 

  Dr. Anil Takvani

  11 Mar 2020 10:54:43 AM

  Great, thanks Utsav for posting not uncommon scenario.

  Why you have done PSA ? It is only 10th post operative day since TUR-P.

  I think this PSA value can not help us in determining risk.

  Biopsy S/O Gleason 3+3 Ca Prostate(attaching the biopsy report)

  In this circumstances I doubt transrectal peripheral prostate biopsy can add anything more.

  I will say wait, keep him in follow up. Repeat S. PSA after another 6 to 8 weeks.

  Let us hear from few more members to have subsequent robust discussions/debate on this scenario.

   

• 

  Utsav Shah

  11 Mar 2020 11:01:34 AM

  Agreed sir we shud have waited for 2 weeks atleast. Half life of PSA is 48-72 hours and it’s suggested to wait for 3-4 half lives before repeating.

  We prematurely repeated: however, let us assume that the PSA after a month is also the same(11.4). 

  
  

  Is there a role of TRUS biopsy then? If yes why and if no why not?

• 

  Dr. Roy Chally

  11 Mar 2020 03:46:56 PM

  57yrs old diagnosed with CA Prostate after TURP

  Repeat PSA after 1m. If abnormal mpMRI for staging. 

  Repeat biopsy : not going to make a difference. 

  
  

• 

  Rahul Kapoor

  11 Mar 2020 06:11:45 PM

  This is what i feel. 

  1. I will not repeat a biopsy. Its positive once. 

  2. Would like to know the percentage involved. 

  3. Wait for 1 months. This part I would like to take others opinion.  

  4. Do MRI Pelvis and then PSMA PET SCAN.

  He is young, intermediate risk if localised would operate. 

  
  

  
  

• 

  Ashish parikh

  11 Mar 2020 11:17:35 PM

  My opinion

  No need for TRUS prostate biopsy

  Repeat PSA after 1 month

  Do MRI Pelvis after 6-8 week of TURP.

  Treat it as non-palplable tumor.

  all the option r feasible like active surveillance, RP, RT. with due work up and as per risk stratification.

  i attached one article for referrence purpose.

  Thanks and Regards

  Ashish

  View Document

• 

  Utsav Shah

  12 Mar 2020 10:37:53 AM

  Thank you all for solving my doubt😊

• 

  JG Lalmalani

  18 Mar 2020 03:23:40 PM

  Treat as any fresh Ca Prostate on merits.

• 

  Dr Prashant Mulawkar

  18 Mar 2020 11:12:46 PM

  Please repeat PSA at least after 4 weeks, (better 8 weeks)

  as a general rule, PSA should be done (if not done earlier)

  1 day after DRE

  1 week after TRUS

  1 month after prostate biopsy or needle aspiration of prostaet abscess

  2 month after TURP

  (This is what I follow. I know that spme of the statements made by me are wrong and do not have scientific basis, sorry for that)

• 

  Ravindra Sabnis

  19 Mar 2020 08:08:34 PM

  Following information / clarification is needed - 

  1) Biopsy report says multiple bits recieved is 4 cc. Is it all TURP specimen size? It also say tumor quantification is 2%. What does it mean? Of all chips, only 2% show 3+3? 

  More clarity on this issue is required. 

  2) 57 years is very early age for TURP especially after failed medical therapy. Was PSA done before TURP? Is it your protocol to do PSA in all cases before TURP especially <60 years. 

  3) Is there any family history of Ca prostate? 

  Please provide this useful information. 

  Facts are

  1)  - 3+3 now a days is not considered as Ca at all, That too if it inly 2% - still insignificant. 

  2) Repeat PSA was too early - even though you calculated 4 half life, it does not work out after TURP. Generally it takes 3-4 weeks for PSA to returns to original levels. I can understand that patients become anxious after seeing report. But it is our job to relieve their anxiety. 

  PSA can be repeated after 4 weeks. May be once again after 2 more weeks. Nothing lost in buying time. to get realistic idea of base line PSA

  3) Is biopsy reviewed again? There are many inter pathologists variation especially while reporting Gr 3. Often pathologists get confused between benign & Gr3 - especially because there are always cautery artefact which destroys architecture & Gr 3 & benign tissue is difference in architecture. 

  I think if you clarify on these points, we can have more discussion.  

• 

  Utsav Shah

  20 Mar 2020 11:58:42 AM

  Respected Ravindra Sabnis Sir,

  
  

  1) I confirmed with pathology colleagues. They said only 4cc chips were received and a total of 2% quantification out of entire specimen was found(i have read abt <5% considered as less important but that was for RP specimen). 

  PATHOLOGICAL REVIEW WAS NOT DONE. 

  
  

  2) patient was on alpha blockers since 2 yrs. he was highly motivated for surgery and so we went ahead. 

  Intraop small gland was noted and less chips were removed. 

  
  

  3)Patient has refused any family history of Ca Prostate at the follow up visit. However, he is expected to come again after 2 weeks for a repeat PSA. SHALL INQUIRE AGAIN IN DETAIL SIR. 

  
  

  —>At present, as advised by all senior members, patient is asked to follow up after 1 month from date of surgery when we will repeat a PSA and then decide what next. 
  

  
  

  Sir, my doubts are:

  This patient qualifies as T1c acc to TNM. However, we only remove the transitional zone during TURP. Shouldn’t this patient undergo a formal 12 core biopsy? Yes, the argument is that it will be an overkill but maybe the stage can increase to intermediate risk of any core reveals Gleason gr 4. 

  So why not?

• 

  Ravindra Sabnis

  20 Mar 2020 04:58:01 PM

  When he comes for FU, after 1 month, do PSA - if still high, obviously then he needs further evaluation. 

  Options are - 

  1) MPMRI - See if any suspicious areas? What is pirade scoring. If no suspicious areas, & pirade III or less - keep under observation. if more - he goes for biopsy. 

  2) 12 core biopsy - if -ve observation. & regular PSA on FU. 

  2% of entire specimen is very less - but specimen itself was less. 3+3 is now not considered as cancer. There is consensus on that, However when you get 3+3 - it is your duty to find out if any area harbouring grade 4 disease. Pt is very young. SO above 2 options depending upon pt's choice. 

  Small gland, obstructive, 57 yrs age - suggest fibrotic prostate, Chronic prostatitis. PSA is prostate specific & not cancer specific. SO it can be raised in many conditions. especially infections. 

• 

  Utsav Shah

  20 Mar 2020 06:11:29 PM

  Thank you Sabnis sir. 

  Yes even we are thinking of doing an MpMri.