When is repeat biopsy indicated in the diagnosis of prostate cancer?

Updated: Jan 14, 2019
  • Author: Lanna Cheuck, DO; Chief Editor: Edward David Kim, MD, FACS  more...
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In patients with a persistently elevated PSA level in the face of negative biopsy results, the literature supports repeating the biopsy once or twice. Among cancer cases, 31% were detected on repeat biopsy and 39% were detected if the PSA value was greater than 20ng/mL. If all of the biopsy results are negative, a repeat round of biopsies has been suggested when the PSA increases by 25% from the level at which the last biopsies were performed.

According to European guidelines, indications for repeat biopsy after a previously negative biopsy are as follows [17] :

  • Rising and/or persistently elevated PSA
  • Suspicious findings on DRE (5-30% cancer risk)
  • Atypical small acinar proliferation (ie, atypical glands suspicious for cancer; 40% risk)
  • High-grade prostatic intraepithelial neoplasia (HGPIN) at ≥3 biopsy sites (~30% risk)
  • A few atypical glands immediately adjacent to HGPIN (~50% risk)

The guidelines recommend that repeat biopsies after negative biopsies be performed with MRI targeting.

Further workup depends on the clinical staging. A higher clinical stage of cancer determined by DRE findings, PSA level, and Gleason score (as determined by biopsy) correlates with an increased risk of extraprostatic spread, and these tests are considered key factors in determining the staging workup and predicting patient prognosis.

Bul et al studied the factors predicting reclassification from low-risk to higher-risk prostate cancer in men undergoing active surveillance and found a significant association between an increase in risk classification and the number of initial positive biopsy cores obtained. However, patient age, clinical stage, total number of biopsy cores, and PSA did not significantly influence the outcome. (Although a PSA doubling time of under 3y also had a significant link to reclassification to higher risk. [19] )

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