How to manage an increasing PSA level after negative prostate biopsy?

초록

Prostate cancer is the most common male cancer. The standard detection in the vast majority of cancers is from assessment of PSA and DRE. In patients with increased levels of serum PSA or suspicious DRE, TRUS-guided biopsies are performed. However, men with an elevated serum PSA may have negative results at biopsy. The result of a negative biopsy dose not rule out malignancy with certainty. Furthermore, second biopsy in these patients detects cancer in 20~30% of such patients. Third and even fourth biopsies may detect cancer in 5% and 4% of patients, respectively. Patients who have a previously negative biopsy in the setting of clinical suspicion of prostate cancer still have a high risk of harboring significant undiagnosed disease. Increase in PSA levels is nonspecific and can be associated with benign causes. Despite of its vague implications, physicians are compelled to evaluate increasing PSA levels to avoid missing a diagnosis of prostate cancer. The management of the patient with repeatedly negative prostate biopsies and clinical characteristics suggestive of cancer remains a challenging problem for both of physicians and patients. Which findings necessitate repeat biopsy and when repeat biopsies would be recommended is difficult to determine. With low certainty of finding a high risk cancer on repeat biopsy, the benefits of determining a diagnosis must be weighed against the risks of subjecting patients to biopsy-related morbidities. Various markers such as PSAV, PSAD, PCA3, and newer markers may aid in repeat biopsy selection. Repeating the same biopsy procedure in such patients does not yield high cancer detection rates. More anteriorly directed transrectal or transperineal biopsies are indicated. mp-MRI can detect abnormal areas, and lesion-targeted biopsies can improve the cancer detection rate in the population with persistently elevated or rising PSA level to select patients that can avoid unnecessary prostate biopsy.