Initial Evaluation and Management of Suspected Prostate Cancer

Diagnostic Approach

The initial evaluation of a patient with suspected prostate cancer should include digital rectal examination, PSA testing, and transrectal ultrasound-guided biopsies, with at least six systematic biopsies targeting particularly the posterior zone of the prostate 1, 2
Any abnormality detected during DRE suggestive of prostate cancer in the absence of infection should be investigated further with a transrectal ultrasound-guided biopsy, even if the PSA concentration is normal 2, 3
Total serum PSA determination (upper limit of reference range: 4 ng/mL) remains the reference test for screening and primary indication for biopsy 2, 4
A lower upper limit of the reference range (between 2-4 ng/mL) can be used in men under 65 years old or those at higher risk 4
Repeated PSA determinations should be performed by the same laboratory using the same technique 4
PSA density adjustment using age and prostatic volume has not been validated against the decision to perform biopsies 4

A definitive diagnosis of prostate cancer is made following histopathological examination of prostatic biopsy samples 1, 5
For potentially curative situations, at least six systematic transrectal ultrasound-guided biopsies should be performed, particularly sampling the posterior zone 5
Rectal preparation by enema and prophylactic antibiotics effective against Gram-negative bacteria should be administered to prevent infectious complications 5
The patient must be informed about the risks of the procedure and provided with emergency contact information 5
Biopsies can be performed in day-hospital or outpatient settings, usually with local anesthesia 5

The pathology report should specify: histological type, percentage of Gleason grades 4 or 5, Gleason score, proportion of involved cores, and any extraprostatic extension 2, 3
Optional information includes: perineural invasion, vascular invasion, PIN foci, post-therapeutic changes, atypical adenomatous hyperplasia, and benign hypertrophy 2, 3

Further staging should be performed to guide treatment decisions 6, 7
Digital rectal examination and transrectal ultrasound should be performed prior to, and used as a guide for, biopsies of the periprostatic tissue and seminal vesicles 6
A renal ultrasound and CT scan should be performed for patients with stage T3 cancer 6
Abdominal and pelvic CT scan should be performed in patients with T2a stage disease or higher, PSA concentration greater than 15 ng/mL, and a Gleason score of at least 7 6, 7
Bone scan is indicated if PSA >10 ng/mL, Gleason grade 4 or 5 is present, bone pain is present, or locally advanced tumor (T3Nx or T1-4N1-3) is identified 7

For patients with T1a disease over 65 years old: re-evaluation after 2 months by digital rectal examination, PSA determination, and systematic transrectal ultrasound-guided biopsies 6, 7
Curative treatment is not recommended for patients with a life expectancy of less than 10 years 6, 7

Transurethral resection is not recommended as a first-line biopsy if prostate cancer is suspected 5
A single negative biopsy does not definitively rule out prostate cancer, especially with persistent clinical suspicion 5, 4