No biopsy needed at a PSA of this level and a malignant feeling prostate (if that is what you are describing), but a bone scan would demonstrate non visceral bony mets, if the CT with bony windows doesn't. Testosterone ablation will quickly reduce this PSA, but unfortunately not permanently. However, the purist view would still contend that biopsy is a simple and safe procedure on those with minimal other morbidities and not on anti-coagulation, and it may be that tissue retrieved before testosterone deprivation therapy may be of benefit in terms of future as yet not available therapies, or as part of a cancer registry/bio bank for future research on the genetic profile of prostate cancer. PSA over 50 ng/ml is 98.5% predictive of prostate cancer.

Reference: The accuracy of the increased prostate specific antigen level (greater than or equal to 20 ng./ml.) in predicting prostate cancer: is biopsy always required?

Gerstenbluth RE, Seftel AD, Hampel N, Oefelein MG, Resnick MI. J Urol. 2002 Nov;168(5):1990-3.

biopsy is necessary to avoid medico-legal problems. Two to Three Carrots are sufficient to confirm the diagnosis, histological type and have the Gleason score.

academic exercise.

A histological diagnosis would certainly be helpful but it depends on his premorbid state. If he is crumbly and unfit, doing a TRUS biopsy may be an

There would be a few more details I would seek before embarking on this.

a) the pre-TRUS logistics: Is his hip joint replacement recnt? Doing a biopsy on a lateral position and the timing of this is essential and may warrant a discussion with the orthopaedic colleagues. The last thing you want is to dislocate a joint. Also, there would be a risk of infection to the joint following the TRUS. You may want to speak to them about this too , counsel the patient and even, cover him with a longer course of antibiotics.

b) Events around the high PSA - make sure an MSU is sent. A UTI must be excluded. Did he have a catheter - since you mentioned "obstructive LUTS"? Was this a single PSA? Did he have any further readings - past or future?

c) Was it an adequate CT?. I am surprised at the amount of information surrounding the prostate that was obatined, as this often prove difficult with an arificial hip.

academic exercise.

A histological diagnosis would certainly be helpful but it depends on his premorbid state. If he is crumbly and unfit, doing a TRUS biopsy may be an

academic exercise.

( oops I pressed "add" too fast)

Assuming that all the above mentioned circumstances are covered, and if he is relatively fit, I would do a TRUS. If this comes back showing an aggressive prostate cancer, I would commence androgen deprivation.

However, the argument agst this would be that there nearly enough evidence to suspect an N1 disease arising from his prostate, which makes obtaining a histological diagnosis superfluos. I would also add a bone scan which may help to further clinch the diagnosis.

We must do the minimal maneuvers but not less than minimal. A DRE has a lot of value. In this case CT scan does not show bone metastasis then we need a bone scan. If you want to save something a finger-guided biopsy is enough and gives a lot of information: by example, transitional cancer associated

Yes, I think TRUS biopsy is needed to confirm the diagnosis, although this level of PSA is highly suggestive for prostate cancer. After confirmation of prostate cancer bone scan is needed to diagnose the bone metastases. According to the age of patient (less than 75), and the probable metastases definitive therapy is needed using ADT.

NO.

We don´t need biopsy to start the prostate cáncer treatment.

No other disease rather tan prostate cáncer could produce that amount of PSA. Does anyone know another disease what produce this amount of PSA???

The patient should start ADT and a bone scan to treat eventual metastases.

I have a patien who starts with 905 of PSA and a bone scan plenty of mts and one year later have a PSA 2,9 and no pain at 82 years.

YES.

In my Country we have many patients with elevated PSA > 100 ng/ml and have refused DRE so it is important make sure to get a prostatic Biopsy and then controled them with a Oncologic Center near to them. in terms of quality life control ESSALUD gives the best chances to do this right.

If you perform a biopsy you have to wait to make the biopsy and then wait the results.

In Argentina It will take a month.

I prefer to start treatment inmediatly. The Aurgentinian Asocciation Of Urology allows to start treatment withouth a biopsy in apatientes with PSA more tan 100

As an academic excersise I m going to point it out that as Dr . Barreiro said there is no need dto perform any biopsy to start treatment , its clear that the patient had a prostate cancer although legal enviroment shoulld be consider in any country and you should stay with the statements of the society of urology of your own country

As well bone scan is needed , TRUS with biopsy is needed too to confirm the histological type of cancer , as not the same treating a gleason 6 than a sarcoma of prostate but you could go for it , when ADT it is already started and patient will be in better clinical position asumming that with that level of PSA its probably due to bone metastatic affection, i ve never see a PSA >1000 without bone affection, so puting him into ADT with a bone scan should be my first treatment/diagnostic decision and then will go with the histological confirmation.

Another reason to biopsy the prostate is so that he can be recruited to trials if they are available, but with this clinical picture a biopsy shoukdn't delay commencing treatment.

He should also have a bone scan. In the UK elderly men with PSA greater than 20 and positive bone scan is enough to confirm diagnosis and start treatment.

Biopsy are necessary , even if the probability of prostate cancer is 100%.

Medicolegal and medicoeconomic reasons justify my answer.

So as to limit the risks of such biopsies ; 4 cores maximum, and transperineal approach should be respected.

Because of obstructive LUTS, another option would be TURP. It may allow a correction of urinary symptoms and the answer to the pathological question. It may also prevent renal failure by freeing ureters and/or placing JJ stents.

thanks for your valuable suggestions..

ultimately i have done biopsy that turns to be Ca P gleason 4+3

bone scan is interestingly negative..

pt is on complete androgen blockade.

his PSA returns normal...

followup scan shows regression in the size of lymph nodes.

And his LUTS ?

I think this uncommon clinical picture represents a typical clinical case (TNM cT4 N2 M0 ADK Gleason 4+3). All the arguments raised by the partecipants are interesting, but I still consider the biopsy as a necessary step. Of course the detection rate of a prostate cancer is quite 100%. Nevertheless, we need to know as much hystological details as possible. For example the presence of neuroendocrine cells could suggest different therapeutical approach. The absence of bone metastasis is an unusual finding, nevertheless the bone health of this patient should be seriously evaluated (alkaline phosphatase, calcemia, etc).

As far as the choice of medical therapy either degarelix or LHRH + antiandrogens or LHRH alone or alphablockers should be discussed. Personally I would consider also the use of bisphosfonates as prevention of skeletal events (bone mets are probably not detected but present), the prescription of alphablockers, the planning of a prostate resection to palliate LUTS.

With this high level of PSA, large prostate with calcification, and lymphadenopathy, it is clear to be CaP. but we my need biopsy for grading, and typting of the tumour.

I had 1 patient with PSA level of 600, whom I give ciprofloxacin for 1 month , PSA became 25 then become normal in next month.???