and decreasing prostate cancer mortality since

up to 30–50% may have prostate cancer on

the widespread introduction of PSA testing as

repeat biopsy.

evidence supporting the continued use of PSA

testing with DRE.

Incontrast,in2008theUnitedStatesPreventive

Pathology

Services Task Force (USPSTF) stated that the

current evidence is insufficient to assess the bal-

Almost all prostate carcinomas are adenocarci-

ance of benefits and harms of prostate cancer

noma. Other tumor types are rare, and include

screening among men aged less than 75 years.

ductal carcinoma, mucinous adenocarcinoma,

Among men over 75 years of age, the USPSTF

and transitional carcinoma of the prostate.

recommends against screening, believing that

Small-cell (neuroendocrine) tumors of the pros-

the limited average life expectancy and known

tate are even less frequent. Both primary transi-

harms of screening outweigh the potential ben-

tional carcinomas and small-cell carcinomas of

efit of early detection of prostate cancer in these

the prostate are very aggressive and carry a poor

elderly men. PSA testing in elderly men is com-

prognosis. These tumors require aggressive sur-

mon and indiscriminate, so it is doubtful that

gical intervention for localized disease.

these practice patterns will soon change.20–22

Additional tests may provide assistance when

The histologic grade assigned to prostate ade-

nocarcinoma is based on the system developed

uncertainty exists as to whether a prostate

by Gleason. The Gleason grade is the sum of the

biopsy is indicated. For men with a PSA level

most common cellular pattern (1–5) and the

<10 ng/mL, a commonly employed test is the

second most common cellular patterns (1–5) in

ratio of free/total PSA (percent free PSA). In

the biopsy or surgical specimen. This histologic

men with no prior biopsy who have a PSA level

grade provides valuable prognostic information,

of at least 4.0 ng/mL, a free PSA of less than 25%

in addition to the PSA at the time of biopsy and

may indicate a 50–60% chance of prostate can-

clinical stage.

cer. Among men with a prior negative biopsy, a

free PSA <10% is an indication for repeat biopsy.

PCA3 is a urine-based mRNA assay which may

Prognosis

assist in determining whether men with a prior

negative prostate biopsy should undergo repeat

biopsy.23,24

Central to the management of the disease is an

understanding of prostate cancer risk stratifica-

Biopsy

tion, the patient’s health status, and life expec-

tancy. The TNM system is widely accepted for

When indicated, prostate biopsy is typically per-

the clinical staging of prostate cancer (Table 38.1).

formed as an office procedure.Under ultrasound

Tumors confined to the prostate gland are T1 or

guidance, 8–12 tissue cores are obtained tran-

T2, whereas once local extension occurs, tumors

srectally with an 18-gauge biopsy gun. Typically,

are classified as T3 or T4. Several systems have

this procedure is performed under local anes-

been developed for risk stratifying prostate can-

thesia (peri-prostatic nerve block with lido-

cer based on PSA, clinical stage, and Gleason

caine). The primary side effects of prostate

score. The Partin Tables define the probability of

biopsy are hematochezia and hematuria lasting

organ-confined disease, extraprostatic exten-

for 2–3 days. Hematospermia may last up to

sion, seminal vesicle invasion, and lymph node

4–6 weeks. Significant infection following pros-

invasion.26–28 Subsequently, D’Amico et al. devel-

tate biopsy occurs in 0.5–1% of cases, with

oped risk groupings for newly diagnosed men

appropriate antibiotic prophylaxis.

with localized disease (Table 38.2). Three risk

If the prostate biopsy is negative, men should

stratifications (low, intermediate, high) for

undergo continued monitoring of PSA and DRE

relapse after initial local therapy are defined,

annually, with rebiopsy as indicated by a rapid

again using clinical stage, Gleason grade, and

rise in PSA or a new abnormality on DRE. Men

PSA.29,30 The D’Amico risk stratification system

with high-grade prostatic intraepithelial neo-

has come into widespread use for counseling

plasia or atypical small acinar proliferation

and planning interventions. Finally, preoperative

should undergo repeat biopsy in 3–6 months, as

and postoperative nomograms predicting risk of