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Modern transrectal ultrasound instrumentation provides high-definition images of the prostate Transrectal ultrasonography has been used largely for the staging of prostate carcinomas In addition, transrectal ultrasound-guided rather than digitally guided biopsy of the prostate is a more accurate way to investigate suspicious lesions Most prostate cancers are hypoechoic MRI of the prostate allows for evaluation of the prostate lesion as well as regional lymph nodes The positive predictive value for detection of both capsular penetration and seminal vesicle invasion is similar for both transrectal ultrasound and MRI CT scanning plays little role in evaluation because of its inability to accurately identify or stage prostate cancers CT scanning can be useful to detect regional lymphatic metastases and intra-abdominal metastases Radionuclide bone scan is superior to conventional plain skeletal x-rays in detecting bony metastases Most prostate cancer metastases are multiple and are most commonly localized to the axial skeleton Because of the high frequency of abnormal scans in patients in this age group resulting from degenerative joint disease, plain films are often useful in evaluating patients with indeterminate radionuclide findings Intravenous urography and cystoscopy are not routinely used to evaluate patients with prostate cancer Imaging can be tailored to the likelihood of advanced disease in newly diagnosed patients Asymptomatic patients with well to moderately well differentiated cancers thought to be localized to the prostate on DRE and transurethral ultrasound and associated with normal or only modest elevations of PSA (ie, < 10 ng/mL) need no further evaluation Those with more advanced local lesions, symptoms of metastases (ie, bone pain), high-grade prostate cancer, and elevations in PSA greater than 20 ng/mL should undergo radionuclide bone scan Cross-sectional imaging of the prostate is usually indicated only in those patients in the latter group who have negative bone scans in an attempt to detect lymph node metastases Patients found to have enlarged pelvic lymph nodes are candidates for FNA Despite applica-.

concentration is directly related to patient age, establishment of age-specific reference ranges would increase specificity (fewer older men with benign prostate hyperplasia would undergo evaluation) and increase sensitivity (more younger men with cancer would undergo evaluation) Age-specific reference ranges have been established: men 40 49, < 25 ng/ mL; men 50 59, < 35 ng/mL; men 60 69, < 45 ng/mL; and men 70 79, < 65 ng/mL (based on a previously normal serum PSA of < 4 ng/mL) Black men have lower age-specific reference ranges (age 40 49, < 2 ng/mL; age 50 59, < 4 ng/ mL; age 60 69, < 45 ng/mL; age 70 79, < 55 ng/mL) The most recent attempt at refining PSA has been the measurement of free serum and protein-bound levels (cancer patients have a lower percentage of free serum PSA) Numerous centers are analyzing this assay to define an optimal cutoff level Generally, men with free fractions exceeding 25% are unlikely to have prostate cancer, whereas those with free fractions less than 10% have an approximately 50% chance of having prostate cancer Early reports using cutoffs of 18 20% of free PSA resulted in 5 10% lost sensitivity for 15 40% gains in specificity The frequency of PSA testing remains a matter of some debate In men with a normal DRE and a PSA > 25 ng/mL, PSA testing should be performed yearly because approximately 50% of these patients convert to having a PSA > 4 ng/mL It can be performed biennially in those with a normal DRE and serum PSA < 25 ng/mL Conversion in this group is much less likely

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tion of modern and sophisticated imaging, understaging of prostate cancer occurs in at least 20% of patients

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FIGURE 11-6

Whether screening for prostate cancer will result in a decrease in yearly mortality rates due to the disease is the subject of much current debate The screening tests currently available include DRE, PSA testing, and transrectal ultrasound Depending on the patient population being evaluated, detection rates using DRE alone will vary from 15% to 7% Unfortunately, most cancers detected in this way are advanced (stages T3 or greater) Transrectal ultrasound should not be used as a first-line screening tool because of its expense, its low specificity (and therefore high biopsy rate), and the fact that it increases the detection rate very little when compared with the combined use of DRE and PSA testing PSA testing will increase the detection rate of prostate cancers compared with DRE Approximately 2 25% of men older than 50 years of age will be found to have prostate cancer using PSA testing compared with a rate of approximately 15% using DRE alone PSA is not specific for cancer, and there is considerable overlap of values between men with benign prostate hyperplasia and those with prostate cancers The sensitivity, specificity, and positive predictive value of PSA and DRE are listed in Table 39 6 PSA-detected cancers are more likely to be localized compared with those detected with DRE alone To improve the performance of PSA as a screening test, several investigators have developed alternative methods for its use The serial measurement of PSA (PSA velocity) may increase specificity for cancer detection with little loss in sensitivity A rate of change in PSA greater than 075 ng/mL per year is associated with an increased likelihood of cancer detection In a patient with a normal DRE, an elevated PSA, and a normal transrectal ultrasound, the indications for prostate biopsy may be refined by calculating PSA density (serum PSA/volume of the prostate as measured by ultrasound) Patients with high PSA density are more likely to have disease in spite of a normal DRE and normal transrectal ultrasound Some have found measurement of PSA transition zone density (the zone of the prostate that undergoes enlargement during development of benign prostate hyperplasia) to be more predictive of the presence or absence of cancer than PSA density calculated using the entire prostate volume As PSA.

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