NEJM Resident eBulletin – Elevated PSA

Teaching Topic

Elevated PSA

Case Records of the Massachusetts General Hospital

Case 9-2012: A 67-Year-Old Man with a Persistently Elevated PSA Level

D.S. Kaufman and Others

CME Exam

At least 30% of clinically important prostate cancers may be missed during transrectal ultrasound-guided biopsy, and the results are not improved if more than 12 cores are taken (so-called “saturation biopsies”).

Clinical Pearls

Clinical Pearl  What is a Gleason score?

The Gleason score is the sum of the two most common histologic grades in a prostate-gland tumor, each of which is rated on a scale of 1 to 5, with 5 being the most cytologically aggressive. It correlates with prognosis. A higher score is more likely to be seen with disease that is not confined to the prostate, and is also correlated with poorer response to treatment of localized disease.

Clinical Pearl  What are the criteria for active surveillance in prostate cancer?

The authors report that criteria for active surveillance for prostate cancer include a PSA level less than 10 ng per milliliter. While the decision to carry out active surveillance is one that must be individualized, in general, in addition to having a relatively low PSA, patients with early clinical disease stage and a Gleason score indicating well or moderately differentiated tumor may be considered for active surveillance.

Morning Report Questions

Q. What is transperineal template-guided mapping biopsy (TTMB) of the prostate?

A. Traditional transrectal ultrasound-guided needle biopsy of the prostate allows excellent and convenient sampling of the posterior aspect of the prostate gland, where prostate cancers most commonly originate. On occasion, however, the cancer may arise either centrally or anteriorly and may be beyond the reach of a biopsy needle inserted through the rectum. However, the anterior gland can be reached through a perineal approach, a technique that is used to insert radioactive seeds into the prostate gland for the purpose of treatment (brachytherapy). Precision is needed to ensure that the needles are placed correctly. To achieve this, transrectal ultrasonography is used to visualize the needles, and the needles themselves are passed through holes in a template (grid) that is secured against the perineum. The perforations ensure that the needles are inserted in parallel and with a known relationship to one another. The “repurposing” of this brachytherapy technique for prostate biopsy is known as TTMB, or “grid” biopsy, and the template may be used to insert biopsy needles precisely to any location in the prostate gland.

Figure 3. Transperineal Template-Guided Mapping Biopsy of the Prostate.

Q. What are the indications for consideration of TTMB?

A. A PSA level higher than expected for the size of the gland should prompt consideration of TTMB for better sampling of the prostate. Biopsies performed with the use of templates are important for carefully selected patients in whom there is an unexplained discordance between PSA readings and findings on examination of biopsy specimens obtained via transrectal approach. One quarter of patients who undergo TTMB after at least one negative specimen obtained by transrectal ultrasound-guided biopsy will have positive results on TTMB. Up to half of these patients have cancers with a Gleason score of 7 or higher. In patients with two or more negative specimens from transrectal ultrasound-guided biopsies, the most common finding in specimens obtained by TTMB was cancer in the anterior lobes. The morbidity associated with TTMB is greater than that associated with transrectal ultrasound-guided biopsies; there is a higher incidence of acute urinary obstruction. Overall, the costs associated with TTMB (e.g., the costs of general anesthesia, the operating room, and the processing of a large number of tissue cores) render it far more expensive than transrectal ultrasound-guided biopsies.

Biomarkers May Help Heart Failure Risk Prediction

After accounting for the clinical risk score, several echocardiographic findings were independently associated with incident heart failure HRs 1.11 to 2.91, P≤0.001 for all:

  • Reduced left ventricular ejection fraction
  • Abnormal mitral inflow E/A peak velocity ratio a measure of diastolic function
  • Enlarged left atrium Increased left ventricular mass

These variables were used to create an echocardiographic score.Elevated levels of NT-proBNP also were independently associated with heart failure risk HR 1.61 as a continuous variable and HR 2.7 for values greater than 190 pg/mL, P

via Medical News:Biomarkers May Help Heart Failure Risk Prediction – in Cardiovascular, CHF from MedPage Today.

Prostate Cancer Biomarker

The results, published in the Public Library of Science (PLoS) ONE journal, showed that MSMB is found at significantly lower levels in the urine of men diagnosed with prostate cancer than those without the disease. They also showed men with aggressive tumors were also likely to have lower levels of the protein in their urine.

Protein urine test may signal prostate cancer | Reuters

Pay Attention to Vitamin D Levels

Medical News: HFSA: Vitamin D Marker for HF Deaths – in Meeting Coverage, HFSA from MedPage Today

Heart failure death occurred two to three times more often in people with vitamin D insufficiency or deficiency compared with those who had normal levels of the vitamin, according to data from a government survey.