What is the utility of a biopsy in the setting of an elevated post-prostatectomy PSA and imaging noting a local prostate bed recurrence?

It would generally be reasonable to treat an imaging detected prostate bed mass without a confirmatory biopsy if one was going to treat the patient whether the biopsy was positive or negative.

Some radiation oncologists are escalating doses to higher that standard levels in the postoperative setting and one might want to confirm cancer with biopsy before relatively non-standard dose escalation.

Additionally, there might be information from the tumor grade that could help with prognosis and potentially help with treatment decision making, for example the duration of ADT, if employed, might be longer if the tumor is very high grade.

Good question. To begin with, I have been involved with care of over few thousand prostate cancer patients, and in those who I have seen that had "only" PSA recurrence (with negative metastatic work up -> bone/CT scans) I don't recall either of them having biopsy confirmation. Maybe there were but they were so few, that I just don't recall any. I don't know if it was because of private practice urologists were less likely to biopsy, or what??. And still to this day, in those PSA progression cases, that I have seen recently, in a large system, I can't recall many confirmation prostate fossa biopsies after negative systemic work-ups in those cases. Having said that, because of the newer imaging (Fluciclovine 18 scans) advances these will prob...

I perform a DRE on all prostate cancer patients at the time of consultation, including the patients that have had a prior prostatectomy. In many circumstances I have discovered palpable nodules in the prostate fossa. In addition, some of these have been discovered with either CT or MR.

I place fiducial markers in the prostate bed in our radiation oncology office. If I can visualize the nodule on the TRUS, I will perform a tru-Cut needle biopsy of the nodule. I do this to establish the grade of the recurrence which may influence the addition and duration of adjuvant ADT. More than once I have found that the recurrent nodule was of a higher grade than the RP specimen and I’ve recommended longer duration ADT for those patients.

I recently had a surprising case that benefited from a biopsy. Several years after surgery he had a slowly rising PSA. I ordered an MRI which revealed a surprisingly large mass. On biopsy there was no evidence of cancer, only several cores of Benign Prostatic Hyperplasia.

Nice case scenarios.

I, too, perform DREs on "all" new PC patients I see unless they refuse.

For @Dr. First Last's case, it would be interesting to see what would have shown up on the prostate specific PET scan, if it was done. Still, it proves MRIs are useful in these regards. And, I suspect PET scanning will dominate imaging for recurrence, and the like, if not, initial staging imaging as well, for PC in the near future.

My thoughts!?!?!?!

Thanks,

@Dr. First Last