What is the psa predictive value of the patients with atypical small acinar proliferation (asap)? is the second biopsy always necessary?

Ediz C and İhvan N.A

Objective: The aim is to discuss the necessity of implementation of the second prostate biopsy on the patients atypical small acinar proliferation (ASAP) detected as a result of histopathologic examination and on the patients appliedprostate biopsy due to abnormal findings during the prostate specific antigen (PSA) height and/or digital rectal examination, and to detect necessity criteria of the second biopsy.
Materials and Methods: 2295 patients that transrectal ultrasonography-guided prostate biopsy was applied between January 2008 and January 2016 have been evaluated retrospectively. ASAP was detected on 228 of them following the histopathologic examinations. 217 patients, whose data were reached, are taken into the study. Re-biopsy was applied on 120 of 217 patients within a period of 3-6 months.  Before the first and the second biopsy, total PSA, free PSA, free/total PSA rate, PSA density were calculated. Second biopsy results and changes in the data are compared. Data disagree with normaldistribution, and they are summarized by the median, minimum, and maximum values. To compare the first and the second biopsy, Wilcoxon signed rank test is used. The significance level is taken as 0,05 for all tests.
Results: The median age of 120 patients with ASAP who included this study was 63,06 (40-78). Prostate volume mean is 54,04 cc (10-140). Median total PSA value was detected as 8,63 ng/ml (0,9-32,5), free PSA value was detected as 1,59 ng/ml (0,0017-8,9), free/total PSA rate was determined as 19,77% (0,0014-0,79), PSA density was detected as 0,1959 ng/mL/cc (0,01-0,98). Average in 1,3 number (1-5) of the biopsy specimens, ASAP was detected. As a result of the second biopsies of 120 patients with ASAP, second biopsy result was reported as benign for 73 patients (60,8%), ASAP was reported for 24 patients (20%) and prostatic adenocarcinoma (PCa) was detected on 23 patients (19,2%). Although statistically significant decrease(p<0,001) was determined on total PSA, free PSA and PSA density tests of the patients whose second biopsy was reported as benign, no difference on free/total PSA rates was available. For the group whose second biopsy showed ASAP again, there was no significant difference on any variable. While total PSA values of the patients whose second biopsy was PCa increased (p=0,009), there was no significant difference in free PSA values (p=0,297). Also, on PCa group free/total PSA value decreased (p<0,001) and PSA density values increased (p=0,010).
Conclusions: Total PSA, free PSA, free/total PSA rate and PSA density should be evaluated routinely in the patients with ASAP before the second biopsy, and before the second biopsy, the changes in these parameters should be considered and accordingly, a re-biopsy decision should be made. If there is a decrease in total PSA value, the decision for the second biopsy should not be hasted; however if there is an increase in total PSA value, the second biopsy should be done before it is too late.


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