Dear Dr. Motola,** I am a healthy, very active 71 year old male. MY PSA level increased over the past 16 months from 2.1 to 3.2 and as a consequence my new urologist suggested a biopsy even though his digital rectal exam showed a healthy prostate.**** The biopsy (12 samples taken) showed 4 areas of high-grade PIN. My urologist suggested that a follow-up biopsy be done in three months.**** I emailed my previous urologist and asked his opinion on the necessity of so early a follow-up biopsy when high-grade pin is discovered.**** His response was that in general he recommends a follow up biopsy when high-grade PIN is found, a year following the finding, and then quarterly PSA testing during the year.**** When I shared his recommendation with my current urologist, he said that PSA levels no longer have any diagnostic benefit once high-grade PIN is discovered and insisted the proper follow up biopsy should be done in three months.**** Can you tell me what the most typical approach is after a finding of high-grade PIN? Is another biopsy necessary so soon?**
High grade prostatic intraepithelial neoplasia (HGPIN) is an entity that is associated with the subsequent development of subsequent prostate cancer. Many studies indicate that most patients with HGPIN will develop adenocarcinoma of the prostate within 5-10 years. It has been identified as the most significant risk factor for prostate cancer in biopsy specimens.
With a normal rectal examination and a PSA that has not doubled in a 71 y.o male, I am not convinced that I would have performed the biopsy to begin with.
Various treatment paradigms have been proposed for patients who have high grade PIN, and one of these is to have follow-up biopsies at 3 to 6 month intervals for 2 years, and then at 12-month intervals. I tend not to be as aggressive in my patients with HGPIN when they are over 70, and usually follow these patients with follow-up PSA testing at 3-month intervals. If there is a significant rise in PSA, then I recommend a follow-up biopsy. Another approach is to perform saturation biopsies with general anesthesia with the understanding that HGPIN is associated with cancer in 85% cases of prostate cancer.
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