## Diagnosis of Prostate Cancer **Key Point:** Transrectal ultrasound (TRUS)-guided prostate biopsy is the gold standard investigation for confirming prostate cancer in patients with elevated PSA and/or abnormal DRE findings. ### Why TRUS-Guided Biopsy? **High-Yield:** TRUS-guided biopsy provides histopathological confirmation, which is essential for: - Definitive diagnosis of malignancy - Gleason grading (prognostic significance) - Determination of tumor extent and aggressiveness - Treatment planning and risk stratification ### Indications for Prostate Biopsy | Indication | PSA Level | DRE Finding | | --- | --- | --- | | Biopsy recommended | >4.0 ng/mL (or higher based on age) | Nodular, firm, irregular | | Risk factors | Rapid PSA rise | Family history of PCa | **Clinical Pearl:** The standard approach is a 12-core biopsy (6 cores from each lobe), though extended schemes (16-18 cores) may be used in high-risk patients. ### Technique Details 1. Transrectal ultrasound probe inserted to visualize prostate 2. Biopsy gun with 18-gauge needle used under real-time visualization 3. Samples taken from peripheral zone (where 70% of cancers arise) 4. Local anesthesia (periprostatic nerve block) used 5. Specimens sent for histopathology and Gleason grading **Warning:** Do not confuse diagnostic biopsy with staging investigations — MRI and CT are used for staging *after* diagnosis is confirmed, not for initial diagnosis. ### Gleason Grading (Post-Biopsy) Histopathology report includes: - Gleason score (sum of two most common patterns, range 2–10) - Percentage of cancer in cores - Perineural invasion status - Extraprostatic extension **Mnemonic:** TRUS-GB = **T**ransrectal **U**ltrasound-guided **B**iopsy = gold standard for **G**etting **B**iopsied tissue.
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