Prostate Cancer: Diagnostic Tests

Initial diagnosis includes digital rectal examination (DRU), a palpation examination in which the prostate is palpated from the rectum. In this way, any hardening and irregularities of the prostate surface can be detected. If there is a suspicion of tumor disease, further diagnostic measures can be initiated.Obligatory Medical Device Diagnostics

  • Transrectal prostate ultrasonography (TRUS; ultrasound diagnosis of prostate and seminal vesicles) including prostate biopsy (punch biopsy/collection for the purpose of histological/fine tissue examination) of ten to twelve tissue cylinders – this is necessary if there is an abnormal digital-rectal examination or an elevated PSA

Further notes

  • Note: “For the early detection of prostate cancer, imaging techniques are not suitable as a primary examination.”
  • However, an MRI-based examination (magnetic resonance imaging, MRI) can improve the diagnosis of suspected prostate cancer, as one study showed, by detecting clinically relevant tumors more accurately and helping to avoid unnecessary biopsies. In biopsy specimens from the MRI group, tumors of any relevance were detected in 44% of all biopsies, but in only 18% of cases from a standard TRUS-based biopsy.Conclusion: MRI-based examination versus TRUS. Is a paradigm shift imminent?
  • Multiparametric MRI examination (mpMRI; in addition to T1 and T2 weighting, diffusion-weighted MRI and dynamic MRI are performed after contrast administration) – Men with suspected prostate cancer without biopsy benefit from mpMRI: specificity was 59% (95% confidence interval: 54.5-63.3%) and sensitivity was 82.1% (95% confidence interval: 77.2-86.3%). Follow-up examinations: An interval of two years is usually appropriate, but closer monitoring may be warranted if growth is more rapid. Note: Normal mpMRI does not rule out prostate cancer, but may be useful in decision making about whether to proceed with biopsy and subsequent treatment.

Optional medical device diagnostics – depending on the results of the history, physical examination, laboratory diagnostics and obligatory medical device diagnostics – for differential diagnosis (tumor staging/stage determination or recurrence diagnosis).

  • X-ray of the thorax (X-ray thorax/chest), in two planes – to detect metastases (daughter tumors).
  • Skeletal scintigraphy (nuclear medicine procedure that can represent functional changes in the skeletal system, in which regionally (locally) pathologically (pathologically) increased or decreased bone remodeling processes are present) – to detect bone metastases.
  • Computed tomography (CT) of the abdomen (abdominal CT)/pelvis (pelvic CT) – to exclude lymph node involvement.
  • Magnetic resonance imaging of the abdomen (abdominal MRI)/pelvis (pelvic MRI), preferably as multiparametric magnetic resonance imaging (mpMRI; in addition to T1 and T2 weighting, diffusion-weighted MRI and dynamic MRI are performed after contrast administration; high positive predictive value will potentially significantly reduce the need for biopsies in the future):
    • For primary diagnosis
    • For the exclusion of lymph node involvement
    • As a complementary imaging diagnosis after negative biopsy.

    Note: The National Institute for Health and Care Excellence (NICE) in the United Kingdom has included MRI in the diagnosis of prostate cancer and recommended it as a biopsy-sparing strategy.

  • Prostate MRI with diffusion-weighted imaging (“DWI”) (PI-RADS and ESUR guidelines).
  • MRI-ultrasound fusion biopsy (synonym: MRI/sonography-guided fusion biopsy) – this involves real-time injection of magnetic resonance imaging results into the ultrasound image (TRUS image; transrectal ultrasound), allowing for more targeted biopsy of prostate tumors; this approach has improved detection of high-risk carcinomas in a large prospective study A number of 4 biopsies (tissue sampling) per target (target area) should be aimed for.
  • Should not be used for primary diagnosis:
    • Ultrasound elastography
    • Computer-assisted ultrasound (histoscanning)
    • diffusion-weighted MRI as well as dynamic contrast-enhanced MRI.
    • PET/CT diagnostics

Notes on recurrence diagnostics

  • PSMA-PET: Positron emission tomography (PET) can target prostate cancer cells after recurrence using a radioactive marker that recognizes prostate-specific membrane antigen (PSMA).
    • Staging in recurrence after primary curative therapy, making tumor recurrence detectable even at very low PSA levelsNote: there are cases with PSMA-negative metastases (daughter tumors).
    • Can detect occult metastases that are not clearly detected by conventional imaging, at least not yet.
  • In the context of recurrence diagnosis after radiotherapy, PET/CT diagnostics should not be performed unless the PSA is at least 2 ng/ml.
  • In asymptomatic patients with biochemical recurrence, bone scintigraphy should not be performed if PSA is <10 ng/ml [Grade of recommendation: B].
  • Whole-body magnetic resonance imaging (whole-body MRI) – appears to be well suited for therapy monitoring; therapy response is appropriate for both PSA-positive and PSA-negative metastases; duration of examination when using fast sequences in 30 to 40 minutes.