Which of the following will best establish the diagnosis? A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable.
A. Clinical follow-up during the ensuing year B. Repeat determination of PSA C. Transrectal needle biopsy of the mass D. Transrectal sonogram of the prostate E. Transurethral resection of the prostate
Transrectal needle biopsy of the mass -cancer of the prostate will be discovered early by either the discovery of a hard nodule (as in this case), or the identification of elevated psa. these are complementary examinations. one may be normal, while the other may be revealing. in this case, the recent normal psa does not exclude the need to biopsy this mass. clinical follow up (choice a) is inappropriate at this age, but it is not a completely stupid option: it would be the thing to do if the man had been 75. as pointed out above, regardless of psa levels (choice b) we need to biopsy this mass. a sonogram (choice d) might be needed to identify a tumor that is not palpable, but has been discovered by the psa. in this case the tumor has been felt. it can be biopsied, guided by the finger or by a sonogram if you prefer. but, the sonogram will not establish the diagnosis, it will only help do the biopsy. let us not resect the prostate (choice e) before we have a diagnosis. depending on the results of the complete workup, one might elect a different surgical approach or a different treatment (radiation, for instance).