To the Editor:

In patients with PIRADS 5 lesions who are candidates for radiation therapy, combining prostatic biopsy and fiducial placement would be a good option, during COVID pandemic as well as in patients on anticoagulants/ antiplatelets.

We read with interest the article “Management of prostate cancer patients during COVID-19 pandemic. Prostate cancer and prostatic diseases” [1] and would like to make a suggestion that may be useful in the COVID situation.

Traditionally, prostate biopsy under TRUS (Transrectal Ultrasound) guidance is done to establish the diagnosis of carcinoma prostate. Then, before radiation planning, gold fiducials are placed under TRUS guidance, for assessing daily set up errors and offline organ motion during radiation therapy. Both procedures require bowel preparation (including enema), oral antibiotic cover and, if the patients are on anticoagulants/ antiplatelets, stopping these drugs to reduce risk of post-biopsy bleeding.

In a 73-year-old post CABG (coronary artery bypass graft) and post angioplasty diabetic patient on antiplatelet drugs, with PIRADS 5 lesion on MRI, we did both TRUS-guided sextant biopsy & fiducial placement in the same sitting, after stopping antiplatelets for 5 days and after obtaining informed consent. Biopsy report showed carcinoma with Gleason score 4 + 4. Post 2 antiandrogen depot injections (leuprolide acetate), he underwent underwent IGRT (Image guided radiotherapy); the depot injections (once in 3 months) are being continued, post RT. He is now asymptomatic, with non-detectable PSA, 1.5 years after the biopsy-cum-fiducial placement procedure.

If the biopsy & fiducial placement procedures are combined in patients on anticoagulants/antiplatelets, these drugs need to be stopped only once, reducing the risk of thrombosis at sites like coronary stents. The shedding of COVID-19 virus in stool may be an additional indication for avoiding repeated TRUS-guided procedures.

In patients with PIRADS 5 lesions who are candidates for radiation therapy, combining prostatic biopsy and fiducial placement may be a win-win situation for all (benefitting the concerned patient, doctors, as well as other patients who can be accommodated in the freed-up procedure slot).