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We experienced a case of metastatic prostate cancer that was difficult to detect by repeat prostate biopsy despite a markedly elevated serum PSA level.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Case presentation<\/jats:title>\n            <jats:p>A 64-year-old man was referred to our hospital with lumbar back pain and an elevated serum PSA level of 2036\u00a0ng\/mL. Computed tomography, bone scintigraphy, and magnetic resonance imaging showed systemic lymph node and osteoblastic bone metastases. Digital rectal examination revealed a small, soft prostate without nodules. Ten-core transrectal prostate biopsy yielded negative results. Androgen deprivation therapy (ADT) was started because of the patient\u2019s severe symptoms. Twelve-core repeat transrectal prostate biopsy performed 2\u00a0months later, and transurethral resection biopsy performed 5\u00a0months later, both yielded negative results. The patient refused further cancer screening because ADT effectively relieved his symptoms. His PSA level initially decreased to 4.8\u00a0ng\/mL, but he developed castration-resistant prostate cancer 7\u00a0months after starting ADT. He died 21\u00a0months after the initial prostate biopsy from disseminated intravascular coagulation.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>CUP remains a considerable challenge in clinical oncology. Biopsies of metastatic lesions and multimodal approaches were helpful in this case.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/1756-0500-7-64","type":"journal-article","created":{"date-parts":[[2014,1,29]],"date-time":"2014-01-29T20:31:30Z","timestamp":1391027490000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["A case of metastatic cancer with markedly elevated PSA level that was not detected by repeat prostate biopsy"],"prefix":"10.1186","volume":"7","author":[{"given":"Hiromichi","family":"Iwamura","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shingo","family":"Hatakeyama","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshimi","family":"Tanaka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Toshikazu","family":"Tanaka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noriko","family":"Tokui","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hayato","family":"Yamamoto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Atsushi","family":"Imai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takahiro","family":"Yoneyama","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasuhiro","family":"Hashimoto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takuya","family":"Koie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kazuaki","family":"Yoshikawa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chikara","family":"Ohyama","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2014,1,29]]},"reference":[{"issue":"4","key":"2626_CR1","doi-asserted-by":"publisher","first-page":"530","DOI":"10.1016\/j.eururo.2013.05.030","volume":"64","author":"MJ Roobol","year":"2013","unstructured":"Roobol MJ, Kranse R, Bangma CH, van Leenders AG, Blijenberg BG, van Schaik RH, Kirkels WJ, Otto SJ, van der Kwast TH, de Koning HJ, et al: Screening for prostate cancer: results of the Rotterdam section of the European randomized study of screening for prostate cancer. 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