Multiple vesico-urethral biopsies following radical prostatectomy: the predictive roles of TRUS, DRE, PSA and the pathological stage

INTRODUCTION: The aim of this study is to verify the predictive role of transrectal ultrasound (TRUS) of prostatic fossa, digital rectal examination (DRE), prostate specific antigen (PSA) and pathological stage after radical prostectomy in the detection of a prostate tumor recurrence at the level of the vesico-urethral anastomosis by means of multiple TRUS biopsies (6-8 cores).MATERIAL AND METHODS: From October 1997, following a radical prostatectomy, 119 consecutive patients (median age: 67.9 years) with a PSA>or=0.2 ng/ml (median PSA: 0.9 ng/ml) underwent DRE and TRUS examinations with a 5.0-7.5 MHz variable frequency end-fire probe (Hitachi Medical System) and an EUB-525 machine. All patients received six TRUS-guided biopsies of the vesico-urethral anastomosis, and 1-2 additional biopsies directed to hypo-echoic or suspicious areas, if detected by TRUS.RESULTS: Biopsies revealed recurrent carcinoma in 50% of patients (60/119). TRUS proved more sensitive than DRE (75% vs. 50%; p=0.01) and, conversely, DRE proved more specific than a TRUS (85% vs. 66%; p=0.03). Cancer was detected in 45% of the 34 patients with a PSAor=2.0 ng/ml (24 patients), TRUS was able to detect every biopsy-proven local recurrence lesion (sensitivity: 100%). Conversely, all patients with a PSA>or=2.0 ng/ml and a negative TRUS had a negative biopsy (negative predictive value: 100%). In a multi-variable logistical analysis, the most predictive parameters determining a positive biopsy rate among those values studied (PSA, DRE, TRUS, positive surgical margins, pathological stage and time to PSA elevation) were TRUS and DRE findings (p=0.003, with an odds ratio of 4.6 and p=0.02, with an odds ratio of 4.1, respectively).CONCLUSION: TRUS and TRUS biopsies utilizing 6-8 cores are efficient tools in the detection of local recurrence after a radical prostatectomy, even with a PSAor=2.0 ng/ml and a negative TRUS, a biopsy of the vesico-urethral anastomosis could be avoided since the negative predictive value is 100%. Cancer recurrence detection seems to be predicted by TRUS and DRE findings, but not by PSA levels, pathological stage, status of the surgical margins or time to PSA elevation.     

Examination of prostate biopsy among Japanese with less than 4.0 ng/ml prostate specific antigen--usefulness of free/total PSA ratio

The low specificity of the prostate specific antigen (PSA) test is considered to be a problem when PSA measurement alone is performed to detect cancer. Therefore, we examined a method to decrease the number of unnecessary biopsies while maintaining the power of the test by using PSA, PSA free/total ratio (PSAf/t), and digital rectal examination (DRE). The subjects were 232 patients with PSA levels of 4.0 ng/ml or less who underwent biopsy for prostate cancer. An endorectal ultrasound perineal biopsy was conducted, and the average biopsy core number was 21. Cancer was detected in 37 of the 232 subjects. Receiver operating characteristic curves of PSA and PSAf/t were subsequently determined. Although the area under the curve (AUC) was 0.56 for PSA alone, the AUC increased to 0.75 when the factor of positive data in DRE was taken into account. Although the AUC was 0.62 for PSAf/t alone, when the factor of positive data in DRE was added as for PSA, the AUC increased to 0.79. In addition, as a result of examining the combination of PSA, PSAf/t and DRE, the condition of the biopsy for prostate cancer in the cases with PSA of 4.0 ng/ml was determined as follows: PSA should be 3.1 ng/ml or more and PSAf/t 27% or less, or the result of DRE should be positive. Based on these criteria, the sensitivity, specificity and detection rate of cancer increased to 0.919, 0.436 and 23.2%, respectively. We consider that this approach will be useful.     

Screening of prostate cancer with PSA and transperineal six sextant biopsy]

OBJECT: The objectives of this study are to examine how many cancer patients we can detect among the outpatients whose PSA values are above 4.0 ng/ml, and to compare the usefulness of transperineal six sextant biopsy (ss-biopsy) with that of transrectal one. METHODS: All the male outpatients (above 50 years old) were inspected Tandem-R PSA levels and digital rectal examination (DRE). Among them, 129 patients showed more than 4.0 ng/ml of PSA values and/or positive finding of DRE, and underwent subsequent transperineal ss-biopsy. RESULTS: Cancers were detected in 52 patients (40.3%) without major complications. Among 64 gray zone (PSA 4.1-10.0 ng/ml) patients, 17 (26.6%) were found to be cancer by ss-biopsy, meanwhile only 2 cancer patients (8.9%) were detected from 23 gray zone ones by traditional directed biopsy. Application of PSA density could not be found practicable to eliminate unnecessary biopsies in the gray zone group. CONCLUSION: Prostate cancer could be found nearly a fourth in the gray zone group of the outpatients. To enhance the detection rate, obtaining at least 6 core samples are recommended from either perineal or rectal root.     

Histological characteristics and clinical significance of Japanese prostate cancer with low levels of prostate specific antigen of 4.0 ng/ml or lower]

PURPOSE: They set a normal limit of prostate specific antigen (PSA) to 4.0 ng/ml in Tandem R assay at most institutions. We investigated clinical and histological characteristics of prostate cancer based on whole mount step-section histology of radical prostatectomy specimens, and taking notice of Japanese prostate cancer whose levels of PSA are less than 4.0 ng/ml in normal levels. MATERIALS AND METHODS: One hundred and twenty-two patients underwent radical prostatectomy for clinically resectable prostate cancer at University Hospital from February 1992 to April 1997. Clinicopathological findings were stratified according to the preoperative PSA levels in 111 patients without preoperative endocrine therapy. Immunohistochemical study for PSA was conducted in 7 randomly selected patients. RESULTS: Of the patients 22 (19.8%) had normal (4.0 ng/ml or lower) preoperative serum PSA. Mean tumor volume in this PSA range was 1.5 cm3 with one pT 0 case included. Pathologically organ confined, potentially curable disease (< pT 3) was found in 17 (77.3%) patients and extracapsular extension and seminal vesicle invasion in 5 (23.8%), respectively. No patients had positive pelvic lymph nodes. Well differentiated tumors of Gleason scores 2-4 were found in 9 (40.9%) of the patients, moderately differentiated tumors (Gleason scores 5, 6) in 5 (22.7%) and poorly differentiated histology (Gleason scores 7-10) in 7 (31.8%). Sixteen (72.7%) patients had clinically significant tumors (> 0.5 cm3, Gleason score > or = 7). All 7 patients had positive staining for PSA, but its intensity did not correlate with serum PSA levels. CONCLUSIONS: Many prostate cancers found in surgical specimens were clinically significant despite the low levels of PSA and potentially curable by definitive treatment. Age, co-morbidity and other clinicopathological variables as well as PSA levels should all be taken into account when treatment options are discussed.     

Predictors of subsequent prostate cancer in men with a prostate specific antigen of 2.6 to 4.0 ng/ml and an initially negative biopsy

PURPOSE: Almost 75% of men with a prostate specific antigen (PSA) of 2.6 to 4.0 ng/ml have no evidence of prostate cancer on biopsy. Deciding whether and when to repeat the biopsy is challenging. We determined if patient specific variables might identify men at increased risk for the subsequent detection of prostate cancer. MATERIALS AND METHODS: We analyzed the records of 24,893 men from a community based prostate cancer screening study. Our study group consisted of 1,202 men with PSA 2.6 to 4.0 ng/ml and a previously negative prostate biopsy. Patient specific variables were analyzed for their value in predicting a future diagnosis of prostate cancer. RESULTS: Of 1,011 men with adequate followup 136 (13.5%) were subsequently diagnosed with prostate cancer. Mean followup +/- SD in men without prostate cancer was 72 +/- 36 months. Prostate cancer was subsequently diagnosed in 35% of men with high grade prostatic intraepithelial neoplasia (HGPIN) on initial biopsy (p <0.0001), in 18% with abnormal or suspicious digital rectal examination (DRE) (p = 0.02) and 16% with an annual PSA velocity of 0 ng/ml (p = 0.002). Multivariate analysis identified HGPIN, initial PSA 3.6 to 4.0 ng/ml, abnormal DRE, family history of prostate cancer and annual PSA velocity 0 ng/ml as predictors of prostate cancer. CONCLUSIONS: Men with a PSA of 2.6 to 4.0 ng/ml and negative biopsy should be advised to undergo repeat biopsy if they have HGPIN, initial PSA 3.6 to 4.0 ng/ml, abnormal DRE, a family history of prostate cancer or a PSA velocity of 0 ng/ml or greater.     

Prognostic value of circulating prostate cells in patients with a rising PSA after radical prostatectomy

BACKGROUND: To predict poor outcome in patients with a biochemical recurrence (rising PSA) after radical prostatectomy (RP), urologists rely primarily on Gleason score, PSA doubling time, and time from surgery to biochemical (i.e., PSA) recurrence. In the present study, we assess the value of RT-PCR detection circulating prostate cells in blood of patients with a rising PSA. METHODS: RNA from blood samples was obtained from 55 patients with a rising PSA and from 45 patients without evidence of biochemical failure (PSA < 0.1 ng/ml). Both groups were matched for age, Gleason score, pT stage, and interval between radical prostatectomy and PCR testing. RESULTS: PSA positive cells were detected in 1/45 (2%) patients without a PSA recurrence and 19/55 (34%) patients with a PSA recurrence. In the rising PSA group, mean PSA doubling time was significantly shorter in patients with positive RT-PCR (5 months) than in patients with negative RT-PCR (16 months; P = 0.001). An earlier onset of recurrence was also detected in patients with a positive RT-PCR (31 months for positive RT-PCR vs. 50 months for negative RT-PCR) but this result did not achieve statistical significance (P = 0.102). Salvage radiation therapy was administered in 15 patients. Three of the five patients with a positive RT-PCR progressed during radiotherapy whereas 7 of the 10 patients with a negative RT-PCR obtained a complete response and none have progressed. CONCLUSIONS: These preliminary results suggest that RT-PCR detection of prostate cells in blood of patients after RP correlates with rapidly progressing biochemical failure after RP.     

Usefulness of MRI prior to prostate needle biopsy in PSA gray zone

To evaluate the diagnostic accuracy of prostate magnetic resonance imaging (MRI), we compared MRI findings with the results of biopsy as well as findings from specimens following total prostatectomy. The subjects consisted of 260 males who showed a prostate specific antigen (PSA) level in the gray zone (4 ng/ml ≤PSA <10 ng/ml) and also underwent digital rectal examination (DRE), transrectal ultrasound (TRUS), and MRI prior to prostate biopsy between April 2005 and December 2009. In Evaluation 1, the results of DRE/TRUS/MRI were compared with those of prostate biopsy. The biopsy-positive rate was higher in males positive in each examination. However, 24.8% of males negative in all examinations were biopsypositive. Thus, these examinations were considered to be inappropriate for secondary screening. In evaluation 2, the prostate was divided into 4 regions, and the findings from specimens following total prostatectomy were compared with MRI findings in each region. For the region containing prostate cancer, MRI showed a sensitivity of 26.0%, specificity of 98.3%, positive predictive value of 96.2%, and negative predictive value of 44. 4%. In patients with a Gleason score ≥7, cancer foci were more frequently detectable using MRI. MRI prior to prostate biopsy in patients in the PSA gray zone is inappropriate for secondary screening due to its low sensitivity. However, by virtue of its high positive predictive value, MRI is useful for determining patients indicated for biopsy, as well as DRE and TRUS. Accurate evaluation of the localization of all cancer lesions is difficult using MRI. However, when MRI findings are present, they frequently indicate the cancer lesion, which may be useful information for treatment.     

Screening with low PSA cutoff values results in low rates of positive surgical margins in radical prostatectomy specimens

BACKGROUND: In the literature, positive margins in radical prostatectomy specimens, the rate of which ranges between 7% and 46%, are associated with adverse patient survival. The aim of the present study was to determine the predictive value of preoperative serum prostate specific antigen (PSA) values for the rate of positive margins in radical retropubic prostatectomy. METHODS: The study included a cohort of 845 patients who underwent radical retropubic prostatectomy between October of 1993 and December of 1999. All patients were stratified in groups on the basis of their preoperative PSA values: PSA group I, 0-1.99 ng/ml; PSA group II, 2-3.99 ng/ml; PSA group III, 4-5.99 ng/ml; PSA group IV, 6-7.99 ng/ml; PSA group V, 8-9.99 ng/ml; and PSA group VI, >10 ng/ml. For each group, the pathologic stage, Gleason score, and the incidence of positive margins were analyzed. For statistical analysis, the Mann Whitney U-test was used. RESULTS: Our data show a significantly higher rate of organ-confined prostate cancers and a significantly lower rate of positive surgical margins in patients with preoperative total PSA values of less than 4 ng/ml compared with patients with higher preoperative total PSA levels. CONCLUSION: As tumor stage and surgical margin status after radical prostatectomy are important predictors of the likelihood of PSA recurrence, which necessitates additional therapy, these findings support the concept of PSA screening by using low PSA cutoff levels.     

Prostate-specific antigen (PSA) value change after antibacterial therapy of prostate inflammation, as a diagnostic method for prostate cancer screening in cases of PSA value within 4-10 ng/ml and nonsuspicious results of digital rectal examination.

OBJECTIVES: Investigation of the possibilities of improving the accuracy of prostate cancer (PC) screening among patients with a PSA value of 4-10 ng/ml and nonsuspicious results of digital rectal examination (DRE), using as diagnostic method the PSA value change (PSA-VCh) after antibacterial treatment of prostate inflammation. METHODS: The study included 61 patients with PSA 4-10 ng/ml, nonsuspicious DRE and inflammation in expressed prostate secretion (EPS). All these patients underwent antibacterial therapy with the following repeated PSA determination and PSA-VCh assessment. RESULTS: Antibacterial therapy led to PSA decrease in 80% of cases. Effectiveness of PSA-VCh in PC screening was estimated. Sensitivity of PSA-VCh (with cut-off point -0.1.100%) equaled 85%, specificity 96%, positive predictive value 85% and negative predictive value 96%. CONCLUSIONS: Prostate inflammation proves to be a significant factor contributing to serum PSA elevation up to 10 ng/ml among patients with nonsuspicious DRE. Assessment of PSA-VCh after antibacterial treatment can improve PC screening accuracy in cases of PSA 4-10 ng/ml, nonsuspicious DRE and inflammation in EPS.     

Significance of prostatic specific antigen in the mass screening for prostate cancer]

The significance of prostatic specific antigen (PSA) was investigated in the subjects examined by the mass screening for prostate cancer from 1985 to 1990. All subjects was examined by digital rectal examination (DRE) and with prostatic acid phosphatase (PAP) and the subjects in whom prostate cancer (Pca) was suspected from abnormal DRE and/or elevated PAP were recommended to receive the secondary screening to confirm the presence of Pca. PSA was measured by radioimmunoassay using Ball-Elsa-PSA-kit. 1,600 serum samples were obtained from our serum bank. The relationship among PSA, prostate size estimated by DRE and age was investigated. PSA was increased with age and the prostate size, PSA being more closely related with the latter. Therefore, we estimated that PSA has an ability to detect benign prostatic hypertrophy (BPH) in the mass screening. This estimation should be confirmed by using an ultrasound tomography because the prostate size obtained by DRE is inaccurate as compared with that obtained by ultrasound tomography. The cut off level of PSA was determined by control which was composed from the subjects with normal size prostate and one with BPH. When the cut off level was 8.6 ng/ml, the sensitivity, specificity and efficiency as Pca marker was 73.9%, 97.4% and 97.1%, respectively. PSA was more than 8.6 ng/ml in all of Pca with elevated PAP. PSA was expected to improve the Pca detection rate in our mass screening system.     

8-month neoadjuvant hormonal therapy before radical prostatectomy for high-risk prostate cancer

PURPOSE: To evaluate the clinicopathological outcomes of 8 months of neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy for high-risk prostate cancer. PATIENTS AND METHODS: A multi-institutional prospective trial was performed between July 2000 and May 2003 involving high-risk prostate cancer patients without metastasis, including 21 who received 8 months of NHT before radical prostatectomy. High-risk group was defined as clinical stage > or =T2c and/or prostate-specific antigen (PSA) >20 ng/ml and/or Gleason score > or =8. PSA values were considered elevated (biochemical failure) if values of 0.1 ng/ml or greater were obtained. RESULTS: Median of initial PSA levels before prostate biopsy was 27.6 ng/ml (8.5-80.7 ng/ml), and median of pre-operative PSA levels after NHT was 0.28 ng/ml (0.02-4.2 ng/ml). There were 5 patients (23.8%) with lower limit of PSA detection (less than 0.02 ng/ml) in 8 months after NHT. The clinical T stage was T1c in 9 patients (42.9%), T2a-b in 8 patients (38.1%), T2c in 3 patients (14.3%), and T3a in 1 patient (4.8%). The median follow-up was 25 months (range 4 to 37). There were 2 patients (9.5%) in pT0, 5 patients (23.8%) with positive surgical margin, 5 patients (23.8%) with extracapsular extension (ECE) and 3 patients (14.3%) with seminal vesicle involvement (SVI). Biochemical failure was occurred in 9 of 21 (42.9%) including of one pT0. Range of time to postoperative biochemical failure was 2 to 25 months (median 6 months) and most of biochemical failure was found within 12 months after surgery. Biochemical failure rate was significantly higher in patient with positive SVI (p = 0.0308) and higher in patients with pre-operative PSA levels of more than 0.1 ng/ml (p = 0.0836), positive ECE (p = 0.0545) and positive surgical margin (p = 0.0545). CONCLUSION: Biochemical failure was frequent after this combined treatment, even in a pT0 case. Long-term follow-up of patients is needed to assess the impact of this therapy on mortality.     

Early detection of prostate cancer in the ESRD population

BACKGROUND: There are currently no prostate cancer screening guidelines specific to the end-stage renal disease (ESRD) population. With this in mind, we evaluated the clinical usefulness of digital rectal examination (DRE), serum total prostate-specific antigen (PSA), prostate-specific antigen density (PSAD) and transrectal ultrasound (TRUS) in predicting prostate cancer in men with ESRD. METHODS: Fifty male ESRD patients age 40 years and older with no prior history of prostate cancer were enrolled in the study. All patients underwent PSA measurement and a DRE followed by a TRUS. PSAD was calculated as the total PSA divided by the prostate volume. Ultrasound-guided prostate biopsies were performed on any patient with 1 or more of the following abnormal findings: a nodule detected on DRE; an abnormal TRUS; PSA > 4.0 ng/ml, or a PSAD > 0.15 ng/ml/cm3. RESULTS: Abnormal findings were detected in 19 patients. Two (4%) had an abnormal DRE, 3 (6%) had PSA > 4.0 ng/ml, 3 (6%) had PSAD > 0.15 ng/ml/cm3 and 16 (32%) had abnormal findings on TRUS. Three patients had 2 abnormal findings and 1 had 3. Of the 15 prostate biopsies performed, 4 (27%) revealed prostate cancer and 3 (20%) high-grade prostatic intraepithelial neoplasm (HGPIN) comprising 8% and 6%, respectively, of the studied population. Of the 4 patients diagnosed with prostate cancer, none had abnormal DRE, 2 (50%) had PSA > 4.0 ng/ml (sensitivity = 66.7% and PPV = 50% (p = 0.236)), 3 (75%) had PSAD > 0.15 ng/ml/cm3 (sensitivity = 100% and PPV = 75% (p < 0.018)), and 3 (75%) had abnormal findings on TRUS (sensitivity = 30% and PPV = 75% (p = 1.000)). CONCLUSION: Routine screening with PSA and DRE does not seem sensitive enough to predict the presence of the disease. Although TRUS detected abnormalities in 16 patients (32%), sensitivity was very low (30%). In our patients, PSAD increased the sensitivity and positive predictive value (PPV) of detecting prostate cancers compared to PSA alone.     

Significance of preoperative PSA velocity in men with low serum PSA and normal DRE

Objectives  

A PSA velocity (PSAV) >0.35 ng/ml/year approximately 10–15 years prior to diagnosis is associated with a greater risk of lethal prostate cancer. Some have recommended that a PSAV >0.35 ng/ml/year should prompt a prostate biopsy in men with a low serum PSA (<4 ng/ml) and benign DRE. However, less is known about the utility of this PSAV cutpoint for the prediction of treatment outcomes among men undergoing radical prostatectomy (RP).     

Effect of digital rectal examination on plasma prostate-specific antigen (PSA)

Presented are results of determination of plasma PSA before, 1 and 24 hours and 3 weeks after digital rectal examination (DRE) in 130 patients with prostatic adenoma (BPH). Mean pre-examination PSA level was 8.5 ng/ml (max. 27.0 ng/ml, min 0.3 ng/ml, SD=6.2). PSA rose at 1 and 24 hr post-DRE: 9.4 ng/ml (max. 28.9 ng/ml, min 0.5 ng/ml, SD=6.7) and 10.7 ng/ml (max. 28.0 ng/ml, min 0.5 ng/ml, SD=7.9), respectively. Conclusion: in patients with prostatic adenoma DRE is followed by a rise in plasma PSA, which returns almost to baseline values by 3 weeks.     

Diagnosis of localized prostate cancer: screening and preoperative staging]

In 712 patients, mapping of the prostate by six systematic ultrasound-guided core biopsies was performed without major side effects using the "biopyt gun". The histologic findings provided data on patients with normal and those with abnormal prostates on digital rectal examination (DRE). Only 3 of 72 (4%) nonurologic patients with normal prostate-specific antigen (PSA; less than 4 ng/ml) had prostate cancer. In patients with firm prostates on DRE and normal PSA, 13 out of 101 (13%) had prostate cancer. In patients in whom PSA was greater than or equal to 4 ng/ml, 92 of 158 (58%) had prostate cancer. In patients with clinical stage B or C and PSA less than 4 ng/ml, 20/56 (36%) had prostate cancer, compared to 155 of 187 (83%) patients with PSA greater than or equal to 4 ng/ml. Transrectal ultrasound (TRUS) seemed not to be useful in screening for prostate cancer, due to its low specificity of 54%, although in patients with clinical stage B or C TRUS identified 157/175 (90%) patients with prostate cancer. For staging prostate cancer we compared in 103 men with pelvic lymph node dissection the value of digital rectal examination, computerized tomography (CT), magnetic resonance imaging (MRI), PAS, TRUS, and random systematic biopsy for identification of lymph-node-positive patients before radical prostatectomy. CT had a sensitivity of only 7% and a specificity of 96% in detecting lymph nodes, whereas MRI had a sensitivity of 50% and a specificity of 100%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Retrospective study of 101 cases with incidental prostate cancer stages T1a and T1b

PURPOSE: The purpose of this retrospective study was to clarify the character of incidental prostate cancer, stages T1a and T1b. METHODS: We analysed 101 cases of incidental prostate cancer. Incidental prostate cancer was diagnosed on the basis of normal digital rectal examination findings, a serum prostate-specific antigen (PSA) level of less than 4.0 ng/mL, and no abnormal computed tomography or ultrasonography findings. All patients were treated at Gifu University Hospital or an affiliated hospital during the period January 1992 through December 2001. RESULTS: There were 64 stage T1a cancers and 37 stage T1b cancers. The mean age of patients was 71.3 years (range 51-87 years). The mean serum PSA level was 1.63 ng/mL (range 0.2-4.0 ng/mL). Thirty-five stage T1a patients (56.5%) and thirty-two stage T1b patients (86.5%) underwent some type of treatment. Total prostatectomy was performed in eight stage T1a cases and fifteen stage T1b cases. Pathological diagnoses were as follows: pTx (n = 1), pT0 (n = 5) and pT2 (n = 2) for stage T1a cancers, and pT0 (n = 6), pT2 (n = 8) and pT3 (n = 1) for stage T1b cancers. Only one stage T1b cancer recurred. CONCLUSION: The outcome of patients with incidental prostate cancer was satisfactory; disease recurred in only one case of stage T1b cancer and there were no cases of PSA failure, although the pathological diagnosis in nine of the fifteen stage T1b cases (60.0%) treated with total prostatectomy was pT2 or pT3. Careful monitoring was indicated for stage T1a cancer, and some treatment was necessary for stage T1b cancer.     

Diagnostic significance of PSA density adjusted by transition zone volume in males with PSA levels between 2 and 4ng/ml

OBJECTIVE: To investigate the diagnostic significance of prostate-specific antigen (PSA), density (PSAD), and PSAD adjusted by transition zone volume (PSATZD) in men with PSA levels between 2.1 and 4.0ng/ml. METHODS: Between 1993 and 2000, 69 men with PSA levels between 2.1 and 4.0ng/ml underwent transrectal ultrasonography (TRUS) and 8-core prostate biopsy. Diagnostic accuracies for various cut-offs of PSAD and PSATZD were investigated according to subdivided PSA levels of 2.1 to 3.0ng/ml and 3.1 to 4.0ng/ml. RESULTS: The detection rate of prostate cancer was 21.7% (15/69). The percentage of patients with extracapsular disease was 33.3% (5/15) and primary Gleason grade 4 or 5 was obtained in 4 (26.7%) patients. The transition zone volume and PSATZD in cancer cases were significantly different in comparison with those in non-cancer cases. The area under the receiver operating characteristic curve for PSATZD was significantly higher in comparison with that for PSAD in the same subdivided PSA ranges. The diagnostic efficiency for PSATZD was higher than that for PSAD. The diagnostic efficiency showed the highest value at the cut-off level for PSATZD of 0.23 and 0.28 in men with PSA levels of 2.1 to 3.0ng/ml and 3.1 to 4.0ng/ml, respectively. CONCLUSIONS: The use of PSATZD cut-offs as a biopsy indication may reduce many unnecessary biopsies without missing most prostate cancer cases in the PSA range of 2.1 to 4.0ng/ml.     

Invasion of bladder neck after radical prostatectomy: one definition for different outcomes

The aim of the study was to evaluate factors of progression after radical prostatectomy in patients with bladder neck invasion (BNI). From 1988 to 2006, 1395 patients underwent radical prostatectomy, 120 (8.6%) had microscopic BNI (pT4 N0, TNM 2002). Group 1 was defined as BNI alone, group 2 as BNI plus extracapsular extension and group 3 as BNI plus seminal vesicle invasion (SVI). Postoperative follow-up data were obtained through routine serum prostate-specific antigen (PSA) and digital rectal examination. Biochemical progression was defined as a single detectable PSA level postoperatively (>0.2 ng ml(-1)). Groups 1, 2 and 3 included 38 (31%), 35 (30%) and 47 (39%) patients, respectively. Preoperative PSA (11.1 vs 24.7 and 23.3 ng ml(-1), P=0.01), biopsy Gleason score (5 vs 6 and 6, P=0.003) and specimen Gleason score (6 vs 7 and 7, P=0.02) were statistically different between three groups. None of the patients had a specimen Gleason score >or=8 in group 1. After a mean follow-up of 27 months, 51 (42.5%) patients had biochemical progression. The 5-year progression-free survival was 87, 53 and 17% for groups 1, 2 and 3, respectively (P<0.001). Within pT4 prostate cancer, those tumors with isolated microscopic BNI appear to have better prognosis than those with associated extracapsular extension and/or seminal vesicle invasion, and should be distinguished in TNM classification.     

Complexed prostate specific antigen density is better than the other PSA derivatives for detection of prostate cancer in men with total PSA between 2.5 and 20 ng/ml: results of a prospective multicenter study

PURPOSE: This prospective, multicenter study was initiated to evaluate the diagnostic performance of PSA, free/total PSA (f/tPSA) and complexed PSA (cPSA) with volume-based parameters for early detection of prostate cancer in patients with PSA between 2.5 and 20 ng/ml. MATERIALS AND METHODS: 408 subjects with serum PSA values between 2.5 and 20 ng/ml regardless of digital rectal examination (DRE) were included in to the study. The diagnostic validity, sensitivity, specificity and cut-off values were evaluated by Receiver Operating Characteristic (ROC) curve analysis. RESULTS: Of 408 patients 77 (18.9%) were positive for prostate cancer. Digital rectal examination was non-suspicious in 86% (351/408) of the patients. Area under curve (AUC) values for cPSA were better than PSA and f/tPSA in patients with PSA values of 2.5-10 ng/ml and 4-10 ng/ml, as well as the whole group. Furthermore, on ROC curve analysis cPSAD was the best predictor of prostate cancer for all PSA ranges regardless of the DRE findings except PSA values between 2.5 and 4 ng/ml. The cut-off value of cPSAD at 90% sensitivity was 0.06 ng/ml/cm(3) with a 35.3% specificity saving 126 unnecessary biopsies in the whole group. CONCLUSION: cPSA might be a better initial test than PSA for prostate cancer detection and measurement of cPSA alone and its derivatives obviate the need for additional fPSA testing.     

Early detection of prostate cancer with low PSA cut-off values leads to significant stage migration in radical prostatectomy specimens

BACKGROUND: The introduction of prostate-specific antigen (PSA) contributed to a shift in tumor stage at diagnosis in patients with prostate cancer. The aim of the present study was to evaluate the effects of PSA screening with low PSA cut-off values on mean total and percent-free PSA levels in patients with prostate cancers at the time of diagnosis as well as on pathologic stage and mean Gleason scores in positive biopsies and radical prostatectomy specimens. METHODS: Data of 875 patients who were diagnosed with prostate cancers between 1996 and 2001 were analyzed. Patients were stratified into six groups according to the year of biopsy. Annual changes in total and percent-free PSA values, in Gleason scores of biopsies and radical prostatectomy specimens, and in pathologic stages of radical prostatectomy specimens were assessed. RESULTS: Mean PSA of patients diagnosed with prostate cancer decreased from 13.11 ng/ml (percent-free PSA: 11.89%) in 1996 to 7.33 ng/ml (percent-free PSA: 12.58%) in 2001 (P < 0.05). The percentage of organ-confined prostatectomy specimens increased from 64.3% in 1996 to 81.5% in 2001 (P < 0.05). However, mean Gleason scores increased from 5.23 to 6.33 over the 6 years (P < 0.05). The percentage of patients with biopsy-proven prostate cancers and PSA values below 4 ng/ml increased from 14.0% in 1996 to 39.2% in 2001. In the group with PSA values below 4 ng/ml organ-confined cancers were found in 80.0-95.2% of patients. CONCLUSIONS: PSAg screening with low cut-off levels has led to a significant reduction of mean baseline PSA levels in prostate cancer patients and to a significant increase in the percentage of organ-confined radical prostatectomy specimens, whereas mean Gleason scores have remained relatively constant.