Importance of prostate volume in the European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculators: results from the prostate biopsy collaborative group

Objectives

To compare the predictive performance and potential clinical usefulness of risk calculators of the European Randomized Study of Screening for Prostate Cancer (ERSPC RC) with and without information on prostate volume.

Methods

We studied 6 cohorts (5 European and 1 US) with a total of 15,300 men, all biopsied and with pre-biopsy TRUS measurements of prostate volume. Volume was categorized into 3 categories (25, 40, and 60?cc), to reflect use of digital rectal examination (DRE) for volume assessment. Risks of prostate cancer were calculated according to a ERSPC DRE-based RC (including PSA, DRE, prior biopsy, and prostate volume) and a PSA?+?DRE model (including PSA, DRE, and prior biopsy). Missing data on prostate volume were completed by single imputation. Risk predictions were evaluated with respect to calibration (graphically), discrimination (AUC curve), and clinical usefulness (net benefit, graphically assessed in decision curves).

Results

The AUCs of the ERSPC DRE-based RC ranged from 0.61 to 0.77 and were substantially larger than the AUCs of a model based on only PSA?+?DRE (ranging from 0.56 to 0.72) in each of the 6 cohorts. The ERSPC DRE-based RC provided net benefit over performing a prostate biopsy on the basis of PSA and DRE outcome in five of the six cohorts.

Conclusions

Identifying men at increased risk for having a biopsy detectable prostate cancer should consider multiple factors, including an estimate of prostate volume.     

Prostate cancer detected after Holmium laser enucleation of prostate (HoLEP): significance of transrectal ultrasonography

Purpose

To identify predictors of incidental prostate cancer following Holmium laser enucleation of the prostate (HoLEP).

Methods

We retrospectively analyzed 458 consecutive patients who underwent HoLEP. Patients were classified into two groups: patients who received prostate biopsy prior to HoLEP (biopsy group, n = 174) and patients who did not (non-biopsy group, n = 284). The two groups were compared. Logistic regression analysis was performed to determine the predictive factors.

Results

A total of 27 patients (5.9 %) were incidentally diagnosed with prostate cancer. The incidence of prostate cancer was not significantly different between the two groups (biopsy group vs. non-biopsy group: 6.9 vs. 5.3 %, p = 0.48). Using multivariate analysis, a hypoechoic lesion identified by transrectal ultrasonography (TRUS) was the only predictor of incidental prostate cancer (odds ratio 2.829; 95 % confidence interval 1.061–7.539; p = 0.038). In the biopsy group, there were no significant differences in baseline characteristics including prostate size, prostate-specific antigen (PSA), PSA density, digital rectal examination (DRE) findings, and TRUS findings, between patients with and without prostate cancer. However, in the non-biopsy group, a hypoechoic lesion was found more frequently in patients with prostate cancer (prostate cancer vs. benign prostatic hyperplasia: 20.0 vs. 3.3 %, p = 0.02).

Conclusions

Prior negative prostate biopsy does not rule out the possibility of prostate cancer after HoLEP. The presence of a hypoechoic lesion on TRUS might be helpful to predict incidental prostate cancer after HoLEP in patients with normal PSA and negative DRE. Prostate biopsy prior to HoLEP should be considered in these patients.     

Low serum testosterone levels are predictive of prostate cancer

Purpose

Although hormones play fundamental roles in prostate growth, their clinical significance is not completely clear. Aims of present study were to assess whether testosterone and serum sex hormone levels are predictors of benign prostatic hyperplasia (BPH) or prostate cancer (PC) and to verify whether prostate cancer is associated with low testosterone levels, and to test association between testosterone levels and known prognostic factors in prostate cancer.

Methods

In 206 consecutive patients with benign prostatic hyperplasia or prostate cancer testosterone, follicle-stimulating hormone, luteinizing hormone and prolactin levels were tested and correlated with disease. In patients with prostate cancer, hormone levels were also correlated with known prognostic factors. Predictive value was assessed for age, prostate-specific antigen (PSA), PSA ratio, PSA density, prostate volume and serum sex hormone levels using multiple logistic regression analysis and receiver operating characteristic curves.

Results

Considering sex hormones, only testosterone levels were significantly lower in patients with prostate cancer than those with BPH; testosterone levels appear to be independent predictor of prostate cancer, enhancing predictive accuracy for BPH and PC. Testosterone levels do not seem to be associated with known clinical prognostic factors.

Conclusions

This study supports experimental findings that testosterone levels are predictor of prostate cancer and that prostate cancer is frequently associated with low testosterone levels. In the diagnostic work-up for prostate cancer, adding testosterone determination to PSA test may improve predictive accuracy.     

Low testosterone bioavailability is related to prostate cancer diagnose in patients submitted to prostate biopsy

Introduction

Relationship between prostate cancer (PCa) and testosterone (T) is controversial. Conflicting evidence has been published about T levels and development of PCa.

Aim

(1) To determine the relationship between hormone levels and the diagnosis of PCa. (2) To specifically focus on the relationship between PCa and T in men classified as biochemically hypogonadal.

Materials and methods

Prospective analysis of 1,000 transrectal ultrasound guided prostate biopsies (5?+?5 cores biopsies) between September 2007 and January 2010 in one center. Indication for prostate biopsy was suspicion of PCa on the basis of elevated prostate-specific antigen (PSA) and/or digital rectal examination (DRE). Serum testosterone and sex hormones binding globulin (SHBG) were determined in these patients. Of 557 men, the data were sufficient for further analysis. Age, body mass index (BMI), smoking/drinking habits, PSA, free PSA, PSA density, prostate volume, number of previous biopsies, DRE, and hormone levels were prospectively recorded.

Results

No relationship was found between T and PCa (449?±?167?ng/dL in PCa versus 437?±?169?ng/dL in non-PCa). SHBG was significantly higher in patients with PCa (51?±?27?ng/dL in PCa vs. 44?±?18?ng/dL in non-PCa). In hypogonadal men, T levels correlated with the PCa (235?±?95?ng/dL in men with PCa versus 270?±?58?ng/dL in men without PCa, P?=?0.004).

Conclusions

T levels were comparable in men with and without PCa, but SHBG levels were significantly higher in men with PCa. In men with low T, the men with PCa had a lower serum T levels and a lower prostate volume than the men without PCa.     

The impact of obesity on the predictive accuracy of PSA in men undergoing prostate biopsy

Purpose

Obese men have been reported to have lower serum PSA values relative to normal-weight men in population-based studies, screening cohorts, and in men with prostate cancer (CaP) treated with surgery. There are concerns that PSA may be less accurate in detecting prostate cancer in men with increased body mass index (BMI). We determine whether the diagnostic potential of PSA is negatively influenced by obesity by comparing its operating characteristics across BMI categories among men undergoing prostate biopsy.

Methods

Demographic, clinical, and histopathological data on 917 men who underwent trans-rectal ultrasound-guided prostate needle biopsy from 2002 to 2010 at a University hospital in Italy were used in the study. Men were categorized for BMI as follows: <25 kg/m² (normal weight), 25–29.9 kg/m² (overweight), and ≥30 kg/m² (obese). Receiver operator characteristics (ROC) curves were used to assess PSA accuracy for predicting prostate cancer overall and then stratified according to digital rectal examination (DRE) findings using the area under the ROC curve (AUC).

Results

The obesity rate of the study cohort was 21 %. There was no statistically significant difference in the overall AUCs of PSA for predicting CaP among normal-weight (AUC = 0.56), overweight (AUC = 0.60), and obese men (AUC = 0.60; p = 0.68) in either DRE-positive or negative men.

Conclusions

In a cohort of Italian men undergoing prostate biopsy, the performance accuracy of PSA as a predictor of CaP is not significantly altered by BMI. Obesity does not negatively impact the overall ability of PSA to discriminate between CaP and benign conditions.     

Serum prostate-specific antigen and digital rectal examination for early detection of prostate cancer in a national community-based program

Objectives

This study analyzed methods of prostate cancer early detection in community settings throughout the United States against standards and findings of earlier studies conducted at academic medical centers.

Methods

The study was conducted at 148 clinical centers during Prostate Cancer Awareness Week in September 1993 and continued through June 1994. A total of 31,953 eligible subjects were tested by both digital rectal examination (DRE) and prostate-specific antigen (PSA). PSA was tested with the Abbott IMx PSA assay and reported by Roche Biomedical, Inc.

Results

The study confirmed that elevated PSA levels (greater than 4.0 ng/mL) aid in the detection of organconfined prostate cancer when used in conjunction with the DRE. Reflecting more conservative biopsy decision-making practices, study results nonetheless are comparable to earlier reports. Among 1307 subjects who underwent biopsy, 322 cancers were detected. The cancer detection rate was 3.6% for PSA, 3.0% for DRE, and 4.7% if either test result was positive. The positive predictive value (PPV) for elevated PSA levels (greater than 4.0 ng/mL) was 31.6%, significantly better (P <0.0001) than the PPV for abnormal DRE results (25.5%). Nearly 90% (88.9%) of staged cancers were diagnosed as localized. Elevated PSA levels detected more localized cancers (76 of 105 [72.4%]) than the DRE (72 of 105 [68.6%]). Of localized tumors, 33 (31.4%) were missed by DRE and detected solely by PSA, and 29 (27.6%) were missed by PSA and detected solely by DRE. The combined use of the two methods detected 33 additional localized tumors.

Conclusions

Community practice throughout the United States demonstrates that PSA and DRE are consistently effective and efficient in the early detection of prostate cancer.     

Mittelstandsorientierung des PSA-Screenings?

Background

Prostate cancer is the most frequent male cancer. In Germany most tumors are detected by PSA testing. Data on the long-term survival of patients with localized early prostate carcinoma are insufficient. We examined the relative survival of the patients with organ-defined prostate cancer (TNM T1–2N0M0, UICC I-II) compared to the standardized age-adjusted rates of the normal male population.

Methods

Epidemiological and clinical data from 4,124 patients with prostate cancer diagnosed from 1998 to 2007 were extracted from the cancer registry of the tumor center in Regensburg; 2,087 patients suffered from localized early cancer. Kaplan-Meier analysis was used to estimate the overall survival rates in the patient cohorts irrespective of primary cancer therapy. These rates were adjusted for the expected survival rates in a comparable set of individuals from the general population.

Results

Eight years after diagnosis, patients with stage I and II localized prostate cancer had an approximately 10% relative increase in survival compared with the normal male population. This relative increase in survival was already observed 3 years after diagnosis.

Conclusion

Patients with stage I–II localized prostate cancer have improved survival compared with the normal male population. This finding cannot be explained solely by the administration of prostate cancer treatments, which do not affect survival until 8–10 years after treatment, suggesting that men who participate in PSA testing may have a better overall health status. Another hypothesis may be a social gradient of PSA testing in Germany.     

Parameter zur Verbesserung der Spezifit?t des prostataspezifischen Antigens

Purpose

The aim of the study was to improve the case detection rate of prostate cancer for patients who had unremarkable palpation findings and a PSA value in the range of 4 to 10?ng/ml by combination of the parameters total PSA (tPSA), f/tPSA ratio, prostate volume, PSA density, patient??s age and transrectal ultrasound findings.

Methods

Sextant biopsy of the prostate was performed for 619 patients aged 45?C75?years who had unremarkable palpation findings and PSA values in the range of 4 to 10?ng/ml. The f/tPSA ratio was determined, transrectal ultrasound examination was performed, the prostate volume was measured and the PSA density calculated. The relationship between the various test variables ?C and their combination ?C and the histology results was investigated using logistic regression.

Results

Prostate cancer was detected in 131 of 619 patients. Analysis of the aforementioned test variables by means of logistic regression revealed that the combination of the parameters f/tPSA ratio, PSA density and patient??s age can significantly increase the sensitivity and specificity of PSA in predicting prostate cancer compared with the use of these parameters on an individual basis. With an assumed limit value of 5% for performance of punch biopsy, 31% of biopsies could be avoided in practice. In such a case, only 3% of instances of prostate cancer would have gone undetected.

Conclusion

The combined use of f/tPSA ratio, PSA density and patient??s age can significantly enhance the case detection sensitivity for the PSA range of 4 to 10?ng/ml.     

Laparo-endoscopic single-site (LESS) radical nephrectomy with renal vein thrombectomy: initial report

Background

The aim of the following study is to evaluate the advancement of incidentally diagnosed prostate cancer in specimen after cystoprostatectomies caused by muscle-invasive bladder cancer. Secondly we assessed the survival in patients after radical cystoprostatectomy whose postoperative specimen was characterized by the presence of co-existing prostate cancer or prostate infiltration by urothelial bladder cancer.

Methods

Between 1993 and 2009 a total of 320 patients with muscle-invasive bladder cancer underwent cystoprostatectomy. The first analyzed group consisted of 52 patients with bladder cancer infiltrating prostate, while the second group consisted of 21 patients with co-existing prostate cancer. In all patients cancer specific survival and progression were analyzed. Average follow up was 75.2 months (range: 0 - 181).

Results

Cancer-specific survival was significantly shorter in group I (p = 0.03). Neoplastic progression in patients from group I was observed in 42.2% of patients, while in patients from group II in 23.6% of patients (p = 0.04). No statistical difference was observed in the percentage of positive lymph nodes between the groups (p = 0.22). The median Gleason score in patients with co-existing prostate cancer was equal to 5. The stage of prostate cancer pT₂/pT₃ was equal to 20 (96%)/1 (4%) patients. 12 (57%) prostate cancers were clinically insignificant. Biochemical recurrence occurred in 2 (9%) patients.

Conclusions

1. Incidentally diagnosed prostate cancer in specimen after cystoprostatectomies is frequently clinically insignificant and characterized by low progression.
2. Patients with bladder cancer infiltrating prostate are characterized by higher percentage of progression and death in comparison with patients with co-existing prostate cancer.

     

Can mycoplasma contribute to formation of prostate cancer?

Purpose

To reveal the possible role of mycoplasmas in the etiopathogenesis of prostate cancer.

Methods

In the study, prostate biopsy was performed on 62 patients with an abnormal digital rectal examination and/or elevated PSA. The patients’ age was between 62 and 77 (mean 65.4 years) years. Thirty-one patients had adenocarcinoma of the prostate histopathologically (group 1). From these patients, the specimens were divided into two subgroups as specimens with malignant findings (group 1A) and specimens with benign findings (group 1B). The control group consisted of 31 patients with benign prostatic hyperplasia (group 2). In the specimens, the presence of mycoplasma DNA was investigated by the polymerase chain reaction method.

Results

The mycoplasma DNA was found to be positive in 11 (35.4 %) patients in group 1A and in 4 (12.9 %) patients in group 1B. There was no mycoplasma DNA in the patients in group 2. The differences between group 1A and group 1B, and between group 1A and group 2 were statistically significant (p values, respectively, 0.006 and 0.0001).

Conclusions

Our data supported the thesis that mycoplasma infections play a role in the etiopathogenesis of the prostate cancer.     

Association between percent-free prostate-specific antigen and glomerular filtration rate in transrectal ultrasound-guided biopsy-proven patients with prostate-specific antigen levels ranging from 4 to 10 ng/ml

Purpose

The aim of this study was to investigate the relationship between percent-free prostate-specific antigen (PSA) and estimated glomerular filtration rate (GFR) in men whose PSA level was 4–10 ng/ml with biopsy-proven prostate status.

Methods

Between 2004 and 2010, the medical records of 495 cases (404 cases without prostate cancer and 91 cases with prostate cancer) who underwent prostate biopsy were reviewed and their GFR was calculated using the Cockcroft–Gault equation, adjusted for body surface area. Correlation and multivariate regression analyses were conducted among percent-free PSA, body mass index, prostate size, and GFR in patients with and without prostate cancer, respectively.

Results

The mean patient age was 64.6 years, and the median PSA and free PSA were 5.64 and 0.87 ng/ml. The mean GFR was 61.02 mL/min/1.73 m², and mean percent-free PSA was 18.9 %. Correlation analysis showed that percent-free PSA was correlated with GFR, age, and prostate size in the non-cancer cohort and correlated with only prostate size in the cancer cohort. Multivariate regression analysis showed that percent-free PSA was influenced by GFR (p < 0.001) and prostate size (p < 0.001) independently in the non-cancer cohort, while only by prostate size (p = 0.008) in the cancer cohort.

Conclusions

Percent-free PSA has a negative relationship with GFR in the benign prostate group, while it does not in the prostate cancer group. Screening with current cutoff value of percent-free PSA can be applied to the patients with impaired renal function.     

Outcomes of salvage prostate cryotherapy stratified by pre-treatment PSA: update from the COLD registry

Objectives

In this study, we evaluate the outcomes of salvage cryotherapy for locally recurrent prostate cancer within the COLD (cryo online data) Registry. Furthermore, we assess the results of salvage cryotherapy (with intermediate follow-up) stratified by pre-treatment prostate-specific antigen (PSA) levels to determine which patients may best be suited for treatment.

Methods

The COLD registry was developed as a prospective, centrally collected database among patients undergoing salvage cryoablation for locally recurrent prostate cancer following primary prostate radiotherapy with curative intent. Of the patients undergoing salvage cryotherapy (without neoadjuvant hormonal ablative therapy), complete medical records were available in 156 patients, with their mean follow-up being 3.8 years (0.9–12.7 years). The treatment outcomes of salvage cryotherapy were assessed using the Phoenix definition (nadir PSA + 2 ng/ml) of biochemical failure.

Results

Of our entire study population, the biochemical disease-free survival (bDFS) rates at 1, 2, and 3 years were 89.0, 73.7, and 66.7 %, respectively. Stratification of our patients into two subgroups is based on their pre-treatment total serum PSA values <5 and ≥5 ng/ml, and bDFS rates at 3 years for these two subgroups were 78.3 and 52.9 %, respectively. A Kaplan–Meier analysis of bDFS stratified by these same pre-treatment PSA values revealed that the subset of patients with a PSA ≥ 5 ng/ml had statistically significant poorer bDFS rates (P = 0.01).

Conclusions

Salvage prostate cryotherapy is a potentially curative local salvage therapy. The importance of early referral when patients have a pre-treatment PSA < 5 ng/ml is essential to optimize treatment outcomes.     

EVALUATION OF CHANGES IN PROSTATE SPECIFIC ANTIGEN IN CLINICALLY LOCALIZED PROSTATE CANCER MANAGED WITHOUT INITIAL THERAPY

Purpose

We define changes in prostate specific antigen (PSA) measurements with time in 49 men 71.9 +/− 7.0 years old (mean plus or minus standard deviation) with clinically localized prostate cancer who remain untreated.

Materials and Methods

We retrospectively analyzed PSA changes in prostate cancer patients managed by watchful waiting. In all patients a minimum of 3 PSA levels were measured at intervals of at least 6 months after malignancy was diagnosed. The rate of change in serum PSA level with time (PSA velocity) was determined using an exponential, log linear model.

Results

In 49 patients treated conservatively mean initial PSA level plus or minus standard deviation was 12.3 +/− 11.1 ng./ml. and mean PSA followup during which no therapy for prostate cancer was introduced was 32.1 +/− 13.2 months. PSA levels decreased during the observation period in 11 of the 49 patients (22%) and median PSA doubling time in the remaining 38 was 55.7 months (range 15.1 to 994.5). There was no significant correlation between age at diagnosis, Gleason sum, initial PSA level or clinical stage and PSA velocity. The short-term rate of change in PSA during the first 9 months after prostate cancer was diagnosed correlated poorly with overall PSA velocity. The short-term rate of PSA change was greater than the overall rate of change in 14 of 37 patients (38%).

Conclusions

There is significant variability in the rate of change of PSA with time in men with clinically localized prostate cancer who remain untreated. The usefulness of serial PSA measurements in the management of watchful waiting is unclear. Changes in PSA may not be helpful or appropriate in determining the need for therapy after a period of observation.     

Prostate biopsy: results and advantages of the transperineal approach—twenty-year experience of a single center

Purpose

Detection rate for prostate cancer (PCa) and complications following transperineal prostate biopsy (TPBx) were reported.

Methods

From January 1991 to December 2012, 4,000 men underwent TPBx; from 1991 to 2001, the patients underwent biopsy for suspicious DRE or PSA values >4 ng/mL; moreover, from 2002, the indications were abnormal DRE, PSA >10 ng/mL, PSA values between 4.1 and 10, 2.6 and 4 and <2.5 ng/mL with F/T PSA <25, <20 <15 %, respectively. In case of initial biopsy, the number of needles cores increased from 6 (1991–1996) to 12 (1997–2012) and 18 cores (2002–2012); in case of repeat biopsy, since 2005 a saturation biopsy (SPBx) with >24 cores was performed.

Results

Overall, PCa, normal parenchyma, HGPIN and ASAP were found in 1,379 (34.5 %), 2,400 (60 %), 175 (4.4 %) and 46 (1.1 %) patients, respectively; in case of initial TPBx, the scheme at 18 showed a greater PCa detection in comparison with scheme at 6–12 cores (p < 0.05). In case of repeat biopsy, a higher detection of microfocus of cancer was found performing a SPBx; moreover, 15 % of cancers were localized in the anterior zone. Incidence of hemospermia and urinary retention were correlated with the number of needle cores resulting equal to 30.4 versus 11.1 % in case of SPBx (p < 0.05); moreover, none developed sepsis.

Conclusions

Transperineal prostate biopsy (TPBx) resets the risk of sepsis; moreover, in case of repeat SPBx, the transperineal approach detects a high number of significant PCa localized in the anterior zone (15 % of the cases).     

Preoperative findings,pathological stage PSA recurrence in men with prostate cancer incidentally detected at radical cystectomy: our experience in 242 cases

Purpose

Preoperative findings, pathological stage PSA recurrence in patients with prostate cancer incidentally detected (iPCa) at radical cystectomy (RCP) were prospectively evaluated.

Methods

From July 2000 to July 2013, 242 men 71 years old (median) underwent RCP; preoperatively, all patients underwent digital rectal examination (DRE), total and free/total PSA. The bladder was totally examined; moreover, the prostate gland was step-sectioned at 4-mm intervals. The incidence of iPCa that fulfilled criteria for clinically significant iPCa was recorded: tumor volume ≥0.5 mL, Gleason grade ≥4, extracapsular extension, seminal vesicle invasion, lymph node metastasis or positive surgical margins. In the presence of iPCa, the patients underwent PSA evaluation during the follow-up and recurrence was defined as two subsequent rises >0.2 ng/mL.

Results

Among the 50 (20.6 %) out of 242 patients submitted to RCP, an iPCa was found and 18 (36 %) of them met criteria for insignificant iPCa; moreover, 30 % of the patients had apex involvement. Median total PSA and PSA F/T values were not significantly different in the presence versus the absence of iPCa (2.6 vs 2.7 ng/mL and 26 vs 27 %; p > 0.05) and between significant versus insignificant iPCa (p > 0.05). None of the patients during the follow-up (median 58 months; range 6–102 months) had PSA recurrence.

Conclusions

PSA and PSA F/T values are provided for poor accuracy in distinguishing preoperatively significant from insignificant iPCa; however, the life expectancy of the patients is dramatically influenced by bladder cancer pTN (in our series, none developed PSA failure). In younger men in whom a prostate-sparing cystectomy could be proposed, an accurate preoperative evaluation should be mandatory to rule out significant iPCa at the risk of apex involvement (in our series equal to 30 % of the cases).     

The 20-core prostate biopsy as an initial strategy: impact on the detection of prostatic cancer

Introduction:

To increase the detection rate of prostate cancer in recent years, we examined the increase in the number of cores taken at initial prostate biopsy. We hypothesized that an increasing number of cores may undermine the accuracy of models predicting the presence of prostate cancer at initial biopsy in patients submitted to 20-core initial biopsy.

Methods:

A total of 232 consecutive patients with prostate-specific antigen (PSA) between 4 and 20 ng/mL and/or abnormal digital rectal examination (DRE) underwent 12-core prostate biopsy protocol (group 1) or 20-core prostate biopsy protocol (group 2). The patients were divided into subgroups according to the results of their serum PSA and prostate volume. We evaluated the cancer detection rate overall and in each subgroup. Clinical data were analyzed using chi-square analysis and the unpaired t-test or 1-way ANOVA with significance considered at 0.05.

Results:

The 2 groups of patients were not significantly different with regard to parameters (age, abnormal DRE and serum PSA), although median prostate volume in group 1 (57.76 ± 26.94 cc) were slighter greater than in group 2. Cancer detection rate for patients submitted to 20 prostate biopsy was higher than patients submitted to 12 prostate biopsy (35.2% vs. 25%, p = 0.095). Breakdown to PSA level showed a benefit to 20 prostate biopsy for PSA <6 ng/mL (37.1% vs. 12.9%, p = 0.005). Stratifying results by prostate volume, we found that the improvement of cancer detection rate with 20 prostate biopsy was significant in patients with a prostate volume greater than 60 cc (55% in 20 prostate biopsy vs. 11.3% p < 0.05). Morbidity rates were identical in groups 1 and 2 with no statistically significant difference. There appeared to be no greater risk of infection and bleeding with 20 prostate biopsy protocol.

Conclusion:

The 20-core biopsy protocol was more efficient than the 12-core biopsy protocol, especially in patients with prostate specific antigen <6 ng/mL and prostate volume greater than 60 cc.     

Fehlerkriterien bei der PSA-Diagnostik

Background

The widespread use of prostate-specific antigen (PSA) determination in the diagnosis of prostate cancer has proved to be generally beneficial; however, as a result expert commissions, arbitration committees and the courts have had to deal with an increased number of suspected treatment errors. As a follow-up to the previous report on the decisions made by expert commissions, this paper deals with recent developments and their assessment.

Methods

The procedures followed for assessment have been extensively described in the previous paper. The criteria for assessment of disputed treatment were and are the accepted standards (i.e. the standards applicable to medical specialists) and the quality of care applied in accordance with the pertinent definitions.

Results

In the period from 2005 to 2011 (i.e. 7 years) errors in medical treatment were determined in connection with PSA determinations in 22 out of the 37 cases reviewed, i.e. 71%. These were subdivided into 3 cases from general practitioners, 5 cases from specialists in internal medicine and 15 cases from urologists (in 1 case 2 different doctors were involved). They were faulted for omitting a follow-up biopsy of the prostate. In 12 cases this involved PSA values above the recommended cut-off level without suspicious palpation results, in 7 cases raised PSA levels with suspicious palpation findings, in 2 cases suspicious palpation findings without raised PSA and in 1 case the omission of both palpation and PSA determination. An error in treatment was negated if the PSA value was below the recommended cut-off value or had fallen below it again subsequently (two cases each), if follow-up prostate biopsy was recommended and documented following the determination of raised PSA and/or suspicious palpation findings (three cases) or if follow-up treatment was rejected in spite of a documented recommendation (one case).

Conclusions

Treatment errors in association with PSA determinations can therefore be uniformly and plausibly assessed using objective criteria and can thus be avoided.     

Prostate cancer screening in the Prostate,Lung, Colorectal and Ovarian cancer screening trial: update on findings from the initial four rounds of screening in a randomized trial

OBJECTIVE

To describe the results of the first four rounds (T0‐T3) of prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial (designed to determine the value of screening in the four cancers), that for prostate cancer is evaluating whether annual screening with prostate‐specific antigen (PSA) and a digital rectal examination (DRE) reduces prostate cancer‐specific mortality.

SUBJECTS AND METHODS

In all, 38 349 men aged 55–74 years were randomized to undergo annual screening with PSA (abnormal >4.0 ng/mL) and a DRE. The follow‐up of abnormal screening results was at the discretion of subjects’ physicians. PLCO staff obtained records related to diagnostic follow‐up of positive screen results.

RESULTS

Compliance with screening decreased slightly from 89% at baseline to 85% at T3. Both PSA positivity rates (range 7.7–8.8% at T0‐T3) and DRE positivity rates (range 6.8–7.6% at T0‐T3) were relatively constant over time. The positive predictive value (PPV) of a PSA level of >4.0 ng/mL decreased from 17.9% at T0 to 10.4–12.3% at T1‐T3; the PPV for DRE (in the absence of a positive PSA test) was constant over time (2.9–3.6%). Cancer was diagnosed in 1902 men (4.9%). Screen‐detected cancers at T0 (549) were more likely to be clinical stage III/IV (5.8%) and to have a Gleason score of 7–10 (34%) than screen‐detected cancers at T1‐T3 (1.5–4.2% stage III/IV and 24–27% Gleason score 7–10 among 1054 cases).

CONCLUSION

The present findings on serial prostate screening are similar to those reported from other multi‐round screening studies. Determining the effect of PSA screening on prostate cancer mortality awaits further follow‐up.     

Biopsy-proven brain metastases from prostate cancer: a series of four cases with review of the literature

Aims

Prostate cancer is very common and is the second most common cause of cancer death in males in Australia; however, brain metastases are exceedingly rare.

Materials and methods

We review four cases of biopsy-proven brain metastases from prostate cancer and review the relevant literature.

Results

Three of four patients had acinar adenocarcinoma of prostate with one patient having ductal adenocarcinoma variant on histopathology. Three patients had the brain as the only site of metastatic disease. All patients underwent surgery, and three of four patients underwent adjuvant palliative radiotherapy to the brain.

Conclusion

Brain metastases from prostate cancer are rare, but brain metastases without other sites of metastatic disease are exceedingly rare and may be more common with ductal adenocarcinoma variant.     

Hormone therapy for radiorecurrent prostate cancer

Background

The management of patients who relapse after radical radiotherapy is a challenging problem for the multidisciplinary team. This group of men may have been considered ineligible or chosen not to be treated with an initial surgical approach as a result of high-risk features or significant comorbid conditions. It is important not to miss the opportunity for definitive local salvage therapies at this stage, and eligible patients should undergo careful restaging to determine their suitability for these approaches. For those men not suitable for local treatment, androgen deprivation therapy (ADT) remains an option.

Methods

Literature review of the evidence relating to the management of hormone therapy for radiorecurrent prostate cancer.

Results

Results from retrospective studies have shown that not all men with biochemical relapse will experience distant metastasis or a reduction in survival due to prostate cancer progression. Therefore, the timing of ADT commencement remains controversial. However, it would seem appropriate to offer immediate therapy to men with advanced disease or unfavourable prostate-specific antigen (PSA) kinetics at relapse. Patients with more favourable risk factors and PSA kinetics may be considered for watchful waiting and deferred ADT to avoid or delay the associated toxicities. Patients with non-metastatic disease can be given the option of castration-based therapy or an antiandrogen such as bicalutamide which may have potential advantages in maintenance of sexual function, physical capacity and bone mineral density but at the expense of an increase in gynaecomastia and mastalgia. Recent data suggest the burden of toxicity from ADT may be reduced by the use of intermittent hormone therapy without compromising survival in this group of patients with radiorecurrence.

Conclusions

Hormone therapy remains an option for men with radiorecurrent prostate cancer.