以前列腺特异抗原水平分组筛查与前列腺穿刺阳性率的关系

目的探讨不同血清前列腺特异抗原(PSA)水平前列腺癌检出情况以及直肠指诊(DRE)、经直肠超声检查(TRUS)、PSA密度(PSAD)等指标对筛查前列腺穿刺活检病例的意义。方法回顾性分析在1996年4月至2002年12月间行TRUS引导前列腺6点系统穿刺活检的634例患者的诊断资料,对各PSA组(≤4.0,4.1~,10.1~和>20.0μg/L组)中前列腺癌的检出率,以及PSA、DRE、TRUS、PSAD等对前列腺癌的预测作用进行t检验、χ2检验和多因素Logistic回归分析。结果PSA≤4.0,4.1~,10.1~和>20.0μg/L各组的前列腺癌检出率分别为11.6%(17/146),26.8%(38/142),39.8%(68/171)和68.6%(120/175)。PSA的敏感性最高(93.0%),特异性低(33.0%);DRE、TRUS等诊断效率较低。随血清PSA水平升高,前列腺癌检出率以及DRE、TRUS的阳性预测值逐渐升高;在PSA4.1~20.0μg/L者中,PSAD对前列腺癌有较大的预测价值(OR=687.09±646.96,P=0.000)。以PSAD≥0.13μg.L-1.cm-3为截点筛查前列腺穿刺病例,可在不明显降低敏感性的基础上,减少阴性穿刺。结论各PSA组国人与欧美等国前列腺癌检出率有较大差别;DRE、TRUS的筛查作用与血清PSA水平有关;按PSA水平分组筛查穿刺病例,可提高前列腺穿刺的阳性率。     

Volume-adjusted prostate-specific antigen (PSA) variables in detecting impalpable prostate cancer in men with PSA levels of 2-4 ng/mL: transabdominal measurement makes a significant contribution

OBJECTIVE: To examine whether prostate-specific antigen (PSA) levels adjusted according to prostate volume improve prostate cancer detection using transrected biopsies in men with PSA levels of 2-4 ng/mL, and benign findings on a digital rectal examination (DRE). PATIENTS AND METHODS: Men aged < or = 79 years and with serum PSA levels of 2-4 ng/mL and normal DRE findings were prospectively enrolled. Eligible patients were recommended for transrectal prostate biopsies after measuring prostate volumes with transrectal (TRUS) and transabdominal (TAUS) ultrasonography, and transition zone volumes with TRUS. In addition to PSA levels and the free-to-total PSA ratio, volume-adjusted PSA levels, PSA densities determined by TRUS (PSAD(TRUS)), and TAUS (PSAD(TAUS)), and PSA transition zone densities (PSATzD) were compared using receiver operating characteristic analysis. RESULTS: Prostate cancer was diagnosed in 31 (22%) of the 139 men who had prostate biopsies. The area under the curve (AUC) of PSAD(TRUS) (0.796) and PSATzD (0.792) was similar and significantly greater than that of PSA (AUC 0.588) and the free-to-total PSA ratio (AUC 0.658). PSAD(TAUS) was a significantly better indicator of prostate cancer than PSA levels alone (P = 0.043). CONCLUSION: As predictors of prostate cancer, there were no significant differences between PSAD(TRUS) and PSATzD. Although PSAD(TAUS) was worse than PSA variables adjusted by total and transition zone prostate volumes determined by TRUS, it was a better predictor than the PSA value alone in men with a low PSA level. These results indicate that TAUS is worthwhile where the routine use of TRUS before biopsy is difficult.     

Community‐based prostate cancer screening in Japan: Predicting factors for positive repeat biopsy

Objectives: To assess possible predictors in determining criteria for repeat biopsy in a prostate cancer screening population. Methods: A total of 50 207 men over 55 years‐of‐age have participated in a prostate cancer screening program in Otokuni, Kyoto, Japan for 12 years. Transperineal systematic biopsy was carried out in case of positive digital rectal examination (DRE) or positive transrectal ultrasonography (TRUS) or a prostate‐specific antigen (PSA) value greater than 10.0 ng/mL. For those with a PSA level from 4.1 to 10.0 ng/mL, and negative DRE and TRUS findings, biopsy was indicated only when PSA density (PSAD) was greater than 0.15. The same indication was applied for the repeat biopsy. Results: A repeat biopsy after an interval of more than 2 years was carried out in 140 patients and was positive in 50 (36%) patients. The PSA value at the diagnosis of cancer declined from the initial value in six (12%) patients. On multivariate logistic regression analysis, PSA velocity (PSAV) as well as PSAD and DRE findings at latest screening were independent predictors for positive repeat‐biopsy outcome. The odds ratio (95% confidence intervals) of PSAV >0.48, latest PSAD >0.33 and positive latest DRE were 4.17 (1.05–18.5), 4.15 (1.31–14.0), and 3.62 (1.06–13.2), respectively. A combination of three variables defined as positive if any of these were positive, reduced 31% of unnecessary biopsies while missing 8% of low volume, low grade cancers. Conclusions: A combination of latest PSAD, PSAV and positive DRE at latest screening might help to reduce unnecessary repeat biopsies in high‐risk patients with an initial negative biopsy.     

USEFULNESS OF DIGITAL RECTAL EXAMINATION, SERUM PROSTATE-SPECIFIC ANTIGEN, TRANSRECTAL ULTRAS ONOGRAPHY AND SYSTEMATIC PROSTATE BIOPSY FOR THE DETECTION OF ORGAN-CONFINED PROSTATE CANCER

The detection rate of organ-confined prostate cancer by digital rectal examination (DRE), serum prostate-specific antigen (PSA), and transrectal ultrasound (TRUS) of the prostate, as well as the value of a directed, guided transrectal core biopsy for the prostate (TRUS-guided biopsy) combined with systematic biopsy, were evaluated. The subjects were 171 patients with urinary symptoms suggestive of prostatic disease excluding those with clinical stage C and D prostate cancer. Twenty-five patients (14.6%) had prostate cancer, 127 (74.2%) had benign prostate hypertrophy, four (2.3%) had prostatic intraepithelial neoplasia, eleven (6.4%) had inflammation, and four (2.3%) had normal prostate tissue. The incidence of detection of hypoechoic findings by TRUS in the patients in whom nodules were detected by DRE or who had elevated serum PSA was higher than that in patients with negative diagnostic findings. In 22 of the 25 patients with prostate cancer, the cancer was detected by recognition of a hypoechoic area on TRUS. In 10 of these 22 patients, prostate cancer was also detected by systematic biopsy in isoechoic areas. Prostate cancer was detected by systematic biopsy in three patients without hypoechoic findings. The positive predictive value for patients with abnormal findings on all three tests was 64.3%, which is significantly higher than that for patients with any other combination of findings (p < 0.05). Our results indicate that the combination of DRE, serum PSA and TRUS is useful for the detection of organ-confined prostate cancer, and that TRUS and TRUS-guided prostate biopsy combined with systematic biopsy should be performed in patients with abnormal findings for both DRE and PSA. Our results also demonstrate that systematic biopsy is useful for the detention of prostate cancer from the isoechoic area visualized by TRUS.     

The value of prostatic specific antigen density in the early diagnosis of prostate cancer

In order to differentiate benign from malignant prostatic lesions, 42 patients were evaluated using the prostate specific antigen density (PSAD) test. All patients were evaluated with PSA determination, digital rectal examination (DRE), transrectal ultrasonography (TRUS) and ultrasound-guided prostatic biopsies. PSA was analyzed by the I-MX ABBOT assay. PSAD was determined by dividing the serum PSA by the volume of the prostate. Prostatic biopsies identified cancer in 3 of the 42 patients (6.38%). It is concluded that PSAD is valuable for the early diagnosis of localized prostatic carcinoma, especially when there are negative findings from DRE and/or TRUS.     

An algorithm for prostate cancer detection in a patient population using prostate-specific antigen and prostate-specific antigen density

Summary Prostate-specific antigen (PSA) is the most accurate serum marker for cancer of the prostate (CaP). However, its sensitivity and specificity are suboptimal, especially at values ranging between 4.1 and 10.0 ng/ml (monoclonal), because benign prostatic hypertrophy and hyperplasia (BPH) and CaP frequently coexist in this range. This study was undertaken to determine the value of incorporating prostate volume measurements with serum PSA levels in a quotient (PSA/volume) entitled PSA density (PSAD). A total of 3140 patients were analyzed and stratified by serum PSA, digital rectal examination (DRE), transrectal prostate ultrasound (TRUS), TRUS volume determination and PSAD. All patients were referred for evaluation and therefore do not represent a screened population. Patients underwent prostate biopsies when abnormalities in TRUS or DRE were detected. Although both PSA and PSAD have statistical significance when the serum PSA value is 4.0 ng/ml, neither has clinical significance in differentiating BPH from CaP. At serum levels ranging between 4.1 and 10.0 ng/ml, PSA has no ability to differentiate BPH from CaP, whereas PSAD does so with statistical and clinical significance. When the PSA value is between 10.1 and 20.0 ng/ml, only PSAD is statistically significant. When PSA exceeds 20 ng/ml, PSAD is redundant. We conclude that all patients with an abnormality on DRE or TRUS should undergo prostate biopsy. If the PSA value is 4.0 ng/ml, TRUS and PSAD are not warranted and routine biopsy is not recommended. For intermediate PSA levels, 4.1–10.0 ng/ml, TRUS, TRUS prostate volume, and PSAD are important. The use of PSAD provides unique information regarding the need for biopsy and the likelihood of CaP. At PSA levels ranging between 10.1 and 20.0 ng/ml, PSAD will identify those patients who are less likely to have CaP, but all should undergo biopsy. If the PSA value is >20 ng/ml, all patients should undergo a biopsy.     

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.     

Value of prostate volume measurement using transabdominal ultrasonography for the improvement of prostate-specific antigen-based cancer detection

PURPOSE: To examine value of prostate-speci fi c antigen (PSA) adjusted by prostate volume measured using transabdominal ultrasonography in prostate cancer detection among men with elevated PSA. METHODS: 238 men aged 79 years or younger with serum PSA levels of 2.0-20.0 ng/mL and normal digital rectal examination fi ndings were studied in terms of total and free PSA, prostate volumes with transrectal (TRUS) and transabdominal (TAUS) ultrasonography and transition zone volumes with TRUS prior to transrectal 10-core biopsy. In addition to sole PSA values and the free-to-total PSA ratio, volume-adjusted PSA values, PSA densities determined by TRUS (PSAD(TRUS)), and TAUS (PSAD(TAUS)), and PSA transition zone densities (PSATzD) were compared using receiver operating characteristic (ROC) analysis. RESULTS: Prostate cancer was diagnosed in 58 (24.4%) of the 238 men who underwent prostate biopsies. Of the areas under ROC curves (AUC) of studied parameters, PSATzD (AUC 0.751) was the best and signi fi cantly superior to PSAD(TAUS) (AUC 0.664, P = 0.007). However, PSAD(TAUS) exceeded PSA (AUC 0.559, P = 0.004) and showed potential capability of a one-fourth reduction in unnecessary biopsies without spoiling sensitivity (90%). Cancer detection rate was only 4.2% in the 48 patients whose prostate volume in TAUS was > 50 mL and PSAD(TAUS) was < 0.075. CONCLUSIONS: Since PSAD(TRUS) and PSATzD were signi fi cantly superior to PSAD(TAUS), TRUS is feasible as the standard fashion to determine prostate volume in the diagnosis of prostate cancers. However, TAUS is also worthwhile as it can improve the prostate cancer detection using sole PSA, and primary use of TAUS has the potential to reduce the substantial number of unnecessary biopsy safely.     

常规临床检查与PSA灰区患者前列腺癌检出率的关系

目的:探讨直肠指检(DRE)、影像学(TRUS、MRI)检查、血清游离与总前列腺特异性抗原(PSA)比值(f/t)与PSA在4～10μg/L之间患者前列腺癌检出率的关系。方法:回顾性分析365例PSA处于灰区的患者进行DRE、TRUS、MRI检查、游离PSA测定,并对这些患者行经直肠B超引导下的前列腺穿刺活检。评估其临床资料与前列腺穿刺病理结果的关系。结果:在365例患者中,穿刺病理为前列腺癌的患者共有87例(23.84%)。DRE阳性的患者共有128例,穿刺阳性40例,阳性率为31.25%,TRUS检查的患者共有257例,其中有异常回声结节的69例患者中穿刺阳性26例,阳性率为37.68%,MRI检查的患者共有191例,其中有异常信号结节的107例患者中穿刺阳性59例,阳性率为55.14%。198例患者行fPSA与tPSA比值分析,其中前列腺癌患者的平均f/t PSA明显低于穿刺阴性患者。f/t PSA受试者曲线(ROC)下的面积(0.725)高于患者PSA ROC的面积(0.542)。结论:结合临床DRE、影像学资料及f/t PSA比值可以有效提高前列腺癌检出率,从而减少不必要的穿刺给患者带来的痛苦。     

PSAD在PSA 4～10ng患者前列腺癌诊断中的价值

目的探讨前列腺特异性抗原密度（PSAD）在前列腺特异性抗原（PSA）值介于4～10ng之间患者前列腺腺癌诊断中的应用价值。方法回顾性分析183例血清PSA值介于4～10ng之间疑似前列腺癌患者的临床资料,所有患者均经直肠B超测得前列腺体积后再行经直肠超声引导下前列腺穿刺术,通过接受者工作特征曲线分析法评价PSAD在预测诊断前列腺癌中的应用价值。结果 183例患者中36例经直肠超声下前列腺活检的患者被诊断为前列腺癌,占19.7%。良性前列腺增生组与前列腺癌患者之间,PSA（0.681 5）与PSAD（0.721 4）的曲线下方面积比较相似,而游离前列腺特异性抗原与总前列腺特异性抗原比值（f/tPSA）的曲线下面积只有0.318 2,相比PSA,PSAD值将是一个更好的预测前列腺癌的指标。结论 PSAD对于PSA值介于4～10ng/mL的中国患者是一项更好的预测前列腺癌的指标。     

Diagnostic significance of digital rectal examination and transrectal ultrasonography in men with prostate-specific antigen levels of 4 ng/mL or less

Objectives. To investigate the usefulness of digital rectal examination (DRE) and transrectal ultrasonography (TRUS) for prostate cancer diagnosis and to propose a diagnostic algorithm for individual-based cancer screening in subjects with prostate-specific antigen (PSA) levels of 4.0 ng/mL or less.Methods. Between January 1992 and March 2000, 129 subjects with PSA levels of 4.0 or less and abnormal findings on DRE or TRUS underwent prostate biopsy. The subjects were divided into four groups according to the PSA range: 0 to 0.9 ng/mL, 1.0 to 1.9 ng/mL, 2.0 to 2.9 ng/mL, and 3.0 to 4.0 ng/mL. The reliability of the DRE and TRUS and the clinicopathologic features of prostate cancer were investigated among these four groups.Results. Of the 129 subjects, 17 (13.2%) patients with prostate cancer were diagnosed. The detection rate was 2.2% (1 of 45), 0% (0 of 27), 20.6% (7 of 34), and 39.1% (9 of 23) in subjects with PSA levels of less than 1.0 ng/mL, 1.0 to 1.9 ng/mL, 2.0 to 2.9 ng/mL, and 3.0 to 4.0 ng/mL, respectively. The proportion of patients with Stage II, III, and IV was 58.8%, 41.2%, and 0%, respectively. The percentage with Gleason scores of 8 to 10 was 17.6%. The detection rate of abnormal findings on DRE and TRUS was 14.4% (13 of 90) and 9.5% (7 of 74), respectively. Adding TRUS to DRE in the screening program of subjects with PSA levels of 2.0 to 4.0 ng/mL, increased the detection rate of prostate cancer to 30.8% (4 of 13).Conclusions. Routine prostate biopsy should not be undertaken except for highly suspicious DRE findings in subjects with PSA levels less than 2.0 ng/mL. The additional use of TRUS in subjects with PSA levels of 2.0 to 4.0 ng/mL would improve the sensitivity of prostate cancer detection. The diagnostic algorithm proposed in the present study is useful as a screening method for prostate cancer in subjects with PSA levels of 4.0 ng/mL or less.     

Predictors of prostate cancer on repeat transrectal ultrasound-guided systematic prostate biopsy

BACKGROUND: We analyzed the outcome of repeated transrectal ultrasound (TRUS)-guided systematic prostate biopsy in Japanese men whose clinical findings were suspected of prostate cancer after previous negative biopsies. METHODS: Between January 1993 and March 2002, 1045 patients underwent TRUS-guided prostate biopsy. Among them, 104 patients underwent repeat biopsy due to indications of persistent elevated serum prostate-specific antigen (PSA), abnormal digital rectal examination (DRE) or TRUS, increased PSA velocity, and/or previous suspicious biopsy findings. Several clinicopathological factors were evaluated for their ability to predict the detection of prostate cancer on repeat biopsy. RESULTS: Prostate cancer was detected in 22 of 104 patients (21.2%) who underwent repeat biopsies. PSA concentration and PSA density at both the initial and repeat biopsies, and PSA velocity in men with positive repeat biopsy were significantly greater than those in men with negative repeat biopsy. The incidence of abnormal findings in DRE and TRUS at initial biopsy in men with positive repeat biopsy was also significantly higher than that in men with negative repeat biopsy. However, neither the presence of prostatic intraepithelial neoplasia nor number of biopsy cores at initial biopsy had a significant association with the results of the repeat biopsy. Furthermore, multivariate analysis revealed that PSA and PSA density at both the initial and repeat biopsies, PSA velocity, and DRE and TRUS findings at initial biopsy were independent predictors of malignant disease on repeat biopsy. CONCLUSION: Despite an initial negative biopsy, repeat TRUS-guided biopsy should be carried out to exclude prostate cancer in cases of suspicious clinical findings, such as elevated PSA or PSA-related parameters, or abnormal findings of DRE or TRUS.     

Digital rectal examination, transrectal ultrasonography and prostate specific antigen for diagnosis of prostate cancer in clinical urological practice-detection of impalpable cancer]

OBJECTIVE: The clinical usefulness of multimodality detection for prostate cancer by digital rectal examination (DRE), transrectal ultrasonography (TRUS) and serum PSA determination (PSA) was evaluated in this retrospective study. PATIENTS AND METHODS: A total of 1344 symptomatic male patients who underwent DRE, TRUS and PSA in our outpatient clinic were studied. Prostate biopsies were performed when at least one diagnostic test was positive. RESULTS: Of 1344 patients, 436 (32.4%) had positive test results. Among 403 patients who underwent biopsy, 121 patients (30.0%) were found to have prostate cancer. The overall cancer detection rate was 9.0%. Among the 121 cancer patients, if examination had been carried out using only one or two tests, cancer would have not been detected in 22 patients (18.2%) by DRE alone, 27 patients (22.3%) by TRUS alone, 18 patients (14.9%) by PSA alone, 12 patients (9.9%) by a combination of DRE and TRUS, and 6 patients (5.0%) by a combination of DRE and PSA. Among the 121 patients with cancer, 22 (18.2%) had impalpable cancer. Impalpable cancer was more likely to be localized (77.3%) than palpable cancer (28.3%, p < 0.001) and more likely to be well or moderately differentiated (72.7%) than palpable cancer (41.4%, p = 0.008). CONCLUSION: This study confirmed the need for multimodality detection using DRE, TRUS and PSA as complementary methods in order to minimize decrease in cancer detection. In particular, impalbable cancers not detectable by DRE were detected and were revealed to be more likely to be localized and amenable to curative therapy. These results therefore underscore the importance of multimodality detection for early diagnosis of prostate cancer in urological practice.     

Clinicopathological Features of Prostate Cancer Detected by Transrectal Ultrasonography-Guided Systematic Six-Sextant Biopsy

Background :
The objectives of this study were to compare the efficacy of 3 modalities (prostate-specific antigen (PSA) assay, digital rectal examination (DRE), and transrectal ultrasonography (TRUS)) in detecting prostate cancer which was pathologically confirmed by TRUS-guided systematic six-sextant biopsy, and to investigate the relationship between the number of positive cores and several clinicopathological parameters.
Methods :
Between 1 992 and 1994, 297 males (155 from a mass screening program and 142 identified as outpatients) with a mean age of 71 years, underwent examinations including PSA determination, DRE, TRUS and systematic six-sextant biopsy, and/or additional directed biopsy.
Results :
Prostate cancer was detected in 93 men. The sensitivity level of the PSA assay was significantly higher (85%) than that of either DRE or TRUS. Patients with an abnormal DRE or TRUS, elevated PSA levels, and those in the T3-T4 category or with moderate to poorly-differentiated adenocarcinomas had more positive biopsy cores (P< 0.05). Also, the relationships of both the number of positive biopsy cores and tumor grade to bone metastasis were significant (P < 0.01). Of 209 hypoechoic areas identified by transrectal ultrasonography, 42% were cancerous, and of 427 isoechoic areas, 1 2% were cancerous. The percentage of positive biopsy cores with hypoechoic areas was 86% in the subjects with a PSA > 10 ng/mL, but low (9%) in subjects with a PSA < 4 ng/mL, and the percentage of negative biopsy cores with a normal TRUS was high (98%) in subjects with a PSA of < 4 ng/mL, but lower (67%) in subjects with a PSA > 10 ng/mL.
Conclusion :
The serum PSA assay was more useful than either DRE or TRUS in detecting prostate cancer. The percentage of bone metastasis increased concomitant with the number of positive biopsy cores, and the positive biopsy rate of hypoechoic areas positively correlated with the PSA level.     

Prostatic volume and volume-adjusted prostate-specific antigen as predictive parameters for prostate cancer patients with intermediate PSA levels

The object of the study was to examine the usefulness of volume-adjusted prostate-specific antigen (PSA) parameters for prediction of prostate cancer in the patients with intermediate PSA levels. The subjects were 235 patients with intermediate PSA levels (range: 4.1-10.0 ng/ml) whose prostate volume (PV) and prostate transition zone volume (TZV) were evaluated between August 1996 and April 2004. PSA, PV, TZV, PSA density (PSAD) (PSA/PV) and PSA transition zone density (PSATZD) (PSA/TZV) were assessed with the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Simple and multivariate logistic regression analyses were used to analyze the odds ratios of age, PSA, PSAD, PSATZD, PV, TZV, digital rectal examination (DRE) and transrectal ultrasonography (TRUS) findings. Fifty-five patients (23.4%) of 235 patients had biopsy-proven prostate cancer. The univariate analysis revealed significant differences in the mean values of age, PSAD, PSATZD, PV, TZV and DRE between the patients with cancer and the non-cancer patients. The ROC curve analysis revealed that PV, TZV, PSAD and PSATZD had significant predictive values as compared with that of PSA. However, there was no difference in AUC between them. The stepwise logistic regression analysis showed that the age, PV, PSATZD and DRE had significant predictive values, and that PSATZD had the most predictive power. In conclusion, both PSAD and PSATZD had significant predictive values in discriminating prostate cancer. Furthermore, the stepwise logistic regression analysis showed that PSATZD had the strongest predictive value.     

前列腺特异性抗原≤4.0μg/L前列腺癌的诊断

目的:评价直肠指检(DRE)、经直肠超声(TRUS)、游离前列腺特异性抗原/总前列腺特异性抗原(fPSA/t-PSA)、前列腺特异性抗原密度(PSAD)对前列腺特异性抗原(PSA)≤4.0μg/L PCa的诊断价值。方法:回顾性分析1996年4月至2012年12月解放军总医院超声科PSA≤4.0μg/L的前列腺穿刺患者共343例,年龄30~91岁。将患者按PSA含量0.0~1.0μg/L、1.1~2.0μg/L、2.1~3.0μg/L、3.1~4.0μg/L分为4组,评价DRE、TRUS、f-PSA/t-PSA、PSAD在不同PSA水平下PCa患者中的诊断价值,同时按年龄分为5组:≤49岁、50~59岁、60~69岁、70~79岁、≥80岁,评价不同PSA水平下不同年龄患者PCa的检出率。结果:343例患者中,共检出PCa 65例,检出率19.0%。PSA含量0.0~1.0μg/L、1.1~2.0μg/L、2.1~3.0μg/L、3.1~4.0μg/L时PCa的检出率分别为16.28%(21/129)、17.17%(17/99)、21.82%(12/55)、25.00%(15/60)。PSA≤2.0μg/L时,f-PSA/t-PSA比值在PCa和非PCa患者中没有明显差异(P0.05),而PSA2.0μg/L时有明显差异(P0.05)。而PSAD值在PCa组与非PCa组中分别为(0.09±0.16)μg/L/ml、(0.06±0.07)μg/L/ml,没有明显差异(P0.05)。随着PSA含量的升高,PCa的检出率相应升高,各年龄段的检出率没有明显差异(P0.05)。结论:当PSA含量在2.1~4.0μg/L时,若DRE/TRUS异常,则应引起重视,定期随访,监测PSA变化;若f-PSA/t-PSA≤0.15,伴或不伴DRE/TRUS异常,均应该行前列腺穿刺活检,以明确诊断。而对于PSA在0.0~2.0μg/L时,DRE、TRUS、f-PSA/t-PSA比值和PSAD均不能有效诊断PCa。     

Evaluation of Prostate Specific Antigen Density and Transrectal Ultrasonography-Guided Biopsies in 100 Consecutive Patients with a Negative Digital Rectal Examination and Intermediate Serum Prostate Specific Antigen Levels

Background : This study was undertaken to assess the importance of prostate biopsies in patients with a negative digital rectal examination (DRE) and elevated prostate specific antigen (PSA) levels and to investigate the role of PSA density (PSAD) and hypoechoic lesions on transrectal ultrasound (TRUS) in increasing the diagnostic sensitivity and specificity for prostate cancer (PCa). Methods : One hundred patients with varied initial symptoms who had a negative DRE and a PSA level between 4 and 20ng/mL underwent TRUS-guided systematic and, if present, lesion-directed biopsies. Results : PCa was detected in 11 patients (11%). TRUS examinations revealed hypoechoic lesions in 31 patients. Lesion-directed biopsies revealed PCa in 1 3% (4/31) of patients with abnormal TRUS whereas, 7% (5/69) of patients with negative TRUS findings had PCa. Additional systematic biopsies detected PCa in 2 patients where lesion-directed biopsies were negative. None (0/19) of the lesions smaller than 0.2 ml on TRUS had PCa whereas, 33% (4/1 2) of patients with lesions greater than 0.2 ml had PCa. When the subgroup of patients with negative TRUS and PSA levels between 4 and 10ng/mL were considered, 25% (1/4) of cases with PCa would have been missed if 0.15 was used as the cut-off point for PSAD, however, this would save 61% (30/49) of unnecessary biopsies. The positive predictive value of PSA (cut-off level lOng/mL), PSAD (cut-off level 0.15), and hypoechoic lesions on TRUS were found to be 11.5%, 33%, and 13%, respectively. When hypoechoic lesions greater than 0.2 mL were taken as the positive finding, the positive predictive value and specificity rates of TRUS increased to 33% and 91 %, respectively, without any change in the sensitivity. Conclusions : In patients with a negative DRE and intermediate PSA levels, the application of PSAD would have saved 49% of study patients with BPH from a biopsy, but would have missed 27% of PCa cases. By ignoring lesions smaller than 0.2 mL on TRUS, a very high specificity of 91% was achieved with a sensitivity of 36%. Thus, further investigations aimed at defining a better mode of diagnosis of PCa are warranted.     

血清PSA密度变化对前列腺癌高危人群的诊断价值

目的:探讨前列腺特异抗原(PSA)、前列腺特异抗原密度(PSAD)变化对前列腺癌高危人群的诊断价值。方法:对初次活检阴性的432例患者进行随访,其中79例重复穿刺活检,确诊前列腺癌27例(34.2%),消化道来源肿瘤1例,BPH25例,前列腺上皮内肿瘤(PIN)13例,慢性前列腺炎13例。对重复活检患者的PSA、PSAD等临床资料进行统计分析。结果:配对t检验显示,良性病变首末次穿刺前PSA、PSAD差异均无统计学意义,而前列腺癌末次穿刺前PSA、PSAD较首次穿刺前升高,差异有统计学意义。以PSA>4ng/ml筛选前列腺癌,其敏感性、特异性、阳性预测值分别为92.5%、17.6%、37.6%,PSA末-PSA首>0筛选前列腺癌的敏感性、特异性、阳性预测值分别为85.2%、41.2%、40.4%;而以PSAD末-PSAD首>0筛选前列腺癌的敏感性、特异性、阳性预测值分别为81.5%、54.9%、48.9%。结论:在前列腺癌高危人群中应该重复穿刺,以减少漏诊;以PSAD动态升高来指导穿刺,可以明显提高阳性率。     

Prostatic volume and volume-adjusted prostate-specific antigen as predictive parameters for T1c prostate cancer

We examined the usefulness of the volume-adjusted prostate-specific antigen (PSA) parameters for prediction of T1c prostate cancer on 210 patients who had abnormal PSA levels but no abnormal findings in digital transrectal examination (DRE) or transrectal ultrasonography (TRUS). PSA, prostate volume (PV), transition zone volume (TZV), PSAD (PSA/PV) and PSATZD (PSA/TZV) were assessed with the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Simple and stepwise logistic regression models were used to calculate the odds ratios of these parameters. Fifty-three (25.2%) of all 210 patients and 31 (19.9%) of 156 patients with intermediate PSA levels had biopsy-proved prostate cancer. The ROC curves of all patients revealed that PSA, PV, TZV, PSAD and PSATZD had significant predictive values, while AUCs of PV, PSAD and PSATZD had significant predictive values as compared to that of PSA. In the patients with intermediate PSA levels, the ROC curves revealed that PV, TZV, PSAD and PSATZD had significant predictive values, but there were no significant differences in AUCs among these parameters. The stepwise logistic regression analysis showed that PV and PSATZD were significant predictive parameters in all patients and that PSATZD was the only significant predictive parameter in the patients with intermediate PSA levels. In conclusion, not only PSAD and PSATZD but also PV and TZV had significant predictive values in discriminating prostate cancer. However, the multivariate analysis showed that PSATZD had the strongest predictive value in all patients and in those with intermediate PSA levels.     

Predictive value of the international prostate symptom score for positive prostate needle biopsy in the low-intermediate prostate-specific antigen range

PURPOSE: Serum prostate-specific antigen (PSA) has a restricted predictive value for prostate cancer in the low-intermediate PSA range (2.5-10 ng/ml). Our aim was to determine the predictive value of the International Prostate Symptom Score (IPSS) for positive prostate needle biopsy (PNB) in patients who underwent transrectal ultrasound (TRUS)-guided prostate biopsy with a low-intermediate PSA level. PATIENTS AND METHODS: Between 2001 and 2004, the data of 389 consecutive patients applying for any urologic complaint to our department and who underwent TRUS-guided prostate biopsy due to an elevated serum PSA and/or abnormal digital rectal examination (DRE) were retrospectively analyzed. A total of 158 eligible patients with a low-intermediate PSA level were included in the study. The patient's age, PSA, free PSA, free/total PSA, prostate volume, PSA density (PSAD), pre-biopsy IPSS were compared in the positive and negative biopsy groups. RESULTS: Fifty-eight of 158 patients (37%) who underwent TRUS-guided prostate biopsy had positive PNBs. Forty-eight patients (30%) had abnormal DREs. In the positive PNB group, the mean age was older and PSAD was higher, but the means of the prostate volumes and total IPSS were lower (p<0.05). Multivariate analysis demonstrated that age and IPSS were independent predictors of a positive PNB (p<0.05). The odds ratio of mild IPSS for positive PNB controlled for age was 3.0 (95% CI 1.5-6.7). Receiver-operating characteristics analysis revealed a mild IPSS (AUC=0.640) and was a considerable predictor for positive PNB as well as PSAD (AUC=0.648). The sensitivity and specificity of IPSS with a cutoff value of 7.5 points were 31 and 87% for prediction of prostate cancer detection. CONCLUSION: In the low-intermediate PSA range, mild IPSS may be a predictive factor for positive PNB with a similar specificity of PSAD.