Prospective identification of National Institutes of Health category IV prostatitis in men with elevated prostate specific antigen

PURPOSE: Although prostatitis may cause elevated prostate specific antigen (PSA), asymptomatic patients are not routinely screened for this diagnosis before transrectal biopsy is performed to rule out cancer. Many negative biopsies reveal evidence of prostatitis classified as National Institutes of Health (NIH) category IV prostatitis or asymptomatic inflammation. To our knowledge this report represents the initial study of the incidence of NIH category IV prostatitis in men before biopsy and its clinical significance. MATERIALS AND METHODS: From 1996 to 1998 asymptomatic men with elevated PSA levels were evaluated for laboratory signs of prostatitis. Patients with expressed prostatic secretions or post-prostate massage urine (voiding bottle 3 [VB3]) positive for greater than 20 and greater than 10 white blood cells per high power field, respectively, received antibiotics for 4 weeks and were reevaluated after 6 to 8 weeks. Men without these clinical signs promptly underwent biopsy. Those with acute urinary tract infection and PSA greater than 30 ng./ml., without a rectum or who refused biopsy were excluded from study. RESULTS: Of the 187 study patients 122 were evaluable with a mean PSA of 9.35 ng./ml., including 51 (42%) with laboratory signs of prostatitis. After treatment PSA was normal in 22 cases and remained elevated in 29, including 9 in which biopsy revealed cancer. The change or improvement in PSA was significantly greater in men with benign results than in those with prostate cancer (-21.32 versus -1.33%, p = 0.001). In the cohort with negative expressed prostatic secretion and VB3 results transrectal ultrasound guided biopsy was done promptly. Screening decreased the number of biopsies by 18% (22 of 122 cases). The positive predictive value of PSA for detecting biopsy proved cancer improved with screening for prostatitis (45 of 122 cases or 37% versus 36 of 71 or 51%). Long-term followup revealed continued normal or stable PSA in the prostatitis cohort. CONCLUSIONS: Screening for NIH category IV prostatitis should be considered in men with elevated PSA. Although patients may be asymptomatic, anxiety caused by prostate cancer and diagnostic procedures contributes to the clinical significance of this disorder.     

经直肠超声引导下“10+X”点法前列腺穿刺活检术在PSA值介于4～20ng/ml之间患者前列腺癌诊断中的价值

目的 探讨经直肠超声引导下“10 +X”前列腺穿刺活检术在PSA值介于4 ～20ng/ml之间患者前列腺癌诊断中的价值。方法 回顾性分析226例血清PSA值介于4～20ng/ml之间疑似前列腺癌患者临床资料,所有患者均行经直肠超声引导下前列腺穿刺术活检。结果 前列腺癌47例,前列腺增生158例,前列腺炎11例,前列腺上...     

Elevated prostate specific antigen serum levels after intravesical instillation of bacillus Calmette-Guerin

PURPOSE: We determined whether intravesical bacillus Calmette-Guerin (BCG) instillation is associated with elevated prostate specific antigen (PSA). MATERIALS AND METHODS: We treated 36 consecutive patients with bladder cancer with a 6-week course of BCG, followed by cystoscopy at 6 weeks. Blood samples for PSA determination were obtained before each BCG instillation and at cystoscopy with each patient also serving as a control. PSA elevation was defined as 2-fold the baseline level in at least 2 specimens and any PSA level greater than 4 ng./ml. was considered clinically significant. Digital rectal examination was done to identify firm nodules and prostate size. The prostate was examined histologically by transrectal ultrasound guided biopsy or after radical cystectomy. RESULTS: We observed elevated PSA in 27 men (75%) during BCG treatment, of whom 15 (41.6%) had a clinically significant elevation. Overall average PSA increased from 1.3 ng./ml. before BCG instillation to 3.8 during treatment (range 0.1 to 21.5, p <0.0001). In those with a clinically significant elevation average PSA increased from 2.31 ng./ml. at baseline to 6.97 during treatment (p <0.0001) and returned to 3.86 ng./ml. 3 months after treatment. Palpation demonstrated prostatic findings in 10 patients, including firm nodules in 7, while there was significantly elevated PSA in 5 with firm nodules and 2 with diffuse prostatic enlargement. Histological examination of the prostate in 10 patients was diagnostic for granulomatous prostatitis, nonspecific inflammation and benign prostatic hyperplasia in 3, 3 and 4, respectively, of whom none had prostate cancer. CONCLUSIONS: Intravesical BCG therapy is associated with significantly elevated PSA in up to 40% of cases. This effect is self-limited and PSA reverts to normal in 3 months. Therefore, we suggest that prostate biopsy be withheld in such patients and PSA monitored.     

The accuracy of the increased prostate specific antigen level (greater than or equal to 20 ng./ml.) in predicting prostate cancer: is biopsy always required?

PURPOSE: Urologists are often referred patients who initially present with an extremely high serum prostate specific antigen (PSA) level. Despite a presumptive diagnosis of prostate cancer, many of these men undergo biopsy to obtain a tissue diagnosis before treatment with androgen ablative therapy. We examined a data base of men undergoing prostate biopsy to determine the accuracy of high PSA levels (greater than or equal to 20 ng./ml.) in predicting prostate cancer. MATERIALS AND METHODS: We reviewed the records of 1,250 consecutive patients undergoing transrectal ultrasound guided prostate biopsy at 1 institution. From this data base we identified all patients with PSA greater than or equal to 20 ng./ml. at the time of prostate biopsy. The accuracy of PSA in predicting cancer was determined by calculating positive predictive values for PSA ranges and PSA cutoffs. RESULTS: We identified 187 men (15%) presenting with PSA greater than or equal to 20 ng./ml. Of these 187 men 157 (84.0%) were diagnosed with prostate cancer on initial biopsy. Due to a negative initial biopsy, yet a high suspicion of cancer, 12 (6.4%) patients underwent at least 1 repeat biopsy. Of these 12 men 6 (50%) were diagnosed with cancer on repeat biopsy. Overall, 163 of the 187 men (87.2%) were diagnosed with prostate cancer by biopsy. Stratified by PSA ranges, positive predictive values were 73.6% for 20 to 29.9, 90.3% for 30 to 39.9, 93.8% for 40 to 49.9, 100% for 50 to 99.9, 95% for 100 to 199.9 and 100% for greater than or equal to 200 ng./ml. Using PSA cutoffs positive predictive values were 95.7% for PSA greater than or equal to 30, 97.6% for PSA greater than or equal to 40 and 98.5% for PSA greater than or equal to 50 ng./ml. CONCLUSIONS: Serum PSA, when increased above 50 ng./ml., is 98.5% accurate in predicting the presence of prostate cancer on tissue biopsy. Nonetheless, since transrectal prostate biopsy has a low complication rate and is relatively well tolerated, we recommend continuing to biopsy most patients with high PSA levels. However, carefully selected elderly patients on chronic anticoagulation, with severe co-morbidities or presenting with spinal cord compression may not require biopsy before androgen ablative therapy since PSA is highly accurate in diagnosing prostate cancer at levels greater than 50 ng./ml.     

Prevalence and Predictors of a Positive Repeat Transrectal Ultrasound Guided Needle Biopsy of the Prostate

Purpose

We determined the prevalence of and risk factors for carcinoma in patients with 1 previously negative prostate biopsy.

Materials and Methods

Transrectal ultrasound guided prostate needle biopsies were repeated in 130 men. Risk factors analyzed included age, pathological result of initial biopsy, inter-biopsy interval, prostate specific antigen (PSA), PSA density, PSA velocity, digital rectal examination, abnormal transrectal ultrasound and family history of prostate cancer.

Results

A total of 39 patients (30%) had positive biopsies for cancer. Univariate analysis revealed that PSA more than 20 ng./ml. and abnormal transrectal ultrasound were more frequent in men with positive second biopsies. Using multivariate logistic regression analysis only PSA more than 20 ng./ml. was a significant risk factor (adjusted odds ratio 4.48, 95% confidence interval 1.02 to 20.1). We determined the incidence of carcinoma in patients who represent the lowest risk group as defined by PSA less than 10 ng./ml., PSA density less than 0.15 mg./ml./cm.³, PSA velocity less than 0.75, ng./ml. per year, no prostatic intraepithelial neoplasia plus negative transrectal ultrasound, digital rectal examination and family history. Of 21 patients who fit this cohort 5 (23.8%) had carcinoma on repeat biopsy.

Conclusions

A significant false-negative rate for initial transrectal ultrasound guided prostate biopsies exists. Baseline risk in lowest risk patients is sufficiently high such that one cannot define a subset of patients for whom repeat biopsy is unnecessary. We recommend repeat biopsy in all patients who meet the criteria for a transrectal ultrasound guided biopsy and in whom the initial biopsy is negative.     

The effect of digital rectal examination on the serum prostate specific antigen concentration: results of a randomized study.

To determine the effect of digital rectal examination on the serum prostate specific antigen (PSA) concentration a prospective, randomized, controlled trial involving 143 patients was conducted. Of the patients 86 (60%) had benign prostatic hyperplasia (BPH), 47 (33%) had prostate cancer and 10 (7%) had chronic prostatitis. The study group consisted of 71 men, all of whom had a serum PSA determination followed by a digital rectal examination and then a second serum PSA determination. The control cohort consisted of 72 men, all of whom had 2 serum PSA determinations without an intervening digital rectal examination. The median change in the serum PSA level for the study group was 0.4 ng./ml. compared to -0.1 ng./ml. for the control cohort (p less than 0.0001). For 76% of the study patients the second serum PSA level was greater than the initial value; only 32% of the control patients exhibited a higher second serum PSA level than the initial level (p less than 0.0001). However, only 4 patients with an initial PSA value in the reference range (0.0 to 4.0 ng./ml.) had a post-digital rectal examination value greater than 4.0 ng./ml. and only 1 patient whose presenting serum value was less than 10.0 ng./ml. had a serum PSA level greater than this cutoff point after digital rectal examination. This minimal change in serum PSA after digital rectal examination was independent of the diagnosis (BPH, cancer or chronic prostatitis), initial serum PSA concentration and examiner. Thus, although digital rectal examination had a statistically significant effect on the serum PSA concentration, the clinical significance of a 0.4 ng./ml. median increase appears inconsequential. Based on these findings, physicians should be confident that the serum PSA concentration in the immediate post-digital rectal examination period is accurate and does not compromise clinical use of the tumor marker.     

Extensive repeat transrectal ultrasound guided prostate biopsy in patients with previous benign sextant biopsies

PURPOSE: Standard sextant prostate biopsy may underestimate cancer in men in whom clinical findings are suspicious for localized prostate cancer. We describe our experience with extensive transrectal ultrasound guided prostate biopsy in men in whom previous sextant biopsy was negative. MATERIALS AND METHODS: Between November 1997 and March 1999, 57 men 47 to 72 years old (mean age 61.4) underwent extensive transrectal ultrasound guided biopsy of the prostate using intravenous sedation at our institution. An average of 22.5 cores (range 15 to 31) were obtained depending on prostate size. Biopsies were obtained from each of 6 sagittal regions, including samples from the far lateral and mid transitional zones. Each patient had undergone at least 1 previous benign transrectal ultrasound guided sextant biopsy (mean 2.1, range 1 to 4). Indications for repeat biopsy were persistently elevated prostate specific antigen (PSA) in 89% of the cases, increased PSA velocity in 63%, suspicious free-to-total PSA in 39% and a previous suspicious biopsy finding in 32%. Clinical factors (PSA, PSA velocity, free-to-total PSA and previous suspicious biopsy) were analyzed for the ability to predict positive biopsy, and tumor parameters were assessed pathologically in patients undergoing radical prostatectomy. RESULTS: Adenocarcinoma was identified in 17 of the 57 men (30%). Biopsy revealed a Gleason score of 6 to 8 (mean 6.4). In 7 of the 17 patients (41%) in whom cancer was identified only 1 biopsy core was positive. Of the 15 patients in whom previous sextant biopsy had demonstrated high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation extensive biopsy revealed cancer in 7 (47%). Although serum PSA was higher and free-to-total PSA was lower in those with cancer, the only statistically significant predictor of positive biopsy was PSA velocity (p <0.001). Prostate cancer was noted in 64% of the men with PSA velocity 1 ng./ml. or greater. Of the 13 patients undergoing radical prostatectomy pathologically significant disease was identified in all but 1 (92%). Complications of extensive biopsy included urinary retention in 6 patients and limited rectal bleeding in 1. CONCLUSIONS: Extensive prostate biopsy identifies significant prostate cancer in many men in whom previous sextant biopsy was benign. This procedure should be considered when findings are suspicious for adenocarcinoma despite previously negative sextant biopsy.     

Does normalizing PSA after successful treatment of chronic prostatitis with high PSA value exclude prostatic biopsy?

Objective

Evaluate male patients with diagnosed chronic prostatitis, elevated serum prostate-specific antigen (PSA) to find out whether medical treatment with antibiotics and anti-inflammatory drugs can lower serum PSA, and consequently decrease the prostate cancer detection rate in patients with post-treatment PSA<4 ng/mL.

Materials and methods

This prospective study evaluated 142 male patients aged 40-73 years whose presented with elevated serum PSA>4 ng/mL and were consequently diagnosed with chronic prostatitis as expressed prostatic excretions examination revealed more than 10 white blood cells per high power field. The Patients underwent treatment with antibiotics and nonsteroidal anti-inflammatory agents for 6-weeks. Subsequently, all patients are Followed-up by serum PSA and performed transrectal ultrasonography-guided prostate biopsy within 2 months of treatment.

Results

Mean patient age was (54.4±13.5) years. The mean PSA pretreatment was (8.11±3.7) ng/mL and after treatment, the mean PSA denoted a significant decrease to (4.7±3.5) ng/mL (P=0.002). The percent of changes in mean PSA was 41.9%. Prostatic biopsy after treatment showed that, cancer prostate in 31 patients (21.8%), chronic prostatitis in 71 patients (50.7%), chronic prostatitis plus benign prostatic hyperplasia (BPH) in 31 (21.8%) and BPH in 9 patients (6.3%) With regard to PSA values, cancer prostate patients were 3/25 (12%) if PSA<2.5 ng/mL, 6/47 (12.7%) if 4.0>PSA≥2.5 and 21/70 (30%) if PSA≥4.0. The numbers of cancer prostate detected patients were 30 (21.1%).

Conclusions

Chronic prostatitis is one of the causes that elevate serum PSA levels. Treatment of chronic prostatitis with elevated PSA by antibiotics and anti-inflammatory agents can decrease the elevated PSA to the normal levels. Nevertheless, the opportunities of potential prostate cancer still exist in patients with a decreased PSA level even also if PSA<2.5 ng/mL.     

RATIO OF FREE-TO-TOTAL PROSTATE SPECIFIC ANTIGEN IN SERUM CANNOT DISTINGUISH PATIENTS WITH PROSTATE CANCER FROM THOSE WITH CHRONIC INFLAMMATION OF THE PROSTATE

Purpose

We demonstrate the effect of chronic inflammation of the prostate on the ratio of free-to-total prostate specific antigen (PSA) in serum calculated as a percentage of free PSA and, therefore, that percentage of free PSA is an unspecific means to distinguish among prostate cancer, chronic prostatitis and benign prostatic hyperplasia (BPH).

Materials and Methods

Total, free and percentage of free PSA was measured in 66 men with prostate cancer, 119 with BPH and 17 with asymptomatic chronic prostatitis. In all patients the diagnosis was histopathologically confirmed by microscopic examination of prostatic specimens after sextant biopsy, transurethral prostatic resection or prostatectomy.

Results

The median values of total, free and percentage of free PSA were 4.11 micro g./l., 0.75 micro g./l. and 20.4% in patients with BPH, 10.0 micro g./l., 0.84 micro g./l. and 8.5% in those with prostate cancer, and 7.60 micro g./l., 1.23 micro g./l. and 10.6% in those with chronic prostatitis. Patients with prostate cancer and chronic prostatitis had a significantly lower percentage of free PSA than those with BPH. Receiver operating characteristics curve analysis showed that percentage of free PSA as a discriminator between prostate cancer and BPH was not suitable for differentiating between prostate cancer and chronic prostatitis.

Conclusions

Chronic prostatitis is not characterized by elevated total PSA concentrations alone but also by a decreased percentage of free PSA, a tendency similar to that in prostate cancer. This unspecific change in percentage of free PSA must be considered to interpret the percentage of free PSA correctly.     

PSA〉10ng／ml时经直肠前列腺穿刺活检的临床分析

目的探讨当PSA〉10ng／ml时经直肠前列腺穿刺活检的临床价值。方法对120例前列腺特异性抗原（PSA）〉10ng／ml的患者行超声引导下经直肠前列腺穿刺活检。结果120例患者中前列腺癌患者46例,前列腺增生患者44例,前列腺炎患者9例,前列腺上皮内瘤（PIN）患者19例,前列腺梗死患者3例。有38例出现一过性肉眼血尿;发热16例;败血症5例;无血精、前列腺脓肿等并发症发生。结论PSA〉10ng／ml不能作为前列腺穿刺活检的绝对指征,应该综合考虑DRE、TRUS、PSA,提高穿刺阳性率,同时避免不必要的穿刺。     

The issue of prostate cancer evaluation in men with elevated prostate-specific antigen and chronic prostatitis

Elevated levels of prostate-specific antigen (PSA) in men may result from a variety of causes, such as prostate cancer, benign prostatic hyperplasia, acute urinary tract infection, and bacterial prostatitis. In recent years, several studies have also demonstrated a relationship between chronic prostatitis/chronic pelvic pain syndrome and increased PSA levels. However, asymptomatic patients are not routinely screened for this diagnosis before transrectal biopsy is performed to rule out prostate cancer. These asymptomatic men with elevated PSA levels frequently have evidence of inflammation when their expressed prostatic secretions are examined, or on their prostate biopsy specimens. This raises the problem of appropriate evaluation in the presence of chronic prostatitis and elevated PSA levels--not only in prostate cancer screening programmes, but also in cancer-negative biopsy findings. Evidence from the literature indicates that antimicrobial treatment may lower the PSA levels to what is considered the normal range. Despite that, general recommendations for the practical management are lacking and undetected prostate cancer in men with chronic prostatitis remains a difficult issue.     

Prostate cancer screening with prostate specific antigen in spinal cord injured men

PURPOSE: As the spinal cord injured population ages, prostate cancer becomes a more significant cause of potential mortality. Consequently due to various bladder management techniques the validity of standard prostate specific antigen (PSA) screening values in this population must be evaluated. We compared screening PSA values in a large population of spinal cord injured patients with those in age matched, nonspinal cord injured men. MATERIALS AND METHODS: Screening PSA values were obtained using the AxSYM assay (Abbott Laboratories, Abbott Park, Illinois) in 366 spinal cord injured men 40 to 79 years old. In those with PSA elevated to greater than 4 ng./ml. who consented to further evaluation standard sextant needle biopsy of the prostate were performed under transrectal ultrasound guidance. Data were compared with data on 371 randomly selected, age matched controls from the Baylor College of Medicine community screening program database of more than 19,000 patient-tests. Analysis was performed with the unpaired Student t test. RESULTS: When we divided patients 40 to 80 years old into 4 age groups by decade and compared them with normal controls by decade, there was no statistically significant difference in mean PSA in the 2 groups. Of 18 spinal cord injured patients with PSA greater than 4 ng./ml. 12 underwent transrectal ultrasound guided needle biopsy of the prostate and 6 refused further evaluation. Five of these biopsies (1.3% overall) were positive and 7 were negative for adenocarcinoma. CONCLUSIONS: As in healthy men, PSA and digital rectal examination can be performed in spinal cord injured men to screen for prostate cancer. None of the various bladder management techniques in these cases seemed to affect screening results.     

ROLE OF PROSTATE-SPECIFIC ANTIGEN AND DIGITAL RECTAL EXAMINATION IN THE DETECTION OF PROSTATE CANCER

Prostate-specific antigen (PSA) is a kallikrein-like serine protease that is secreted exclusively by the epithelial cells of all types of prostatic tissue, benign and malignant. Its serum concentration is raised in men with prostatic disease including cancer. We have evaluated its usefulness in the diagnosis of prostate cancer by measuring serum PSA concentrations in 260 men aged 50 years or over. All had abnormalities at digital rectal examination (DRE) involving suspected cancer, signs and symptoms of benign prostatic hyperplasia and equivocal findings on DRE, and miscellaneous other conditions, including hematospermia, chronic prostatitis and microscopic hematuria. Transrectal prostatic needle biopsies were performed in the men with abnormal findings on DRE or elevated serum PSA (above 4ng/ml). Serum PSA ranged from 4.0 to 9.9ng/ml in 14 (5%) of the 260 men. Four of the men in this group (31%) who underwent prostatic biopsy had prostate cancer. Serum PSA levels greater than or equal to 10.0 ng/ml were found in 8 (3%) of the 260 men. 5 of these 8 (63%) who underwent prostatic biopsy had cancer. If DRE alone had been used to screen the men having biopsies, 4 of the 10 cancers (40%) would have been missed. If PSA alone had been used to screen these men, only 1 of the 10 cancers would have been missed. Serum PSA measurement was more reliable than DRE for detecting prostate cancer. Since these two methods do not always detect the same malignant tumor, the combined use of DRE and PSA testing affords a more complete evaluation of the prostate gland for malignant involvement.     

Can Free and Total Prostate Specific Antigen and Prostatic Volume Distinguish Between Men With Negative and Positive Systematic Ultrasound Guided Prostate Biopsies?

Purpose

We evaluated the role of free and total serum prostate specific antigen (PSA) and prostate volume in discriminating between men with negative and positive transrectal ultrasound guided biopsies.

Materials and Methods

A total of 104 consecutive men with a positive biopsy and at least 3 mm. of prostate cancer was compared to 110 consecutive men with a negative biopsy. Prostate volume was determined by transrectal ultrasound. Total PSA was determined by the Tosoh AIA-600† PSA assay and free PSA was measured by the PSA II Dianon‡ assay. We determined the free-to-total PSA ratio, free and total PSA densities, and the relationship of free PSA and free-to-total PSA ratio to prostate volume.

Results

Using a 23% cutoff value of free-to-total PSA, only 22.7% of biopsies were preventable in patients with a negative biopsy but 9.6% of the cancers were missed. At a total PSA of 4 to 10 ng./ml. 44.4% of the biopsy negative cases were correctly identified while missing 9.1% of the cancers if a 20% free PSA cutoff is used. For total PSA more than 10 ng./ml. an 18% free PSA cutoff properly identified 30.2% of the biopsy negative cases while missing 9.3% of the cancers. Percent free PSA is a better discriminant than prostate volume for total PSA more than 4 ng./ml. and the combination was not helpful. Free PSA density was identical in patients with negative and positive biopsies. There was no relationship between free PSA or free-to-total PSA ratio levels and prostate volume.

Conclusions

Use of a single discriminant criterion of free-to-total PSA ratio in the practical clinical setting of distinguishing negative and positive biopsies appears useful in patients with a total PSA of 4 to 10 ng./ml. Since free PSA is unrelated to prostate volume in biopsy negative and positive cases the physiological basis of free PSA is an enigma.     

Transperineal prostate biopsy after abdominoperineal resection

PURPOSE: Prostate cancer evaluation in men who have undergone abdominoperineal resection poses a challenge for urologists. Diagnosis and staging methods are limited because as access to the prostate via digital rectal examination is not possible. Prostate specific antigen (PSA) has been used to screen for malignancy in this population. However, the conventional diagnostic technique with transrectal ultrasound guided biopsies cannot be used. Transperineal ultrasound and biopsy have been described to evaluate the prostate in this setting. We report our experience with transperineal ultrasound biopsy for evaluating the prostate in patients with elevated PSA who have previously undergone abdominoperineal resection. MATERIALS AND METHODS: We reviewed the records of 28 patients treated at 2 institutions. All patients had a history of abdominoperineal resection and subsequent transperineal ultrasound guided prostate biopsy for evaluating elevated PSA. Mean serum PSA in this population was 22 ng./ml. (median 9.5, range 4.1 to 237). Abdominoperineal resection was done in 16 patients (57%) for colorectal cancer, in 11 (39%) for ulcerative colitis and in 1 (4%) for familial polyposis coli. Average time since resection was 14 years (range 1 to 33). Five patients had previously undergone radiation therapy as part of treatment for colorectal cancer before transperineal ultrasound biopsy. RESULTS: Of the 28 biopsies performed 23 revealed prostate cancer, 2 revealed prostatitis and 3 were benign. Average Gleason grade was 6.6 (range 3 to 9). Of the 23 patients with prostate cancer 22 were treated with androgen deprivation therapy (7), prostatectomy (8), external beam (6) and high dose (1) radiation therapy. Of the 8 patients who underwent prostatectomy pathological stage was T2 in 3 and T3 in 4, while pathological findings were not determined in 1 patient in whom the prostate was removed in pieces. CONCLUSIONS: In patients with a history of abdominoperineal resection and elevated PSA transperineal ultrasound guided biopsy of the prostate can provide an accurate tissue diagnosis.     

CRYOSURGICAL ABLATION OF PROSTATE CANCER: PATTERNS OF CANCER RECURRENCE

Purpose

We determined the rate of biochemical and biopsy failure in relation to the prostate specific antigen (PSA) nadir, the effect of neoadjuvant androgen blockade and the pattern of residual tumor after cryosurgical ablation of prostate cancer.

Materials and Methods

From July 1993 to April 1996, 134 patients underwent 147 cryosurgical ablation procedures. Of those patients, 110 had adequate followup and did not receive post-treatment androgen deprivation. Followup included PSA determination at 3, 6 and 12 months, and every 6 months thereafter. Biopsies were performed at 6 months or with biochemical failure defined as PSA nadir 0.5 ng./ml. or greater or subsequent biochemical failure (PSA increase 0.2 ng./ml. or greater). Biochemical and biopsy failures were correlated with PSA nadir values following cryosurgery (less than 0.1 ng./ml., 0.1 to 0.4 and or greater 0.5). A total of 68 patients had careful ultrasound guided mapping biopsy preoperatively and postoperatively to define the sites of disease. The likelihood of residual disease was correlated with the initial site(s) of the cancer in an attempt to identify if areas of the prostate and/or seminal vesicles were more likely to be sites of treatment failure.

Results

At a mean followup of 17.6 months biochemical failure (subsequent rise in PSA 0.2 ng./ml. or greater) was lowest in those who achieved PSA nadirs less than 0.1 ng./ml. (21%) but it was noted in 48% of patients with nadirs between 0.1 and 0.4 ng./ml. Those patients with PSA nadirs 0.5 or greater had either immediate local failure (46%), subsequent local or biochemical failures (43%) or extremely high PSA nadirs (greater than 30 ng./ml.) necessitating hormonal therapy (11%). Biopsy failure was lowest in those with nadirs less than 0.1 ng./ml. (7%) and those with nadirs 0.1 to 0.4 ng./ml. (22%). In contrast, 60% of the patients with nadir values 0.5 ng./ml. or greater had biopsy failure. Biochemical and biopsy failure tended to occur within the first 18 months after treatment. Neoadjuvant androgen blockade appeared to reduce subsequent biochemical failure in patients with stages T1 and T2 cancers (11% versus 50% in those without androgen deprivation) but not in those with T3 and T4 cancers. Recurrence was more common in cancers at the apex (9.5%) and seminal vesicles (44%), in contrast to those located in the mid gland (4%) and base (0%).

Conclusions

A PSA nadir of 0.4 ng./ml. or less should be achieved following cryotherapy. Higher values are associated with a significant risk of continued PSA elevation and a high likelihood of residual disease detected on prostatic biopsy. Local failure tends to occur at the apex and seminal vesicles. Neoadjuvant androgen blockade reduces the risk of biochemical failure in patients with stages T1 and T2 cancers.     

Prospective Evaluation of Prostate Specific Antigen and Prostate Specific Antigen Density in the Detection of Nonpalpable and Stage T1C Carcinoma of the Prostate

Purpose

We evaluated prospectively prostate specific antigen (PSA) and prostate specific antigen density in the detection of prostate cancer in patients with normal findings on digital rectal examination with and without normal transrectal ultrasound.

Materials and Methods

Consecutive patients (184) with an elevated serum PSA and normal digital rectal examination underwent transrectal ultrasound with lesion directed and systematic biopsies (6 if prostatic volume was 50 cc or less and 12 if volume was more than 50 cc). Receiver operating characteristic curves, predictive values and likelihood ratios were calculated for PSA and PSA density.

Results

Of the 184 patients 50 (27 percent) with a normal digital rectal examination had cancer compared to 30 of 112 (27 percent) with a normal digital rectal examination and transrectal ultrasound. Median PSA or PSA density did not differ between the positive and negative biopsy groups among patients with a normal digital rectal examination (8.4 versus 7.1 and 0.22 versus 0.14 ng./ml., respectively) or a normal digital rectal examination and transrectal ultrasound (8.2 versus 7.5 and 0.21 versus 0.14 ng./ml., respectively). PSA density was superior to PSA by receiver operating characteristic analysis for cancer detection when all PSA values or those between 4 and 20 ng./ml. were considered. However, the significance was lost for a PSA of 4 to 10 ng./ml. Likelihood ratios demonstrated insignificant changes in the post-test probability if PSA density was used to determine the need for biopsy and many cancers would have been missed.

Conclusions

PSA density should not be used to determine the need for biopsy in patients with a normal digital rectal examination and/or transrectal ultrasound.     

PSA＞1Ong/ml时经直肠前列腺穿刺活检的临床分析

目的 探讨当PSA＞ 10ng/ml时经直肠前列腺穿刺活检的临床价值。方法 对120例前列腺特异性抗原(PSA)＞ 10ng/ml的患者行超声引导下经直肠前列腺穿刺活检。结果 120例患者中前列腺癌患者46例,前列腺增生患者44例,前列腺炎患者9例,前列腺上皮内瘤(PIN)患者19例,前列腺梗死患者3例。有38例出现一...     

PROSTATE CANCER DIAGNOSIS USING A SATURATION NEEDLE BIOPSY TECHNIQUE AFTER PREVIOUS NEGATIVE SEXTANT BIOPSIES

PURPOSE: We hypothesized that markedly increasing the number of cores obtained during prostate needle biopsy may improve the cancer detection rate in men with persistent indications for repeat biopsy. MATERIALS AND METHODS: We performed saturation ultrasound guided transrectal prostate needle biopsy in 224 men under anesthesia in an outpatient surgical setting in whom previous negative biopsies had been performed in the office. The mean number of previous sextant biopsy sessions plus or minus standard deviation before saturation biopsy was 1.8 (range 1 to 7). A mean of 23 saturation biopsy cores (range 14 to 45) were distributed throughout the whole prostate, including the peripheral, medial and anterior regions. Indications for repeat biopsy were persistent elevated serum prostate specific antigen (PSA) in 108 cases, persistent elevated PSA and abnormal rectal examination in 27, persistent abnormal rectal examination in 4, high grade prostatic intraepithelial neoplasia in the previous biopsy in 64 and atypia in the previous biopsy in 21. RESULTS: Cancer was detected in 77 of 224 patients (34%). The number of previous negative sextant biopsies was not predictive of subsequent cancer detection by saturation biopsy. Median PSA was 8.7 ng./ml. and median PSA velocity was 0.63 ng./ml. yearly. Of the 77 patients in whom cancer was detected radical prostatectomy was performed in 52. Pathological stage was pT2 in 48 patients and pT3 in 4, while Gleason score was 4 to 5, 6 to 7 and 8 in 5, 46 and 1, respectively. At prostatectomy median cancer volume was 1.04 cc and 85.7% of removed tumors were clinically significant, assuming a 3-year doubling time. The overall complication rate for saturation needle biopsy was 12% and hematuria requiring hospital admission was the most common event. CONCLUSIONS: Saturation needle biopsy of the prostate is a useful diagnostic technique in men at risk for prostate cancer with previous negative office biopsies. This technique allows adequate sampling of the whole prostate gland and has a detection rate of 34% in this cohort of patients.     

The efficacy of cryosurgical ablation of prostate cancer: the University of California, San Francisco experience.

PURPOSE: We analyze biopsy and prostate specific antigen (PSA) results following cryosurgery for patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 176 patients underwent 207 cryosurgical procedures for clinically localized (stages T1 to T4) prostate cancer using a multiprobe cryosurgical device. Cancer stage was T1 in 8.7%, T2 in 30%, T3 in 59% and T4 in 2.3% of the 176 patients. Neoadjuvant androgen deprivation was delivered to 101 patients (57%). End points used to determine efficacy of the procedure included analysis of posttreatment serum PSA characteristics (nadir and nonrising status) and biopsy results (absence of cancer). Cryosurgery was considered successful if PSA reached a nadir of less than 0.5 ng./ml. and did not increase by more than 0.2 ng./ml. on 2 consecutive occasions. Mean followup for the entire group was 30.8 months, with 122 patients (60%) followed for 24 or more months and 75 (36%) followed for 36 or more months. RESULTS: Serial PSA data was available after 181 initial and repeat procedures. Nadir PSA was undetectable in 88 patients (49%), between 0.1 and 0.4 ng./ml. in 39 (21%) and 0.5 ng./ml. or greater in 54 (30%) following cryosurgery. After 78 of these procedures (43%) serum PSA reached a nadir of less than 0.5 ng./ml. and failed to increase greater than 0.2 ng./ml. on at least 2 occasions. Prostate biopsy was performed following 167 procedures and was positive after 64 (38%). CONCLUSIONS: Cryosurgery was associated with favorable serum PSA characteristics in 49% of patients 3 years after treatment. Undetectable PSA nadir and pretreatment PSA 10 ng./ml. or less were associated with a favorable outcome, with a biochemical disease-free survival of 77% and 61% 3 years after treatment, respectively.