Elevated serum prostate-specific antigen due to acute bacterial prostatitis

Digital rectal examination impact on PSA derivatives and prostate biopsy triggers: a contemporary study

OBJECTIVE

To evaluate the impact of the digital rectal exam (DRE) on PSA measurements and clinical decision-making.

METHODS

Healthy male volunteers between 50 and 70 years old were recruited during a 30-day public screening program. PSA levels were measured using two different methods (standard enhanced chemiluminescence immunoassay-ECLIA, and novel immunochromatography assay-ICA/rapid PSA) in the same blood sample. Two blood samples were drawn; first before DRE and the second 30-40 min after DRE. The effect of DRE on PSA levels and its impact on clinical decision-making for individual patients were evaluated based on different biopsy trigger cutoffs.

RESULTS

ECLIA-PSA was measured in 74 participants both pre- and 37 ± 5 min post-DRE, mean age 57.2 ± 8.3 years, and mean prostate volume 33.6 (20-80) cm³. Both total and free ECLIA-PSA increased significantly after DRE (mean increase of 0.47 and 0.26 ng/ml, respectively, both p < 0.001). Different internationally accepted biopsy triggers were reached after DRE only: 5 total PSA > 3 ng/ml, 13 increase > 0.75 ng/ml, 3 PSA density > 0.15, and 1 free/total PSA < 0.18. On two occasions, patients were pushed away from biopsy trigger after DRE due to free/total PSA > 0.18. ICA-PSA was detectable (> 2.0 ng/ml) in 5 of 45 measured samples (11%) before DRE and 13/45 (29%) after DRE, p = 0.0316. Four among five detectable ICA-PSA tests increased after DRE.

CONCLUSION

Performing DRE immediately before PSA measurement might change the clinical decision-making on a significant number of occasions (roughly 1 in 3); even though the mean increase (0.47 ng/ml) looks deceivingly small. Further studies are required that include gold standard tests (biopsy, or imaging).

Photoacoustic tomography of intact human prostates and vascular texture analysis identify prostate cancer biopsy targets

Prostate cancer is poorly visualized on ultrasonography (US) so that current biopsy requires either a templated technique or guidance after fusion of US with magnetic resonance imaging. Here we determined the ability for photoacoustic tomography (PAT) and US followed by texture-based image processing to identify prostate biopsy targets. K-means clustering feature learning and testing was performed on separate datasets comprised of 1064 and 1197 nm PAT and US images of intact, ex vivo human prostates. 1197 nm PAT was found to not contribute to the feature learning, and thus, only 1064 nm PAT and US images were used for final feature testing. Biopsy targets, determined by the tumor-assigned pixels' center of mass, located 100% of the primary lesions and 67% of the secondary lesions. In conclusion, 1064 nm PAT and US texture-based feature analysis provided successful prostate biopsy targets.

Elevated Serum PSA is Associated With Human Herpesvirus 8 Infection and Increased Circulating Cytokine Levels in Men From Tobago

BACKGROUND

Serum-prostate specific antigen (PSA) levels have been used for many years as a biomarker for prostate cancer. This usage is under scrutiny due to the fact that elevated PSA levels can be caused by other conditions such as benign prostatic hyperplasia and infections of or injury to the prostate. As a result, the identification of specific pathogens capable of increasing serum levels of PSA is important. A potential candidate responsible for elevated PSA is human herpesvirus 8 (HHV-8). We have reported previously that HHV-8 is capable of infecting and establishing a latent infection in the prostate. In this current study we test the hypothesis that HHV-8 infection is associated with elevated PSA levels. Circulating cytokine levels between men with elevated PSA and controls are also compared.

METHODS

HHV-8 serostatus was determined among men with elevated serum PSA (≥4 ng/ml; n = 168, no prostate cancer on biopsy) and age-matched controls (PSA <4 ng/ml; n = 234), Circulating cytokine levels were determined among a subset of each group (116 with elevated PSA and 85 controls).

RESULTS

Men with an elevated serum PSA were significantly more likely to be HHV-8 seropositive (42.9%) than the age-matched cancer-free men (22.2%; OR 2.51; 95%CI 1.48-4.29, P = 00001). Comparison of circulating cytokine levels between men with elevated serum PSA and controls indicated that elevated serum PSA is associated with a pro-inflammatory response with a mixed Th1/Th2 response while HHV-8 infection was associated with significantly higher levels of IL12p70, IL-10, and IL-13 indicating a Th2 immune response.

CONCLUSIONS

We found a significant association between HHV-8 infection and increased levels of serum PSA. In an age of patient-centered medicine, men with an elevated serum PSA should be considered for HHV-8 serology testing to determine if HHV-8 is responsible for the elevated PSA. Prostate 77: 617-624, 2017. © 2017 Wiley Periodicals, Inc.

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.

Does Rigid Cystoscopy Affect the Total Serum Prostate-Specific Antigen Levels?

In the present study, we aim to prospectively evaluate the effect of performing rigid cystoscopy (CPE) in urological patients on the total serum prostate-specific antigen (PSA) levels. The study design was a prospective observational study. After giving informed consent, urological patients visiting the outpatient clinic of our institution from November 2010 to March 2012 who satisfied our protocol entry/exclusion criteria were recruited into the present study. Blood sample was withdrawn 1 h prior to CPE for serum PSA estimation, and CPE was performed with a 17-Fr rigid cystoscope. Blood was again withdrawn at 1 and 24 h after CPE for serum PSA estimation. The study used paired samples test (two tailed) for statistical analysis. A total of 50 patients with mean age of 60 years underwent CPE. The baseline, 1-h, and 24-h post CPE mean serum PSA levels were 1.98 ± 2.25 (0.02-12.33), 2.90 ± 2.81 (0.3-14.26), and 3.04 ± 2.95 (0.2-15.03) ng/dl, respectively. The paired samples test (two tailed) revealed that the rise in the baseline PSA versus 1-h PSA and baseline PSA versus 24-h PSA was highly significant at P < 0.001 and P < 0.002, respectively; however, the 1-h PSA versus 24-h PSA rise was not so significant (P < 0.043). The present study demonstrated that rigid cystoscopy may be associated with a variable rise in the serum PSA that may persist for a period of up to or beyond 24 h. Thus, we believe that the history of recent cystoscopy must be taken into consideration while interpreting the serum PSA value in the routine urological setting, as this will reduce unnecessary prostate biopsies in patients with an elevated serum PSA. Therefore, it may be advisable to wait for 24-48 h before withdrawing blood for serum PSA estimation in patients with history of CPE in the previous 24-48 h.

Effect of histological inflammation on total and free serum prostate-specific antigen values in patients without clinically detectable prostate cancer

Purpose

We are often confronted with patients in the "gray zone" (prostate-specific antigen [PSA]<10 ng/mL) whose biopsies reveal no malignancy but only inflammation. We investigated the relationship between histological inflammation and total PSA (tPSA), free PSA (fPSA), and percentage of free PSA (f/tPSA) levels in patients without prostate cancer (PC).

Materials and Methods

We studied 106 men with tPSA<10 ng/mL who had undergone biopsy that was negative for PC and who had no clinical prostatitis. Inflammation observed at biopsies was scored for inflammation type in each biopsy core by use of a four-point scale and was then correlated with tPSA, fPSA, and f/tPSA.

Results

Different patterns of inflammation were found in each set of biopsies. Regression factor analysis was used to form two groups according to inflammation type: more chronic and more acute. Median tPSA, fPSA, and f/tPSA levels in the more chronic and more acute inflammation groups were 6.4 ng/mL, 1.09 ng/mL, and 15%, and 7.3 ng/mL, 0.79 ng/mL, and l2%, respectively. A significant difference was found in fPSA (p=0.003) and f/tPSA (p<0.001), whereas the difference in tPSA was not significant (p=0.200). Total PSA correlated with fPSA (r=0.4, p<0.001) but not with inflammation type (r=0.12, p>0.010). A correlation existed between inflammation type and fPSA (r=-0.31, p=0.001) and f/tPSA (r=-0.43, p<0.001) in that the fPSA and f/tPSA were lower in the group with more acute inflammation.

Conclusions

Subclinical inflammation has a significant influence on fPSA in patients with tPSA<10 ng/mL but without PC or clinical prostatitis. Subclinical inflammation is not characterized by elevated tPSA alone but also by a decreased fPSA, a tendency similar to that in PC.

Emerging PSA-based tests to improve screening

This article updates advances in prostate cancer screening based on prostate-specific antigen, its derivatives, and human kallikrein markers. Many men are diagnosed with indolent disease not requiring treatment. Although there is evidence of a survival benefit from screening, the numbers needed to screen and treat remain high. There is risk of exposing men to the side effects of treatment for nonthreatening disease. A screening test is needed with sufficiently good performance characteristics to detect disease at an early stage so treatment may be offered with curative intent, while reducing the number of negative or unnecessary biopsies.

Empiric antibiotics for an elevated prostate-specific antigen (PSA) level: a randomised, prospective, controlled multi-institutional trial

OBJECTIVE

To determine the impact of empiric antibiotics on men with an elevated prostate-specific antigen (PSA) level.

SUBJECTS/PATIENTS AND METHODS

Men of any age with a PSA level of >2.5 ng/mL and normal digital rectal examination undergoing their first prostate biopsy were recruited from five medical centres. Patients with previous biopsy, prostate cancer, urinary tract infection (UTI) or prostatitis within the prior year, antibiotic use within 1 month, 5α-reductase inhibitor use, allergy to fluoroquinolones or clinical suspicion of UTI were excluded. Men were randomised to 2 weeks of ciprofloxacin or no antibiotic. A PSA measurement was obtained 21-45 days after randomisation immediately before prostate biopsy. The primary endpoint was the change in PSA level between baseline and immediately before biopsy.

RESULTS

Complete data were available for 77 men with a mean (interquartile range) age of 60.6 (53-66) years. In the control group of men not receiving antibiotic (39 men), the mean baseline and pre-biopsy PSA levels were 6.5 and 6.9 ng/mL, respectively (P = 0.8). In men receiving ciprofloxacin (38 men), the mean baseline PSA level was 7.6 ng/mL and after 2 weeks of ciprofloxacin was 8.5 ng/mL (P = 0.7). Compared with controls not receiving antibiotic, use of ciprofloxacin was not associated with a statistically significant change in PSA level (P = 0.33). Prostate cancer was detected in 36 (47%) men, 23 (59%) in the control group and 13 (34%) in the antibiotic group (P = 0.04). Detection rates were not significantly associated with the change in PSA level between baseline and biopsy. The primary limitation of the study is early stoppage due to an interim futility analysis and poor accrual.

CONCLUSION

Despite not meeting the target accrual goal, empiric use of antibiotics for asymptomatic men with an elevated PSA level does not appear to be of clinical benefit.

The epigenetic promise for prostate cancer diagnosis

BACKGROUND

Prostate cancer is the most common cancer diagnosis in men and a leading cause of death. Improvements in disease management would have a significant impact and could be facilitated by the development of biomarkers, whether for diagnostic, prognostic, or predictive purposes. The blood-based prostate biomarker PSA has been part of clinical practice for over two decades, although it is surrounded by controversy. While debates of usefulness are ongoing, alternatives should be explored. Particularly with recent recommendations against routine PSA-testing, the time is ripe to explore promising biomarkers to yield a more efficient and accurate screening for detection and management of prostate cancer. Epigenetic changes, more specifically DNA methylation, are amongst the most common alterations in human cancer. These changes are associated with transcriptional silencing of genes, leading to an altered cellular biology.

METHODS

One gene in particular, GSTP1, has been widely studied in prostate cancer. Therefore a meta-analysis has been conducted to examine the role of this and other genes and the potential contribution to prostate cancer management and screening refinement.

RESULTS

More than 30 independent, peer reviewed studies have reported a consistently high sensitivity and specificity of GSTP1 hypermethylation in prostatectomy or biopsy tissue. The meta-analysis combined and compared these results.

CONCLUSIONS

GSTP1 methylation detection can serve an important role in prostate cancer managment. The meta-analysis clearly confirmed a link between tissue DNA hypermethylation of this and other genes and prostate cancer. Detection of DNA methylation in genes, including GSTP1, could serve an important role in clinical practice.

Is prostate biopsy essential to diagnose prostate cancer in the older patient with extremely high prostate-specific antigen?

Purpose

The results of all prostate biopsies may be positive and suggestive of adenocarcinoma in patients with prostate-specific antigen (PSA) values higher than 100 ng/ml. We considered that the prostate cancer in patients with high PSA might be advanced disease and therefore that the treatment strategy should not be changed according to pathological reports. Thus, we assessed the role of prostate biopsy when diagnosing prostate cancer in patients with extremely high PSA levels.

Materials and Methods

We reviewed the records of 1,150 cases undergoing prostate biopsies. Patients with urinary tract infection and acute urinary retention were excluded. According to the pre-biopsy PSA level, patients were divided into 6 groups (group A, 4 to 20 ng/ml; B, 20 to 40 ng/ml; C, 40 to 60 ng/ml; D, 60 to 80 ng/ml; E: 80 to 100 ng/ml; and F, above 100 ng/ml).

Results

The calculated positive predictive value (PPV) for prostate cancer was 22% in group A, 54% in group B, 73% in group C, 75% in group D, 89% in group E, and 100% in group F, respectively. Pathological diagnosis was adenocarcinoma in all patients in group F (n=56). Among them, 38 patients (67.9%) had lymph node metastasis or extra-prostatic disease or both and 43 patients (76.8%) had bony metastasis. In group F, all cases were advanced prostate cancer (stage III or IV). All of them received hormonal therapy following diagnosis.

Conclusions

We suggest the possibility for biopsy-free diagnosis of prostate cancer in patients with extremely high levels of serum PSA and evidence of advanced disease in imaging studies, especially in older patients with comorbid medical problems.

Characterization of the seminal plasma proteome in men with prostatitis by mass spectrometry

Background

Prostatitis is an inflammation of the prostate gland which affects approximately 10% of men. Despite its frequency, diagnosing prostatitis and monitoring patient response to treatment remains frustrating. As the prostate contributes a substantial percentage of proteins to seminal plasma, we hypothesized that a protein biomarker of prostatitis might be found by comparing the seminal plasma proteome of patients with and without prostatitis.

Results

Using mass spectrometry, we identified 1708 proteins in the pooled seminal plasma of 5 prostatitis patients. Comparing this list to a previously published list of seminal plasma proteins in the pooled seminal plasma of 5 healthy, fertile controls yielded 1464 proteins in common, 413 found only in the control group, and 254 found only in the prostatitis group. Applying a set of criteria to this dataset, we generated a high-confidence list of 59 candidate prostatitis biomarkers, 33 of which were significantly increased in prostatitis as compared to control, and 26 of which were decreased. The candidates were analyzed using Gene Ontology and Ingenuity Pathway analysis to delineate their subcellular localizations and functions.

Conclusions

Thus, in this study, we identified 59 putative biomarkers in seminal plasma that need further validation for diagnosis and monitoring of prostatitis.

A prospective study of reducing unnecessary prostate biopsy in patients with high serum prostate-specific antigen with consideration of prostatic inflammation

Purpose

We aimed to reduce unnecessary prostatic biopsy in patients with high prostate-specific antigen (PSA) by consideration of prostatic inflammation.

Materials and Methods

The investigation was conducted prospectively in 413 patients with a PSA level of 4 to 10 ng/ml from January 2004 to December 2009. All patients underwent the expressed prostatic secretion (EPS) or voided bladder urine 3 (VB3) test to be classified into two groups: positive group and negative group. Patients with a positive result on the EPS or VB3 test were treated with antibiotics for 2 months, and in cases in which the PSA level remained high, we performed prostate biopsy. In patients with a negative result on the VB3 test, we performed prostate biopsy directly.

Results

Of the 413 study patients, 215 (52%) patients had positive findings on the EPS or VB3 test. After 8 weeks of antibiotics therapy, 53 of the 215 men avoided prostate biopsy because their PSA level was normalized. The other patients (162 of 215) still had elevated PSA levels of more than 4 ng/ml, including 7 patients in whom the biopsy revealed cancer. Patients with negative findings (198 of 413) underwent prostate biopsy. Of the 198 patients, 41 were diagnosed with prostate cancer. The total prostate cancer detection rate was 11.6% in our subjects, where as it was 20.7% in the patients with negative findings on the EPS or VB3 and 3.3% in the patients with positive findings, respectively.

Conclusions

In cases in which the PSA level is increasing, if we first exclude prostatitis and carry out a serial diagnostic procedure, it may help to reduce unnecessary prostatic biopsy.

Changes in serum prostate-specific antigen after treatment with antibiotics in patients with lower urinary tract symptoms/benign prostatic hyperplasia with prostatitis

PURPOSE

Many urologists have performed prostate biopsy in men with a high level of prostate-specific antigen (PSA) alone. However, high levels of PSA may be induced by infection. We studied the effects of antibiotics on serum total PSA and PSA density (PSAD) in men with total PSA between 4 and 10 ng/ml and normal digital rectal examination (DRE) and transrectal sonographic findings.

MATERIALS AND METHODS

From January 2005 to October 2009, a total of 107 patients with complaints of lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH) were evaluated. To be included in this study, patients had to be at least 50 years old, have a palpably normal DRE, have infection in the prostate, have a total serum PSA of 4 to 10 ng/ml, and have transrectal ultrasound findings that did not show a hypoechoic lesion in the prostate. Only patients in whom the PSA level was rechecked after short-term antibiotics administration (8 weeks) were included. Serum PSA and PSAD were measured before transrectal ultrasound or EPS and after 8 weeks of treatment with antibiotics (quinolone). Age, prostate volume, serum PSA, PSAD, and PSA rate of change were compared.

RESULTS

The mean age of the patients was 66.3 years. The mean prostate size was 48.8±24.9 g. Forty patients had a high level of PSAD. Total PSA and PSAD significantly decreased after treatment (p<0.05). In 45 of the 107 men, total PSA after antibiotics treatment was normalized (less than 4 ng/ml). PSAD after treatment was normalized (less than 0.15 ng/ml/cm(3)) in 23 of the 40 patients with a high level of PSAD.

CONCLUSION

Antibiotics treatment for at least 8 weeks in BPH patients with an increased PSA level (4-10 ng/ml), infection, and normal DRE and transrectal sonographic findings may decrease serum PSA significantly. However, because the PSA level was not decreased to the normal range (less than 4 ng/ml) in all patients, it seems that antibiotics therapy before prostatic biopsy is not necessary.

Prostate kallikrein markers in diagnosis, risk stratification and prognosis

The kallikrein, prostate-specific antigen (PSA), is one of the world's most frequently used disease biomarkers. After almost two decades of research and clinical experience, the diagnostic and monitoring limitations of PSA are beginning to be understood. Most physicians are aware of PSA's low specificity for cancer among older men with benign prostatic conditions; fewer are aware of recent data, which show that a prior negative biopsy or a prior PSA value below the threshold for biopsy might compromise the predictive accuracy of PSA even further. Furthermore, a subtle increase in serum PSA level during early middle age is strongly correlated with clinically important prostate cancer. We review current and past reports on the prostate kallikreins PSA and hK2 in relation to pathology and epidemiology.

Post-prostatic massage examination for prediction of asymptomatic prostatitis in needle biopsies: a prospective study

PURPOSE

Although asymptomatic prostatitis is the most common noncancer diagnosis as demonstrated histologically by biopsies, screening and identification before biopsy remain unclear. In this study we prospectively evaluate the efficacy of examination of post-prostatic massage urine for prediction of asymptomatic prostatitis in biopsies.

MATERIALS AND METHODS

A total of 161 consecutive men 50 to 80 years old with serum prostate specific antigen 4.1 to 10.0 ng/ml, normal digital rectal examination, no evidence of clinical prostatitis or urinary tract infection, who underwent 8 or 10-core prostate biopsies under transrectal ultrasonography guidance were included in the study. Immediate pre-biopsy leukocyte count in post-prostatic massage urine was determined per high power field (400 x). We selected 5, 7 and 10 leukocytes per high power field as cutoffs, and urine was examined for prediction of histological prostatitis.

RESULTS

Histological diagnosis was prostatitis, benign prostatic hyperplasia and prostate cancer in 66 (41.0%), 63 (39.1%) and 32 (19.9%) patients, respectively. The mean number of leukocytes and percentage of positive post-prostatic massage urine microscopy for all cutoffs were significantly higher in subjects with prostatitis than in those without prostatitis (p <0.0001). Histological prostatitis was predicted most accurately by the 5 leukocyte cutoff (sensitivity 68.2%, specificity 82.1% and area under the receiver operating characteristics curve 0.75).

CONCLUSIONS

In asymptomatic men with mild increases of prostate specific antigen histological evidence of prostatic inflammation is common. The leukocyte count in post-prostatic massage urine appears to be useful for screening of this condition before biopsy. Our data suggest that 10 leukocytes per high power field in post-prostatic massage urine, the usually applied cutoff, may be too high for the definition of prostatic inflammation.

Exclusion of inflammation in the differential diagnosis of an elevated prostate-specific antigen (PSA)

Prostate inflammation can lead to an elevation in the serum PSA concentration and confound the use of PSA kinetics. This can have considerable clinical consequences, since these measurements form the basis for important clinical decisions. Thus, there has been investigation into ways to decrease the confounding from inflammation, including repeat PSA measurements after a period of observation or a course of empiric antibiotics. This article reviews the evidence about elevations in PSA due to prostatitis and describes the controversy over the optimal approach to reduce its confounding impact on prostate cancer screening.

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.

Predicting biochemical failure and overall survival through intratherapy PSA changes during definitive external beam radiotherapy

PURPOSE

To determine whether intratherapy prostate-specific antigen (itPSA) changes during radiotherapy (RT) predict prostate cancer outcomes.

METHODS AND MATERIALS

We retrospectively identified patients treated with definitive external beam RT without hormonal therapy who had at least two itPSA measurements. We calculated the adjusted ratio of rise (ARR) in itPSA relative to the pretreatment baseline PSA for each patient. This was defined as ln(maximal itPSA + 1)/ln(baseline PSA + 1). We stratified patients according to an ARR of <1 vs. >1.1. This corresponded to an approximately <30% vs. >30% increase in PSA during RT. Univariate and multivariate analyses were performed examining for biochemical failure-free survival (BFFS) and overall survival (OS).

RESULTS

At a median follow-up of 74 months, we identified 307 patients who met our criteria. Univariate analysis revealed that patients with an ARR of <1.1 (n = 182) had statistically significant inferior BFFS and OS compared with those with an ARR of >1.1 (n = 125). The median BFFS and OS for these two groups was 51 vs. 101 months (p = 0.001) and 96 vs. 128 months (p = 0.01), respectively. On multivariate analysis, the effect of ARR on the risk of biochemical failure for patients with an ARR of <1.1 was significant (p = 0.03) only during the first year after RT. In contrast, the effect of the ARR on OS remained significant for a full 5 years (p = 0.05).

CONCLUSION

The results of our study have shown that an ARR of <1.1 predicts for inferior BFFS and OS in patients treated with RT alone. PSA measurement during RT is a novel clinical tool that could be used to identify patients who might warrant more aggressive therapeutic intervention.

PSA reduction (after antibiotics) permits to avoid or postpone prostate biopsy in selected patients

Microscopic foci of prostatitis may induce prostate-specific antigen (PSA) increase. PSA reduction after antibiotics might identify those patients in whom biopsy can be avoided. Ninety-nine patients received ciprofloxacin for 3 weeks, of whom 59 showed PSA reduction. Histology detected small foci of prostatitis in 65% of cases. Carcinoma was found in 40 and 20.3% of patients with unchanged or decreased PSA, respectively (P=0.03). No cancer was detected if PSA decreased below 4 ng/ml or more than 70%. Biopsy can be postponed, with a low risk of missing a cancer, if PSA decreases more than 70% or below 4 ng/ml.

Relationship between Serum Prostate Specific Antigen and the Pattern of Inflammation in Both Benign and Malignant Prostatic Disease in Middle Eastern Men

To determine the effect of prostatitis on serum prostate specific antigen in the diagnosis of prostate cancer in Middle Eastern men, H&E-stained sections of all consecutive prostate specimens were reviewed for diagnosis (malignant or benign) and pattern of inflammation. Inflammation was categorized into acute, active chronic and chronic inactive and graded semi-quantitatively according to previously published criteria. Results were correlated with serum PSA obtained from patients' records. Of 513 prostate specimens reviewed; 435 (84.8%) were benign and 78 (15.2%) were malignant. Chronic inactive prostatitis was present in 259 (204 benign, 55 malignant) and active chronic prostatitis in 221 (204 benign, 17 malignant). Acute prostatitis alone was not observed and prostatitis was absent in 33 (27 benign, 6 malignant). There was no significant difference in the prevalence of inactive chronic prostatitis between benign and malignant specimens (p < 0.071), but active chronic prostatitis was more prevalent in benign specimens (p < 0.001). Increasing serum PSA was observed for increasing grades of both inactive and active chronic prostatitis in both benign and malignant disease. Prostate cancer showed higher serum PSA levels than benign, at different cut-off points (4 ng/ml = p < 0.0001; 8 ng/ml = p < 0.0001; 12 ng/ml = p < 0.0001). However, significant numbers of patients with benign prostate biopsies presented with PSA above 12 ng/ml (82/260 = 32%). We conclude that active chronic prostatitis is common in Middle Eastern men with benign prostatic disease and a significant number of these present with very high PSA levels, some over 300 ng/ml.

Prostate-specific antigen test in diagnostic evaluation of chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To determine whether prostate-specific antigen (PSA), the percent free PSA, or free PSA isoforms may be used as diagnostic markers for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS; National Institutes of Health category IIIa and IIIb).

METHODS

We evaluated 421 patients enrolled in the Chronic Prostatitis Cohort Study and 112 age-matched controls. Subjects were stratified by the number of white blood cells (WBCs) in their expressed prostatic secretions and pain as determined by the National Institutes of Health Chronic Prostatitis Symptom Index.

RESULTS

Total PSA, free PSA, and [-2]proPSA ([-2]pPSA) were significantly elevated in those with CP/CPPS compared with controls (mean PSA 1.97 ng/mL versus 1.72 ng/mL, P = 0.03; mean free PSA 0.76 ng/mL versus 0.70 ng/mL, P = 0.01; and [-2]pPSA 2.38 ng/mL versus 1.80 ng/mL, P = 0.04). The percent free PSA was not significantly different between the patients and controls. For those with CP/CPPS, the percent free PSA was significantly lower as the WBC count rose in the expressed prostatic secretions (0 WBCs = 43.29 versus more than 25 WBCs = 26.52; P < .0001). A PSA level of 4.0 ng/mL or greater was found in 10% of patients and 7% of controls (P = 0.03).

CONCLUSIONS

Men with elevated PSA values and CP/CPPS should be treated as one would any other patient screened for prostate cancer with an elevated PSA level. Although PSA, free PSA, and [-2]pPSA were slightly elevated in men with CP/CPPS, the low sensitivity and specificity do not warrant using them as biomarkers for CP/CPPS.

Prostatitis and serum prostate-specific antigen

Prostatitis is an inflammatory condition of the prostate and has been divided into four categories according to the National Institutes of Health classification. This article reviews the various types of prostatitis and their effect on serum prostate-specific antigen levels. Various proposed mechanisms of this elevation include leakage of prostate-specific antigen (PSA) into the blood stream, hypervascularity, and altered vascular permeability secondary to inflammation. Acute prostatitis can lead to an increase in PSA, which usually returns to normal levels with appropriate antibiotics within 1 to 3 months. Patients with chronic prostatitis have a less well-defined decrease in PSA after an antibiotic course. Whether a course of antibiotics prior to biopsy increases the yield has not been well established. Asymptomatic inflammation of the prostate has been recognized to be an important confounding factor in patients with an elevated PSA. Inflammation has been proposed to be a precursor of prostate adenocarcinoma.

Influence of asymptomatic histologic prostatitis on serum prostate-specific antigen: a prospective study

OBJECTIVES

To determine the influence of asymptomatic inflammatory processes of the prostate on serum prostate-specific antigen (PSA) levels.

METHODS

A total of 51 patients with no evidence of prostate cancer or clinical prostatitis were prospectively studied. All subjects underwent 10 to 12 sector transrectal-ultrasound guided needle biopsies of the prostate. Serum PSA was measured 10 minutes before the biopsies. The fragments were stained and histologically analyzed. Two different classifications were used. One divided patients according to the number of specimens with inflammatory processes: 20% or less (group 1), more than 20% to 50% or less (group 2), and greater than 50% (group 3). Any kind of inflammatory process was considered positive. The second was the presence or absence of foreign body-type giant cells. Pearson's nonparametric test was used in the statistical analysis, with P <0.05 considered statistically significant.

RESULTS

The number of specimens with an inflammatory process was statistically significant (P = 0.02), with a median PSA level of 4.96 ng/mL in group 1 patients, 7.40 ng/mL in group 2, and 8.03 ng/mL in group 3 patients. The presence of foreign body-type giant cells in the histologic analysis was not statistically significant, with a median PSA level of 10.21 ng/mL compared with 5.89 ng/mL in the group without these cells.

CONCLUSIONS

The extension of the inflammatory process, as evaluated by the number of specimens involved, was directly related to elevations of serum PSA levels in asymptomatic patients. We could not find a statistically significant relationship between the presence of foreign body-type giant cells and serum PSA levels.

Effect of subclinical prostatic inflammation on serum PSA levels in men with clinically undetectable prostate cancer

OBJECTIVES

To examine whether subclinical prostatic inflammation might influence serum prostate-specific antigen (PSA) levels in men with clinically undetectable prostate cancer.

METHODS

A total of 461 patients who underwent prostate biopsy at our hospital were studied between January 1996 and December 1999. Of these patients, a total of 125 patients without detectable prostate cancer or a history or symptoms of prostatitis, with serum PSA levels of less than 20.0 ng/mL and other specified exclusion criteria, were included in the study. Inflammation observed at biopsy was scored for inflammation extent and inflammatory aggressiveness, and the effects of these morphologic aspects of inflammation on serum PSA levels were examined.

RESULTS

The extent of inflammation tended to increase as the prostate volume increased (P = 0.006). Patients with a PSA greater than 2.5 ng/mL had a greater extent and aggressiveness of inflammation than those with PSA levels of 2.5 ng/mL or less (P = 0.004 and P = 0.050, respectively). However, no statistically significant differences were found in terms of the extent of inflammation or inflammatory aggressiveness between patients with PSA levels greater than 4.0 ng/mL and those with PSA levels of 4.0 ng/mL or less. Furthermore, the extent of inflammation did not account for PSA levels greater than 2.5 or 4.0 ng/mL by multivariate analysis.

CONCLUSIONS

Our results indicate that subclinical prostatic inflammation is not the etiology of a serum PSA greater than 4.0 ng/mL in men without clinically detectable prostate cancer.

Total and free serum prostate specific antigen levels during the first month of acute prostatitis

OBJECTIVES

The level of total prostate specific antigen (PSA) rises in acute prostatitis. The PSA fraction responsible for this increase and the evolution of the free/total PSA ratio are little known at the present time. We therefore carried out a prospective study of the evolution of total and free PSA levels and the free-to-total PSA ratio for one month after diagnosis of acute prostatitis.

PATIENTS AND METHODS

Between January 1999 and February 2001, 31 consecutive patients (mean age 51 years) were treated for acute prostatitis. No patient had a history of prostate cancer or of recent prostatitis. Measurement of C-reactive protein (CRP), total PSA and free PSA was done at days 0, 3, 10 and 30.

RESULTS

During the first month of acute prostatitis and under an adapted antibiotherapy, CRP progressively decreased and returned to normal levels at about day 10. Total PSA level increased up to day 3 and then gradually decreased until at least the end of the first month. The level of free PSA decreased up to day 10 and was still low at one month, leading to a decrease in the free-to-total PSA ratio which was reached its lowest level at day 10 and was still low at one month.

CONCLUSION

The increased level of total PSA in acute prostatitis is secondary to the proportional increase in bound serum PSA and decrease in free PSA. Free PSA was still low at one month, maintaining a low free-to-total PSA ratio.

High serum prostate-specific antigen levels in the absence of prostate cancer in Middle-Eastern men: the clinician's dilemma

OBJECTIVE

To investigate the common causes of total serum prostate-specific antigen (PSA) values of> 10 ng/mL in an Arab population, as in the USA and Europe the risk of prostate cancer is considered high in men with such PSA levels.

PATIENTS AND METHODS

Serum total PSA was measured in men presenting to our hospital as part of the investigation for prostate cancer screening and/or in elderly men with prostatism. Men with a serum PSA level of> 10 ng/mL were further investigated by transrectal ultrasonography (TRUS) of the prostate and biopsy of suspicious lesions for histological diagnosis. In addition, the percentage of free PSA, PSA velocity and PSA density were determined. All the patients included in this study were men of Arab origin residing in Kuwait.

RESULTS

In all, 1700 men (mean age 55.6 years, range 35-94) were assessed; of these, 161 had a serum PSA of> 10 ng/mL, attributable to benign prostatic hyperplasia (BPH) in 110 (68%), BPH with histological features of prostatitis in 33 (21%) and prostate cancer in 18 (11%). TRUS of the prostate in 143 of the 161 men with either BPH or BPH with prostatitis showed varying grades of intraprostatic calcifications in 22 (15%). Both PSA density and percentage free PSA did not contribute to determining the causes of total PSA levels of> 10 ng/mL. There was a progressive decline in PSA in all patients with BPH and prostatitis, except one who at re-biopsy had prostate cancer (T1N0M0, G1).

CONCLUSION

Total PSA values of> 10 ng/mL in Arab men may be a result of BPH, BPH with prostatitis or prostate cancer, in that order. A gradual decline in total PSA (decreased PSA velocity) with time to < 4 ng/mL often confirms the diagnosis of BPH with prostatitis. The percentage of free PSA and PSA density may not be helpful in diagnosing prostate cancer with certainty in these patients. Compared with Caucasians in the USA and Europe, BPH and BPH with prostatitis appear to be more frequent causes of serum PSA levels of> 10 ng/mL in Arab men.

Validity of PSA, free/total PSA ratio and complexed/total PSA ratio measurements in men with acute urinary retention

The reliability of serum prostate specific antigen (PSA) measurements in men with acute urinary retention is unclear. Total PSA, free and complexed PSA were measured, and the free/total (f/t) PSA and complexed/total (c/t) PSA ratios calculated, prior to catheterisation and at 48 and 72 h post-catheterisation in 39 men with acute retention. Subsequent histology showed 12 patients had prostate cancer and 27 benign prostatic hypertrophy. Serum free and total PSA fell following catheterisation, while complexed PSA rose during the first 48 h then subsequently fell. The f/t PSA and c/t PSA ratios provided the best discrimination at 48-72 h with 100% sensitivity and 75-82% specificity.Prostate Cancer and Prostatic Diseases (2001) 4, 167-172.

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.

Early management of prostate cancer: how to respond to an elevated PSA?

Support for prostate cancer screening efforts is provided by observational studies reporting decreases in prostate cancer-specific mortality in areas where screening is performed with digital rectal exam (DRE) and measurement of serum prostate-specific antigen (PSA) levels. The combination of PSA and DRE is an excellent cancer-screening tool with sensitivity and positive predictive value superior to that of mammography and breast exam. Use of percent free PSA further improves the specificity of PSA testing, particularly in the range of 4-10 ng/ml, at which most false positive PSA tests occur. Men older than 50 with a >10-year life expectancy should be considered for prostate cancer screening. Those with an abnormal DRE or a PSA above 4 ng/ml should be referred to a urologist for further discussion of the risks and benefits of a prostate biopsy. Furthermore, those with a significant change in either DRE or PSA results, or those at higher risk for prostate cancer with a PSA level above 2.5 ng/ml, should also be referred for evaluation.

Non-specific eosinophilic granulomatous prostatitis responded favorably to an antimicrobial agent and a hydrocortisone

A case of non-specific eosinophilic granulomatous prostatitis is presented. The patient was a 55-year-old man who was hospitalized with complaints of acute urinary retention and high-grade fever. Results of digital examination and transrectal ultrasonography of the prostate and elevated prostatic specific antigen were suggestive of prostatic cancer. Transrectal needle biopsy of the prostate was performed. Histological examination of the specimens revealed the formation of histiocytic granulomas with eosinophilic infiltration. The patient responded favorably to combination therapy with an antimicrobial agent and a hydrocortisone.

The role of molecular forms of prostate-specific antigen (PSA or hK3) and of human glandular kallikrein 2 (hK2) in the diagnosis and monitoring of prostate cancer and in extra-prostatic disease

Prostate-specific antigen (PSA or hK3) is a glandular kallikrein with abundant expression in the prostate that is widely used to detect and monitor prostate cancer (PCa), although the serum level is frequently elevated also in benign and inflammatory prostatic diseases. PSA testing is useful for early detection of localized PCa and for the detection of disease recurrence after treatment. However, PSA has failed to accurately estimate cancer volume and preoperative staging. There is no PSA level in serum that definitively distinguishes men with benign conditions from those with prostate cancer, although PCa is rare in men with PSA levels in serum < 2.0 ng/ml. This prompted searches for enhancing parameters to combine with PSA testing, such as PSA density, PSA velocity, and age-specific reference ranges. Due to the protease structure, PSA occurs in different molecular forms in serum and their concentrations vary according to the type of prostatic disease. Human glandular kallikrein 2 (hK2) is very similar to PSA, but expressed at higher levels in prostate adenocarcinoma than in normal prostate epithelium. Blood testing for hK2 combined with different PSA forms improves discrimination of men with benign prostatic disease from those with prostate cancer. Many data have also been reported on the extra-prostatic expression of both PSA and hK2, and it is now believed that they may both have functions in tissues outside the prostate.

Prostate pathology: histologic and molecular perspectives

The field of prostate cancer research is poised for dramatic improvements in our ability to better diagnose men at risk of prostate cancer and to better predict prognosis and response to treatment. Histopathologic and molecular analyses lie at the heart of these issues. Improvements in our understanding of the mechanisms of prostate carcinogenesis and in determining why the prostate seems to be so highly targeted for cancer development will lead to rational strategies of disease prevention.

Consensus development of a histopathological classification system for chronic prostatic inflammation

OBJECTIVE

To develop a standardized histopathological classification system for chronic prostatitis (standardized description of prostatic inflammatory infiltrates) based on a literature review, extensive prospective evaluations in two recognized prostatitis research centres and widespread consensus of international urological centres identified as having major expertise or interest in chronic prostatitis.

METHODS

Relevant articles for review were identified by a Medline search undertaken by the Cochrane Review Group in Prostate Diseases and Urologic Malignancies, and cross-checking bibliographies of retrieved studies, reviews, book chapters and abstracts of the American Urological Association and International Prostatitis Collaborative Network Annual Meetings. Initial drafts were based on classification systems independently developed by the Prostatitis Research Centers at Queen's University in Canada and University of Washington in the USA. A collaborative draft was distributed to 20 urological/pathological clinical centres who participated in the North American Chronic Prostatitis Collaborative Research Network and First International Prostatitis Collaborative Network. A consensus classification system was then distributed to the participating panel for acceptance.

RESULTS

The literature review identified a reasonably consistent description of inflammatory infiltrate locations and patterns that were further incorporated into the draft based on the Queen's University and University of Washington proposals. Eighteen (90%) of the identified Prostatitis Centers participated in the revision of the draft and the final consensus process. The final consensus document classifies prostatic inflammation according to its extent and grade/severity in each tissue compartment (location). Conclusion The consensus of the expert panel was that this classification system can be used in the evaluation of prostatic inflammation in prostate biopsies, transurethral resected prostate chips or prostatectomy specimens. A standardized accepted framework to describe histopathological prostate inflammation will prove useful in evaluating prostate disease.

Prostate-specific antigen

Serum prostate-specific antigen (PSA) measurements are the most useful serum biomarker to aid in early prostate cancer detection, clinical staging and therapeutic monitoring. Although the optimal use of PSA testing remains controversial, population based studies suggest that PSA screening reduces prostate cancer mortality. Customizing screening protocols based on individual risk factors and PSA level may be a useful approach to reduce overall costs incurred by widespread PSA testing. Lowering PSA cut-offs (i.e., from 4.0 ng/ml to 2.5 ng/ml) may reduce advanced stage prostate cancer, and the use of different PSA derivatives and PSA forms may reduce 'unnecessary' biopsies in some men. In addition to prostate cancer, manipulation and benign diseases of the prostate falsely elevate serum PSA levels. In contemporary clinical practice, PSA testing plays an important role in prostate cancer diagnosis and treatment.

Correlation of histological inflammation in needle biopsy specimens with serum prostate- specific antigen levels in men with negative biopsy for prostate cancer

OBJECTIVES

To reveal the possible contribution of histological inflammation within the prostate to the abnormal elevation of serum prostate-specific antigen (PSA) levels in patients with needle biopsy negative for prostate cancer.

METHODS

We reviewed negative needle biopsy specimens obtained in 93 patients. The degree of acute and chronic inflammation as evaluated histologically was compared with serum PSA levels in conjunction with age and prostate volume.

RESULTS

Both age (P <0.01) and prostate volume (P <0.0001) correlated significantly with serum PSA levels and were significantly greater in patients with abnormal serum PSA levels (greater than 4.0 ng/mL) than in those with normal serum PSA levels (4.0 ng/mL or less) (P <0.01). The presence of histological inflammation within the prostate also correlated significantly with serum PSA levels. Multiple regression analysis demonstrated prostate volume to be the only independent determinant of serum PSA levels (P <0.01). In patients with a prostate volume larger than 25 mL, only prostate volume correlated significantly with serum PSA levels (P <0. 05). On the other hand, the degree of acute inflammation as represented by polymorphonuclear leukocyte infiltration was the only parameter correlating significantly with serum PSA levels (P <0.05) in patients with a prostate volume smaller than 25 mL.

CONCLUSIONS

Histologically defined acute inflammation within the prostate is a significant contributor to elevated serum PSA levels, especially in patients with small prostates. In the assessment of needle biopsy results negative for prostate cancer, it might be helpful to evaluate the degree of histological inflammation, especially in terms of the necessity of subsequent repeated biopsies.