Relationship between serum prostate specific antigen and histological prostatitis in patients with benign prostatic hyperplasia

Diagnostic utility of alpha-methylacyl CoA racemase (P504S) on prostate needle biopsy

Alpha-methylacyl CoA racemase (AMACR), also known as P504S, was identified by the analysis of cDNA library subtraction in conjunction with high throughput microarray screening from prostate tissue and has been proven to be one of the very few biomarkers that can distinguish cancer from benign cells with high sensitivity and specificity for prostate carcinoma. It is a successful example of the translation of molecular findings into clinical practice. This review focuses on the study of AMACR (P504S) expression in small focal prostate cancer and atypical small acinar proliferation (ASAP) on needle biopsies and emphasizes the utility of AMACR (P504S) in routine surgical pathology practice. We also discuss the potential pitfalls and caveats in the interpretation of immunostaining results.

Alpha-methylacyl-CoA racemase: a multi-institutional study of a new prostate cancer marker

AIM

To test whether alpha-methylacyl-CoA racemase (AMACR) is a sensitive and specific marker of prostate cancer.

METHODS AND RESULTS

The expression levels of AMACR mRNA were measured by real-time polymerase chain reaction. A total of 807 prostatic specimens were further examined by immunohistochemistry specific for AMACR. Quantitative immunostaining analyses were carried out by using the ChromaVision Automated Cellular Imaging System and the Ariol SL-50 Imaging System, respectively. AMACR mRNA levels measured in prostatic adenocarcinoma were 55 times higher than those in benign prostate tissue. Of 454 cases of prostatic adenocarcinoma, 441 were positive for AMACR, while 254 of 277 cases of benign prostate were negative for AMACR. The sensitivity and specificity of AMACR immunodetection of prostatic adenocarcinomas were 97% and 92%, respectively. Both positive and negative predictive values were 95%. By automatic imaging analyses, the AMACR immunostaining intensity and percentage in prostatic adenocarcinomas were also significantly higher than those in benign prostatic tissue (105.9 versus 16.1 for intensity, 45.7% versus 0.02% and 35.03% versus 4.64% for percentage, respectively).

CONCLUSIONS

We have demonstrated the promising features of AMACR as a biomarker for prostate cancer in this large series and the potential to develop automated quantitative diagnostic tests.

Evaluation of serum and seminal levels of prostate specific antigen in men with spinal cord injury

PURPOSE

Recent studies have used prostate specific antigen (PSA) as an indicator of prostate gland activity in patients with spinal cord injury (SCI). Thus, the present study was performed to determine whether SCI can induce alterations in total serum and seminal PSA, and to compare the findings obtained to those of normal men (controls).

MATERIALS AND METHODS

A total of 44 men with SCI (cases, mean age +/- SD 33.98 +/- 9.12 years) and 44 controls (mean age +/- SD 34.09 +/- 9.16 years) were studied. Blood and semen samples were collected after 3 days of abstinence from ejaculation and stored at a controlled temperature between -70 and -79C. Seminal fluid was kept at room temperature for 15 minutes before storage. The tests for determination of total serum and seminal PSA were performed using AxSYM equipment and reagents.

RESULTS

The mean total seminal PSA obtained from patients (0.609 mg/ml) was lower than the 0.773 mg/ml value obtained from controls (p = 0.0012), but the mean total serum PSA of patients (0.918 ng/ml) did not differ significantly from that obtained from controls (0.976 ng/ml, p = 0.9967).

CONCLUSIONS

SCI patients have a significant decrease in total seminal PSA but total serum PSA is not affected by this lesion.

Pathological and molecular mechanisms of prostate carcinogenesis: implications for diagnosis, detection, prevention, and treatment

Prostate cancer is an increasing threat throughout the world. As a result of a demographic shift in population, the number of men at risk for developing prostate cancer is growing rapidly. For 2002, an estimated 189,000 prostate cancer cases were diagnosed in the U.S., accompanied by an estimated 30,200 prostate cancer deaths [Jemal et al., 2002]. Most prostate cancer is now diagnosed in men who were biopsied as a result of an elevated serum PSA (>4 ng/ml) level detected following routine screening. Autopsy studies [Breslow et al., 1977; Yatani et al., 1982; Sakr et al., 1993], and the recent results of the Prostate Cancer Prevention Trial (PCPT) [Thompson et al., 2003], a large scale clinical trial where all men entered the trial without an elevated PSA (<3 ng/ml) were subsequently biopsied, indicate the prevalence of histologic prostate cancer is much higher than anticipated by PSA screening. Environmental factors, such as diet and lifestyle, have long been recognized contributors to the development of prostate cancer. Recent studies of the molecular alterations in prostate cancer cells have begun to provide clues as to how prostate cancer may arise and progress. For example, while inflammation in the prostate has been suggested previously as a contributor to prostate cancer development [Gardner and Bennett, 1992; Platz, 1998; De Marzo et al., 1999; Nelson et al., 2003], research regarding the genetic and pathological aspects of prostate inflammation has only recently begun to receive attention. Here, we review the subject of inflammation and prostate cancer as part of a "chronic epithelial injury" hypothesis of prostate carcinogenesis, and the somatic genome and phenotypic changes characteristic of prostate cancer cells. We also present the implications of these changes for prostate cancer diagnosis, detection, prevention, and treatment.

Determining variables for repeat prostate biopsy

During the evaluation of prostate cancer, men who have undergone transrectal ultrasound-guided biopsy with negative results present a dilemma as to what further follow-up is required. Multiple variables have been proposed throughout the literature to improve cancer detection rates not only in initial biopsy results, but also on repeat evaluation. These variables include prostate-specific antigen (PSA) velocity, PSA density, free-percent PSA, and histological findings, each of which may singly or collectively dictate the need for further biopsy. After performing a Medline literature search using specific Medical Subject Headings (prostate biopsy, repeat prostate biopsy, PSA velocity, PSA density, free-percent PSA, prostate inflammation), we critically evaluated pertinent articles. Using this accumulated data and information, we composed an algorithm to assist in the decision process for repeat biopsy.

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.

Prostatic calculi do not influence the level of serum prostate specific antigen in men without clinically detectable prostate cancer or prostatitis

PURPOSE

Prostatic calculi are common but little is known of their effect on serum prostate specific antigen (PSA). We investigated whether prostatic calculi might influence serum PSA in men with clinically undetectable prostatic cancer or prostatitis.

MATERIALS AND METHODS

Between November 1999 and November 2001, 581 consecutive patients underwent serum PSA determination and digital rectal examination. Of these patients 486 without detectable prostatic cancer, or a history or symptoms of prostatitis and with other specified exclusion criteria were included in the study. The detection and volume measurement of prostatic calculi, and the measurement of prostate volume were performed by transrectal ultrasonography.

RESULTS

Prostatic calculi were detected in 198 of the 486 men (40.7%). Mean patient age, prostate volume and serum PSA were not significantly different in men with and without prostatic calculi. Prostate volume was significantly greater in patients with abnormally elevated serum PSA than in those with normal levels. However, no significant difference was found between the percent of men with prostatic calculi or the volumes of prostatic calculi in the 2 groups. Univariate logistic regression analysis indicated that the presence or volume of prostatic calculi was not a risk factor for elevated PSA. Multivariate analysis showed that age and prostate volume were associated with elevated PSA.

CONCLUSIONS

The presence or volume of prostatic calculi had no significant effect on serum PSA. Our results suggest that the influence of prostatic calculi is irrelevant in men with elevated PSA.

Evolution of free, complexed, and total serum prostate-specific antigen and their ratios during 1 year of follow-up of men with febrile urinary tract infection

OBJECTIVES

To determine the serum values of free, complexed, and total prostate-specific antigen (PSA) and their ratios in men with febrile urinary tract infection (UTI) during 1 year of follow-up.

METHODS

A total of 54 men were prospectively enrolled in the study, and serum samples were obtained at the acute stage of the UTI and after 1, 3, 6, and 12 months.

RESULTS

Most men had a rise (median 3.1, 7.2, and 14.1 ng/mL, respectively) in free PSA (fPSA), complexed PSA (cPSA), and total PSA (tPSA) during the acute phase of the UTI. After 1 month, fPSA rapidly decreased to levels that were maintained during the rest of the follow-up period, and cPSA and tPSA declined more slowly. At 1, 3, and 6 months after the infection the fPSA/tPSA and fPSA/cPSA ratios were abnormal in one half to two thirds of the men (median ratio 11%, 15%, and 16% and 17%, 24%, and 24%, respectively), comparable to findings in patients with prostate cancer.

CONCLUSIONS

These results confirmed that the prostate is involved in men with febrile UTI. The low fPSA/tPSA and fPSA/cPSA ratios in combination with sustained elevations of cPSA and tPSA for up to 6 months after UTI could be falsely interpreted as a sign of prostate cancer. The prolonged elevation of cPSA indicates a long-lasting inflammation of the nonadenomatous parts of the prostate.

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.

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.

Correlation between inflammatory cells (T and B lymphocytes, macrophages) in prostate biopsies and elevated PSA levels in a PSA screening population

OBJECTIVES

To investigate the relationship between inflammatory cells in prostate biopsies and total serum prostate-specific antigen (PSA) levels in a screening population.

METHODS

In the study, transrectal ultrasound-guided prostate biopsy specimens from 49 patients were assessed. All patients undergoing biopsy had elevated serum PSA levels (as defined by the biopsy criteria of the Tyrol PSA Screening Project) and/or abnormal findings on digital rectal examination. The prostate biopsy specimens were histologically negative for carcinoma. Immunohistologic characterization of the inflammatory cells was performed using CD3, CD4, and CD8 antibodies for the detection of T lymphocytes, CD20 antibodies for B lymphocytes, and CD68 antibodies for macrophages. The percentage of inflammatory cells and their distribution in stromal and glandular tissue was estimated using morphometric methods.

RESULTS

Inflammatory cells in the stroma contained significantly larger numbers of T lymphocytes than B lymphocytes and macrophages. T lymphocytes were also predominant in the glandular region. A significant positive correlation was found between the relative volume (vol%) of macrophages and total PSA levels (P <0.05) and a significant negative correlation between the percent free PSA levels and the relative volumes of T and B lymphocytes.

CONCLUSIONS

The results indicate a significant positive correlation between total PSA levels and macrophages and a significant negative correlation between percent free PSA levels and T and B lymphocytes. No statistically significant correlation was found between total serum PSA levels and the presence of inflammatory cells in the stromal and glandular compartment. Additional studies are needed to compare the amount and types of inflammatory cells with the stage and grade of prostate cancer in positive biopsies and radical prostatectomy specimens.

[Effect of antibiotic treatment on PSA and percentage of free PSA in patients with biochemical criteria of prostatic biopsy]

INTRODUCTION

PSA serum level measurement in the most important tool in the early diagnosis of prostate cancer patients. However, it is recognised it low specificity is due mainly to prostatic benign diseases. Although it is known that inflammation can contribute on this lack of specificity, there is disagreement in the effect of no symptomatic prostatic inflammatory focus on total PSA and percent free PSA serum levels.

AIM

To analyse the biological variability in total PSA and percent free PSA serum levels in patients with biochemical criteria of prostatic biopsy and to compare them with the antibiotic induced variability in a previous urinary infections cohort patients.

PATIENTS AND METHODS

We analysed 60 patients with previous urinary infections, normal digital rectal examination and PSA between 4 and 20 ng/ml. We measured total PSA and percent free PSA serum levels. Thirty were treated with 3 weeks of ofloxacin and following a new marker determination. Sextant ultrasound guided prostatic biopsy was performed in all cases.

RESULTS

45 patients demonstrated BPH (29 with prostatitis) and 15 prostate cancer (T1c). Significant variations were found on total PSA serum levels (6.97 ng/ml vs 5.82 ng/ml, p = 0.001) and percent free PSA (14.73% vs 17.77%, p = 0.01) only in treated patients. These differences were significant in BPH and BPH with prostatitis patients but not in prostate cancer patients. Treated patients trend was to decrease PSA (13 treated patients shown PSA < 4 ng/ml vs 2 control patients) and to increase percent free PSA. The median variation of percent free PSA was higher than total PSA and was not influenced by PSA level or prostatic volume. Taking 25 as cut-off of percent free PSA, 18.3% of prostatic biopsies could be avoided in the first determination and 20% in the second. Adding the total PSA reduction, 56% of prostates biopsies in the treated patients could be avoided.

CONCLUSIONS

Biochemical criteria of prostatic biopsy could be modified in patients with previous urinary infections due to higher variations on serum markers than those explained by biological variations. These variations could be induced by the antibiotic treatment. These results suggested that the inflammatory focus could influence on total PSA and percent free PSA serum levels.

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.

Immune response in hormonally-induced prostatic hyperplasia in the dog

We induced prostatic enlargement in castrated dogs using either androgen alone or androgen combined with estrogen. In addition to previously reported hyperplastic changes, marked infiltration with immune effector cells was observed. This mononuclear cell infiltrate was phenotypically characterized using CD3 as pan T-lymphocyte marker, CD79 for B-lymphocytes, MAC378 for macrophages, and antibodies against kappa- and lambda-immunoglobulin (Ig) light chains for plasma cells. The majority of inflammatory cells (>80%) in the mononuclear infiltrates were T-lymphocytes and the numbers correlated with the degree of inflammation. The B-lymphocytes were found particularly in areas with marked follicular formation and diffuse infiltration, whereas there were only a few positive cells (<10%) in areas with a moderate or slight inflammation. Macrophages were found primarily in areas with atrophic and cystic changes with and without inflammation. The expression of lambda-Ig-positive cells depended on the degree of inflammation (5-10%), whereas immunoreactivity of kappa-Ig did not correlate with the extent of inflammatory reaction. Our present findings together with the evaluation of longitudinal biopsies of hormonally-induced BPH indicate that hyperplasia preceded cell-mediated and humoral immune response.

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.

Asymptomatic inflammation and/or infection in benign prostatic hyperplasia

OBJECTIVE

To determine the extent, pattern and clinical significance of asymptomatic histological inflammation and latent infection (National Institute of Health Category IV prostatitis) in benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

The study included 80 patients (from a cohort of 100 consecutive potentially eligible subjects) with a diagnosis of BPH, but no history or symptoms of prostatitis. Histological sections were obtained from specimens collected prospectively at transurethral resection of the prostate (TURP), immunostained for leukocyte common antigen and scanned using a computerized image-analysis system. Foci of inflammation were categorized as glandular, periglandular, stromal or peri-urethral, and the inflammatory cell density graded from 1 to 3. Relationships and correlations were calculated between the volume, degree and type of inflammation, presence and type of bacteria (culture of deep prostatic biopsies), the use of catheters and prostate specific antigen (PSA) levels.

RESULTS

Inflammation was identified in all patients but the mean tissue surface area involved was only 1.1% of the total specimen, with periglandular inflammation being the predominant pattern (0.5%). Of the prostate specimens, 44% showed bacterial growth (in 67% of the catheterized patients and 28% of those uncatheterized; 42% of patients were catheterized before TURP). There was no significant difference between any combination of inflammation pattern, volume or grade of inflammation in those catheterized or not (P=0.15) or culture-positive (pathogenic or not) and culture-negative cases (P=0.06). Neither total PSA or PSA density was significantly correlated (P>0.05) with the amount, degree or distribution of inflammation.

CONCLUSION

Prostatic inflammation is an extremely common histological finding in patients with symptoms of BPH who have no symptoms of prostatitis. There was no correlation between the degree and pattern of inflammation, catheterization, presence of bacteria, serum PSA or PSA density. The clinical significance of asymptomatic Category IV chronic prostatitis associated with BPH has yet to be determined.

Serum and semen prostate specific antigen concentrations are different in young spinal cord injured men compared to normal controls

PURPOSE

Recent investigations have indicated that factors within the seminal plasma may contribute to the condition of low sperm motility in men with spinal cord injury. To determine whether the prostate gland functions normally in these men we chose prostate specific antigen (PSA) as a marker of prostatic function, and compared serum and semen concentrations in spinal cord injured and healthy noninjured men.

MATERIALS AND METHODS

The study included 21 spinal cord injured men (mean age 33.3+/-1.2 years) and 22 noninjured normal men (mean age 30.3+/-1.5 years). Blood was obtained from subjects following at least 24 hours of abstinence from ejaculation and serum PSA was determined by modified enzyme immunoassay. Antegrade ejaculates from all subjects were frozen to -80 C, exactly 15 minutes after collection. Seminal plasma PSA was determined using Hybritech Tandem MP assay.

RESULTS

Mean serum PSA concentration was 1.20+/-0.19 ng./ml. in spinal cord injured and 0.69+/-0.07 ng./ml. in noninjured men (p<0.02). Mean seminal plasma PSA concentration was 0.59+/-0.11 mg./ml. in spinal cord injured and 1.29+/-0.15 mg./ml. in noninjured men (p<0.001).

CONCLUSIONS

Our findings of elevated serum and decreased seminal plasma PSA concentrations indicate that prostatic secretory dysfunction is present in men with spinal cord injury.

Mitogenic activation of human prostate-derived fibromuscular stromal cells by bradykinin

Biologically active kinin peptides are released from precursor kininogens by kallikreins. Kinins act on kinin receptors to mediate diverse biological functions including smooth muscle contraction, inflammation, pain and mitogenicity. All components of the kallikrein-kinin system exist in human male genital secretions suggesting that these molecules participate in physiological and pathophysiological genitourinary function. The objective of this study was to assess the consequences of kinin action on prostate cells. Primary cultures of prostate secretory epithelial (PE) and prostate fibromuscular stromal (PS) cells were established from human prostate tissue. Transcripts encoding both the human B1 and B2 bradykinin receptor subtypes were detected in human prostate transition-zone tissue and in cultured cells by RT-PCR. In receptor binding assays, the B1 subtype predominated on PE cell membranes and the B2 subtype predominated on PS cell membranes. In PS cells, but not in PE cells, BK induced significant inositol phosphate accumulation and [3H]-thymidine uptake. These responses were mediated through the B2 receptor subtype. The use of signal transduction inhibitors indicated that mitogenic activation by BK occurred through both protein kinase C (PKC) and protein tyrosine kinase dependent mechanisms. PMA (phorbol 12-myristate 13-acetate) produced maximal [3H]-thymidine uptake by PS cells, resulted in cell elongation and caused the alpha-actin fibres present in PS smooth muscle cells to became organized into parallel arrays along the length of the elongated cells. In summary, the prostate contains a functional kallikrein-kinin system, which could be significant in physiological and pathophysiological prostate function.

Effect of transurethral resection on serum free/total prostate-specific antigen levels in patients with benign prostatic hyperplasia

OBJECTIVES

Transurethral resection of the prostate (TURP) can cause elevation of total serum prostate-specific antigen (PSA). However, the effect of these procedures on free PSA and percent free PSA is still unknown. The aim of this study was to investigate the effect of TURP on serum total PSA, free PSA, and free/total (f/t) PSA ratio in patients with benign prostatic hyperplasia (BPH) and to determine the reliability of f/t PSA ratio after such interventions.

METHODS

Fifty-three patients with BPH who underwent TURP because of severe bladder outlet obstruction symptoms were included in this study. All patients underwent digital rectal examination and transrectal ultrasound (TRUS), and routine hematologic (complete blood count) and serum biochemical tests, urine analysis, and a peak urinary flow test were performed. Serum total PSA and free PSA levels were determined 1 hour before and 24 hours after TURP by using enzyme immunometric assay. Preoperative and postoperative free and total PSA and f/t PSA ratio were statistically compared.

RESULTS

Although postoperative total PSA and free PSA increased significantly compared with preoperative values (P <0.001 and P = 0.024, respectively), the difference between preoperative and postoperative f/t PSA ratios was not statistically significant (P = 0.103).

CONCLUSIONS

Finding no significant change in f/t PSA ratio, although there is a significant increase in the serum levels of total and free PSA, suggests to us that f/t PSA ratio may be a more reliable parameter in the early period after such interventions as TURP.

The association of selected pathological features with prostate cancer in a single-needle biopsy accession

Isolated high-grade prostatic intraepithelial neoplasia (PIN) has been shown to be a positive predictor of prostate cancer (PCa) on follow-up biopsy. However, the incidence of isolated high-grade PIN in needle biopsy specimens has been reported with a highly variable frequency of 1% to 15%. The current study examined the relationship of various pathological features with PCa on a single biopsy accession. A study population of 388 community-based consecutive needle biopsy accessions was prospectively recorded by a single pathologist (T.M.W.). All of the individual biopsy specimens were coded for the presence of PCa, high-grade PIN, low-grade PIN, chronic inflammation (CI), intraluminal prostatic crystalloids (IPC) in benign glands, and mucinous metaplasia (MM). One hundred twenty-nine (33%) of the patients were diagnosed with PCa. The 8% incidence of isolated high-grade PIN was consistent with previous studies. The incidence of other pathological features were as follows: high-grade PIN, 14%; low-grade PIN, 13%; CI, 30%; IPC, 4%; and MM, 8%. Of the patients with high-grade PIN, 47% had PCa on a separate core biopsy, whereas 31% of patients without high-grade PIN were observed to have PCa (P=.021). Of the patients with CI, 21% were found to have PCa on a separate core, whereas 38% of patients without CI were found to have PCa (P=.0009). None of the other pathological features surveyed showed any significant association with PCa. High-grade PIN was a relatively common finding (14%) in this study and was positively associated with PCa on a separate core from the same accession biopsy. The negative association of CP with PCa within the same accession has not been reported previously and may be an artifact related to the clinical indications for a prostatic biopsy.

Characterisation of inflammatory cells in benign prostatic hyperplasia

Inflammation is a common finding in benign prostatic hyperplasia (BPH) and may be classified as acute, chronic active or chronic inactive prostatitis. The aim of the present study was to localise the different types of inflammatory cells in prostatic lesions to determine the sequence of events in the cellular reaction. We have carried out immunohistological characterisation of the inflammatory cells, using CD45RO and CD3 antibodies to detect T-lymphocytes, CD20 antibodies to detect B-lymphocytes, CD68 to detect macrophages, kappa and lambda immunoglobulin light chains, and antibodies against prostate specific antigen (PSA) and prostate specific acid phosphatase (PSAP). Macrophages accumulated in the lumen and glandular epithelial layers of damaged prostatic glands and were found in the periglandular cuff of inflammatory cells in acute and chronic active prostatitis. Lymphocytes also accumulated in large numbers in the glandular epithelial layers and around the glands, indicating an association with macrophages. B-lymphocytes were scanty, if at all present, in acute and chronic active prostatitis, but were prominent within well-organised follicle centres in chronic active prostatitis. Cells positive for light chains were few and scattered in prostatic tissue. PSA and PSAP activity was lost in recently damaged prostatic glandular epithelium and reappeared only in regenerating secretory epithelium, indicating leakage as a result of damage. We suggest that the initial response to prostatic injury is cellular, and probably related to leakage into the periglandular tissues of PSA, PSAP and other antigenic molecules normally present in prostatic secretion. Macrophages respond, followed by recruitment of T-lymphocytes which participate in the inflammatory response and accumulate around the damaged glands. B-cell activity appears to be a late event.

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 microg./l., 0.75 microg./l. and 20.4% in patients with BPH, 10.0 microg./l., 0.84 microg./l. and 8.5% in those with prostate cancer, and 7.60 microg./l., 1.23 microg./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.

Endothelin-1 production and agonist activities in cultured prostate-derived cells: implications for regulation of endothelin bioactivity and bioavailability in prostatic hyperplasia

BACKGROUND

Endothelin-1 (ET-1) interacts with specific G-protein-coupled receptors to initiate short-term (contraction) and long-term (mitogenesis) events in target cells. ET-1 is an abundant prostate secretory protein that, in its biologically active form, elicits prostatic smooth muscle contraction. The present study was designed to determine the effects of ET-1 on prostate cell growth and to examine the regulation of endogenous ET-1 activity and bioavailability.

METHODS

Primary cultures of prostate secretory epithelial (PE) and prostate fibromuscular stromal (PS) cells were established from benign human prostate tissue.

RESULTS

In culture, PE cells secrete immunoreactive ET-1 (38.5 +/- 1.6 pg/ml/10(6) cells/24 hr) into the conditioned medium. Levels of immunoreactive ET-1 produced by PS cells were more than 10-fold lower. Endothelin-converting enzyme-1 (ECE-1) mRNA was detected in PE cells and not in PS cells; however, big ET-1 was the predominant immunoreactive ET-1 secretory product of PE cells. The ET(B) endothelin receptor was the predominant subtype in both PE and PS cells. In PS cells, but not PE cells, ET-1 induced significant inositol phosphate accumulation and [3H]-thymidine uptake. Agonist activity was inhibited by the ET(B) receptor selective antagonist, BQ 788. Intact PE cell monolayers secrete ET-1 through the apical surface, consistent with secretion of ET-1 into the glandular lumen in vivo.

CONCLUSIONS

On the basis of these findings, regulation of ET-1 activity and bioavailability appears to be tightly regulated. Such findings have important implications in the pathophysiology of prostate disease.

Prostate-specific antigen as a screening test for prostate cancer. The United States experience

Serum PSA-based early detection for prostate cancer has been studied fairly extensively for the past several years. It appears that we can state fairly categorically what the relative performances of total serum PSA, DRE, and TRUS are in detecting early-stage prostate cancer; that initial screening is effective in detecting histologically significant and pathologically organ-confined prostate cancer; that annual, serial, repetitive screening, at least over a 4- to 5-year horizon, does not overdetect prostate cancer, and that the results of early detection will improve as our ability to use certain PSA transformations such as PSA density, PSA slope, age-specific PSA adjustment, and knowledge of free versus total serum PSA is better characterized. These advances in our ability to diagnose early-stage prostate cancer likely will be coupled with an increased ability to predict the behavior, curability, and significance of individual tumors. It is hoped that information soon will be available to allow physicians to categorize an individual tumor as insignificant, significant and surgically curable, or significant and incurable by standard approaches. This ability, coupled with the demonstrated ability to detect prostate cancer, will make an even more compelling argument for widespread PSA-based screening. At present, annual DRE and total serum PSA measurements are recommended for men older than 50 and among younger men at high risk for prostate cancer. All suspicious DRE findings should be evaluated with prostatic biopsy. Among younger men, PSA levels over 2.5 ng/mL should be considered worrisome and further evaluated. For men older than 65, serum PSA levels above 4 ng/mL should be considered abnormal and warrant biopsy. Men with persistent serum PSA elevation and a negative biopsy should undergo repeat biopsy at least once, and perhaps more often if PSA slope exceeds 0.75 per year, if density is greater than 0.10, or if f-PSA is less than 20%.

The effect of prostatitis, urinary retention, ejaculation, and ambulation on the serum prostate-specific antigen concentration

PSA remains an immensely valuable tool in the diagnosis of prostate adenocarcinoma. Factors such as prostatitis, urinary retention, ejaculation, and inpatient versus outpatient measurement, however, may have a profound effect on the serum PSA concentration. Furthermore, prostate biopsy and TURP result in an increase in the serum PSA value that resolves in 4 to 6 weeks. It is imperative that these factors be taken into account to interpret serum PSA values, to optimize the diagnostic utility of the PSA test.

Prostatic specific antigen and benign prostatic hyperplasia

The aim of this study on patients (n = 51) with urodynamically proven obstruction was to search for correlations between serological levels of prostatic specific antigen (PSA) and age of patients, volume of prostate and prostatic morphology as evaluated on transurethral resection specimens. No correlations could be found between PSA levels and morphological parameters such as degree of inflammation and relative degree of stromal or epithelial hyperplasia. Significant correlations were demonstrated between PSA levels and age of patients and prostatic volume.

Prostate specific antigen density versus prostate specific antigen slope as predictors of prostate cancer in men with initially negative prostatic biopsies

PURPOSE

We determined if prostate specific antigen (PSA) density and PSA slope alone or in combination could be used to predict which men with persistently elevated serum PSA and prior negative prostate biopsies will have prostate cancer on repeat evaluation.

MATERIALS AND METHODS

In our PSA-1 data base we identified 327 men 50 years old or older with an initially negative prostate biopsy who had persistent PSA elevation, and compared those who did and did not have prostate cancer on subsequent serial prostatic biopsy.

RESULTS

Of 70 men with a PSA density of 0.15 or more and PSA slope of 0.75 ng./ml. or more annually compared to 83 with a PSA density of less than 0.15 and PSA slope of less than 0.75 ng./ml. annually 32 (46%) and only 11 (13%), respectively, had prostate cancer on subsequent prostate biopsies (p < 0.0001). In a hierarchical logistic regression analysis PSA density and PSA slope were predictive of prostate cancer on subsequent biopsy (p = 0.001 and 0.03, respectively). PSA density of 0.15 or more alone or PSA slope of 0.75 ng./ml. or more annually alone as the indicator for repeat biopsy would have missed 35 and 40% of cancers, respectively.

CONCLUSIONS

In men with persistently elevated serum PSA after an initially negative prostate biopsy, PSA density and PSA slope alone or in combination provide useful predictive information about the results of repeat prostate biopsies. However, these parameters are not sufficiently sensitive to identify all patients with detectable prostate cancer.

Benign prostatic hyperplasia with PSA > 10.0 ng/ml: Correlations between PSA density and pathological findings of the surgical specimen after open prostatectomy

— Thirty patients with benign prostatic hyperplasia and PSA levels > 10.0 ng/ml were submitted to open prostatectomy after a precise evaluation with transrectal ultrasound and prostatic biopsies. In the surgical specimen 7 prostatic carcinoma (23%) were found incidentally. In the remaining 23 patients the presence of active histological prostatitis was correlated with the PSA and PSA density values but was not directly due to an asymptomatic urinary infection or indwelling catheter. PIN and other pathological findings were not found to be correlated with PSA values.