Screening with low PSA cutoff values results in low rates of positive surgical margins in radical prostatectomy specimens

Investigation on core-fucosylated prostate-specific antigen as a refined biomarker for differentiation of benign prostate hyperplasia and prostate cancer of different aggressiveness

Prostate cancer represents a major cause of cancer death in men worldwide. Novel non-invasive methods are still required for differentiation of non-aggressive from aggressive tumors. Recently, changes in prostate-specific antigen glycosylation pattern, such as core-fucosylation, have been described in prostate cancer. The objective of this study was to evaluate whether the core-fucosylation determinant of serum prostate-specific antigen may serve as refined marker for differentiation between benign prostate hyperplasia and prostate cancer or identification of aggressive prostate cancer. A previously developed liquid chromatography-mass spectrometry/mass spectrometry-based strategy was used for multiplex analysis of core-fucosylated prostate-specific antigen (fuc-PSA) and total prostate-specific antigen levels in sera from 50 benign prostate hyperplasia and 100 prostate cancer patients of different aggressiveness (Gleason scores, 5-10) covering the critical gray area (2-10 ng/mL). For identification of aggressive prostate cancer, the ratio of fuc-PSA to total prostate-specific antigen (%-fuc-PSA) yielded a 5%-8% increase in the area under the curve (0.60) compared to the currently used total prostate-specific antigen (area under the curve = 0.52) and %-free prostate-specific antigen (area under the curve = 0.55) tests. However, our data showed that aggressive prostate cancer (Gleason score > 6) and non-aggressive prostate cancer (Gleason score ≤ 6) could not significantly (p-value = 0.08) be differentiated by usage of %-fuc-PSA. In addition, both non-standardized fuc-PSA and standardized %-fuc-PSA had no diagnostic value for differentiation of benign prostate hyperplasia from prostate cancer. The %-fuc-PSA serum levels could not improve the differentiation of non-aggressive and aggressive prostate cancer compared to conventional diagnostic prostate cancer markers. Still, it is unclear whether these limitations come from the biomarker, the used patient cohort, or the imprecision of the applied method itself. Therefore, %-fuc-PSA should be further investigated, especially by more precise methods whether it could be clinically used in prostate cancer diagnosis.

Disease-specific outcomes of radical prostatectomies in Northern Norway; a case for the impact of perineural infiltration and postoperative PSA-doubling time

Background

Prostate cancer is the most common male malignancy and a mayor cause of mortality in the western world. The impact of clinicopathological variables on disease related outcomes have mainly been reported from a few large US series, most of them not reporting on perineural infiltration. We therefore wanted to investigate relevant cancer outcomes in patients undergoing radical prostatectomy in two Norwegian health regions with an emphasis on the impact of perineural infiltration (PNI) and prostate specific antigen- doubling time (PSA-DT).

Methods

We conducted a retrospective analysis of 535 prostatectomy patients at three hospitals between 1995 and 2005 estimating biochemical failure- (BFFS), clinical failure- (CFFS) and prostate cancer death-free survival (PCDFS) with the Kaplan-Meier method. We investigated clinicopathological factors influencing risk of events using cox proportional hazard regression.

Results

After a median follow-up of 89 months, 170 patients (32%) experienced biochemical failure (BF), 36 (7%) experienced clinical failure and 15 (3%) had died of prostate cancer. pT-Stage (p = 0.001), preoperative PSA (p = 0.047), Gleason Score (p = 0.032), non-apical positive surgical margins (PSM) (p = 0.003) and apical PSM (p = 0.031) were all independently associated to BFFS. Gleason score (p = 0.019), PNI (p = 0.012) and non-apical PSM (p = 0.002) were all independently associated to CFFS while only PNI (P = 0.047) and subgroups of Gleason score were independently associated to PCDFS. After BF, patients with a shorter PSA-DT had independent and significant worse event-free survivals than patients with PSA-DT > 15 months (PSA-DT = 3-9 months, CFFS HR = 6.44, p < 0.001, PCDFS HR = 13.7, p = 0.020; PSA-DT < 3 months, CFFS HR = 11.2, p < 0.001, PCDFS HR = 27.5, p = 0.006).

Conclusions

After prostatectomy, CFFS and PCDFS are variable, but both are strongly associated to Gleason score and PNI. In patients with BF, PSA-DT was most strongly associated to CF and PCD. Our study adds weight to the importance of PSA-DT and re-launches PNI as a strong prognosticator for clinically relevant endpoints.

Tumor markers in prostate cancer I: blood-based markers

The introduction of total prostate specific antigen (total PSA) testing in blood has revolutionized the detection and management of men with prostate cancer (PCa). The objective of this review was to discuss the challenges of PCa biomarker research, definition of the type of PCa biomarkers, the statistical considerations for biomarker discovery and validation, and to review the literature regarding total PSA velocity and novel blood-based biomarkers.

METHODS

An English-language literature review of the Medline database (1990 to August 2010) of published data on blood-based biomarkers and PCa was undertaken.

RESULTS

The inherent biological variability of total PSA levels affects the interpretation of any single result. Men who will eventually develop PCa have increased total PSA levels years or decades before the cancer is diagnosed. Total PSA velocity improves predictiveness of total PSA only marginally, limiting its value for PCa screening and prognostication. The combination of PSA molecular forms and other biomarkers improve PCa detection substantially. Several novel blood-based biomarkers such as human glandular kallikrein 2 (hK2), urokinase plasminogen activator (uPA) and its receptor (uPAR), transforming growth factor-beta 1 (TGF-β1); interleukin-6 (IL-6) and its receptor (IL-6R) may help PCa diagnosis, staging, prognostication, and monitoring. Panels of biomarkers that capture the biologic potential of PCa are in the process of being validated for PCa prognostication.

CONCLUSIONS

PSA is a strong prognostic marker for long-term risk of clinically relevant cancer. However, there is a need for novel biomarkers that aid clinical decision making about biopsy and initial treatment. There is no doubt that progress will continue based on the integrated collaboration of researchers, clinicians and biomedical firms.

Predictive Factors for Prostate Cancer in Biopsy of Patients with Prostate-Specific Antigen Levels Equal to or Less Than 4 ng/ml

PURPOSE

This study was conducted to identify the predictive factors for prostate cancer in patients with prostate-specific antigen (PSA) levels equal to or less than 4 ng/ml.

MATERIALS AND METHODS

A retrospective study of medical records was conducted on 292 patients with initial serum PSA ≤4 ng/ml among 2,305 patients who underwent prostate biopsy from January 2003 to December 2008. Prostate biopsy was performed on patients with PSA ≤4 ng/ml in the case of abnormal findings in the digital rectal examination (DRE) or transrectal ultrasonography (TRUS) or in those with a PSA level higher than the age-adjusted PSA levels. The patients were divided into the group diagnosed with prostate cancer and the non-prostate-cancer group. Subsequently, the variables of the two groups were compared.

RESULTS

The patients' mean age was significantly higher in the prostate cancer group (n=28) than in the non-prostate-cancer group (n=264; p=0.033). In addition, for the patients with a PSA range of 2.0-2.9 ng/ml, their age (p=0.049) and PSA density (PSAD; p=0.042) were significantly higher and the prostate volume (p=0.028) was significantly smaller in the prostate cancer group than in the non-prostate-cancer group.

CONCLUSIONS

Of the patients with PSA ≤4 ng/ml, the age of the patients who showed abnormal findings in the DRE or TRUS or who had a PSA level higher than the age-adjusted PSA level was a significant predictive factor for prostate cancer. In particular, for the PSA range of 2.0-2.9 ng/ml, a thorough screening test for prostate cancer was required if the patients had conditions such as higher age, smaller prostate, and higher PSAD.

Site of positive surgical margins influences biochemical recurrence after radical prostatectomy

OBJECTIVE

To determine whether the number and location of positive surgical margins (PSMs) in radical prostatectomy (RP) surgical specimens affect biochemical recurrence (BCR) rates.

PATIENTS AND METHODS

The locations of PSMs were recorded for 1308 consecutive men who underwent RP between October 2000 and December 2006. BCR was defined as three consecutive prostate-specific antigen (PSA) level rises with the peak level >or=0.15 ng/mL. Multivariate regression analyses were used to identify preoperative predictors of PSMs and BCR. The estimated 5-year risk of BCR was calculated using the Kaplan-Meier method.

RESULTS

In all, 128 (9.8%) men had one or more PSMs. The mean body mass index, mean preoperative serum PSA level, the distributions of clinical stage and biopsy Gleason scores, and the presence or absence of biopsy perineural invasion were significantly different between men with or with no PSMs. In multivariate analysis, baseline serum PSA level, Gleason score and perineural invasion were independent preoperative predictors of PSMs. The 5-year actuarial BCR rates were dependent on the site of the PSM (P = 0.035) and not the number of PSMs (P = 0.18). The rank order of estimated 5-year BCR rates according to the site of PSMs were base > anterior > posterolateral > apex approximately posterior.

CONCLUSIONS

About half of the men with PSMs in the RP surgical specimen in our prospective series did not develop BCR. The risk of BCR was dependent on the site and not the number of PSMs. Adjuvant therapy should be considered in cases with anterior and basilar PSMs due to the very high risk of BCR.

Do Tumor Volume, Tumor Volume Ratio, Type of Nerve Sparing and Surgical Experience Affect Prostate Specific Antigen Recurrence After Laparoscopic Radical Prostatectomy? A Matched Pair Analysis

PURPOSE

We assessed the impact of tumor volume, tumor volume ratio (tumor volume-to-prostate volume), surgical experience and type of nerve sparing procedure on biochemical recurrence after laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Of 1,600 laparoscopic radical prostatectomies performed between March 1999 and May 2006 we evaluated 555 patients who had at least 24 months of followup and received neither neoadjuvant nor adjuvant therapy. Of 555 patients 81 had biochemical recurrence and were match paired in 3 groups with those without recurrence. Matching decisions were based on factors such as age, preoperative prostate specific antigen, pathological stage, Gleason score, surgical margin status with localization, tumor volume, type of nerve sparing procedure, surgeon and date of operation that are related to surgical experience. We evaluated the impact of tumor volume and tumor volume ratio, type of nerve sparing procedure and surgeon on biochemical recurrence, and excluded the factor being investigated in each matched pair.

RESULTS

Tumor volumes were 3.58 vs 3.3 cc and tumor volume ratios were 0.081 vs 0.071 in the biochemical recurrence and no biochemical recurrence groups, respectively (p=0.026 and p=0.040). At the second match pair the numbers of nonnerve sparing, unilateral and bilateral nerve sparing procedures were 65, 12 and 4 vs 62, 13 and 6, respectively, without statistical significance. At the last match pair the volume of cases for the first generation and the other generations were 56 and 25 vs 59 and 22, respectively, also without statistical significance.

CONCLUSIONS

Although surgical experience based on an adequate training program and type of nerve sparing procedure do not have a significant impact on biochemical recurrence, tumor volume and tumor volume ratio do.

Pathologic outcome of laparoscopic and open radical prostatectomy

OBJECTIVES

To compare the clinicopathologic data of 286 laparoscopic radical prostatectomies (LRPs) and 714 open radical prostatectomies (RRPs) performed at the Massachusetts General Hospital from 2001 to 2005.

METHODS

A total of 1000 radical prostatectomy procedures were analyzed for prostate weight, pathologic stage, Gleason score, surgical margin status, and positive margin location.

RESULTS

The mean patient age was 58.6 and 59.1 years for the LRP and RRP groups, respectively. The mean preoperative prostate-specific antigen level was 5.96 and 6.00 ng/mL, respectively. Clinical Stage T1c cancer was seen in 86.4% of the LRP and 90.5% of the RRP patients. Gleason score 7 or less disease was seen on biopsy in 97.5% of the LRP and 96.9% of the RRP patients. The average prostate weight was 46.8 g for LRP and 46.0 g for RRP. In the radical prostatectomy specimens, 94.4% of LRP and 93.3% of RRP patients had Gleason score 7 or less disease and 86.0% of LRP and 81.7% of RRP patients had pathologic Stage pT2 cancer. The rate of positive surgical margins was 15.0% and 17.4% for the LRP and RRP groups, respectively. The positive margins occurred mainly at the peripheral and apical regions in both groups. No significant difference was found in the preoperative variables or final pathologic findings between the two surgical groups.

CONCLUSIONS

With similar case selection, LRP and RRP achieve similar pathologic outcomes.

Pathological outcomes and biochemical progression in men with T1c prostate cancer undergoing radical prostatectomy with prostate specific antigen 2.6 to 4.0 vs 4.1 to 6.0 ng/ml

PURPOSE

Recent studies have suggested that the cut point for recommending prostate biopsy among men with a normal digital rectal examination should be greater than 2.5 ng/ml as opposed to the more traditional greater than 4.0 ng/ml. We compared outcomes between men with clinical stage T1c disease undergoing radical prostatectomy who had a low vs slightly increased prostate specific antigen.

MATERIALS AND METHODS

The study population consisted of 2,896 men treated with radical prostatectomy between 1985 and 2004 at a tertiary care referral center with clinical stage T1c disease and a pre-biopsy prostate specific antigen between 2.6 and 6.0 ng/ml. Using multivariate analysis we evaluated the association between pre-biopsy prostate specific antigen 2.6 to 4.0 ng/ml (784) vs 4.1 to 6.0 ng/ml (2,112), and pathological outcomes and biochemical progression.

RESULTS

After adjusting for multiple clinical and pathological characteristics, lower preoperative serum prostate specific antigen values were associated with decreased odds of Gleason score 7 or greater in the surgical specimen (p = 0.004), positive surgical margins (p = 0.02) and extraprostatic extension (p = 0.001). There was no significant association between these preoperative prostate specific antigen groups and odds of seminal vesicle invasion (p = 0.47) or lymph node metastasis (p = 0.90). Among the 1,534 men with followup information available there was a trend for increased risk of biochemical progression associated with a higher preoperative prostate specific antigen, although this trend did not reach statistical significance (relative risk 1.48, 95% CI 0.69-3.19, p = 0.31).

CONCLUSIONS

In the current study of men with clinical stage T1c treated with radical prostatectomy a lower preoperative prostate specific antigen was associated with significantly more favorable pathological findings. Whether this degree of improved outcomes justifies the limitations associated with decreasing the prostate specific antigen cut point (eg increased biopsies performed and diagnosis of insignificant cancers) remains to be determined.

Prostate cancer detection among men with prostate specific antigen levels of 2.5 to 4.0 ng/ml in a Japanese urological referral population

PURPOSE

Prostate cancer detection at levels of 2.5 to 4.0 ng/ml in a Japanese urological referral population has not been elucidated. The purpose of this study is to investigate the cancer detection rate and clinical relevance of prostate cancer in this PSA range.

MATERIALS AND METHODS

All urological patients 70 years or younger tested for prostate cancer were studied. There were 550, 97, 112 and 52 patients with a PSA of less than 2.5, 2.5 to 4.0, 4.1 to 10.0 and more than 10.0 ng/ml, respectively. Transrectal 10-core prostate biopsy was performed in 80 (82%) of the 97 patients with a PSA of 2.5 to 4.0 ng/ml and 102 (91%) of the 112 patients with a PSA of 4.1 to 10.0 ng/ml.

RESULTS

Cancer detection rates in patients who underwent biopsy were 26.3% and 34.3% at PSA levels 2.5 to 4.0 and 4.1 to 10.0 ng/ml, respectively. High grade cancers with Gleason score 7 or more were found in 19.0% and 22.9% of patients with cancer with PSA 2.5 to 4.0 and 4.1 to 10.0 ng/ml, respectively. No significant difference was found between the 2 groups in pathological findings on biopsy, including percent positive cores (16.7% vs 20.0%, p = 0.10), maximum cancer length (25.0% vs 30.0%, p = 0.28) and maximum percent cancer length (2.0 vs 3.0 mm, p = 0.17).

CONCLUSIONS

Japanese urological referral patients develop prostate cancer quite commonly even if their serum PSA levels are 2.5 to 4.0 ng/ml. Since these cancer cases include high grade, clinically significant cancer, prostate biopsy might be considered at least for selected cases in this PSA range.

[Prognostic implications of positive margins in radical prostatectomy specimens]

To evaluate the histopathologic implication of positive margins of prostatectomy specimens in the biochemical recurrence.

MATERIAL AND METHODS

The study group consisted of 290 patients with clinically localized prostate cancer who were treated by radical retropubic prostatectomy. Patients with neoadjuvant hormonal therapy and positive lymph nodes were excluded. The mean age at the time of surgery was 63 years (range 47-73); 166 (57.2%) patients were T1c and 124 (42.8%) T2; the average time of folow-up was of 4 years (range 1-12). Positive surgical margins were defined as the presence of cancer cells at the surface inked of prostatectomy specimens. They were classified as: Margin for capsular incision (without extraprostatic extension evidence)/ margin for extraprostatic extension, margin with smooth rounded surface/margin with irregular surface, margin < or = 4 mm/margin > 4 mm, unifocal margin/multifocal margin. We define biochemical recurrence if the PSA exceeds 0.20 ng/ml in two consecutive determinations.

RESULTS

The overall rate of positive margins was 65/290 (22.4%). The 5-year survival free of biochemical recurrence was as follows: Negative margins 71% vs positive margins 44% (p < 0.001); positive margins for capsular incision 84% vs positive margins for extraprostatic extension 33% (p < 0.01); positive margins with smooth rounded surface 58% vs positive margins with irregular surface 26% (p < 0.01); positive margins < or = 4 mm 57% vs positive margins > 4 mm 32% (p < 0.05); unifocal margins 53% vs multifocal margins 0% (p < 0.01). The multivariate analysis revealed that preoperative PSA, Gleason score and pathological classification were the best predictors of biochemical recurrence.

CONCLUSIONS

Two groups are established of positive margin. The first group with high probability of biochemical recurrence: margin for extraprostatic. The second group with less probability of biochemical recurrence: margin for capsular incision, margin with smooth rounded surface, margin < or = 4 mm and unifocal margin.

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

OBJECTIVE

To examine whether prostate-specific antigen (PSA) levels adjusted according to prostate volume improve prostate cancer detection using transrected biopsies in men with PSA levels of 2-4 ng/mL, and benign findings on a digital rectal examination (DRE).

PATIENTS AND METHODS

Men aged < or = 79 years and with serum PSA levels of 2-4 ng/mL and normal DRE findings were prospectively enrolled. Eligible patients were recommended for transrectal prostate biopsies after measuring prostate volumes with transrectal (TRUS) and transabdominal (TAUS) ultrasonography, and transition zone volumes with TRUS. In addition to PSA levels and the free-to-total PSA ratio, volume-adjusted PSA levels, PSA densities determined by TRUS (PSAD(TRUS)), and TAUS (PSAD(TAUS)), and PSA transition zone densities (PSATzD) were compared using receiver operating characteristic analysis.

RESULTS

Prostate cancer was diagnosed in 31 (22%) of the 139 men who had prostate biopsies. The area under the curve (AUC) of PSAD(TRUS) (0.796) and PSATzD (0.792) was similar and significantly greater than that of PSA (AUC 0.588) and the free-to-total PSA ratio (AUC 0.658). PSAD(TAUS) was a significantly better indicator of prostate cancer than PSA levels alone (P = 0.043).

CONCLUSION

As predictors of prostate cancer, there were no significant differences between PSAD(TRUS) and PSATzD. Although PSAD(TAUS) was worse than PSA variables adjusted by total and transition zone prostate volumes determined by TRUS, it was a better predictor than the PSA value alone in men with a low PSA level. These results indicate that TAUS is worthwhile where the routine use of TRUS before biopsy is difficult.

Preoperative PSA and progression-free survival after radical prostatectomy for Stage T1c disease

OBJECTIVES

To examine biochemical progression-free survival (PFS) rates as a function of preoperative prostate-specific antigen (PSA) in patients with clinical Stage T1c prostate cancer treated with radical prostatectomy. Controversy exists about whether performing prostate biopsies for PSA levels in the 2.6 to 4.0 ng/mL range provides a PFS advantage compared with detection at higher PSA ranges.

METHODS

A total of 2804 men with clinical Stage T1c prostate cancer were treated with radical retropubic prostatectomy and monitored prospectively. The study parameters included preoperative PSA level, pathologic tumor stage, and Gleason grade. Patients were grouped into four clinically relevant strata according to their preoperative PSA level: 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10 ng/mL. The primary outcome was the 10-year actuarial biochemical PFS estimate generated using the Kaplan-Meier method. We compared the strata using the log-rank test. Cancer progression rates were compared using the Cochran Armitage test for trend. The chi-square test was used to compare the pathologic parameters among the PSA strata.

RESULTS

Of the men with a preoperative PSA level of 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10.0 ng/mL, 81%, 74%, 72%, and 60%, respectively, had organ-confined disease (P = 0.001) and 23%, 28%, 35%, and 47%, respectively, had a pathologic Gleason grade of 7 or greater (P = 0.001). The corresponding 10-year PFS estimates were 88%, 80%, 76%, and 61% (P = 0.0001, for trend).

CONCLUSIONS

Among men with clinical Stage T1c prostate cancer, those with a PSA level of 2.6 to 4.0 ng/mL had the greatest rate of organ-confined disease, lowest pathologic Gleason grade, and greatest 10-year PFS rate.

Prostate-specific antigen (PSA) complexed to alpha1-antichymotrypsin improves prostate cancer detection using total PSA in Japanese patients with total PSA levels of 2.0-4.0 ng/mL

OBJECTIVE

To assess the utility of prostate-specific antigen (PSA) complexed to alpha1-antichymotrypsin (PSA-ACT) in prostate cancer screening in Japanese men with a total PSA level of 2.0-4.0 ng/mL, as improving cancer detection in men with these total PSA levels is a challenge for clinical urologists.

PATIENTS AND METHODS

Total PSA and PSA-ACT were prospectively assessed and prostate biopsy recommended for patients who met either of two thresholds, i.e. a total PSA of > or = 2.0 ng/mL or a PSA-ACT of > or= 1.5 ng/mL. The diagnostic ability of total PSA and PSA-ACT, and free-to-total PSA ratio and prostate volume-adjusted density were evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

Of 1003 men enrolled, 547 met the biopsy criteria and a biopsy was taken in 315 (57.6%) patients. The area under the ROC curve for PSA-ACT (0.679) was significantly greater than that for total PSA (0.601, P = 0.04) and equivalent to that for the free-to-total ratio (0.686, P = 0.911) in 116 men, including 27 with cancer with total PSA levels of 2.0-4.0 ng/mL. PSA-ACT was more specific than the free-to-total ratio at a sensitivity of 95% (36% vs 18%, P < 0.05). The best variable for discriminating between cancer and benign disease in men with PSA levels of 2.0-4.0 ng/mL was PSA-ACT density (area under the curve 0.852) which provided 66% specificity at a sensitivity of 90%.

CONCLUSIONS

PSA-ACT is better than total PSA and equivalent to the free-to-total ratio for detecting prostate cancer in men with PSA levels of 2.0-4.0 ng/mL, and is thus useful for reducing the number of unnecessary biopsies.

Case Selection for Radical Prostatectomy in the UK

INTRODUCTION

Radical prostatectomy is an increasingly popular treatment option for clinically localised prostate cancer, yet PSA outcome figures are rare in the UK. This makes it difficult to establish appropriate criteria for case selection. We conducted an audit of PSA recurrence of 5 large centres in the south of England and investigated the use of pre-operative PSA to improve case selection and outcome.

METHOD

854 patients notes were audited for pre-operative staging parameters and follow-up data obtained. Patients with neoadjuvant and adjuvant treatment as well as patients with incomplete data and follow-up were excluded.

RESULT

Median follow-up was 52 months for the remaining 663 patients. Median PSA was 10 ng/ml. A large improvement of PSA recurrence free survival rates was observed from 1988 to 1998 as a result of change in case selection and stage migration. Overall Kaplan-Meier PSA recurrence free survival probability at 1, 3, 5 and 8 years was 0.83, 0.69, 0.60 and 0.48, respectively. Five-year PSA recurrence free survival probability for PSA ranges <4 ng/ml, 4.1-10 ng/ml, 10.1-20 ng/ml and >20 ng/ml was 0.82, 0.73, 0.59 and 0.20, respectively (Wilcoxon, p < 0.0001). A simulation of biochemical recurrence free survival for patient cohorts with stepwise reduced inclusion PSAs suggests an improved outcome for patients with a pre-operative inclusion PSA of <12 ng/ml. Further reduction of the inclusion PSA does not improve outcome.

CONCLUSION

Intermediate PSA recurrence free survival has improved over time in England. PSA recurrence free survival estimates are less optimistic compared to frequently quoted American figures. A reduced pre-operative PSA cut-off for case selection may be used to improve outcome.

Detection of prostate cancer in men with prostate-specific antigen levels of 2.0 to 4.0 ng/mL equivalent to that in men with 4.1 to 10.0 ng/mL in a Japanese population

OBJECTIVES

To analyze prospectively whether prostate cancer (CaP) incidence differs between Japanese men with a prostate-specific antigen (PSA) level of 2.0 to 4.0 ng/mL and those with a PSA level of 4.1 to 10.0 ng/mL.

METHODS

Men 79 years old or younger who were referred to our clinic were screened for CaP. Individuals with PSA levels of 2.0 ng/mL or greater were recommended for transrectal prostate biopsy. The prebiopsy clinical characteristics, cancer detection rate, and pathologic findings from the needle biopsy and prostatectomy specimen were compared between the low (2.0 to 4.0 ng/mL) and intermediate (4.1 to 10.0 ng/mL) PSA groups.

RESULTS

Of 858 patients screened for CaP, 440 with benign findings on digital rectal examination met the criteria, and 274 (62.3%) underwent biopsy. Of those undergoing biopsy, 110 and 123 patients had a low or an intermediate PSA level, respectively. Men in the low PSA group had a higher free/total PSA ratio, smaller prostate volume, and lower PSA density compared with those in the intermediate PSA group. CaP was diagnosed in 26 (23.6%) of 110 in the low and 29 (23.6%) of 123 in the intermediate PSA group. No statistically significant difference was found between the two groups in the pathologic findings of needle biopsy, including Gleason score, number of cores per biopsy, percentage of positive cores, and cancer length in the positive cores.

CONCLUSIONS

No statistically significant difference was found in the incidence of CaP (23.6%) between men with low and intermediate PSA levels in a Japanese population. The diagnostic yield was comparable to that reported for both white and black men.

Serum pro-prostate specific antigen preferentially detects aggressive prostate cancers in men with 2 to 4 ng/ml prostate specific antigen

PURPOSE

Pro forms of prostate specific antigen (PSA) have been reported to be more cancer specific markers of prostate cancer than total PSA and they also may preferentially detect the more aggressive forms of the disease.

MATERIALS AND METHODS

Research immunoassays with high specificity for pro-PSA forms were used to study 1091 retrospective serum specimens, including 555 with 2 to 4 and 536 with 4 to 10 ng/ml PSA, from men enrolled in prostate cancer screening studies who underwent prostate biopsy.

RESULTS

In the 2 to 4 ng/ml PSA range the ratio of pro- to free-PSA (percent pro-PSA) using a cutoff of 1.8% for recommending prostate biopsy detected 90% of cancers, including 16 of 16 extracapsular tumors and 28 of 29 tumors with a pathology Gleason score of 7 or greater, while avoiding 19% of unnecessary biopsies. Serum percent pro-PSA was significantly increased for Gleason score 7 or greater vs less than 7 (p = 0.0018). In the PSA range of 4 to 10 ng/ml percent pro-PSA had the highest cancer specificity, avoiding 31% of unnecessary biopsies, while detecting 34 of 35 cancers with a pathology Gleason score of 7 or greater and 29 of 31 extracapsular tumors. Neither percent free PSA nor complexed PSA enhanced the detection of aggressive cancers in the 4 to 10 ng/ml PSA range.

CONCLUSIONS

Percent pro-PSA was superior to percent free and calculated complexed PSA for the detection of prostate cancer in the PSA range of 2 to 10 ng/ml and it had selectivity for detecting more aggressive cancers, as indicated by Gleason score 7 or greater and/or extracapsular tumor extension.

An evaluation of the decreasing incidence of positive surgical margins in a large retropubic prostatectomy series

PURPOSE

Positive surgical margins adversely affect biochemical recurrence-free survival after radical retropubic prostatectomy (RRP) for prostate cancer. We retrospectively reviewed a large series of men who underwent RRP at a single academic university urology program to define the change in the incidence of organ confined (OC) disease and positive surgical margin (SM+) during the last 2 decades.

MATERIALS AND METHODS

Between 1982 and 2001, 9,035 men underwent RRP for clinically localized prostate cancer (T1 to T3a) at a single institution. We compared the incidences of OC disease and SM+ in this population.

RESULTS

An increasing proportion of men presented with OC disease over time. The incidence of SM+ in the overall RRP population decreased dramatically over time. However, in men with nonorgan confined disease (pT3), the proportion with SM+ was stable and consistently elevated (22.7% to 27.8%), after the initial decrease from the early 1980s (53%).

CONCLUSIONS

Widespread early detection programs for prostate cancer resulted in a downward stage migration in men presenting with clinically localized prostate cancer at our institution during the last 2 decades. The decrease in the percentage of men with SM+ was due to the increasing number of men with organ confined disease. These results imply that the decrease in surgical margin rates in the overall RRP population is most likely due to stage migration and improved patient selection, rather than major improvements in surgical technique. The stable percentage of SM+ among men with pT3 disease dictates the need for continued evaluation of surgical technique and the need for effective adjuvant therapy.

Biochemical outcome after radical prostatectomy among men with normal preoperative serum prostate-specific antigen levels

BACKGROUND

Recent studies have shown that a significant number of men with normal prostate-specific antigen (PSA) levels have prostate carcinoma. Whether malignancies in such men are associated with better outcomes is unclear. The authors compared the risk of biochemical failure after radical prostatectomy (RP) between men with normal PSA levels and men with elevated PSA levels.

METHODS

Data were examined from 1582 men who underwent RP between 1988 and 2002 at 1 of 5 equal-access medical centers. Patients were segregated into groups based on serum PSA levels (with stratification according to age-specific reference ranges). Clinical and pathologic characteristics and biochemical outcome data were compared across groups using analyses of variance, log-rank tests, and Cox proportional hazards analysis.

RESULTS

Men who had normal PSA levels had significantly fewer high-grade tumors compared with men who had higher PSA levels (P < 0.001). The former group had a significantly decreased incidence of positive surgical margins, extracapsular disease, seminal vesicle invasion, and lymph node involvement (P < 0.001). On multivariate analysis, only serum PSA level (P < 0.001) and biopsy Gleason score (P < 0.001) predicted the time to disease recurrence. When only men with serum PSA levels < 10 ng/mL were examined, PSA level treated as a continuous variable remained a significant predictor of time to biochemical failure (P = 0.02).

CONCLUSIONS

Men who had normal PSA levels had significantly fewer high-grade tumors and significantly better biochemical outcomes after undergoing RP compared with men who had elevated PSA levels. Overall, men with normal PSA levels who undergo RP represent a favorable risk group.

Prostate cancer: radical prostatectomy

Today, more men than ever before are being followed after radical prostatectomy. Prognosis and follow-up should be based on the pathologic specimen. Measurable prostate-specific antigen (PSA) after surgery defines failure, with time to detectable PSA and rate of PSA rise being useful prognostic factors. The natural history of untreated biochemical failure is protracted, a fact to be considered in discussions of adjuvant treatment. Early in disease recurrence, imaging studies to locate residual disease rarely are useful clinically. Both adjuvant and salvage radiation to the prostate bed have benefits and risks, but neither is superior in overall prostate cancer survival. The timing of hormone therapy remains largely empiric. The promise of effective cytotoxic chemotherapy still is greater than its actual benefits, although novel cytostatic agents are being developed. The future management of this disease will improve with better molecular definition of risk and therapeutic response.