A new algorithm in patients with elevated and/or rising prostate-specific antigen level, minor lower urinary tract symptoms, and negative multisite prostate biopsies

Outcome of Patients With Elevated Prostate-Specific Antigen and Lower Urinary Tract Symptoms Receiving Holmium Laser Enucleation of the Prostate

Purpose

This study investigated functional outcomes in lower urinary tract symptoms (LUTS), the incidence of incidental prostate cancer (PCa), and changes in prostate-specific antigen (PSA) levels after holmium laser enucleation of the prostate (HoLEP) in patients with elevated PSA and benign prostatic hyperplasia (BPH).

Methods

A retrospective review of a prospectively designed protocol for patients who underwent HoLEP at our institution from January 2010 to May 2020 was conducted. Patients were classified into low-PSA (<3.0 ng/mL) and high-PSA (≥3.0 ng/mL) groups at baseline. Follow-up for PSA was performed at the sixth postoperative month. Baseline and postoperative clinical parameters, functional parameters, PCa incidence, and postoperative changes in PSA were compared between the low- and high-PSA groups.

Results

The baseline PSA of 1,296 patients (mean age, 69.7±6.8 years) was 4.0±4.1 ng/mL, with 712 patients (55.0%) in the low-PSA group (1.6±0.8 ng/mL), and 584 patients (45.0%) in the high-PSA group (6.9±4.7 ng/mL). Incidental PCa was detected in 82 patients (6.3%), with a similar incidence in the low-PSA (41 patients, 5.9%) and high-PSA (41 patients, 7.0%) groups (P>0.05). At 6 months postoperatively, both groups showed significant improvements in the maximum flow rate, postvoid residual volume, and all domains of the International Prostate Symptom Score (P<0.05). At postoperative 6 months, the PSA level significantly decreased by 66.6%±23.6% in all patients (54.3%±23.9% in the low-PSA group; 79.6%±14.7% in the high-PSA group) (P<0.05), and the PSA levels of 1,264 patients (97.6%) had normalized.

Conclusions

In patients with elevated PSA presenting with LUTS/BPH, our study demonstrated significant improvements in functional parameters and decreased PSA after HoLEP. The incidental PCa detection rate did not show a statistically significant difference between the low- and high-PSA groups. Timely surgery for LUTS/BPH without delay due to PSA monitoring should be considered.

Role of Hiraoka's transurethral detachment of the prostate combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of prostate cancer

BACKGROUND

Persistent suspicion of prostate cancer (PCa) due to a rising prostate-specific antigen (PSA) level after repeated negative biopsies is a serious challenge in clinical practice.

AIM

To determine the role of Hiraoka’s transurethral detachment of the prostate (TUDP) combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of PCa.

METHODS

We retrospectively evaluated the records of 10 patients who were eligible for inclusion in our hospital between December 2012 and August 2017. Patient demographics, a family history of PCa, the number of biopsies, prostate volume, pathological examination, and perioperative PSA level were obtained.

RESULTS

Two of 10 patients were pathologically diagnosed with PCa after surgery; the Gleason scores were 4 + 4 and 4 + 3, respectively. Both patients subsequently underwent laparoscopic radical prostatectomy. The median PSA levels preoperatively, and 3 mo and 1 year postoperatively in the other eight patients who were diagnosed with benign prostate hyperplasia after surgery were 19.10 ng/mL, 1.10 ng/mL, and 1.15 ng/mL, respectively. The adjusted P values of the 3-mo and 1-year post-operative PSA level vs pre-operative PSA level were 0.003 and 0.026, respectively. None of the patients had increased PSA levels or PCa detected after a median 35 mo of follow-up.

CONCLUSION

TUDP combined with peripheral zone biopsy may improve the detection rate of PCa in patients with repeated negative biopsies. The PSA level declined rapidly in patients who had negative pathological examinations after TUDP, which remained stable 1 year after surgery.

Incidental prostate cancer: a 10-year review of a tertiary center, Tehran, Iran

Objective

Incidental prostate cancer (IPCa) is defined as a symptom-free cancer unexpectedly discovered upon microscopic examination of resected tissue. The aim of this study was to report the correlation between some specific clinical criteria in patients incidentally diagnosed with prostate cancer (PCa) during transurethral resection of the prostate (TURP) or open prostatectomy (OP) after clinically suspected benign prostatic hyperplasia.

Patients and methods

This was a cross-sectional, retrospective study. Data were collected from Shohada-e-Tajrish Hospital database during November 2006 to October 2016. Four hundred and twenty three men suffering from symptomatic benign prostatic hyperplasia who underwent either TURP or OP that provided a prostate specimen were evaluated. The data analysis was performed using Pearson correlation test and independent t-test using SPSS version 20 software.

Results

The mean age of subjects was 68.74±9.87 years old (45-93 years). The mean prostate specific antigen (PSA) level was 21.47±13.44 ng/mL (0.6-47.1 ng/mL). Results showed that 84 patients (19.9%) had PCa (40 patients who underwent TURP [12.6%] and 44 patients who underwent OP [40.7%] groups). Cut-off point of PSA for detecting IPCa was 3.8 ng/mL in our study, and this showed sensitivity, specificity, negative predictive value, and positive predictive value of 26.08%, 100%, 100%, and 29.79%, respectively. Twenty two patients with cancer had a positive family history for PCa; thus, a significant relationship between familial history of PCa and its occurrence was shown (p=0.0001).

Conclusion

According to the results of this study, the cut-off point for PSA levels in detecting PCa was 3.8 ng/mL, which is similar to that reported by other studies. Familial history of PCa and PSA levels were two predictors in determining the PCa.

How should prostate specific antigen be interpreted?

Since from its clinical introduction to the present time, measurement of serum prostate specific antigen (PSA) level is one of the most widely used tests in urology practice. Initially, the upper limit for PSA was 4 ng/mL, but today, a reduction for the upper limit is recommended to 2.5-3 ng/mL for patients between 60 and 65 years of age and younger. On the use of PSA as a screening test for prostate cancer, there are differences of opinion. However, it is a recommended test in the evaluation and monitoring of the risky group for prostate cancer. In conclusion PSA test should be performed at appropriate intervals for appropriate people with an appropriate age, after informing the patient about the test in detail.

A novel equation and nomogram including body weight for estimating prostate volumes in men with biopsy-proven benign prostatic hyperplasia

Anthropometric measurements, e.g., body weight (BW), body mass index (BMI), as well as serum prostate-specific antigen (PSA) and percent-free PSA (%fPSA) have been shown to have positive correlations with total prostate volume (TPV). We developed an equation and nomogram for estimating TPV, incorporating these predictors in men with benign prostatic hyperplasia (BPH). A total of 1852 men, including 1113 at Tokyo Medical and Dental University (TMDU) Hospital as a training set and 739 at Cancer Institute Hospital (CIH) as a validation set, with PSA levels of up to 20 ng ml(-1), who underwent extended prostate biopsy and were proved to have BPH, were enrolled in this study. We developed an equation for continuously coded TPV and a logistic regression-based nomogram for estimating a TPV greater than 40 ml. Predictive accuracy and performance characteristics were assessed using an area under the receiver operating characteristics curve (AUC) and calibration plots. The final linear regression model indicated age, PSA, %fPSA and BW as independent predictors of continuously coded TPV. For predictions in the training set, the multiple correlation coefficient was increased from 0.38 for PSA alone to 0.60 in the final model. We developed a novel nomogram incorporating age, PSA, %fPSA and BW for estimating TPV greater than 40 ml. External validation confirmed its predictive accuracy, with AUC value of 0.764. Calibration plots showed good agreement between predicted probability and observed proportion. In conclusion, TPV can be easily estimated using these four independent predictors.

Predicting prostate biopsy outcome: artificial neural networks and polychotomous regression are equivalent models

INTRODUCTION

Complex statistical models utilizing multiple inputs to derive a risk assessment may benefit prostate cancer (PC) detection where focus has been on prostate-specific antigen (PSA). This study develops a polychotomous logistic regression (PR) model and an artificial neural network (ANN) for predicting biopsy results, particularly for clinically significant PC.

METHODS

There were 3,025 men undergoing TRUS-guided biopsy (BX) with PSA <10 ng/ml selected. BX outcome classified as benign, atypical small acinar proliferation or high-grade prostatic intraepithelial neoplasia (ASAP/PIN), non-significant (NSPC) or clinically significant PC (CSPC). PR and ANN models were developed to distinguish between BX categories. Predictors were age, PSA, abnormal digital rectal examination (DRE), positive transrectal ultrasound (TRUS) and prostate volume.

RESULTS

Among the BXs, 44% were benign, 14% ASAP/PIN, 16% NSPC and 25% CSPC. Median age, PSA and volume were 64 years, 5.7 ng/ml and 50 cc. TRUS lesion was present in 47%, and DRE was abnormal in 39%. PR and ANN models did not differ on percentage BX outcomes correctly predicted (55, 57%, respectively) and were equally poor for both ASAP/PIN (0%) and NSPC (2%). For PR and ANN, 74-78% ASAP/PIN predicted benign, 2% NSPC and 20-24% CSPC. For NSPC, 69-71% predicted benign, 27-29% CSPC. Benign outcomes were well identified (86-88%), although 12-13% classified CSPC. CSPC was correctly identified in 65-66% with misclassifications largely benign (33% for PR and ANN).

CONCLUSIONS

Neither PR nor ANN was able to distinguish between the four biopsy outcomes: ASAP/PIN and NSPC were not distinguished from benign or CSPC. ANN did not perform better than PR. Inclusion of additional predictors may increase the performance of statistical models in predicting BX outcome.