Prostate-specific antigen testing in untreated and treated prostatic adenocarcinoma

Prognostic grouping of metastatic prostate cancer using conventional pretreatment prognostic factors

OBJECTIVE

To develop three prognostic groups for disease specific mortality based on the binary classified pretreatment variables age, haemoglobin concentration (Hb), erythrocyte sedimentation rate (ESR), alkaline phosphatase (ALP), prostate-specific antigen (PSA), plasma testosterone and estradiol level in hormonally treated patients with metastatic prostate cancer (PCa).

MATERIAL AND METHODS

The present study comprised 200 Finnprostate 6 study patients, but data on all variables were not known for every patient. The patients were divided into three prognostic risk groups (Rgs) using the prognostically best set of pretreatment variables. The best set was found by backward stepwise selection and the effect of every excluded variable on the binary classification cut-off points of the remaining variables was checked and corrected when needed.

RESULTS

The best group of variables was ALP, PSA, ESR and age. All data were known in 142 patients. Patients were given one risk point each for ALP > 180 U/l (normal value 60-275 U/l), PSA > 35 microg/l, ESR > 80 mm/h and age < 60 years. Three risk groups were formed: Rg-a (0-1 risk points), Rg-b (2 risk points) and Rg-c (3-4 risk points). The risk of death from PCa increased statistically significantly with advancing prognostic group.

CONCLUSION

Patients with metastatic PCa can be divided into three statistically significantly different prognostic risk groups for PCa-specific mortality by using the binary classified pretreatment variables ALP, PSA, ESR and age.

Clinical Approach to the Prostate: An Update

Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.

Management of patients with an increasing prostate-specific antigen after radical prostatectomy

Since the late 1980s, early detection and monitoring of men for prostate cancer by serum prostate-specific antigen (PSA) measurement has resulted in an increase in the number of men presenting with a potentially curable disease. During the same time, in an attempt to provide a definitive cure, radical prostatectomy has been performed increasingly and now is regarded as the management option of choice for many patients with clinically localized prostate cancer. Radical prostatectomy involves the removal of all of the prostate tissue resulting in the serum PSA level to steadily decline to an undetectable level within 4 to 6 weeks after surgery. Despite improvements in surgical technique and a marked downward stage shift brought about by serum PSA testing, approximately 25% of men ultimately will experience a subsequent increase in serum PSA to a detectable level indicating disease recurrence after radical prostatectomy within 15 years. In this brief review, the factors associated with a high risk for disease recurrence after radical prostatectomy are discussed. Factors indicating whether the increasing serum PSA is caused by local recurrence or metastatic disease and the management options available to address serum PSA recurrence also are discussed.

Early detection of prostate cancer with low PSA cut-off values leads to significant stage migration in radical prostatectomy specimens

BACKGROUND

The introduction of prostate-specific antigen (PSA) contributed to a shift in tumor stage at diagnosis in patients with prostate cancer. The aim of the present study was to evaluate the effects of PSA screening with low PSA cut-off values on mean total and percent-free PSA levels in patients with prostate cancers at the time of diagnosis as well as on pathologic stage and mean Gleason scores in positive biopsies and radical prostatectomy specimens.

METHODS

Data of 875 patients who were diagnosed with prostate cancers between 1996 and 2001 were analyzed. Patients were stratified into six groups according to the year of biopsy. Annual changes in total and percent-free PSA values, in Gleason scores of biopsies and radical prostatectomy specimens, and in pathologic stages of radical prostatectomy specimens were assessed.

RESULTS

Mean PSA of patients diagnosed with prostate cancer decreased from 13.11 ng/ml (percent-free PSA: 11.89%) in 1996 to 7.33 ng/ml (percent-free PSA: 12.58%) in 2001 (P < 0.05). The percentage of organ-confined prostatectomy specimens increased from 64.3% in 1996 to 81.5% in 2001 (P < 0.05). However, mean Gleason scores increased from 5.23 to 6.33 over the 6 years (P < 0.05). The percentage of patients with biopsy-proven prostate cancers and PSA values below 4 ng/ml increased from 14.0% in 1996 to 39.2% in 2001. In the group with PSA values below 4 ng/ml organ-confined cancers were found in 80.0-95.2% of patients.

CONCLUSIONS

PSAg screening with low cut-off levels has led to a significant reduction of mean baseline PSA levels in prostate cancer patients and to a significant increase in the percentage of organ-confined radical prostatectomy specimens, whereas mean Gleason scores have remained relatively constant.

Management of high-risk populations with locally advanced prostate cancer

Prostate cancer that extends beyond the confines of the prostatic gland on clinical and/or radiographic assessment, without evidence of lymph node or distant metastases, is regarded as locally advanced. The locally advanced prostate cancer patient population consists of a heterogeneous group of men, some of whom have tumors that may be amenable to primary curative intent with local definitive therapy associated with acceptable long-term cancer control rates. In order to optimally manage this group of patients, it is important to be able to recognize who is at a high risk of tumor recurrence after primary local therapy. In this brief review, we discuss the factors that contribute to the prediction of high risk in populations with locally advanced disease and the treatment options available.

Prostate cancer screening in the Tyrol, Austria: experience and results

This article summarises the experience and results of different prostate carcinoma screening projects using total prostate specific antigen (PSA) and per cent free PSA as the initial test. Of the 21078 volunteers 1618 (8%) had elevated PSA levels. Of these men 778 (48%) underwent biopsies; 197 (25%) biopsies were positive for prostate carcinoma and 135 (17%) underwent radical prostatectomy. 95 were found to be organ-confined. A PSA cut-off of 2.5 ng/ml in men aged 45-49 years and of 3.5 ng/ml in men aged 50-59 years resulted in an 8% increase in the detection rate of organ-confined disease. 284/2272 men (13%) had elevated PSA levels and prostate carcinoma was detected in 62 men (3%). All patients underwent radical prostatectomy and histological examination revealed organ-confined tumour in all but 8 men. 98/340 men (29%) had biopsies positive for carcinoma; 28 of these patients (29%) had carcinoma that originated in the transition zone only. In the retrospective study, receiver operating characteristic curve analysis showed that by using a per cent free PSA of less than 18% as a biopsy criterion, 37% of the negative biopsies could be eliminated although 94% of all carcinomas would still be detected. In the first prospective study, 106/158 men (67%) with elevated PSA levels below 10.0 ng/ml were further evaluated and 37 (35%) prostate carcinomas were detected. By using a per cent free PSA of <22% as a biopsy criterion, 30% of the negative biopsies could be eliminated although 98% of the carcinomas would still be detected. In the second prospective study, 120/465 men (26%) with total PSA levels between 1.25 and 6.49 ng/ml and a per cent free PSA<18% were further evaluated and 27 (23%) were found to have prostate carcinomas. Receiver operating characteristic curve analysis for PSA transition zone (TZ) density showed that by using a PSA transition zone density of >22 ng/ml/cc as a biopsy criterion, 24.4% of negative biopsies could be avoided without missing a single carcinoma. In the prescreening era the incidence of T1a Grade 1 and 2 carcinomas was 3.1% and the incidence of T1a and T1b Grade 3 carcinoma was 2.3% whereas in the years after the establishment of PSA-based screening the incidence was 4.6 and 1.03% respectively. The rate of organ-confined tumours increased from 28.7% in 1993 to 65.7% in 1997. In this evaluation a new approach, to proceed with a prostate biopsy based upon the individual risk of having prostate cancer rather than a single PSA cut-off point was developed. High total PSA levels, PSA density and PSA transition zone density correlated significantly with high Gleason scores, capsular penetration, a high percentage of cancer in the prostatectomy specimen and a high cancer volume. In this evaluation all of the 95 patients with PSA levels below 3.99 ng/ml who underwent radical prostatectomy showed clinically significant, organ-confined prostate cancer with negative surgical margins. The results of this evaluation suggest that older men have larger tumour volumes compared with younger men with the same PSA levels. These data suggest that PSA-based screening with low PSA cut-off values increase the detection rate of clinically significant, organ confined and potentially curable prostate cancer. Per cent free PSA and PSA transition zone density provide an additional diagnostic benefit over total PSA.

Correlation between preoperative predictors and pathologic features in radical prostatectomy specimens in PSA-based screening

BACKGROUND

Measurement of percent free prostate-specific antigen (PSA), PSA density, and PSA-transition zone density (PSA-TZ density) in addition to total PSA is known to improve the specificity of PSA-based prostate cancer screening. We evaluated the ability of total PSA, percent free PSA, PSA density, and PSA-TZ density to predict pathologic features in radical prostatectomy specimens.

METHODS

The levels of total PSA, percent free PSA, PSA density, and PSA-TZ density assessed prior to the diagnosis of prostate cancer were correlated with the pathologic findings in 102 prostate glands with cancer obtained at radical prostatectomy. The entire organs were examined histologically; Pearson correlation coefficients were used for statistical analysis.

RESULTS

High levels of total PSA, PSA density, and PSA-TZ density correlated significantly with capsular penetration, high Gleason scores, and large cancer volumes in the prostatectomy specimens. Free PSA was found to correlate well with high Gleason scores, high percentages of cancer, and large cancer volumes, but not with capsular penetration. The four parameters were evaluated by means of logistic regression, which showed that only percent free PSA and total PSA were significant predictors of Gleason scores > or =7 and cancer volumes > or =0.5 cc. With regard to clinically insignificant cancers, only percent free PSA and the Gleason score obtained at biopsy were significant predictors.

CONCLUSIONS

In men whose prostate cancers are detected by PSA-based screening, high total PSA levels in combination with low percent free PSA levels are suggestive of a potentially more aggressive type of prostate cancer. This may help both patient and clinician in selecting the most appropriate therapeutic approach.

Pretreatment plasma testosterone and estradiol levels in patients with locally advanced or metastasized prostatic cancer. FINNPROSTATE Group

BACKGROUND

Studies concerning pretreatment plasma hormonal environment in relation to stage of prostatic cancer have given conflicting results. The aim of the present study was to compare the pretreatment plasma testosterone (T), free T (fT), estradiol (E2), and free E2 (fE2) levels in patients with locally advanced (T3-4 M0) and metastatic (T1-4 M1) prostatic cancer, and to further examine the effect of the patients' general condition on these levels.

METHODS

The present series consisted of 238 patients (Finnprostate 6 study). The variables analyzed were E2, fE2, T, fT, age, body mass index (BMI), sex hormone binding globulin capacity (SHBG), prostate-specific antigen (PSA), alkaline phosphatase (ALP), hemoglobin concentration (Hb), erythrocyte sedimentation rate (ESR), and performance status (PS).

RESULTS

The E2 and fE2 levels were significantly higher in M0 patients than in M1 patients, with no significant differences in T and fT levels. In multivariate analyses, a decline in performance status (PS), an increase in ESR, or a decrease in Hb, were related to a decrease in T, fT, E2, or fE2 levels.

CONCLUSIONS

Pretreatment plasma estradiol was significantly lower in M1 patients than in M0 patients, but there were no significant differences in T levels, although the poor general condition was related to a decrease in the pretreatment levels of both testosterone and estradiol.

Transperineal 125iodine implantation for treatment of clinically localized prostate cancer: 5-year tumor control and morbidity

PURPOSE

To evaluate the efficacy and toxicity of transperineal 125I implants for clinically localized prostate cancer in elderly men in a community cancer setting.

METHODS AND MATERIALS

From 1988 to 1993, 206 patients, median age 77 years, with localized (Stage T1 and T2), low-grade (Gleason score < or = 7) prostate cancer were treated using pre-planned 125I transperineal implants. Patients were followed for biochemical freedom from disease, overall survival, and treatment-associated morbidity.

RESULTS

The 5-year actuarial biochemical freedom from failure rate for all patients available for follow-up was 63%. Specifically, biochemical freedom from failure was 76% in patients with pretreatment PSA < or = 10 ng/ml, compared to 51% of patients with values > 10 ng/ml (median observation time 35 months). Actuarial freedom from failure for patients with PSA < or = 4 ng/ml was 84%. Stage and Gleason score did not predict outcome. PSA nadir was the strongest predictor of long-term biochemical disease-free survival (p < 0.001) with only 2 failures in 62 patients who achieved a posttreatment PSA nadir < or = 0.5 ng/ml.

CONCLUSION

Transperineal 125I implants for early prostate cancer are efficacious and feasible for certain populations of elderly patients with favorable prognostic indicators in the community cancer setting. Patients with poor prognostic indicators at diagnosis do not appear to be candidates for treatment with implant alone. ( 1999 El.vit r 'Cio;noo lnc

Stage T1c prostate cancer: defining the appropriate staging evaluation and the role for pelvic lymphadenectomy

A good staging system should be able to accurately reflect the natural history of a malignant disease, to express the extent of the disease at the time of diagnosis, and stratify patients in prognostically distinctive groups. The staging system for prostate cancer, as it is today, fails to fulfill these requirements. Approximately one third of the patients who undergo surgery for complete excision of prostate cancer in fact do not have a localize disease. The incidence of tumor at the inked margin may reach 30% for T1 stage and up to 60% for clinical T2b prostate cancer according to comparison with pathologic examination of resected specimen. Several concepts have been recently proposed as a means of improving the accuracy of the available staging system. In this paper, we review current aspects of clinical and pathological staging of prostate cancer, and the importance of these new concepts on the early stages of prostate cancer.

Update on the appropriate staging evaluation for newly diagnosed prostate cancer

PURPOSE

Prostate cancer clinical staging methods and decision support tools were reviewed to assess their accuracy to predict pathological staging results and determine what comprises an appropriate clinical staging evaluation.

MATERIALS AND METHODS

The MEDLINE data base was searched and 238 abstracts were obtained. Data were extracted from 142 articles that evaluated the preoperative accuracy of digital rectal examination, prostate specific antigen, prostatic acid phosphatase, systematic biopsy parameters (including Gleason scoring), seminal vesicle biopsy, various imaging studies and pelvic lymphadenectomy versus pathological staging results. The sensitivity, specificity and accuracy rates were calculated and tabulated from the reported data on each method or decision support tools for organ confined, nonorgan confined and lymph node metastatic tumor.

RESULTS

Decision support tools based on logistic regression analysis, which combine several statistically independent staging parameters, had greater accuracy than any single clinical staging method alone. The most accurate decision support tools for clinical staging combined digital rectal examination (T stage), systematic biopsy parameters (including Gleason scoring) and prostate specific antigen.

CONCLUSIONS

The components that comprise the most accurate decision support tools for clinical staging represent an appropriate staging evaluation for the newly diagnosed prostate cancer patient in 1997. Limited use of radiographic imaging and seminal vesicle biopsy may be indicated in select patients to detect bone metastases, and plan pelvic lymphadenectomy and surgical therapy.

Why neoadjuvant androgen deprivation prior to radical prostatectomy is unnecessary

Neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy has been advocated for downstaging of tumors and reducing the rates of positive surgical margins with the expectation that disease-free survival will be improved. Despite the apparent favorable impact on pathologic findings, randomized trials to date show no benefit of NHT in prostate-specific antigen progression rates. Consequently, there is serious concern about the validity and biologic significance of the apparent downstaging and decreased rate of positive margins, and no evidence exists that there is improved time to progression and survival; therefore, the authors do not recommend NHT outside of a clinical trial.

The clinical usefulness of prostate specific antigen: update 1994

In conclusion, PSA is the first prostate specific serum marker of clinical usefulness in urology. It represents a valuable clinical tool that has improved our ability to detect early prostate cancer and to monitor response to therapy. While large PSA screening studies have demonstrated an appreciable increase in the detection of organ confined, potentially curable prostate cancers, no study to date has yet demonstrated that the increased detection rate will decrease the prostate cancer-specific mortality rate. Yet more importantly, no study to date has demonstrated that early diagnosis using PSA will not decrease the prostate cancer specific mortality rate and until such data exist, PSA should be used to aid in early diagnosis and treatment planning for men with prostate cancer. PSA, when combined with other variables such as Gleason score and clinical stage, improves the prediction of pathological stage for prostate cancer. The introduction of PSA velocity and age specific reference ranges should further enhance the clinical usefulness of PSA. New advances in PSA research hold great promise for further improvements in PSA, and truly make it the most important and useful tumor marker for adenocarcinoma of the prostate.

Radiotherapy for isolated increases in serum prostate-specific antigen levels after radical prostatectomy

OBJECTIVE

To assess the outcome of radiotherapy in patients with increased serum prostate-specific antigen (PSA) levels 6 months or more after radical prostatectomy.

DESIGN

In 27 Mayo Clinic patients, we examined the results of radiotherapy relative to various potentially prognostic factors during a median follow-up of 25 months.

MATERIAL AND METHODS

All 27 patients had no nodal involvement at the time of prostatectomy and no clinical evidence of disease, as determined by history, physical examination, a radionuclide bone scan, computed tomography of the abdomen and pelvis, chest roentgenography, complete blood cell counts, and serum chemistry profiles. With use of 10-MV photons and a four-field approach, these patients received irradiation to the prostatic bed (60 to 67 Gy in 1.8- to 2.0-Gy fractions).

RESULTS

Levels of PSA initially decreased in 24 of the 27 patients (89%). In 16 of the 27 patients (59%), the PSA level decreased to 0.3 ng/mL or less without hormonal intervention. "Freedom from failure" (defined as the actuarial chance of maintaining a PSA level of 0.3 ng/mL or less) was 58% at 2 years and 48% at 3 years. The response to salvage radiotherapy was more favorable in patients with no tumor spread into the seminal vesicles and those with serum PSA levels of less than 1.1 ng/mL at the beginning of radiotherapy than in those with seminal vesicle involvement or higher PSA levels. In addition, patients who received radiation doses of 64 Gy or more had more favorable responses than did those who received lesser doses. Radiotherapy resulted in no severe toxicity. No patient had clinical evidence of disease at the time of this report.

CONCLUSION

Isolated increases in serum PSA after prostatectomy indicate the presence of residual or recurrent disease, and radiotherapy effectively decreases the PSA in approximately half the cases. This result is achieved by eradicating residual or recurrent cancer in the postoperative tumor bed.

Role of PSA on Diagnosis and Clinical Stadiation of Prostatic Cancer

The Authors review the literature and summarize the role of the PSA in early diagnosis, screening and clinical staging of prostatic carcinoma. Both advantages and limits of the test are emphasized. In spite of its limited sensitivity (57%) and low positive predictive value (49%) in early diagnosis of prostate cancer, the marker has an overall diagnostic efficiency of 64-70% and provides better detection rates of the tumor than digital rectal examination (DRE) and transrectal ultrasonography (TRUS). In screening studies, additional advantages of PSA in comparison with the other tests, are objectivity and better patient acceptance. Combination of PSA with DRE and TRUS provides the best results in early diagnosis of prostate cancer. The highest detection rates are observed with a positive DRE and high levels of PSA. The main controversies concern the group of patients with negative DRE and intermediate levels of PSA (4,1-10 ng/ml; Hybritech); in these cases other parameters, such as PSA density and/or PSA velocity, can be useful. The relationship between serie levels of the marker and age of the patients can also increase the diagnostic accuracy of the test. A screening programme in subjects at risk for prostate cancer (because of age, family history and race) may be founded on the association of PSA and DRE, using TRUS only when both PSA and DRE are positive or dubious. Lastly the Authors emphasize the importance of PSA in the clinical staging of the prostatic carcinoma, especially as predictor of bone metastases.

Prostate-specific antigen. An important marker for prostate cancer treated by external beam radiation therapy

BACKGROUND

Prostate-specific antigen (PSA) is a valuable serum marker for prostate cancer. However, the prognostic importance of baseline PSA values in relation to other prognostic factors has not been elucidated. The incidence of postradiation rising PSA values has not been documented, and the extent to which PSA influences the assessment of radiation therapy is unclear. This study was designed to address these issues.

METHODS

Three hundred and fourteen consecutive patients with baseline PSA values who were treated between 1987 and 1991 with external beam radiation alone were reviewed for disease outcome and posttreatment PSA levels.

RESULTS

Clinical stages at diagnosis were: Stage A2, 87 (28%); Stage B, 108 (34%); and Stage C, 119 (38%). At a mean follow-up of 21 months, 25 patients had relapsed, 53 had developed rising PSA profiles, and 58 had either relapsed or had rising PSA profiles. The actuarial relapse rate was 20% at 4 years, the incidence of rising PSA profiles was 38% at 4 years, and the incidence of either relapse or rising PSA was 40% at 4 years. In multivariate analysis, baseline PSA value was the single most important factor predicting for local relapse, metastatic relapse, any disease relapse, and posttreatment rising PSA values. Using relapse or rising PSA as endpoints, the following four prognostic groupings based on baseline PSA and M.D. Anderson (MDA) grade were delineated: I, PSA less than or equal to 4 ng/ml, any grade; II, PSA greater than 4 but less than or equal to 10 ng/ml, Grades 1 and 2; III, PSA greater than 4 but less than or equal to 10 ng/ml, Grades 3 and 4 or PSA greater than 10 but less than or equal to 30 ng/ml, Grades 1 and 2; and IV, PSA greater than 10 but less than or equal to 30 ng/ml, Grades 3 and 4 or PSA greater than 30 ng/ml, any grade. The actuarial incidence of relapse or rising PSA in these groups was: I, less than 10% at 3 years; II, 20% at 3 years; III, 55% at 3 years; and IV, 90% at 30 months. When using traditional endpoints of disease outcome, the patients in this series had an outcome equivalent to that in 799 patients treated in our institution in the pre-PSA era; when using rising PSA profiles as endpoints, treatment was significantly less effective.

CONCLUSIONS

Pretreatment serum PSA level is the single most significant predictor of disease outcome after radiation therapy for local-regional prostate cancer. Moreover, postirradiation PSA values may potentially serve as an early endpoint to evaluate treatment efficacy. Using a rising posttreatment PSA profile as an index of treatment failure reveals that total and permanent eradication of prostate cancer with radiation therapy alone is not achieved as often as previously believed and that multimodal treatment approaches to prognostically unfavorable early stage disease need investigation.

Preoperative androgen deprivation therapy: artificial lowering of serum prostate specific antigen without downstaging the tumor

We studied 22 patients with clinical stage B2 (T2c) or C (T3) prostate cancer who underwent androgen deprivation therapy before radical prostatectomy as part of a downstaging protocol (group 1). The concentration of serum prostate specific antigen (PSA) was determined before and at the conclusion of androgen deprivation therapy, just before the operation. For each group 1 patient a match patient who had not received preoperative endocrine therapy (group 2) was chosen. The age of the group 2 patients was similar to that of the group 1 patients. The clinical stage of disease and pretreatment tumor grade in group 2 were identical to the stage and grade in group 1, and the serum PSA value in group 2 was similar to that of group 1 before initiation of androgen deprivation therapy. In group 1 the median serum PSA concentration was 14.8 ng./ml. (range 3.1 to 99) before endocrine therapy and 0.2 ng./ml. (range 0.1 to 3.4) after hormonal treatment. Group 2 had a median level of 13.3 ng./ml. (range 3.4 to 100). The median decrease in the serum PSA concentration for group 1 as a result of androgen deprivation therapy was 98.5%. The radical prostatectomy specimens from these 2 groups of similar patients had no difference with regard to maximal tumor dimension, pathological stage and deoxyribonucleic acid ploidy status. These findings indicate that serum PSA becomes an unreliable indicator of disease status after initiating preoperative androgen deprivation therapy and that preoperative androgen deprivation therapy has little or no benefit for decreasing the extent of tumor or pathological stage. The concept of downstaging is misleading and must be examined in a randomized clinical trial.

Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels

BACKGROUND

Prostate-specific antigen (PSA) is an important marker for adenocarcinoma of the prostate and is of clinical utility in assessment of residual carcinoma after radical prostatectomy. Although elevated postoperative serum PSA levels have been linked to pathologic stage in radical prostatectomy specimens, limited data are available on the relationship of postoperative PSA levels to margin positivity, intraglandular tumor extent, and histologic grade.

METHODS

Initial postoperative serum PSA levels were related to pathologic features of 90 radical prostatectomy specimens with adenocarcinoma of the prostate. Logistic regression analysis was used to stratify pathologic stage, percentage intraglandular carcinoma, histologic grade, and margin positivity as predictors of elevated initial postoperative PSA levels.

RESULTS

Pathologic stage, percentage carcinoma, and margin positivity were nearly equivalent in strength of prediction, whereas Gleason histologic grade was a significant but less reliable predictor of elevated initial postoperative PSA levels. Thirty-one of 51 (60.8%) patients with extension of carcinoma outside the prostate gland had an elevated initial postoperative PSA level, whereas only 5 of 39 (12.8%) patients with organ-confined carcinoma had an elevated postoperative PSA level. Intraglandular tumor extent greater than 10% was associated with a greater likelihood of an elevated postoperative PSA level. Additional predictive capacity was obtained with concurrent use of pathologic stage and percentage carcinoma or margin positivity in multivariate analysis.

CONCLUSIONS

In radical prostatectomy specimens, pathologic stage, intraglandular carcinoma extent, and margin positivity are particularly important morphologic parameters because they are predictive of residual carcinoma that is detected early, as judged by an elevated initial postoperative serum PSA level.

Inter-relation between measurement of serum prostatic specific antigen and transrectal ultrasound in the diagnosis of benign prostatic hyperplasia and prostatic cancer

Serum prostatic specific antigen (PSA) and ultrasound-determined prostatic volume (UPV) were measured in 50 patients with histologically proven benign prostatic hyperplasia (BPH) and in 40 patients with histologically proven prostatic cancer of whom 17 had evidence of distant metastases (M1) and 23 did not (M0). A good correlation between log PSA and UPV was demonstrated in the BPH group and rearrangement of the linear regression equation allowed calculation of a single variable--the log PSA corrected to a standard prostate volume for any given individual. A volume-corrected PSA correctly identified all patients with M1 disease and greatly improved but did not eliminate overlap of M0 disease with BPH. Reduction of serum PSA to a single volume-corrected variable will allow the introduction of practical and optimum protocols for the management of patients with prostatic enlargement.

Androgen effect on prostate specific antigen secretion

Prolonged parenteral androgen therapy for 1 year resulted in the hypersecretion of prostate specific antigen (PSA) in a patient with no clinical evidence of prostate carcinoma, who had been treated with diethylstilbestrol (DES) for 9 years. The PSA level declined to normal values upon temporary discontinuation of androgen therapy and increased again upon resumption of treatment. This case seems to confirm the regulatory effect of androgens of PSA secretion and to suggest a possible "rebound" elevation of PSA in patients with androgen deprivation treated with testosterone replacement. The estrogen suppressed prostatic epithelial cells were able to respond to androgen stimulation with a steady increase in the PSA secretion and positive immunohistochemical PSA staining.