Total PSA, free PSA/total PSA ratio, and molecular PSA detection in prostate cancer: which is clinically effective and when?

A dual-round signal amplification strategy for colorimetric/photoacoustic/fluorescence triple read-out detection of prostate specific antigen

The detection of prostate specific antigen (PSA) is extremely important for the early diagnosis of prostate cancer. Herein, we report a dual-round signal amplification strategy for colorimetric/fluorescence/photoacoustic triple read-out detection of PSA using a silica coated Au@Ag core-shell nanorod (denoted Au@Ag@SiO2) based enzyme-linked immunosorbent assay (ELISA) system. In the presence of PSA, monoclonal primary antihuman PSA antibody (Ab1) captured PSA and was subsequently recognized by the secondary antihuman PSA detection antibody (Ab2) which was conjugated with glucose oxidase (GOx) functionalized magnetic beads (MBs) for signal amplification, then GOx catalyses the addition of glucose to generate hydrogen peroxide that etches the silver layer in Au@Ag@SiO2, thus producing abundant Ag+ to realize the second signal amplification. With the degradation of the silver layer, an obvious color change (green-to-pink) of the Au@Ag@SiO2 solution could be observed by the naked eye and its surface plasmon resonance (SPR) absorption had a red-shift, enhancing photoacoustic signal read-out at 780 nm. Additionally, the released Ag+ was caught by a Ag+-fluorescent probe (Ag+-FP) for enhanced fluorescence signal read-out. These results suggested that this ELISA system achieves a triple read-out detection of PSA. This work provides a promising strategy for multiple read-out detection of biomarkers, which has great potential in clinical diagnosis.

A portable chemiluminescence imaging immunoassay for simultaneous detection of different isoforms of prostate specific antigen in serum

A multianalyte chemiluminescence (CL) imaging immunoassay strategy for sensitive detection of different isoforms of prostate specific antigen (PSA) was developed. The microtiter plates were fabricated by simultaneously immobilizing of free-PSA (f-PSA) and total-PSA (t-PSA) capture antibody on nitrocellulose (NC) membrane. Each of the array were spotted in replicates of six spots within a spacing of 2mm. 16 or 48 detection wells were integrated on a single NC membrane and each well could be used as a microreactor and microanalysis chamber. Under a sandwiched immunoassay, the CL signals on each sensing site were collected by a charge-coupled device (CCD), presenting an array-based chemiluminescence imaging. Soybean peroxidase (SBP) was used to label f-PSA or t-PSA monoclonal antibody. With the amplification effects of two enhancers, 3-(10'-phenothiazinyl) propane-1-sulfonate (SPTZ) and 4-morpholinopyridine (MORP), the CL intensity could significantly enhanced, which improved the sensing sensitivity and detection limit. Under the optimal conditions, the linear response to the analyte concentration ranged from 0.01-36.7ng/mL and 0.02-125ng/mL for f-PSA and t-PSA, respectively. The results for the detection of forty serum samples from prostate cancer patients and cancer-free patients showed good agreement with the clinical data, suggesting that the proposed assay had acceptable accuracy. The proposed CL imaging immunoassay possess high throughput and acceptable reproducibility, stability and accuracy, which made it great potential to available to distinguish different isoforms of PSA in serum samples.

MicroRNA Regulating Glutathione S-Transferase P1 in Prostate Cancer

Glutathione S-transferase P1 (GSTP1), an enzyme involved in detoxification process, is frequently inactivated in prostate cancer due to epigenetic modifications. Through in silico analysis we identified a subset of miRNAs that are putative targets in regulating GSTP1. miRNAs are small endogenous non-coding RNA that are critical regulators of various physiologic and pathologic processes and their level of expression may play a precise role in early diagnosis and prognosis of cancer. These small molecules have been detected in a wide variety of human biological specimens including blood, serum, urine, ejaculate and tissues, which could be utilized as clinically useful biomarker in early detection and prognosis of prostate cancer. The chapter summarizes the current knowledge about miRNA involved in GSTP1 regulation in prostate cancer and their potential as useful biomarkers of disease for early detection and prognosis, along with challenges and limitations in this development.

Advancements in MR imaging of the prostate: from diagnosis to interventions

Prostate cancer is the most frequently diagnosed cancer in males and the second leading cause of cancer-related death in men. Assessment of prostate cancer can be divided into detection, localization, and staging; accurate assessment is a prerequisite for optimal clinical management and therapy selection. Magnetic resonance (MR) imaging has been shown to be of particular help in localization and staging of prostate cancer. Traditional prostate MR imaging has been based on morphologic imaging with standard T1-weighted and T2-weighted sequences, which has limited accuracy. Recent advances include additional functional and physiologic MR imaging techniques (diffusion-weighted imaging, MR spectroscopy, and perfusion imaging), which allow extension of the obtainable information beyond anatomic assessment. Multiparametric MR imaging provides the highest accuracy in diagnosis and staging of prostate cancer. In addition, improvements in MR imaging hardware and software (3-T vs 1.5-T imaging) continue to improve spatial and temporal resolution and the signal-to-noise ratio of MR imaging examinations. Another recent advancement in the field is MR imaging guidance for targeted prostate biopsy, which is an alternative to the current standard of transrectal ultrasonography-guided systematic biopsy.

Prostate-specific antigen-based screening for prostate cancer in the third millennium: useful or hype?

Prostate cancer is the most prevalent malignancy in men and the third leading cause of cancer deaths worldwide. Although the wide-spread introduction of total prostate-specific antigen (tPSA) testing has revolutionized the approach to the managed care of this disease, there are some biological, analytical, clinical, and economical issues that argue against the cost-effectiveness of tPSA-based population screening for early identification of cancer. The on-going standardization/harmonization efforts, along with the outcomes of recent epidemiological investigations, demonstrate that the current tPSA thresholds might be revised and possibly recalculated according to several demographical variables, such as age, ethnicity, genotype, family history, and body mass index. A major shortcoming of tPSA screening is the lack of reliable evidences of reduction in prostate cancer-associated mortality, due to the large lead-time because of the indolent growth rate, the impossibility to differentiate high-grade from indolent cancers, and the treatment-associated morbidity. Since no single tPSA cut-off was proven able to efficiently identify men at higher risk of death, the jeopardy of over-diagnosis and over-treatment is also tangible. The large expenditure is an additional source of concern. Finally, a wide-spread population screening also carries several ethical, social, and psychological implications, which might overwhelm the potential benefits.

Quantitative PSA mRNA determination in blood: a biochemical tool for scoring localized prostate cancer

OBJECTIVES

Our aim was to verify whether the quantitative determination of PSA mRNA in circulating cells is helpful in diagnosing and scoring localized prostate cancer (PC).

DESIGN AND METHODS

The study included 145 patients with benign prostatic hyperplasia (BPH), 138 with localized PC and 28 healthy controls (CS). PSA cDNA was amplified by real-time PCR from circulating mononuclear cells. Serum total and free PSA were determined. Prostate cancers were histologically scored according to the Gleason criteria.

RESULTS

The most sensitive index of PC was tPSA (70%), and the most specific was f/t PSA (80%). High PSA mRNA was found more frequently in PC patients with poorly differentiated (23.1%) than in those with well (4.5%) or moderately (4.3%) differentiated tumors.

CONCLUSIONS

tPSA and f/t PSA are the best available tools for discriminating between localized PC and BPH. The quantitative assessment of PSA mRNA in blood might be helpful in the biochemical grading of prostate cancer.

Use of prostate-specific antigen (PSA) isoforms for the detection of prostate cancer in men with a PSA level of 2-10 ng/ml: systematic review and meta-analysis

OBJECTIVE

Measurement of serum prostate-specific antigen (PSA) for the detection of prostate cancer has poor specificity in men with PSA levels between 2 and 10 ng/ml. It has been suggested that measurement of the ratio of free to total PSA (f/tPSA) or complexed PSA (cPSA) might offer an improvement. We performed a systematic review and meta-analysis to evaluate the diagnostic performance of these tests among men with PSA levels between 2 and 10 ng/ml.

METHODS

Data on sensitivity and specificity were extracted from 66 eligible studies. Likelihood ratios and summary receiver operating characteristic curves were estimated and possible sources of heterogeneity between studies examined.

RESULTS

Use of the f/tPSA or the cPSA test improved diagnostic performance among men with a total PSA (tPSA) of 2-4 or 4-10 ng/ml compared to tPSA alone. The diagnostic performance of the f/tPSA test was significantly higher in the tPSA range of 4-10 ng/ml compared to a tPSA range of 2-4 ng/ml (p < 0.01); at a sensitivity of 95%, the specificity was 18% in the 4-10 ng/ml tPSA range and 6% in the 2-4 ng/ml tPSA range. Among studies that measured both isoforms, the diagnostic performance of the f/tPSA test and the cPSA was equivalent in both PSA ranges.

CONCLUSIONS

The use of the f/tPSA or cPSA test among men with PSA levels between 2 and 10 ng/ml can reduce the number of unnecessary biopsies whilst maintaining a high cancer detection rate.

Plasma Chromogranin A in Patients with Prostate Cancer Improves the Diagnostic Efficacy of Free/Total Prostate-Specific Antigen Determination

INTRODUCTION

We ascertained whether plasma chromogranin A enhances the power of serology assessing prostate cancer (PC).

MATERIALS AND METHODS

We studied 56 PC and 83 benign prostatic hyperplasia (BPH) patients. In the sera we measured total prostate-specific antigen (tPSA) and free PSA (fPSA) and calculated the ratio between fPSA and tPSA (f/tPSA). In plasma samples the levels of chromogranin A (CgA) were also assayed.

RESULTS

PC patients had higher CgA (p < 0.005) and tPSA (p < 0.05) levels, and a lower f/tPSA ratio (p < 0.001), than BPH patients. When f/tPSA and CgA were combined, the diagnostic sensitivity was enhanced (57-73%), while the specificity had only an 8% reduction (from 89 to 80%). CgA was only correlated to the Gleason PC score (p < 0.05).

CONCLUSIONS

CgA determination in PC may enhance the diagnostic accuracy of the f/tPSA assay and provides useful information on the tumor grade.

Correlation between prostate-specific antigen and histopathological difference of prostate carcinoma

BACKGROUND: Adenocarcinoma of prostate (ACP) is one of the most frequent tumors in men older than 50. Prostate specific antigen (PSA) is the most reliable serum marker in the diagnostics and following of prostate carcinoma, and Gleason's system of estimation of tumor differentiation, as well as classical estimation of tumor differentiation from 1 to 3, are generally accepted systems of prostate carcinoma evaluation. METHODS: Forty examined individuals with verified ACP and compared values of PSA and tumor differentiation as well as estimated comparability of these two systems are reported. RESULTS: Highly positive correlation between the values of PSA in serum and the degree of tumor differentiation determined by Gleason's system, as well as the low correlation between PSA and histological differentiation estimated using classical system from 1 to 3 were found. CONCLUSION: It could be concluded that Gleason's system for tumor differentiation determination is more superior system of histological grade determination than the other systems.

PSA markers in prostate cancer detection

The PSA revolution that has occurred over the previous 2 decades has positively impacted the detection and treatment of men with prostate cancer. Although methods to improve specificity have shown promise (eg, PSAD, age-specific PSA, and PSA velocity), meaningful interpretation has yet to be uniformly accepted within clinical practice. The identification of other molecular forms of PSA within serum has led to a new era in PSA markers. Initial application employing %fPSA has provided improved discrimination between benign and malignant prostatic disease; however, questions remain regarding the ultimate threshold value. The discovery of various free forms of PSA--such as proPSA, BPSA, and iPSA--also have introduced the potential for improved specificity in detection. Although early results are encouraging, further evaluation is anticipated. The development of improved methods to detect and measure cPSA has demonstrated provocative results, and exhibits the potential to replace PSA as a standard diagnostic test in cancer screening.

Production of serum-free and total prostate-specific antigen due to prostatic intraepithelial neoplasia

OBJECTIVE

High serum total prostate-specific antigen (PSA) levels have proven to be predictive of concurrent cancer but the role of prostatic intraepithelial neoplasia (PIN) in the production of total (t) and free (f) PSA is still the subject of research. In this study we wanted to discover whether variations in serum fPSA and tPSA levels are caused by PIN.

MATERIAL AND METHODS

We reviewed the medical records of 87 patients: in 32 of them the diagnosis of isolated PIN was made from surgical samples (simple prostatectomy, n = 19; radical cystectomy, n = 13); in 30 patients a diagnosis of benign prostatic hyperplasia (BPH) without PIN or prostatic carcinoma was made after simple prostatectomy (n = 20) or radical cystectomy (n = 10); and in 25 patients a clinically significant prostatic cancer was diagnosed and these patients underwent radical prostatectomy. All patients underwent a standard preoperative evaluation, including serum fPSA and tPSA determinations and PSA density.

RESULTS

The frequency of isolated PIN in simple prostatectomy specimens was 6.3%. The mean f/t PSA ratios were 17.66% in the 32 patients with PIN, 19.2% in the 8 patients with low-grade PIN, 17.6% in the 24 patients with high-grade PIN, 24.2% in patients with BPH and 13% in patients who underwent radical prostatectomy.

CONCLUSIONS

We believe that to make a definitive diagnosis of isolated PIN without carcinoma, study of the whole prostate gland is necessary, in order to definitively exclude the presence of concurrent neoplastic foci. Our data show that PIN does not contribute to tPSA levels and density; however, it may be responsible for a slight reduction in the f/t PSA ratio, with a significant reduction in cases with high-grade PIN (17.6%) compared to those with BPH (24.2%).

The relation of prostate biopsy results and ratio of free to total PSA in patients with a total PSA between 4-20 ng/mL

OBJECTIVE

In this study our aim was to investigate the efficacy of free to total PSA ratio in discrimination of benign prostate hyperplasia and prostate cancer.

MATERIALS AND METHODS

A total of 194 patients, 52 to 82 years old (mean 66.06 +/- 0.47 years) with PSA levels between 4 to 20 ng/mL were included into this study. Each patient underwent sextant prostate biopsy under transrectal ultrasound guidance. The patients were divided into two groups as PSA 4-10 and 10-20 ng/mL. Patients with benign and malign results were compared with respect to age, total PSA level, free PSA level and free/total (f/t) PSA ratio.

RESULTS

Biopsies revealed prostate cancer in 16 of 130 patients (12.3%) with serum PSA 4-10 ng/mL and in 10 of 64 patients (15.6%) with serum PSA 10-20 ng/ml. In both PSA groups free PSA and f/t PSA levels were statistically significant, where total PSA levels were not. In patients with 4-20 ng/mL total PSA levels and a cut off level of < 0.18 for f/t PSA, the sensitivity, specificity and positive predictive value for prostate cancer were 88.5%, 53.6% and 20.4% respectively.

CONCLUSION

Higher levels of PSA suggest prostate cancer, but still additional parameters are needed for patients with PSA 4-20 ng/mL, such as free PSA and f/t PSA. Although a cut off level of < 0.18 for f/t PSA seems to be the most accurate one to discriminate benign and malign diseases further studies on larger groups of patients are needed.

Expression analysis of delta-catenin and prostate-specific membrane antigen: their potential as diagnostic markers for prostate cancer

The current approach to prostate cancer diagnosis has major limitations including the inability of prostate-specific antigen (PSA) assays to accurately differentiate between prostate cancer and benign prostate hyperplasia (BPH) and the imprecision of transrectal ultrasound (TRUS) biopsy sampling. We have employed cDNA microarray screening to compare gene expression patterns in BPH and tumour samples to identify expression markers that may be useful in discriminating between these conditions. Screening of 3 individual cDNA arrays identified 8 genes with expression 3-fold greater in 6 tumour tissues than in 1 nontumour sample and 1 BPH sample. Real-time PCR was used to confirm the overexpression of these 8 genes and 12 genes selected from the literature against a panel of 17 tumours and 11 BPH samples. Two genes, delta-catenin (delta-catenin; CTNND2) and prostate-specific membrane antigen (PSMA; FOLH1), were significantly overexpressed in prostate cancer compared to BPH. Prostate epithelial cells stained positively for delta-catenin and PSMA in our prostate cancer tissues, whereas the majority of our BPH tissues were negative for both markers. Thus we have identified delta-catenin (not previously associated with prostatic adenocarcinoma) and confirmed the potential of PSMA as potential candidates for the diagnosis and management of prostate cancer.

Using multiple cutpoints for the free-to-total prostate specific antigen ratio improves the accuracy of prostate cancer detection

BACKGROUND

Using a single cutpoint for the free-to-total (F/T) prostate specific antigen (PSA) ratio loses important diagnostic information. We evaluated the performance of multiple F/T PSA cutpoints in detecting prostate cancer in men with nonspecific PSA values.

METHODS

We extracted sensitivity and specificity data from 12 studies reporting on >or=30 cancer patients with PSA values between 2.0 and 10.0 ng/mL. We calculated stratum-specific likelihood ratios (LR) and areas under the receiver operating characteristic (ROC) curves.

RESULTS

Multiple cutpoints for the F/T PSA ratio significantly increased the area under the ROC (0.70) compared with the single investigator-selected cutpoint (0.62), P < 0.004. The LR for the most positive cutpoint stratum (2.62) was significantly higher than the LR for a positive test from the single cutpoint (1.36), P < 0.004.

CONCLUSIONS

Using multiple cutpoints increased the discriminating power of the F/T PSA ratio and led to greater probability revisions in the most positive test-result strata.

Charting the course of medical laboratories in a changing environment

BACKGROUND

In recent decades, dramatic changes have occurred in the organization, number and type of tests, and role of medical laboratories in healthcare. The role of laboratory professionals has undergone a radical change, which calls for greater analytical accuracy, and more stringent test selection, and interpretation of results.

METHODS

The ancillary role of clinical laboratories in the past was analyzed in order to understand why the change has taken place, and to identify old and new areas in which laboratory information is largely used for improving upon decision making for treatment, and patient management.

RESULTS

The availability of real-time laboratory results and more effective tests, the enhanced clinical consulting role, the involvement in therapeutic decisions, the efforts to prevent rather than cure disease, the shift from anecdotal care to evidence-based medicine, and the assessment of outcome for laboratory tests have all contributed to the changing role and duties of medical laboratories.

CONCLUSIONS

Crucial elements in sustaining the changes in the role and contribution of medical laboratories to a high-quality healthcare are the ability of laboratory professionals to: guarantee the quality of laboratory tests irrespective of where they are performed; improve the quality of services; improve clinical outcomes; and perform joint clinical/laboratory research projects. A key factor in effecting the change has been the awareness of the importance of the knowledge and skills required for the new role of laboratory professionals.

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

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

Contemporary use of complexed PSA and calculated percent free PSA for early detection of prostate cancer: impact of changing disease demographics

OBJECTIVES

To assess the diagnostic performance of complexed prostate-specific antigen (cPSA), total PSA (tPSA), and calculated free/total PSA (f/t PSA) ratios in the differentiation of benign disease from prostate cancer (CaP) using a contemporary patient cohort.

METHODS

The cPSA, tPSA, and calculated fPSA values were determined using the Bayer Immuno-1 system. To validate our calculated f/t PSA ratio, we also retrospectively measured fPSA using the Abbott AxSYM immunoassay system in archival pretreatment sera obtained between 1990 and 1997 from 362 men with clinically and biopsy-confirmed benign prostatic hyperplasia (n = 179) or CaP (n = 183). The diagnostic utility of tPSA, cPSA, and the calculated f/t PSA ratio was assessed using a contemporary test population consisting of sera prospectively collected between June 1999 and June 2000 from 3006 men who had recently undergone a systematic biopsy by urologists in clinical practices throughout the United States. This contemporary patient sample had biopsy diagnoses of either no evidence of malignancy (n = 1857) or CaP (n = 1149). All serum samples had tPSA values between 2.0 and 20.0 ng/mL.

RESULTS

The measured versus calculated f/t PSA ratios had a Pearson's correlation coefficient of 0.9130 in the retrospectively studied population of 362 men. The areas under the receiver operating characteristic curves (ROC-AUCs) for the measured and calculated f/t PSA ratios were indistinguishable (69.6% versus 69.2%, respectively). In the contemporary population (n = 3006), the ROC-AUC for tPSA, cPSA, and the calculated f/t PSA ratio was 52.2%, 53.9%, and 58.4%, respectively. We also compared the diagnostic performance using published cutoffs for tPSA (greater than 4.0 ng/mL), cPSA (greater than 3.8 ng/mL), and the f/t PSA ratio (greater than 15% and greater than 25%) in tPSA reflex ranges of 2 to 20 ng/mL and 2 to 10 ng/mL. We found that both cPSA and the f/t PSA ratio (greater than 25% cutoff) outperformed tPSA and yielded similar results in terms of biopsies spared and cancers missed.

CONCLUSIONS

The calculated f/t PSA ratio and cPSA perform equally well in terms of the improvement of specificity in the discrimination of benign disease and CaP. The f/t PSA ratio and cPSA provide clinical benefits over the use of tPSA alone, such as an increased sparing of unnecessary biopsies performed with a manageable degree of risk of delayed cancer detection.

Determination of immunoreactive gonadotropin-releasing hormone in serum and urine by on-line immunoaffinity capillary electrophoresis coupled to mass spectrometry

The need for urgent diagnoses has propelled the development of automated analyses that can be performed in a short time at reasonable cost. One such method is immunoaffinity capillary electrophoresis. This emerging hybrid technology employs two powerful techniques coupled on-line for the direct and rapid determination of analytes present in biological fluids. The first technique, immunoaffinity, is used for the selective extraction of a molecule present in a complex matrix, utilizing a microscale-format chamber affinity device. An analyte (affinity target) present in serum or urine is captured by an immobilized molecular recognition antibody molecule (affinity ligand) bound to a solid support constituent (glass beads or an appropriate porous structure) of a microchamber affinity device. The second technique, capillary electrophoresis, is used for the high-resolution analytical separation of the purified and concentrated affinity target material after elution from the microchamber affinity device. In this work, immunoaffinity capillary electrophoresis was developed for the identification and characterization of a single constituent of a complex matrix. Immunoreactive gonadotropin-releasing hormone was determined in serum and urine specimens derived from a normal individual and from a patient suffering from benign prostatic hyperplasia. Furthermore, the on-line immuno-separation system was coupled in tandem to mass spectrometry to obtain molecular mass information of the affinity isolated and CE separated neuropeptide. This hybrid immuno-analytical technology is simple, rapid, selective and sensitive. In addition, an attempt was also made to characterize other urinary constituents by CE-MS that may lead to marker activity in the urine of the diseased subject. The hyphenation of analytical techniques has proved valuable in enhancing their individual features. The future of bioanalysis using miniaturized affinity systems is discussed in this paper.