The Relationship Between Prostate Biopsy Results and PSA and Free PSA Ratio Changes in Elevated Serum PSA Patients with and without Antibiotherapy

Objectives:

To evaluate the impact of antibiotic treatment on total prostate specific antigen (PSA) levels and free/total (f/t) PSA ratio and the relevance of these changes to prostate biopsy results.

Methods:

We retrospectively evaluated 1,062 patients with elevated age-adjusted serum PSA levels who underwent prostate biopsy between 2004 and 2016. A total of 303 cases with followup PSA levels and f/t PSA ratio before and after antibiotherapy were included into this study. There were 214 patients with persistent elevated serum PSA levels after antibiotic treatment followed by prostate biopsy (treatment group) and 89 patients who had prostate biopsy after a mean followup of 1 month without antibiotherapy (control group). The groups were compared with regard to both 5% and 10% cut off changes in serum PSA levels and f/t PSA ratios.

Results:

Antibiotic treatment had no impact on the relation between serum PSA levels and biopsy results at both cut off values. On the other hand, f/t PSA ratio changes at both cut off values with relevance to antibiotic treatment were found to be related with histopathologic results. While increase in f/t PSA ratio was more related with benign biopsies, decrease in f/t PSA ratio was more related with cancer (for 5% cut off value p= 0.014, p= 0.004; for 10% cut off value p= 0.026, p= 0.014).

Conclusion:

Changes at f/t PSA ratio rather than total PSA only, particularly in antibiotic treated cases appear to be more useful in decision making for biopsy.

Antibiotic therapy in patients with high prostate-specific antigen: Is it worth considering? A systematic review

Objective: To address the question of whether antibiotic therapy can obviate the need for prostate biopsy (PBx) in patients presenting with high prostate-specific antigen (PSA) levels.

Methods: With the increase in unnecessary PBx in men with high PSA levels, a systematic review was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Results: The literature search yielded 42 studies, of which 11 were excluded due to irrelevance of data. Most of the studies were retrospective, nine studies were randomised controlled trials, and there were seven prospective non-randomised trials. The age range of the patients was 51–95 years. Antibiotics, predominantly ofloxacin or ciprofloxacin, combined with a non-steroidal anti-inflammatory drug (NSAID) or not, were prescribed for 2–8 weeks. All studies focussed on PSA levels ranging from ≤ 4 to ≥ 10 ng/mL. Furthermore, antibiotic therapy normalised PSA levels by a wide variety of percentages (16–59%), and the PSA level decrease also varied widely and ranged from 17% to 80%. For patients who had unchanged or decreased PSA, carcinoma was found in 40–52% and 7.7–20.3%, respectively. No cancer was detected if the PSA level decreased to < 4 ng/mL.

Conclusion: Antibiotic therapy is clinically beneficial in patients with high PSA levels. PSA reduction or normalisation after medical therapy, either antibiotic and/or NSAID, for ≥ 2 weeks can avoid unnecessary PBx. Antibiotic therapy is more beneficial when the PSA level is < 20 ng/mL.

Abbreviations: EPS: expressed prostatic secretion; PBx: prostate biopsy; (%f)(f/t)(t)PSA, (percentage free) (free/total) (total) serum PSA; PSAD: PSA density; RCT: randomised controlled trial; VB3: voided bladder urine 3

Oral administration of cernitin pollen extract (Cernilton® ) for 30 days might be useful to avoid unnecessary biopsy in prostate biopsy candidates: A preliminary study

OBJECTIVES

To assess the effect of cernitin pollen extract on serum prostate-specific antigen level prostate biopsy candidates, and to develop an ideal protocol to avoid an unnecessary biopsy procedure.

METHODS

A total of 61 patients were administrated cernitin pollen extract tablets (two tablets t.i.d.) for 30 days, and then underwent a prostate biopsy with ≥12 systematic and targeted biopsy cores obtained. Serum prostate-specific antigen levels were examined before and after administration of the pollen extract, and the change in serum prostate-specific antigen and the rate of change were analyzed in relation to negative and positive biopsy results for cancer.

RESULTS

The mean change in serum prostate-specific antigen and rate of change after administration of cernitin pollen extract in all patients were -0.6 ± 1.4 ng/mL and -7.6 ± 16.1%, respectively, which were significantly different from the baseline values (P = 0.0003 and P = 0.0005, respectively). When prostate-specific antigen change values and rates were compared between patients negative and positive for cancer, a significant difference between those groups was observed (P = 0.04 and P = 0.03, respectively).

CONCLUSIONS

The present study is the first to show that an ideal protocol using cernitin pollen extract has the potential to avoid an unnecessary prostate biopsy procedure in patients with elevated prostate-specific antigen, possibly caused by inflammation. Additional studies with greater numbers of participants are required to confirm our findings and develop an ideal protocol.

Do antibiotics decrease prostate-specific antigen levels and reduce the need for prostate biopsy in type IV prostatitis? A systematic literature review

INTRODUCTION

Inflammation of the prostate can be a cause of elevated prostate-specific antigen (PSA) in men referred for suspected prostate cancer. This systematic review assesses the evidence for antibiotic therapy in patients with type IV (asymptomatic) prostatitis with regard to reduction of PSA levels and discrimination between prostate cancer and inflammation.

METHODS

MEDLINE, EMBASE, and the Cochrane registry were searched for papers reporting on cohorts of men with elevated PSA and type IV prostatitis that were treated with antibiotics.

RESULTS

The search yielded 160 papers, of which 11 met the inclusion criteria: two randomized trials and nine cohort studies. In total, the studies reported on 1011 patients with type IV prostatitis, of whom 926 were treated with antibiotics. PSA normalization was seen after antibiotic treatment in 33.2% of patients (95% confidence interval [CI] 24.9-42.8). Meta-analysis of the randomized trials did not demonstrate a higher likelihood of PSA normalization in the antibiotics arm as compared to the control arm (odds ratio [OR] 1.27; 95% CI 0.58-2.76; p=0.553). Four studies performed prostate biopsies in all patients. Although three of these studies demonstrated lower prevalence of prostate cancer in patients in whom PSA had normalized, meta-analysis failed to show a statistically significant difference (OR 0.39; 95% CI 0.06-2.49; p=0.319).

CONCLUSIONS

The available evidence does not support antibiotic therapy for differentiation between benign and malignant cause of elevated PSA in men with type IV prostatitis.

Does PSA reduction after antibiotic therapy permits postpone prostate biopsy in asymptomatic men with PSA levels between 4 and 10 ng/mL?

Purpose

We investigated the effect of antibiotics on PSA in asymptomatic patients with mild PSA elevation.

Materials and Methods

We prospectively evaluated, in a non-randomized design, 106 asymptomatic patients with PSA of 4-10ng/mL, with a negative digital rectal examination and with no urinary tract infection evidence for 2 years. Patients were divided into two groups: those treated with antibiotics for 3 weeks (G1) and those who were not treated (G2). PSA was taken six weeks after and prostate biopsy was performed in all patients.

Results

PCa was diagnosed in 25 of 106 patients (23.6%): 16 (25.0%) in G1 and 9 (21.4%) in G2 (p>0.05). PSA normalization was experienced in 24.5%. In G1, PSA returned to <4ng/mL in 15 (23.4%) patients compared to 11 (26%) patients in G2. In the patients with a positive biopsy, no significant variation was noted in PSA, fPSA, %fPSA and DPSA after antibiotic treatment. A significantly lower cancer detection rate was noted with decreased PSA, fPSA, and DPSA after antibiotic use. A PSA reduction rate of ≥10% occurred in 58.5%, and this was similar in both G1 and G2 groups. The sensibility, specificity and accuracy of PSA reduction of ≥10% were 31%, 23% and 25%, respectively.

Conclusion

Empirical antibiotic therapy in asymptomatic male patients is not related to PSA reduction. The greater than 10% PSA reduction after antibiotic in this population cannot postpone prostate biopsy.

Male hypogonadism

Male hypogonadism is a clinical syndrome that results from failure to produce physiological concentrations of testosterone, normal amounts of sperm, or both. Hypogonadism may arise from testicular disease (primary hypogonadism) or dysfunction of the hypothalamic-pituitary unit (secondary hypogonadism). Clinical presentations vary dependent on the time of onset of androgen deficiency, whether the defect is in testosterone production or spermatogenesis, associated genetic factors, or history of androgen therapy. The clinical diagnosis of hypogonadism is made on the basis of signs and symptoms consistent with androgen deficiency and low morning testosterone concentrations in serum on multiple occasions. Several testosterone-replacement therapies are approved for treatment and should be selected according to the patient's preference, cost, availability, and formulation-specific properties. Contraindications to testosterone-replacement therapy include prostate and breast cancers, uncontrolled congestive heart failure, severe lower-urinary-tract symptoms, and erythrocytosis. Treatment should be monitored for benefits and adverse effects.

Adding Cyclooxygenase-2 inhibitor to alpha blocker for patients with benign prostate hyperplasia and elevated serum prostate specific antigen could not improve prostate biopsy detection rate but improve lower urinary tract symptoms

AIMS

To investigate the impact of cyclooxygenase-2 (COX-2) inhibitor with α-adrenoceptor blocker (α-blocker) for men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) for detecting prostate cancer in men with elevated prostate specific antigen (PSA).

MATERIALS AND METHODS

Male patients with clinical BPH, elevated serum PSA (> 4 ng/ml), and significant LUTS (International Prostate Symptom Score [IPSS] ≥ 8) were randomly assigned to receive doxazosin 4 mg daily plus celecoxib 200 mg daily (study group) or doxazosin 4 mg daily alone (control group) for 3 months. Patients were investigated for the changes in IPSS, maximum flow rate (Qmax), voided volume, postvoid residual (PVR) volume and serum PSA from baseline to 3 months after treatment. After the 3-month therapy, prostate biopsy was performed in the patients whose PSA were still higher than 4 ng/ml.

RESULTS

A total of 82 patients completed the study. The improvement in IPSS-voiding was significantly greater in the study group than control group (p = 0.034). In the study group, patients with prostatic hyperplasia or inflammation on the prostate biopsy had a significantly better result than in patients with prostatic adenocarcinoma, typically in the changes of Qmax and voided volume (p = 0.012 and p = 0.005, respectively). The PSA level in the study group showed significant improvement after treatment (p < 0.01). However, prostate cancer detection rate failed to show any significant difference between the patients whose PSA levels decreased or not (6/21 = 29% vs. 5/24 = 20%, respectively, p = 0.447).

CONCLUSIONS

Treatment with COX-2 inhibitor and α-blocker for 3 months could not improve prostatic cancer detection rate. But it could increase therapeutic effectiveness of LUTS in men with BPH and elevated PSA levels. The changes in Qmax and voided volume after combination treatment were significantly greater in patients with prostatic hyperplasia or inflammation than adenocarcinoma.

Antimicrobial therapy for asymptomatic patients with elevated prostate-specific antigen: can the change in prostate-specific antigen reliably guide prostate biopsy decisions?

OBJECTIVES

To assess the effects of a 4-week levofloxacin course on PSA in asymptomatic men with elevated prostate-specific antigen (PSA) and on prostate biopsy decision.

METHODS

Fifty asymptomatic men with elevated PSA (4.0-10.0 ng/dl) were given levofloxacin 500 mg/day for 4 weeks followed by repeat PSA. Prostate biopsy was recommended at the end of the study. We compared pre- and post-treatment PSA as well as PSA changes between prostate cancer cases and non-cancer patients.

RESULTS

Mean (±SD) PSA decreased from 6.91 ± 2.13 to 6.05 ± 3.0 ng/dl after antimicrobial treatment (p = 0.025). Twenty-five (56.8%) patients had a post-treatment decrease in PSA, including 20 (45.5%) patients to <4.0 ng/dl and/or >25% of the initial PSA value. The difference in PSA change between prostate cancer and non-cancer patients was not statistically significant (p = 0.104).

CONCLUSIONS

Levofloxacin resulted in an overall decrease in PSA for asymptomatic men with PSA in the 4-10 ng/dl range. PSA changes, however, were not significantly different between patients with prostate cancer and non-cancer patients. Prostate cancer was detected in 20% of patients with a clinically relevant PSA decline.

Does an inflammatory pattern at primary biopsy suggest a lower risk for prostate cancer at repeated saturation prostate biopsy?

INTRODUCTION

To evaluate if an inflammatory pattern at primary biopsy is associated with a lower risk for cancer in men submitted to repeated saturation prostate biopsy (SPBx).

METHODS

From January 2005 to January 2010, 320 patients, after a negative primary extended biopsy (median 18 cores), underwent SPBx by transperineal approach performing 27 cores (median). 210 (65.6%) patients had a normal parenchyma and 110 had an inflammatory pattern (34.4%) at primary biopsy (none of them complained of symptoms suggesting a diagnosis of acute prostatitis at the time of biopsy). Moreover, median prostate-specific antigen and abnormal digital rectal examination was equal to 7.3 ng/ml and 3.6% versus 8.2 ng/ml and 3.8%, respectively.

RESULTS

Prostate cancer (PCa) was found in 66 (20.5%) of 320 patients. Of these, 42 (63.6%) and 24 (36.4%; p = 0.007) had a histological diagnosis of chronic prostatitis and normal parenchyma at primary biopsy, respectively.

CONCLUSIONS

An inflammatory pattern at primary biopsy is not associated with a decrease in PCa incidence at repeated SPBx; therefore, only an accurate clinical evaluation including more parameters (i.e. urinary PCA3) could hopefully select men who need to undergo rebiopsy in the presence of persistent suspicion of cancer.

Body mass index and serum lipid profile influence serum prostate-specific antigen in Chinese men younger than 50 years of age

This study is to assess the potential factors that could affect the serum prostate-specific antigen (PSA) level in healthy younger men. We evaluated the associations of age, body mass index (BMI) and serum lipid profile with serum PSA level in 6774 Chinese men (aged 20-49 years) who received a routine health examination. Eligible men were classified into 10-year age groups. BMI was categorized as underweight (<18.5), normal (18.5-22.9), overweight (23.0-24.9), obese (25.0-29.9) and very obese (>30) according to the redefined World Health Organization (WHO) criteria for the Asia-Pacific region. PSA levels were compared among groups as well. In multiple linear regression analysis, PSA was positively correlated with age (P<0.0001). Negative correlations existed between PSA and BMI (P<0.0001) and triglyceride level (P=0.01). No relationship could be found between PSA and serum cholesterol (P=0.711) or high-density lipoprotein (HDL; P =0.665). In addition, we found that serum PSA levels increased with age and decreased with BMI. Our study demonstrates that age, BMI and triglyceride levels influence the PSA level in men <50 years of age.

PSA levels of 4.0 - 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy

PURPOSE

The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy.

MATERIALS AND METHODS

We conducted a retrospective chart review of patients in a large community practice (2003 - 2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1- to 2-month intervals, whether a prostate biopsy was performed and its result.

RESULTS

One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1%) having received antibiotics (group 1); the PSA levels decreased in 39 (60%) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25%). Twenty-six (40%) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12%). The other 70 (51.9%) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60%) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31%). In the other 28 (40%) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42%).

CONCLUSIONS

There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

The correlation of extent and grade of inflammation with serum PSA levels in patients with IV prostatitis

OBJECTIVES

The inflammation was categorized more profoundly, using the standardized histopathological classification system for chronic prostatitis of NIH, to determine the influence of prostatic inflammation on serum PSA levels.

METHODS

The study included 120 patients who underwent transperineal ultrasound-guided prostate biopsy. The patients were divided into groups using 3 grades for the extent, the location and the aggressiveness of prostate inflammation. The serum tPSA levels, fPSA levels, %fPSA, and PSAD in each group were compared.

RESULTS

Of 120 patients, 80 with benign prostatic tissue in their biopsy specimens met the inclusion criteria, excluding 40 cases with prostate cancer. The inflammation was present in 46(57.5%) of 80 cases. The extent of inflammation correlated positively with the total PSA level (r = 0.6, P < 0.001), fPSA (r = 0.5, P = 0.001) and PSAD (r = 0.6, P < 0.001). The grade of inflammation correlated positively with the total PSA level (r = 0.5, P < 0.001), fPSA (r = 0.4, P = 0.008) and PSAD (r = 0.7, P < 0.001). A negative correlation was found between the grade of inflammation and %fPSA (r = -0.4, P = 0.013).

CONCLUSIONS

If the elevation of serum PSA is thought to be caused by asymptomatic prostatitis with high aggressiveness score in BPH patients without clinical prostatitis, it might prevent unnecessary repeated biopsies.

Prostate specific antigen decrease and prostate cancer diagnosis: antibiotic versus placebo prospective randomized clinical trial

PURPOSE

Prostate inflammation can lead to an increase in serum prostate specific antigen concentration and confound the use of prostate specific antigen kinetics. Repeat prostate specific antigen measurements after a period of observation or a course of empirical antibiotics are controversial in terms of the optimal approach to reduce the confounding impact on prostate cancer screening. This issue was analyzed in patients with a diagnosis of type IV or asymptomatic prostatitis (National Institutes of Health classification) and high prostate specific antigen.

MATERIALS AND METHODS

We studied 200 men between 50 and 75 years old with a high prostate specific antigen (between 2.5 and 10 ng/dl). Of these patients 98 (49%) had a diagnosis of type IV prostatitis. In a prospective, double-blind trial they were randomized to receive placebo (49 patients, group 1) or 500 mg ciprofloxacin (49 patients, group 2) twice a day for 4 weeks. Prostate specific antigen was determined after treatment and all patients underwent transrectal ultrasound guided biopsy of the prostate.

RESULTS

In group 1, 29 (59.18%) patients presented with a decrease in prostate specific antigen and 9 (31%) had cancer on biopsy, while in group 2 there were 26 (53.06%) patients with a decrease in prostate specific antigen and 7 (26.9%) with prostate cancer. There was no statistical difference in either group in relation to prostate specific antigen decrease after treatment or the presence of tumor.

CONCLUSIONS

A considerable number of patients (49%) were diagnosed with type IV prostatitis and high prostate specific antigen in agreement with the current literature. Of the patients 26.9% to 31% presented with a decrease in prostate specific antigen after the use of antibiotic or placebo and harbor cancer as demonstrated on prostate biopsy. Prostate specific antigen decreases do not indicate the absence of prostate cancer.

Effectiveness of antibiotics given to asymptomatic men for an increased prostate specific antigen

PURPOSE

Although there is controversy surrounding this subject, some urologists in daily practice often prescribe antibiotics before biopsy to men with a newly increased prostate specific antigen. We evaluated the effects of antibiotics on serum total prostate specific antigen, free prostate specific antigen, percent free prostate specific antigen and prostate specific antigen density in men with prostate specific antigen between 4 and 10 ng/ml and normal digital rectal examination. We also investigated the incidence of prostate cancer after antibiotic treatment by performing prostate biopsies in all patients regardless of posttreatment prostate specific antigen.

MATERIALS AND METHODS

Between May 2006 and April 2008 a total of 100 men with total prostate specific antigen between 4 and 10 ng/ml were enrolled in this study. In addition to total prostate specific antigen, free prostate specific antigen, percent free prostate specific antigen and prostate specific antigen density values were evaluated for all of the patients. Patients with pathological digital rectal examination and urinalysis were excluded from the study. All patients received 400 mg ofloxcacin daily for 20 days. After treatment the patients were reevaluated. Regardless of the total prostate specific antigen value after therapy transrectal ultrasound guided prostate biopsy was performed.

RESULTS

Overall 23 men (23%) had histologically proven prostate cancer on biopsy. Mean total prostate specific antigen, free prostate specific antigen and prostate specific antigen density decreased after treatment in patients with and without prostate cancer. However, these reductions within these parameters were not significantly different between patients with and without prostate cancer. Only percent free prostate specific antigen change after treatment was found to be significantly different between patients with and without prostate cancer (p = 0.015). In 17 of the 100 men total prostate specific antigen after treatment was less than 4 ng/ml and of these 5 (29.4%) had prostate cancer on biopsy.

CONCLUSIONS

Although antibiotic therapy will decrease serum total prostate specific antigen, it will not decrease the risk of prostate cancer even if the prostate specific antigen decreases to less than 4 ng/ml. Therefore, prescribing antibiotics for asymptomatic men with a newly increased prostate specific antigen may not be an appropriate method of management.