Hyper-elevated prostate-specific antigen levels are not always carcinoma

Abstract

An 81-year-old man with a past history of diabetes, hypertension, ischaemic heart disease and cerebrovascular disease was admitted to hospital with hypotension and bradycardic collapse. Owing to persistent hypotension and a low urine output, an indwelling catheter (IDC) was inserted per urethra and a cardiac pacemaker was placed the following day. A serum prostate-specific antigen (PSA) level was back-ordered on initial bloods taken before IDC insertion, as passing the catheter was difficult and he was noted to have an enlarged prostate. A trial of void without catheter was successful 24 hours after initial insertion, leading to discharge that evening He represented to the emergency department in acute urinary retention the day following discharge and gave no past history of significant lower urinary tract symptoms. An IDC was again inserted draining 700 ml and notes were obtained from his previous admission indicating that he had a PSA of 933 ng/ml (Immulite 2000, Diagnostic Products Corporation, Los Angeles, USA) on admission. The plan was for staging of prostate cancer and needle biopsy in the future to confirm the diagnosis. On examination, his prostate was enlarged and firm with no obvious nodular change. A bone scan was negative for metastatic prostate cancer. Prostatic needle biopsies (18 gauge) were undertaken revealing benign glands and also the edge of coagulative necrosis (Figure 1). The necrosis involved both stroma and glands, and was surrounded by a zone of immature fibrous tissue containing nests of metaplastic squamous epithelium (Figure 2). Findings were consistent with prostatic infarction and there was no evidence of malignancy. A repeat serum PSA demonstrated a rapid descent to 9.3 ng/ml. The patient was discharged after a successful trial of void and is now catheter free.