Elevated Prostate-specific Antigen Levels Research Articles

Relation of Serum Prostate-Specific Antigen with Histological Features and Grading of Prostate Adenocarcinoma in Prostatic Biopsies

Abstract Introduction: The present study was undertaken on cases of prostate carcinoma and we tried to determine the relationship of elevated prostate specific antigen (PSA) level to histopathologic features associated with cancer in prostate biopsies and their relation to newest grade groups. Materials and Methods: The study was conducted in a tertiary health care center over a span of 3 years on patients with prostatic adenocarcinoma. The hematoxylin and eosin sections were reviewed as per World Health Organization 2016 new grading system and various other associated histopathological findings in the tissue noted. We tried to analyse correlation between serum PSA levels and histopathological features. Results: The majority of patients were in the age group of 70–80. Many patients (9/44) had the PSA in the range of 20–40 ng/ml and 10 patients (22.7%) had 80–100 ng/ml. There were three patients with normal PSA level and six patients with borderline level. Nine of 10 patients with marked increase in PSA level had higher grade groups. Histological subtyping showed 42 cases of acinar adenocarcinoma and 2 cases of ductal carcinoma. A number of associated findings were seen like benign prostatic hyperplasia (BPH): 13 cases, prostatitis: 28 cases, prostatic intraepithelial neoplasia: 7 cases - Low grade (1 case) and high grade (6 cases), and atrophy: 9 cases. Conclusions: We noticed majority of patients with grade group (GG) 3 and above had PSA value of more than 40 ng/ml, but PSA of <40 ng/ml did not correlate with the histologic grade groups. There was significant cut off value of PSA level 20 ng/ml between GG2 and GG3, differentiation of which is of clinical and histopathological significance. Histological subtyping showed acinar adenocarcinoma has no significant correlation with PSA levels however ductal carcinoma was associated with PSA levels <20 ng/ml. BPH association was seen to have PSA level of <40 ng/ml in majority of cases. The intensity of inflammation did not correlate with either degree of PSA level or histologic GG. We concluded serum PSA assay has prognostic application in the evaluation of patients undergoing prostate biopsies.

Preoperative PSA levels and development of PSA after 180-W XPS greenlight laser treatment of the prostate: what is the reality in clinical routine practice?

The aim of this retrospective study was to evaluate preoperative levels of PSA (prostate-specific antigen) and the postoperative development after 180-W XPS™ greenlight laser treatment of the prostate under real-world conditions. Preoperative PSA levels were evaluated in 749 patients undergoing a 180-W XPS greenlight laser procedure from 2012 to 2017 in Witten, Germany, in relation to age, volume of the prostate, urinary tract infection, Foley catheter and co-morbidities. The postoperative development of PSA was identified by retrieving PSA levels from general practitioners or urologists. The average age of the patients was 73.33 ± 9.26 years. The prostate volume measured by rectal ultrasound was 42.42 ± 18.33 ml. Median preoperative PSA was 2.59 ng/ml. In 268 patients (35.8 %), the PSA level was above 4 ng/ml. It was evaluated by prostate biopsy in 106 patients (39.6 %). 6 months after the surgical procedure (n = 86), PSA decreased to 1.25 ng/ml and increased slightly to 1.46 ng/ml after 12 months (n = 126). Logistic regression analysis demonstrated that a PSA level elevated to more than 4 ng/ml preoperatively is related to prostate volume (p = 0.001) the existence of a transurethral Foley catheter (p = 0.002), but not to age (p = 0.349), the existence of a suprapubic catheter (p = 0.207), an infection of the lower urinary tract (p = 0.966) and the number of co-morbidities mentioned in the discharge letter (p = 0.936). In line with expectations and clinical trials, there was a postoperative decrease of PSA by more than a half of the preoperative value. Significant factors related to preoperative elevation of the PSA level were prostate volume, a transurethral Foley catheter instead of the suprapubic type of catheter and a urinary infection. Although elevated PSA levels were seen in about one third of patients, evaluation by prostate biopsy was only performed in 39.6 % of these patients due to their performance status and other clinical issues.

Measurement of Prostate Volume with MRI (A Guide for the Perplexed): Biproximate Method with Analysis of Precision and Accuracy

To review the anatomic basis of prostate boundary selection on T2-weighted magnetic resonance imaging (MRI). To introduce an alternative 3D ellipsoid measuring technique that maximizes precision, report the intra- and inter-observer reliability, and to advocate it’s use for research involving multiple observers. We demonstrate prostate boundary anatomy using gross pathology and MRI examples. This provides background for selecting key boundary marks when measuring prostate volume. An alternative ellipsoid volume method is then proposed using these boundaries in an attempt to improve inter-observer precision. An IRB approved retrospective study of 140 patients with elevated serum prostate specific antigen levels and/or abnormal digital rectal examinations was done with T2-weighted MRI applying a new (Biproximate) technique. Measurements were made by 2 examiners, correlated with each other for inter-observer precision and correlated with an expert observer for accuracy. Correlation statistics, linear regression analysis, and tests of means were applied using p ≤ 0.05 as the threshold for significance. Inter-observer correlation (precision) was 0.95 between observers. Correlation between these observers and the expert (accuracy) was 0.94 and 0.97 respectively. Intra-observer correlation for the expert was 0.98. Means for inter-rater reliability and accuracy were all the same (p = 0.001). We conclude that using more precise reproducible landmarks with biproximate technique, precision and accuracy of total prostate volume is found to be demonstrated.

Magnetic resonance imaging-ultrasound fusion-targeted biopsy combined with systematic 12-core ultrasound-guided biopsy improves the detection of clinically significant prostate cancer: Are we ready to abandon the systematic approach?

Background:Multiparametric (mp) magnetic resonance imaging (MRI)–ultrasound fusion-targeted biopsy (TB) has improved the detection of clinically significant prostate cancer (csCaP) using the Prostate Imaging Reporting and Data System (PI-RADS) reporting system, leading some authors to conclude that TB can replace the 12-core systematic biopsy (SB). We compared the diagnostic performance of TB with SB at our institution.Methods:Eighty-three men with elevated prostate-specific antigen levels (6.6 ng/mL, interquartile range [IQR] 4.5–9.2) and abnormal mp-MRI (127 lesions, PI-RADS ≥3, median size: 1.1 cm, IQR 0.8–1.6) underwent simultaneous TB and SB. Diagnosis of any CaP (Gleason score, [GS] ≥6) and csCaP (GS ≥7) was compared using the McNemar's exact test.Results:SB showed higher, but not statistically significant, detection rates of any CaP and csCaP (51.8% and 34.9%) versus TB (44.6% and 28.9%) (P = 0.286 and P = 0.359, respectively). TB outperformed SB in the quantification of 56.6% CaP and detecting cancer in anterior sectors (7.2%). Compared to SB, TB missed twice the amount of any CaP and csCaP. SB alone detected 22.2% of all csCaPs and upgraded 20.6% of TB-detected CaP. SB identified cancer invisible on mp-MRI (13.7% of all CaP) or missed by TB due to a small size (<1 cm) and sampling error (7% of lesions).Conclusion:A combination of SB with TB remained necessary for achieving the highest cancer detection rates. Limiting prostate biopsy to TB alone can miss csCaP due to the presence of synchronous high-grade cancer invisible on MRI or failure to hit the target. TB is the best approach for anterior lesions and tumor quantification.

Mapping Prostate Cancer Lesions Before and After Unsuccessful Salvage Lymph Node Dissection Using Repeat PSMA PET.

The aim of this study was to analyze patterns of persistent versus recurrent or new PET lesions in a selected patient cohort with prostate-specific antigen (PSA) persistence after salvage lymph node dissection (SLND) and pre-procedure and post-procedure prostate-specific membrane antigen (PSMA) ligand PET. Methods: Sixteen patients were included in this multicenter study. The inclusion criteria were PSMA PET performed for biochemical recurrence before SLND (pre-SLND PET) and repeat PSMA PET performed for a persistently elevated PSA level (≥0.1 ng/mL) at least 6 wk after SLND (post-SLND PET). Image analysis was performed by 3 independent nuclear medicine physicians applying the molecular imaging TNM system PROMISE. Lesions were confirmed by histopathology, presence on correlative CT/MRI/bone scanning, or PSA response after focal therapy. Results: Post-SLND PET identified prostate cancer lesions in 88% (14/16) of patients with PSA persistence after SLND. Median PSA was 1.2 ng/mL (interquartile range, 0.6-2.8 ng/mL). Disease was confined to the pelvis in 56% of patients (9/16), and most of these men had common iliac (6/16, 38%) and internal iliac lymph node metastases (6/16, 38%). Extrapelvic disease was detected in 31% of patients (5/16). In pre- and post-SLND PET comparison, 10 of 16 had at least one lesion already detected at baseline (63% PET persistence), 4 of 16 had new lesions only (25% PET recurrence), and 2 had no disease on post-SLND PET. All validated regions (11 regions in 9 patients) were true-positive. Nine of 14 (64%) patients underwent repeat local therapies after SLND (7/14 radiotherapy, 2/14 surgery). Conclusion: SLND of pelvic nodal metastases was often not complete according to PSMA PET. About two thirds of patients had PET-positive nodal disease after SLND already seen on pre-SLND PSMA PET. Notably, about one quarter of patients had new lesions, not detected by presurgical PSMA PET.

18F-Fluciclovine.

18F-fluciclovine (Axumin; Blue Earth Diagnostics) is an amino acid analog indicated for PET in men with suspected recurrent prostate cancer based on an elevated level of prostate-specific antigen (PSA) after prior treatment ([4][1]). None. ### Before Arrival in PET/CT Department ### On Arrival in

Is Engrailed-2 (EN2) a truly promising biomarker in prostate cancer detection?

Purpose: Prostate-specific antigen (PSA) is a sensitive but unspecific marker for prostate cancer (PC) detection, which may result in harms including overdiagnosis and overtreatment. Therefore, the development of new markers is of absolute value. The urinary level of engrailed-2 (EN2) protein has been recently suggested as a promising PC biomarker, correlating with tumour volume and stage. This study evaluated EN2 and its potential use in clinical practice.Materials and methods: Urinary EN2 was assessed by different commercially available enzyme-linked immunosorbent assay kits. The study sample included 90 patients with clinically localized PC compared to 30 healthy controls, and a group of 40 patients indicated for prostate biopsy due to an elevated PSA level where both pre- and post-digital rectal examination urine samples were collected.Results: No statistical difference between the patient group and the control group was obtained in all measured variables. There was no significant correlation between urinary EN2 and serum PSA, tumour staging and grading. Attentive DRE did not lead to significant changes of urinary EN2 or impact on its predictive power.Conclusions: Our results show that EN2 as a PC biomarker brings no additional value to the current use of PSA in clinical practice.

A novel method for pain control: infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsy using transcutaneous electrical nerve stimulation (TENS).

To describe a novel method for the control of pain during prostate biopsies, infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsies with no further needle insertions for local anesthetic infiltration. A total of 138 men with elevated prostate-specific antigen levels and/or abnormal digital rectal examination findings were included in the study. Of the patients, 73 were assigned to the INFLATE group and 65 to the TRUS-PNB group. Demographic data, PSA levels, findings of digital rectal examinations, and multiparametric prostatic magnetic resonance imaging were recorded. In the INFLATE group, a two-channel TENStem eco basic device with two electrodes was used for pain control during the biopsy. For the TRUS-PNB group, 60mg lidocaine gel was given intrarectally in addition to infiltration of a prilocaine and bupivacaine mixture (5mL of 2% prilocaine + 5mL of 0.25% bupivacaine). Pain perception was assessed using a linear numeric rating scale. The mean ages, BMIs, prostate volumes, and PSA levels were similar between the two groups (p > 0.05). Of the 56 participants with prostate adenocarcinoma, 28 were in the INFLATE group, and 28 were in the TRUS-PNB group with a 40.6% overall cancer detection rate. The mean preoperative and post-operative pain scores during probe insertion, biopsy and post-biopsy were similar between the groups (p > 0.05). The results of the study confirmed that INFLATE for transrectal prostate biopsy using a TENS device could safely and effectively be used for pain control with the advantage of two fewer needle attempts with no increase in significant complications.

Early Dutasteride Monotherapy in Patients With Elevated Serum Prostate-Specific Antigen Levels Following Robot-Assisted Radical Prostatectomy.

Background: To evaluate the efficacy of early dutasteride administration in patients with a detectable prostate-specific antigen (PSA) levels after robot-assisted radical prostatectomy (RARP).Methods: We retrospectively analyzed RARP patients whose pathological stage is T2a to T3b without lymph node or distant metastasis from 2007 to 2017. All patients received a daily dose of 0.5 mg of dutasteride when post-RARP PSA levels were increasing but had not achieved biochemical recurrence. PSA levels were monitored every 3 months after dutasteride administration. None of the patients received radiotherapy (RT) or androgen-deprivation therapy (ADT) before taking dutasteride. All follow-ups were begun from RARP to January 2019 or to the date of RT/ADT.Results: Thirty-five patients were included in this analysis. The median followed up was 53.6 months. Twenty-two patients (62.9%) showed a PSA response in which the PSA decreased more than 10% at the first follow-up after dutasteride administration. The Pathological stage > T2 (p = 0.012) and positive surgical margin (p = 0.046) were prognostic factors for a PSA response. Twenty-three out of 35 included patients (65.7%) did not require further RT/ADT. The significant risk factor was the PSA level (p = 0.011) at the beginning of dutasteride treatment. The cut-off value of the PSA level to avoid further RT/ADT was 0.195 ng/ml.Conclusions: Early dutasteride administration showed a significant decline in the PSA levels of patients with pathology stage >T2 and positive surgical margin in our retrospective hypothesis-generating study. If dutasteride was provided before the PSA value increased to 0.195 ng/ml after RARP, it would reduce the probability of acquirement of RT/ADT.

18F-Choline PET/mpMRI for Detection of Clinically Significant Prostate Cancer: Part 2. Cost-Effectiveness Analysis

The objective of this study was to evaluate the cost-effectiveness of 18F-choline PET/multiparametric MRI (mpMRI) versus mpMRI alone for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 in men with elevated prostate-specific antigen levels. Methods: A Markov model of prostate cancer onset and progression was used to estimate the health and economic consequences of 18F-choline PET/mpMRI for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 in men with elevated prostate-specific antigen levels. Multiple simultaneous hybrid 18F-choline PET/mpMRI strategies were evaluated using Likert or Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) scoring; the first was biopsy for Likert 5 mpMRI lesions or Likert 3-4 lesions with 18F-choline target-to-background ratios of greater than or equal to 1.58, and the second was biopsy for PI-RADSv2 5 mpMRI lesions or PI-RADSv2 3-4 mpMRI lesions with 18F-choline target-to-background ratios of greater than or equal to 1.58. These strategies were compared with universal standard biopsy, mpMRI alone with biopsy only for PI-RADSv2 3-5 lesions, and mpMRI alone with biopsy only for Likert 4-5 lesions. For each mpMRI strategy, either no biopsy or standard biopsy could be performed after negative mpMRI results were obtained. Deaths averted, quality-adjusted life years (QALYs), cost, and incremental cost-effectiveness ratios were estimated for each strategy. Results: When the results of 18F-choline PET/mpMRI were negative, performing a standard biopsy was more expensive and had lower QALYs than performing no biopsy. The best screening strategy among those considered in this study performed hybrid 18F-choline PET/mpMRI with Likert scoring on men with elevated PSA, performed combined biopsy (targeted biopsy and standard 12-core biopsy) for men with positive imaging results, and no biopsy for men with negative imaging results ($22,706/QALY gained relative to mpMRI alone); this strategy reduced the number of biopsies by 35% in comparison to mpMRI alone. When the same policies were compared using PI-RADSv2 instead of Likert scoring, hybrid 18F-choline PET/mpMRI cost $46,867/QALY gained relative to mpMRI alone. In a threshold analysis, the best strategy among those considered remained cost-effective when the sensitivity and specificity of PET/mpMRI and combined biopsy (targeted biopsy and standard 12-core biopsy) were simultaneously reduced by 20 percentage points. Conclusion: 18F-choline PET/mpMRI for the detection of primary prostate cancer with a Gleason score of greater than or equal to 3 + 4 is cost-effective and can reduce the number of unneeded biopsies in comparison to mpMRI alone.

Prostate Cancer Development Is Not Affected by Statin Use in Patients with Elevated PSA Levels.

Background: The role of statins in prostate cancer (PCa) remains unclear. Conflicting evidence has been found concerning risk reduction with the use of statins on biochemical recurrence (BCR). In this study, we evaluated whether statin use decreases the incidence of advanced PCa in males with elevated prostate-specific antigen (PSA; ≥4.0 ng/mL) levels and determined whether statin use reduces the risk of BCR after radical prostatectomy (RP). Methods: Patients visiting the outpatient urology clinic of the VU Medical Center between 2006 and 2018 with elevated PSA were retrospectively analyzed. Biochemical recurrence after RP was defined as a PSA level of ≥0.2 ng/mL (measured twice). Results: A total of 1566 patients were included, of which 1122 (72%) were diagnosed with PCa. At the time of diagnosis, 252 patients (23%) used statins compared to 83 patients (19%) in the non-malignancy group (p = 0.10). No differences were found in the use of statins between the different risk groups. No correlation was found between the risk of BCR after RP and the use of statins in the total (p = 0.20), the intermediate-risk group (p = 0.63) or the high-risk group (p = 0.14). Conclusion: The use of statins does not affect PCa development/progression in patients with elevated PSA levels, nor the development of BCR after RP.

Clinically, Radiologically and Biochemically Metastatic Cancer Prostate: Could be Treated without Biopsy? A Clinical Case Study and Review of Literature

Diagnosis of prostate cancer is suspected if there are abnormalities during digital rectal examination (DRE) and/or steady rising in levels of prostate specific antigen (PSA) and the confirmative diagnosis is established by histopathological confirmation of malignancy by biopsy from the prostate. A 87 years old male not diabetic nor hypertensive or other co-morbidities was well apart from mild lower back pain associated with mild irritative urinary symptoms, diagnosed clinically (DRE), radiologically and biochemically (markedly elevated PSA level) as a case of advanced prostate cancer and started treatment without biopsy by androgen deprivation therapy with other symptomatic support. After one month of treatment and then after, general conditions of the patient started to be significantly improved, the first follow-up CT showed considerable decrease of the mass size, then total non visualization of the previous prostatic mass, with marked decrease of the lymph nodal size in subsequent follow-up, PSA level decreased markedly, dropped from ≥700 ng/mL to 6.867 ng/mL, and then continued to decrease in subsequent monthly evaluations to reach 0.212 ng/mL at the last measurement after 8 months of treatment, that mean near complete radiologic and biochemical response. Treatment of advanced prostate cancer might be started without biopsy if there is high probabilities malignancy by DRE, imaging studies and significant rising in PSA levelin exceptional cases.

High Diagnostic Performance of Short Magnetic Resonance Imaging Protocols for Prostate Cancer Detection in Biopsy-naïve Men: The Next Step in Magnetic Resonance Imaging Accessibility

BackgroundTo make magnetic resonance imaging (MRI) more accessible to men at risk of high-grade prostate cancer (PCa), there is a need for quicker, simpler, and less costly MRI protocols. ObjectiveTo compare the diagnostic performance of monoplanar (“fast” biparametric MRI [bp-MRI]) and triplanar noncontrast bp-MRI with that of the current contrast-enhanced multiparametric MRI (mp-MRI) in the detection of high-grade PCa in biopsy-naïve men. Design, setting, and participantsA prospective, multireader, head-to-head study included 626 biopsy-naïve men, between February 2015 and February 2018. InterventionMen underwent prebiopsy contrast-enhanced mp-MRI. Prior to biopsy, two blinded expert readers subsequently assessed “fast” bp-MRI, bp-MRI, and mp-MRI. Thereafter, systematic transrectal ultrasound-guided biopsies (SBs) were performed. Men with suspicious mp-MRI (Prostate Imaging Reporting and Data System 3–5 lesions) also underwent MR-in-bore biopsy (MRGB). Outcome measurements and statistical analysisPrimary outcome was the diagnostic performance of each protocol for the detection of high-grade PCa. Secondary outcomes included the difference in biopsy avoidance, detection of low-grade PCa, acquisition times, decision curve analyses, inter-reader agreement, and direct costs. Results from combined MRGB and SB were used as the reference standard. High-grade PCa was defined as grade ≥2. Results and limitationsSensitivity for high-grade PCa for all protocols was 95% (180/190; 95% confidence interval [CI]: 91–97%). Specificity was 65% (285/436; 95% CI: 61–70%) for “fast” bp-MRI and 69% (299/436; 95% CI: 64–73%) for bp-MRI and mp-MRI. With fast bp-MRI, 0.96% (6/626) more low-grade PCa was detected. Biopsy could be avoided in 47% for the fast bp-MRI and in 49% for the bp-MRI and mp-MRI protocols. Fast bp-MRI and bp-MRI can be performed in 8 and 13min, respectively, instead of 16min at lower direct costs. Inter-reader agreement was 90% for fast bp-MRI protocol and 93% for bp-MRI protocol. A main limitation is the generalizability of these results in less experienced centers. ConclusionsShort MRI protocols can improve prostate MRI accessibility at a lower direct cost. For fast bp-MRI, this is at the cost of ∼2% more biopsies and ∼1% more overdetection of low-grade PCa. In order to implement this technique in nonexpert, low-volume, lower-field-strength scanners, further prospective studies have to be performed. Patient summaryWe compared the value of three different magnetic resonance imaging (MRI) protocols for the detection of prostate cancer in men with elevated prostate-specific antigen levels. Our results show that, when used in expert centers, shorter MRI protocols do not compromise the detection of harmful disease. This increases MRI capacity at lower direct costs.

Diagnostic value of the density of prostatspecific antigen in the detection of the prostate gland

The problem of diseases of the prostate gland (PG) today is extremely urgent. This is due to an increase in the number of cases of diseases, including malignant neoplasms, the spread of pathology among young men, difficulties in diagnosing, especially in the early stages, late detection, and an increase in mortality. Therefore, the issue of early detection of this nosology is very important. Purpose. Conduct a comprehensive analysis, which consists in comparing the specificity and ratio of indicators such as total PSA, free PSA, PSA-index, the presence or absence of acute urinary retention, and especially the PSA-density indicator with histopathological examination after transrectal biopsy of the prostate gland for early verification clinical diagnosis of prostate cancer. Material and methods. The study involved 112 patients who received treatment in the urology department of the City Clinical Hospital for Emergency and Emergency Medical Aid in Zaporozhye for the period October 2017 – October 2018 about the symptoms of the lower urinary tract and elevated levels of total PSA. All patients underwent general clinical and X-ray examination, laboratory tests, ultrasound of the urinary system, determination of the level of total and free prostate-specific antigen (PSA), digital rectal examination and transrectal biopsy of the prostate gland. All patients had a total PSA above 4 ng/ml. In this regard, a transrectal biopsy of the prostate gland was performed under the control of a transrectal ultrasound transducer. As a result, PHE patients were divided into three groups. The first group consisted of 50 patients who, as a result of PHE, received a conclusion about the presence of benign prostatic hyperplasia in them in the absence of signs of cancer. The second group consisted of 56 patients who, according to the results of PHE, had moderately differentiated (G2) adenocarcinoma of the prostate. Group 3 consisted of 6 patients who were diagnosed with poorly differentiated (G3) adenocarcinoma of the prostate in histopathology report. Results. As a result of this clinical study, it was found that patients with low-grade (G3) adenocarcinoma of the prostate gland had chronic urinary retention more often and had occurred in 83% of patients, in patients with moderately differentiated (G2) adenocarcinoma, and in patients with BPH, this figure was correspondingly 70% and 56%. Chronic urinary retention in patients with adenocarcinoma of the prostate gland was detected more frequently, and in patients with BPH, acute urinary retention was more frequent. (44% in the first group versus 30% and 17% in patients with adenocarcinoma G2 and G3, respectively). The average total PSA in patients of group 1 was 20.09 ng/ml, and in patients with moderately differentiated (G2) adenocarcinoma, it was more than 2 times and amounted to 42.45 ng/ml. It is worth noting that in patients with a diagnosis of low-grade (G3) adenocarcinoma of the prostate gland, this indicator was almost 10 times higher than in patients of group 1 and 5 times compared with patients of group 2 and was respectively 192.46 ng/ml. The maximum indicator of total PSA was also higher in patients of group 3 and amounted to 1046.0 ng/ml, and in patients with BPH and moderately differentiated (G2) adenocarcinoma, this indicator was 71.9 ng/ml and 764.0 ng/ml, respectively. The average PSA index was higher in patients with BPH (26.78%), and in patients with adenocarcinoma of G2 and G3, this figure was 22.14% and 20.5%, respectively. Special attention needs to be stopped as such an indicator as PSA density. In patients with low-grade (G3) prostate adenocarcinoma, this indicator was only in one case in the normal range and its average in group 3 was almost 3 times higher than in patients with moderately differentiated (G2) prostate adenocarcinoma and 12 times higher than in patients with group 1 and amounted to 2.8 ng/ml/cm3. The PSA density levels in patients of groups 1 and 2 were 0.23 ng/ml/cm3 and 1.1 ng/ml/cm3, respectively. The maximum PSA density values †were also significantly higher in patients with G2 and G3 adenocarcinoma and amounted to 15.3 ng/ml/cm3 and 9.5 ng/ml/cm3, respectively, against the results of group 1, where this indicator was 0.65 ng/ml/cm3. Findings. A clinical study allows us to see that the indicators existing in the routine practice of a urologist cannot with great certainty compared with a transrectal prostate biopsy indicate a prostate cancer. Prostate biopsy in the diagnosis of prostate cancer is the gold standard present in identifying this disease.

Prostatic Ductal Adenocarcinoma: An Unusual Subtype of Prostate Cancer

Ductal adenocarcinoma of the prostate (DAP) is defined as malignant epithelial cells filling large prostatic acini ducts, with preservation of basal cells forming either solid or dense cribriform patterns or a loose cribriform or micropapillary pattern with either marked nuclear atypia (nuclear size six times normal or larger) or Nonfocal comedonecrosis. DAP is a rare variant of prostate cancer, and has poorly-identified clinical characteristics. DAP is characterized by a high volume and high-grade disease, with an aggressive behavior. Few cases have been previously reported in Asian males and DAP is more commonly reported in Caucasian males over 70 years of age. In the present study, a 87 year old Asian American male patient that demonstrated nodular prostate with lower urinary tract symptoms and elevated prostatic specific antigen levels underwent a prostate biopsy.

Who Can Avoid Systematic Biopsy Without Missing Clinically Significant Prostate Cancer in Men Who Undergo Magnetic Resonance Imaging-Targeted Biopsy?

The objective of the study was to identify a subset of men who can avoid systematic multisite biopsy (SyB) among those undergoing magnetic resonance imaging (MRI)-targeted transperineal 4-core biopsy (TgB) without missing clinically significant cancer (SC). From April 2013 to December 2017, 304 men with elevated prostate-specific antigen levels (< 20 ng/mL) or abnormal digital rectal examination and positive MRI findings underwent transrecta ultrasound and MRI-targeted transperineal 4-core with 14-core systematic biopsy. MRI findings were prospectively collected and evaluated using Prostate Imaging-Reporting and Data System version 2 (PI-RADS), and scores≥3 were considered positive. SC was defined as Gleason score≥3+ 4 or maximum cancer length≥5mm. We evaluated the diagnostic performance of TgB and SyB to detect SC and characterized men who could avoid SyB without missing SC. Detection rates of any cancer and SC for TgB/SyB/their combination were 59%/63%/68% and 51%/52%/61%, respectively. TgB alone missed 14% (29/207) of any cancer and 16% (29/184) of SC detected using TgB with SyB. In uni- and multivariable analyses, PI-RADS scores of 3 to 4 were independent predictors for missing SC using TgB alone. When restricted to 81 men with PI-RADS scores of 5 (27%), SC was missed using TgB alone only in 3 (4.6% vs. 22% for the remaining 223 men; P= .007). SC was missed using TgB alone in a non-negligible proportion of men who underwent TgB and SyB. SyB might be safely avoided in men with PI-RADS score 5 lesions with reduced risks of missing SC.

The Contribution of Multiparametric Pelvic and Whole-Body MRI to Interpretation of 18F-Fluoromethylcholine or 68Ga-HBED-CC PSMA-11 PET/CT in Patients with Biochemical Failure After Radical Prostatectomy.

Our purpose was to assess whether the addition of data from multiparametric pelvic MRI (mpMR) and whole-body MRI (wbMR) to the interpretation of 18F-fluoromethylcholine (18F-FCH) or 68Ga-HBED-CC PSMA-11 (68Ga-PSMA) PET/CT (=PET) improves the detection of local tumor recurrence or of nodal and distant metastases in patients after radical prostatectomy with biochemical failure. Methods: The current analysis was performed as part of a prospective, multicenter trial on 18F-FCH or 68Ga-PSMA PET, mpMR, and wbMR. Eligible men had an elevated level of prostate-specific antigen (PSA) (>0.2 ng/mL) and high-risk features (Gleason score > 7, PSA doubling time < 10 mo, or PSA > 1.0 ng/mL) with negative or equivocal conventional imaging results. PET was interpreted with mpMR and wbMR in consensus by 2 radiologists and compared with prospective interpretation of PET or MRI alone. Performance measures of each modality (PET, MRI, and PET/mpMR-wbMR) were compared for each radiotracer and each individual patient (for 18F-FCH, or 68Ga-PSMA for patients who had 68Ga-PSMA PET) and to a composite reference standard. Results: There were 86 patients with PET (18F-FCH [n = 76] and/or 68Ga-PSMA [n = 26]) who had mpMR and wbMR. Local tumor recurrence was detected in 20 of 76 (26.3%) on 18F-FCH PET/mpMR, versus 11 of 76 (14.5%) on 18F-FCH PET (P = 0.039), and in 11 of 26 (42.3%) on 68Ga-PSMA PET/mpMR, versus 6 of 26 (23.1%) on 68Ga-PSMA PET (P = 0.074). Per patient, PET/mpMR was more often positive for local tumor recurrence than PET (P = 0.039) or mpMR (P = 0.019). There were 20 of 86 patients (23.3%) with regional nodal metastases on both PET/wbMR and PET (P = 1.0) but only 12 of 86 (14%) on wbMR (P = 0.061). Similarly, there were more nonregional metastases detected on PET/wbMR than on PET (P = 0.683) or wbMR (P = 0.074), but these differences did not reach significance. Compared with the composite reference standard for the detection of disease beyond the prostatic fossa, PET/wbMR, PET, and wbMR had sensitivity of 50%, 50%, and 8.3%, respectively, and specificity of 97.1%, 97.1%, and 94.1%, respectively. Conclusion: Interpretation of PET/mpMR resulted in a higher detection rate for local tumor recurrence in the prostatic bed in men with biochemical failure after radical prostatectomy. However, the addition of wbMR to 18F-FCH or 68Ga-PSMA PET did not improve detection of regional or distant metastases.

Serum Trace Elements and Antioxidant Vitamins among Male Patients with Prostate Disorders in the Delta Region of Nigeria

Background : Prostate cancer remains the commonest form of cancer among Nigerian males, constituting 13.3% of all male cancers encountered in this region. Trace elements and antioxidant vitamins may be of epidemiological significance in the early prediction and treatment of prostate complications. The study aimed to explore the serum trace elements, antioxidant vitamins concentration and serum prostate specific antigen (PSA) among male with prostate disorders in the delta region of Nigeria. Methods : Blood specimens were collected from males with symptoms of prostatitis (n=70), benign prostatic hyperplasia (BPH; n=60) and prostate cancer (PCa; n=70), alongside with apparently healthy male subjects (n=60). The levels of trace elements and antioxidant vitamins were evaluated. Fluorescence immunoassay technique was used to assess the expression of PSA. Results : Compared with the controls, PCa patients had a significantly increased level of vitamin A (p 0.05). Interestingly, there was a significant positive correlation between prostate specific antigen, trace elements and vitamins in BPH group (p<0.05). Conclusions : Prostate disorders such as prostatitis, BPH and PCa may be associated with elevated levels of PSA, but, does not affect the circulating expression of some serum trace elements and antioxidant vitamins.

Safety and efficacy of 177Lu-PSMA-617 therapy in metastatic castration-resistant prostate cancer

Objective To investigate the safety and efficacy of 177Lu-prostate specific membrane antigen (PSMA)-617 in the treatment of metastatic castration-resistant prostate cancer (mCRPC). Methods From August 2017 to September 2018, 11 patients(average age 70.6 years) with mCRPC who underwent 177Lu-PSMA-617 therapy in Nanjing First Hospital were studied. All patients underwent 68Ga-PSMA-11 PET/CT before therapy to assess the tumor radioactive uptake. Blood routine examination and renal function test results were documented before and after therapy to assess the safety. The efficacy was reflected by the changes of prostate specific antigen (PSA) levels and maximum standardized uptake value (SUVmax) on 68Ga-PSMA-11 PET/CT imaging. Paired t test and Wilcoxon′s sign rank test were used to analyze the data. Results No acute side effects were observed after therapy of 177Lu-PSMA-617. There were no statistically significant differences after therapy in WBC counts, RBC counts, and PLT, as well as Hb levels (t values: -0.28-1.11, all P>0.05). No kidney toxicity was found. The PSA level after 177Lu-PSMA-617 therapy was significantly lower than that before therapy (80.70(14.29, 1 538.00) μg/L vs 604.60(88.41, 3 980.00) μg/L; u=59, P=0.023). Of the 11 patients, only 2 had elevated PSA levels and disease progression, while the other 9 patients had varying decreases, of which 2/11 decreased by >30% and 7/11 decreased by >50%. After therapy, SUVmax of metastatic lesions and metastatic lymph nodes were decreased in 9 and 2 patients respectively. Conclusions 177Lu-PSMA-617 has a good therapeutic value for mCRPC. It is safe and has no obvious side effects. Key words: Prostatic neoplasms, castration-resistant; Prostate-specific membrane antigen; Isotope labeling; Lutetium; Radiotherapy; Treatment outcome

Early Experience with MRI-ultrasound Fusion-guided Prostate Biopsy in Japanese Men with Elevated PSA Levels.

Accurate pre-treatment evaluation including prostate multiparametric MRI (mpMRI) and prostate biopsy is required to efficiently discriminate clinically significant prostate cancer (csPC) from clinically insignificant prostate cancer (cis PC). On the other hand, as one solution to the limitations of standard systematic transrectal ultrasonography (TRUS)-guided prostate biopsy including the underestimation of tumor aggressiveness PC such as the Gleason score (GS), the false negative result for anterior lesion, and the overtreatment for detection of cis PC such as small PC with GS 3 + 3, the MRI-ultrasound (US) fusion-guided biopsy is becoming a gradually used method for prostate-targeted biopsy.1 Therefore, the aim of this study was to report our early experience with MRI-US fusion-guided prostate biopsy in Japanese men with elevated prostate-specific antigen (PSA) levels.