Abnormal Prostate Research Articles

Antibiotic prophylaxis for transrectal prostate biopsy.

Prostate cancer is the second most common cause of cancer death in men in the United Kingdom. 1 Transrectal ultrasound (TRUS), digital rectal examination and assay of prostate-specific antigen (PSA) are used in the diagnostic assessment. It is established practice to perform TRUSguided prostate biopsy in patients with palpably and ultrasonically abnormal prostate glands. 1 However, 25% of early prostate cancers are not visible on ultrasound and it is generally accepted that multiple biopsies should be performed systematically in patients with palpably and ultrasonically normal prostates and a serum (PSA) level greater than 10 ng/mL. 1,2 Several studies have shown that, in patients undergoing transrectal prostate biopsy, administration of prophylactic antibiotics results in a lower incidence of post-biopsy febrile episodes, 3‐5 positive urine cultures and bacteraemia. 3‐8 However, little consensus exists as to the most appropriate antibiotic regimen. In a recent survey of 106 radiology and urology departments, we found a total of 48 different regimens utilizing 13 antibiotics. Metronidazole (administered po or pr) was the most commonly used antibiotic, featuring in 55% of regimens, followed by oral ciprofloxacin in 48% of regimens. Gentamicin (iv) was used in 48% of regimens and oral trimethoprim in 14%. Most regimens (89.7%) utilized an oral antibiotic. Of the regimens, 58.6% included an intravenous antibiotic and 29.3% combined intravenous, oral and rectally administered antibiotics; 29.3% of regimens consisted of oral antibiotics alone. Few prospective studies have addressed the issues of antibiotic type, dose, route of administration, duration of treatment and cost in prophylaxis of transrectal prostatic biopsy. The efficacy of oral ciprofloxacin compared with intravenous gentamicin as prophylaxis against bacteraemia after transrectal prostate biopsy has been demonstrated. 9 Patients received either 500 mg ciprofloxacin 12 h before biopsy and 12 h later or 1.5 mg/kg gentamicin intravenously 2 h before biopsy and 80 mg 8 h later. Of the patients who received gentamicin, 37% had bacteraemia after biopsy compared with 7% of those in the ciprofloxacin group. None of the patients given ciprofloxacin developed clinical signs of bacteraemia whereas six of those in the gentamicin group did. The authors concluded that the advantage of ciprofloxacin as prophylaxis against bacteraemia might be due to the drug’s known ability to concentrate in the prostate gland. The authors recommended ciprofloxacin as prophylaxis because, compared with gentamicin, it is less nephrotoxic and ototoxic, less expensive and can be administered orally. 9 In a recent review of the fluoroquinolones 10 the question of their efficacy as prophylaxis in transrectal prostate biopsy was not addressed specifically but the author did recommend that a quinolone be used as first-line therapy in patients with complicated Gram-negative urinary tract infections. In this setting, norfloxacin is cheaper than ciprofloxacin and may be as effective. 10

PSA‐based screening for prostate cancer in asymptomatic younger males: Pilot study in blood donors

BACKGROUND The efficacy and success of a screening program for prostate cancer in young and healthy asymptomatic volunteers are described. METHODS In the present study, prostate specific antigen (PSA) samples obtained from 2,272 males (aged 40–65 years) who donated blood at the local Red Cross Blood Bank were evaluated. Two groups of donors were distinguished, which were investigated in different ways. Group 1 comprised individuals aged 40–49 years (n = 568), while group 2 consisted of males aged 50–65 years (n = 1,704). Volunteers in group 2 who had PSA levels greater than 4 ng/ml (n = 302) were referred for ultrasound guided biopsy irrespective of findings on digital rectal examination (DRE). In group 2, individuals with PSA levels exceeding 4 ng/ml and positive DRE findings biopsy specimen was ordered (n = 2). In patients with unremarkable findings on DRE, serum PSA was determined 1 year later and in case of more than 20% increase in the PSA level biopsy was obtained under ultrasound guidance. RESULTS The biopsy specimen yielded prostatic carcinoma in 58 patients in group 1. As a screening test, serum PSA determination was superior to digital rectal examination. On digital palpation only 2 presented with abnormal prostates. These 58 patients underwent radical prostatectomy and histological examination revealed organ-confined disease in all but 8. In group 2, in 4 of 12 males the biopsy specimen yielded prostatic carcinoma. CONCLUSIONS This study shows that PSA measurement in blood donors is a useful method for recruiting screening volunteers, and therefore represents an additional possibility for early detection of prostate cancer in asymptomatic younger males. Furthermore, it represents an effective tool for following relatively young patients known to have a significant risk of prostate cancer. Prostate 30:20–25, 1997 © 1997 Wiley-Liss, Inc.

PSA-based screening for prostate cancer in asymptomatic younger males: pilot study in blood donors.

The efficacy and success of a screening program for prostate cancer in young and healthy asymptomatic volunteers are described. In the present study, prostate specific antigen (PSA) samples obtained from 2,272 males (aged 40-65 years) who donated blood at the local Red Cross Blood Bank were evaluated. Two groups of donors were distinguished, which were investigated in different ways. Group 1 comprised individuals aged 40-49 years (n = 568), while group 2 consisted of males aged 50-65 years (n = 1,704). Volunteers in group 2 who had PSA levels greater than 4 ng/ml (n = 302) were referred for ultrasound guided biopsy irrespective of findings on digital rectal examination (DRE). In group 2, individuals with PSA levels exceeding 4 ng/ml and positive DRE findings biopsy specimen was ordered (n = 2). In patients with unremarkable findings on DRE, serum PSA was determined 1 year later and in case of more than 20% increase in the PSA level biopsy was obtained under ultrasound guidance. The biopsy specimen yielded prostatic carcinoma in 58 patients in group 1. As a screening test, serum PSA determination was superior to digital rectal examination. On digital palpation only 2 presented with abnormal prostates. These 58 patients underwent radical prostatectomy and histological examination revealed organ-confined disease in all but 8. In group 2, in 4 of 12 males the biopsy specimen yielded prostatic carcinoma. This study shows that PSA measurement in blood donors is a useful method for recruiting screening volunteers, and therefore represents an additional possibility for early detection of prostate cancer in asymptomatic younger males. Furthermore, it represents an effective tool for following relatively young patients known to have a significant risk of prostate cancer.

Impalpable Invisible Stage T1c Prostate Cancer: Characteristics and Clinical Relevance in 100 Radical Prostatectomy Specimens-A Different View

We analyzed 100 consecutive radical prostatectomy specimens to evaluate the extent and clinical relevance of the stage T1c cancers discovered. All cases were diagnosed by systematic prostatic puncture biopsies because of abnormal prostate specific antigen (PSA) or PSA density. Surgical specimens were examined with the whole organ multiple step-section technique (4 mm.) to identify primary tumor location (peripheral or transition zone cancer), tumor volume, tumor volume divided by prostate volume (percent tumor volume), Gleason score, pathological T stage and positive surgical margins. Tumors smaller than 0.5 cm.3 and without unfavorable pathology (Gleason score 7 or more, or positive surgical margins) were considered insignificant. Median patient age, PSA, tumor volume and Gleason score were 64 years, 8.8 micrograms./l., 1.6 cm.3 and 6, respectively. Of the specimens 46 (46%) had transition zone cancer that was clinically undetectable due to anterior location, while peripheral zone cancers were small, diffuse, anterolateral or in large glands with low percent tumor volume. Transition zone cancer showed greater PSA, PSA density, tumor volume and percent tumor volume than peripheral zone cancer (p = 0.08, 0.03, 0.0002 and 0.0004, respectively), yet with similar Gleason score (p = 0.4). Of the tumors 34 (34%) were locally advanced (stage pT3 and/or positive surgical margins, mostly anterior in 16 transition zone cancers, and apical or posterolateral in 18 peripheral zone cancers), whereas 22 were insignificant (6 transition and 16 peripheral zone cancers). Prostatic puncture biopsies with a core cancer length of less than 3 mm. could have predicted 18 of 19 insignificant tumors but underestimated 13 (33%) and 6 (17%) significant transition and peripheral zone cancers. The majority of our stage T1c tumors were significant with a distinguished high incidence of transition zone cancer. Therefore, they were large but occult. Transition zone cancer behaved differently than peripheral zone cancer, and warranted considerations during treatment of stage T1c prostate carcinoma.

Not all patients pursue prostate biopsy after abnormal prostate specific antigen results

In prostate cancer, digital rectal examination (DRE) and serum prostate specific antigen (PSA) are used to evaluate the risk of prostate cancer. However, in published community-based screening samples, not all patients with abnormal test results pursue biopsy. To test the existence of and quantify diagnostic dropout in clinic-based early detection samples, we conducted a prospective patterns-of-care study designed to identify variables associated with pursuit of diagnostic steps. Of 76 patients with abnormal PSA and/or DRE, only 43 (57%) pursued prostate biopsy. Prostate specific antigen, but not age or chart-based comorbidities, was predictive of further diagnostic and therapeutic steps. Among patients with abnormal test results, age and abnormal PSA and DRE, but not chart-based comorbidities, strongly correlated with physician intention to diagnose prostate cancer. The factors that cause diagnostic dropout are unknown, but based on experience with other cancers, they may relate to psychological variables in tested patients. That pursuit of diagnosis and treatment appears to occur with no association with chart-based comorbidities is worrisome given the power of comorbidities to predict mortality in prostate cancer patients. Finally, from a public health perspective, a reproducible dropout phenomenon implies that the positive predictive value of DRE and PSA testing may be seriously underestimated.

Patient Counseling Regarding Treatment of T1/2 (A/B) Prostate Cancer

Mr. Smith, a healthy 67-year-old man, has a "routine" prostate-specific antigen (PSA) of 7 ng/ml by Hybritech assay. No prostate abnormality was appreciated by digital rectal exam. Sextant biopsy revealed three cores positive for 3 + 3 Gleason sum with an area of pattern 4. A bone scan was normal. The patient has no prior history of genitourinary disease, is continent, and is potent. I will review necessary background information concerning the therapy available for localized prostate cancer with Mr. Smith so that together we can identify the option most suited to the stage and grade of his disease, his general health, and his attitude or disposition to therapeutic interventions.

PREPUBIC AND TRANSRECTAL ULTRASONOGRAPHY OF THE CANINE PROSTATE: A COMPARATIVE STUDY

A comparative study was conducted in ten dogs with signs of prostatic disease in order to evaluate the usefulness of the prepubic and transrectal ultrasonography for the examination of the prostate gland and for prostate biopsy guidance. Both techniques were adequate to identify the prostate gland and prostatic urethra. Transrectal ultrasound found 5 occurrencies of parenchymal echogenicity changes whereas the prepubic technique found only 2. Lesions in the cranial prostatic margin (two dogs) were detected only by prepubic ultrasound. Lesions of the caudal prostatic margin (six dogs), prostatic urethra disruption (two dogs) and prostatic capsule abnormalities (five dogs) were only recognized by the transrectal approach. Prepubic ultrasonography was useful for biopsy guidance of cranial prostatic lesions and transrectal ultrasonography was a good means for biopsy guidance of caudal lesions.

Failure of Focal Prostate Cancer on Biopsy to Predict Focal Prostate Cancer: The Importance of Prevalence

Purpose We investigated whether the reported correlation between focal prostate cancer on biopsy and the presence of clinically insignificant cancer applies to men with an elevated serum prostate specific antigen level or a positive biopsy from an area of palpable abnormality. Materials and Methods A total of 33 men with these findings and focal cancer on biopsy underwent radical perineal prostatectomy, with step-section pathological analysis of all specimens and volume determination of all stage pT2a tumors. Results Pathological examination revealed that 17 tumors (52 percent) were stage T3, 10 (30 percent) stage T2b to c and 6 (18 percent) stage T2a, with 4 (12 percent) significant (volumes 0.8 to 1.2 ml.) and 2 (6 percent) insignificant (volumes 0.1 and 0.3 ml.) neoplasms. Thus, focal prostate cancer on biopsy correlated with significant cancer in 94 percent of the cases. Conclusions In patients with another variable controlling for a high prevalence of significant prostate cancer, the focal nature of a positive biopsy probably refects only sampling limitations and should not influence treatment. To restrict prostate biopsy to men with a high prevalence of significant cancer, targeted area biopsy alone must replace sextant biopsy in men with a palpable prostatic abnormality but a normal prostate specific antigen level.

Prostate Cancer Screening Using Fine-Needle Aspiration Cytology prior to Open Prostatectomy

We performed a prospective study to evaluate fine-needle aspiration (FNA) cytology as a screening tool of carcinoma of the prostate in 159 men with normal digital rectal examinations and acid phosphatase prior to open prostatectomy for voiding symptoms. The incidence of carcinoma of the prostate was 5.6%. 4 patients had A1 lesions and 5 had A2 lesions. Only one A2 lesion was malignant cytologically. The sensitivity was 56%, specificity 69%, positive predictive value 24% and negative predictive value 90%. Sufficient cytologic specimens were provided in 66% of cases. While FNA is at least equal to core biopsy as a diagnostic modality of palpable prostatic abnormalities, it does not prove to be an adequate screening modality for occult carcinoma of the prostate in the prostatectomy candidate.

Transrectal ultrasound in male urethritis.

To assess the prevalence of prostatic abnormalities in men with gonococcal and non-gonococcal urethritis using trans-rectal ultrasonic markers. A case control study of patients attending a department of genitourinary medicine with symptoms of urethritis. Department of Genitourinary Medicine and Department of Radiology in Manchester Royal Infirmary. A total of 42 patients were recruited to the study: 26 with urethritis and 16 controls. Of the 26 study patients, six were gonococcal, four chlamydial, two mixed gonococcal and chlamydia and nine non specific (no organisms detected). Of the 26 study patients, 16 had abnormal scans (61.5%), eight from the chlamydia group and eight from the non specific group. No abnormalities were found in the gonococcal and mixed group. Of the 16 control patients, five had abnormal scans (31.25%), three of these have had a past history of chlamydial urethritis. The prevalence of prostatic abnormalities in patients with non-gonococcal urethritis was significantly higher when compared with controls. The cause of these abnormalities is unclear, but is compatible with inflammatory changes within the gland.

The diagnostic value of colour Doppler flow in the peripheral zone of the prostate, with histological correlation

To study the discriminative value of the amount of colour flow on Doppler ultrasound within the peripheral zone of the prostate. One-hundred and twenty three men were studied using a 7 MHz transrectal probe, and 274 guided biopsies were undertaken. With each biopsy histological outcome was correlated with the grade of colour flow on ultrasound hard copy images. Biopsies with inflammatory cell infiltration, but without carcinoma, were subgraded according to the degree of inflammatory cell infiltration; and these grades were correlated with the corresponding colour flow grade. Normal colour flow was seen with both normal and abnormal prostate biopsy. With increased colour flow the likelihood of abnormal tissue increases; the highest grade of colour flow was seen with either carcinoma or prostatitis (grade 0, 1, 2 and 3 colour flow = 23%, 65%, 74% and 100% respectively of biopsies that were abnormal). In biopsies with inflammatory cell infiltration there was no linear relationship between the grades of colour flow and cellular infiltration (r = 0.52, P > or = 0.05, Kendall rank correlation). The mean grade of cellular infiltration was significantly greater in samples with grade 3 colour flow compared with grades 0-2. Grading of the amount of colour flow with Doppler ultrasound is of limited diagnostic discrimination, although with the greatest colour flow specificity for the diagnosis of abnormal prostate (either cancer or prostatitis) is very high. With prostatitis, markedly increased colour flow reflects the severity of inflammatory cellular reaction.

Prostate specific antigen as a predictor of an abnormal digital rectal examination.

To assess the ability of serum prostate specific antigen (PSA) to predict and differentiate patients with normal and abnormal digital rectal findings. A prospective analysis of 1374 participants in a prostate cancer screening programme was performed. After completion of a questionnaire including age and voiding symptoms as well as phlebotomy for PSA analysis, digital rectal examination was performed and the findings were categorized with respect to size, consistency, symmetry and nodularity. In men less than 50 years of age the mean serum PSA level failed to discriminate any of the digital rectal examination categories. In men over 50 there was a statistically significant difference in mean PSA levels between symmetrical, normal sized prostates and symmetrically enlarged glands as well as between symmetrical, normal sized and abnormal prostates (P < 0.05). No statistically significant difference was found in mean serum PSA levels between symmetrically enlarged prostate glands and those with palpable nodules. PSA levels < or = 2.5 ng/ml (normal range for the Yang polyclonal assay) and < 7.4 ng/ml (corresponding to the normal range of < 4.0 ng/ml for the Hybritech monoclonal assay) demonstrated a probability of an abnormal digital rectal examination of 11% and 14% respectively. PSA levels > 18.4 ng/ml (corresponding to monoclonal levels of > 10 ng/ml) had a 67% probability of an abnormal digital rectal examination. However, moderate elevations in PSA could not be used to predict digital examination abnormalities due to the high incidence of moderate PSA elevations associated with symmetrical enlargement of the prostate. Serial annual PSA measurements may provide an alternative means of screening men over 50 years of age. Contamination of results with PSA elevation due to benign prostatic hyperplasia remains, however, a problem.

Growth of the rat prostate gland is facilitated by the autonomic nervous system.

Many factors are implicated in the development of prostatic growth: androgens, growth factors, and stromo-epithelial interaction. This study examines the role of the sympathetic and parasympathetic branches of the autonomic nervous system control of different aspects of rat prostate growth and atrophy. Unilateral sympathectomy leads to decreases in ventral prostate weight, DNA, and protein content in the lesioned side. Unilateral parasympathectomy leads to increases in ventral prostate weight, DNA, and protein content in the intact side. The separate effects of sympathectomy and parasympathectomy are maintained across a diverse combination of neural manipulations. Significant re-innervation does not occur by 60 days after manipulation as assessed by tissue norepinephrine levels. There appears to be a differential effect of the autonomic nervous system on growth and maintenance of the ventral prostate. The mechanism of contralateral hyperplasia and ipsilateral atrophy has potential significance in understanding human abnormal prostate growth.

Systematic Sextant Biopsies in 651 Patients Referred for Prostate Evaluation

In 651 patients mapping of the prostate by 6 systematic sextant ultrasonography guided biopsies was performed without major side effects using the automatic biopsy gun. The histological findings provided data on patients with normal and abnormal prostates as determined by digital rectal examination. Only 3 of 72 nonurological patients (4%) with normal prostate specific antigen (PSA) levels of less than 4 ng./ml. had prostate cancer.Of the 259 patients with a firm prostate on digital rectal examination 105 (41%) had prostate cancer. For those with a PSA level of less than 4 and 4 ng./ml. or greater the positive biopsy rates were 13% and 58%, respectively. Of 56 patients with clinical stage B or C disease and a PSA level of less than 4 ng./ml. 20 (36%) had prostate cancer, compared to 155 of 187 (83%) with a PSA level of 4 ng./ml. or greater. Transrectal ultrasound was not helpful in screening for prostate cancer due to the low positive biopsy rate for hypoechoic lesions. However, among 175 patients with clinical stage B or C disease transrectal ultrasound identified 157 (90%) with prostate cancer.

Influence of efonidipine hydrochloride, calcium antagonist on the epithelium of prostates in spontaneously hypertensive rats.

The hypertensive effect on the development of the prostatic abnormality in spontaneously hypertensive rats (SHRs) was examined using Efonidipine hydrochloride, a calcium antagonist. The control SHRs were given a high sodium and potassium diet (SP-diet) alone, and the treated SHRs were given a SP-diet with 0.15% Efonidipine hydrochloride from 8 to 28 weeks of age. The systolic blood pressure (SBP) in the control SHRs increased with age, while the elevation of SBP was significantly prevented in the treated SHRs. Light-microscopically, the prostatic lesion was observed both in the control and treated SHRs. The glandular lumen was narrowed with papillary protrusions, and the epithelium was composed of tall columnar epithelial cells. However, hypertension-induced complications in kidneys and hearts were not observed in the treated SHRs. These results suggested that the prostatic abnormality of SHRs might not be the consequent lesions upon hypertension.

Comparison of ultrasound-guided and digitally directed transrectal biopsy of palpable prostate lesions

The role of ultrasound in the diagnosis of prostate cancer is still evolving. We used ultrasound to examine 202 patients with palpably abnormal prostates. Of 151 patients undergoing biopsy, ultrasound-guided biopsy was comparable to digitally directed biopsies in cancer detection (92% vs 90.7%). The two methods are complementary and should both be considered in patients with palpably abnormal prostates.

Preferential loss of abnormal prostate carcinoma cells by collagenase treatment

Effects of two different methods of tumor disaggregation on flow cytometric ploidy distribution and intact cell yield were investigated. Either mechanical disaggregation or collagenase digestion was applied to 35 prostate tumor specimens. Seven collagenase-treated samples failed to yield any intact cells, whereas with mechanical disaggregation in all cases a sufficient number of intact cells were obtained. No differences in the FCM ploidy distribution of tumors with a DNA diploid stemline were observed comparing both techniques. In DNA aneuploid tumors, however, collagenase treatment had an adverse effect on the abnormal cell populations. In 14/17 of such tumors, the abnormal cell populations were significantly reduced; in eight of these the percentage of DNA aneuploid cells declined even below the minimum percentage (10%) that was defined for DNA aneuploidy. Since collagenase is a widely used enzyme for tissue disaggregation, especially in tumor cytogenetics, the presented data will have consequences for the interpretation of results obtained by methods involving the use of this enzyme.

Gadolinium-enhanced MRI of the abnormal prostate

A prospective study of the use of a low osmolar gadolinium-based intravenous contrast material for MRI of the abnormal prostate was performed. Eight patients scheduled for prostatectomy, six with prostate cancer and two with benign prostatic hyperplasia (BPH), were imaged preoperatively on a 1.5 T system using a pelvic coil array and employing Gadodiamide (0.3 mmol/kg). T 2-weighted fast-spin echo (FSE) imaging was also performed in the same axial planes employed for gadolinium-enhanced studies. Detailed pathologic correlation was performed for the six patients with carcinoma. While regions of BPH and cancer enhanced to a similar degree following intravenous contrast agent, BPH enhancement was more heterogeneous than cancer. No advantages in detecting prostate cancer, in differentiating cancer from BPH or normal prostatic tissue, or in assessing extra-prostatic spread of cancer were observed for the contrast-enhanced studies compared to T 2-weighted FSE imaging.

Prostate ultrasonography in normal and benign conditions

Transrectal prostate ultrasound (TRUS) is an important method for the evaluation of patients with palpable prostate abnormalities. Knowledge of the appearance of normal and benign conditions of the prostate on ultrasound is required for the identification of prostatic lesions that are suspected of being carcinomatous. The exact role of TRUS in the evaluation of benign disease of the prostate remains under investigation.

Study of prostatic disease in dogs: 177 cases (1981-1986)

Summary Historical and physical signs associated with prostatic disease diagnosed in dogs over a 5.5-year period were defined. One hundred seventy-seven male dogs were determined to have prostatic abnormality. Of the 177 dogs, 87 were determined to have specific prostatic disease. The most common prostatic disease identified in this study was bacterial prostatitis, followed by prostatic cyst, prostatic adenocarcinoma, and benign hyperplasia. The most common prostatic disease identified in neutered dogs was prostatic adenocarcinoma. Mean age at onset of prostatic disease was 8.9 years; statistically significant difference was not observed between age at onset of the various types of prostatic disease identified. Doberman Pinscher was the most common breed with prostate disease. Twenty-nine percent of dogs with a specifically identifiable prostatic disease had signs of systemic illness, 41% had signs of lower urinary tract disease, 28% had signs of gastrointestinal tract abnormalities, and 13% had signs of locomotor difficulty.