AUA 2006 - Prostate Cancer Detection And Screening III

UroToday.com - The role of PSA in the contemporary era and the impact of premalignant conditions on future diagnosis were some of the issues discussed in this section. Figler et al, [ABST 1473] investigated the value of PSA in detecting significant tumors. A cohort of 2067 patients spanning 1993 to 2004 were divided in two epochs [1993-98 and 1999-2004] and evaluated with respect to prostate volume, percent Gleason grade 4/5, overall estimated tumor volume. The preoperative PSA value was positively correlated to tumor volume, volume of high grade disease and tumor gleason grade in both epochs suggesting that there is still contemporary predictive power in a PSA value. A family history of prostate cancer has classically been demonstrated in 15% of younger patients. Hood and associates, [ABST 1483] reviewed a cohort of 724 patients and identified 66 patients under the age of 50. Overall the entire cohort had a family history of prostate cancer in 33.8% of patients. In the younger cohort 28/66 [42.2%] patients had a family history defined as a first or second degree relative. 88% of patients had pathologic stage T2 disease and the majority of patients 44/66 [67%] had Gleason score 6 disease. These data suggest that the early evaluation of younger patients with a family history is clearly warranted.

Patel and colleagues [ABST 1487] reported on a longitudinal follow up of patients with high grade prostatic intraepithelial neoplasia (HGPIN). The method of follow up was empiric and consisted of an interval prostate needle biopsy every 2-3 year even in the absence of PSA of DRE changes. The records of 100 such patients were reviewed and demonstrated a cancer diagnosis rate of 30%. These patients were diagnosed at a median follow up of 32 months. 22/30 were diagnosed after the first biopsy and the remainder on the second biopsy. 29 or 30 men had T1c disease and 12/30 had gleason 7 or greater grade tumors. There was a strong concordance between the site of the original HGPIN diagnosis and the site of cancer diagnosis 21/30 cases. The majority of cases were detected in the peripheral zone (27 of 30. This association with location supports the proposition that HGPIN is a premalignant lesion and underscores the value of routine follow-up biopsies.

Atypical small acinar proliferation or ASAP is an entity regularly noted on prostate needle biopsies and associated with the detection of cancer at a later date. Flury et al [ABST 1492] evaluated prostates from cystoprostatectomy specimens and in a review of evaluable cases 24/65 demonstrated prostate cancer. Nine cases demonstrated high grade PIN and ASAP or ASAP alone. The use of serial sectioning and special stains demonstrated that the majority of these ASAP cases (8/9) could indeed be diagnosed as cancer. These findings suggest that an aggressive clinical evaluation of these lesions is warranted. In an evaluation of evolving technology a report on 117 patients undergoing 11C-PET was described by Seitz et al. [ABST 1498]. In the detection of a primary malignancy a sensitivity of 86.8% and sensitivity of 59.1% was recorded. In the case of metastatic spread a sensitivity of 80% and specificity of 95.1% was noted. It was suggested that the combined use of CT/PET may be of value in the detection of metastatic spread of prostate cancer but this will require further study.

In a further evaluation of the role of body mass index (BMI) an evaluation of the CaPSURE data set identified 6692 men with appropriate data Meng, et all [ABST 1507]. A higher BMI was associated with a lower serum PSA and a larger measured prostate volume. This was independent of age and year of diagnosis. This paradoxical association may have some impact regarding the detection of disease and disparities in treatment outcomes noted so far when trying to evaluate this parameter.

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Supported by an unrestrictional educational grant from Sanofi-Aventis

By S.Bruce Malkowicz, MD

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