Keratin immunoreactivity in the benign and neoplastic human prostate.

Keratin immunoreactivity in the benign and neoplastic human prostate was examined immunohistochemically using two monoclonal antibodies with differing specificities. One of these antibodies stained only the basal cells of the normal and hyperplastic prostatic epithelium, with no reactivity in tumor cells of prostatic adenocarcinoma. The other monoclonal antibody recognized a keratin protein present in all normal and hyperplastic columnar (secretory) epithelial cells, as well as in all cancer cells regardless of degree of tumor differentiation. In addition, the second antibody stained acinar and ductal epithelial cells exhibiting premalignant changes. Our findings indicate that keratin immunoreactivity differs among the epithelial cell populations of the human prostate, probably reflecting expression of different keratin proteins. The distinctive patterns of staining obtained with these two antibodies may assist in distinguishing hyperplastic from neoplastic prostatic epithelium, as well as in the recognition of basal cell hyperplasia, transitional cell metaplasia, and premalignant changes.

Vasectomy and risk of prostate cancer.

Most studies do not support an association between vasectomy and prostate cancer, but a few have suggested a link. Vasectomy is a common birth control method, and prostate cancer is the most frequently diagnosed solid tumor in men, making this a major public health question. This study was specifically designed to determine whether or not vasectomy is associated with risk of prostate cancer. To examine this issue, we conducted a population-based case-control study in King County, Washington. Interviews were completed with men ages 40-64 years newly diagnosed with prostate cancer between January 1993 and December 1996 who were ascertained through the Seattle-Puget Sound Surveillance, Epidemiology, and End Results (SEER) cancer registry (n = 753) and with comparison men without prostate cancer identified from the same general population (n = 703). The odds ratio (OR) for prostate cancer in relation to vasectomy was assessed. The prevalence of vasectomy was similar in cases (39.4%) and controls (37.7%), resulting in no association (adjusted OR, 1.10; 95% confidence interval, 0.9-1.4). There was no consistent evidence that risk varied by the age at which vasectomy was performed, the time since vasectomy, or the calendar period when the vasectomy was performed. The OR in relation to vasectomy was higher in men with less aggressive prostate cancer. Risk estimates did not differ according to age, race, or family history of prostate cancer. This study suggests that vasectomy is not associated with the risk of developing prostate cancer. It also provides evidence that vasectomized men may be more likely to present with earlier-stage, lower-grade prostate tumors.

Prostatic intraepithelial neoplasia: a premalignant lesion.

Putative premalignant changes in the prostate have been recognized for a number of years. A variety of synonyms have been given to the most commonly described lesion, one characterized by proliferation and dysplasia of the normal two cell layers lining prostatic acini and ductules. Currently, "prostatic intraepithelial neoplasia" (PIN) is the term most commonly used to describe this entity. In this review, the requirements for a premalignant lesion, the reason why PIN fulfills the majority of these requirements, and a detailed description of the morphologic and phenotypic similarities between PIN and carcinoma will be outlined. Finally, the clinical significance of PIN will be reviewed.

Comparison of microscopic vascularity in benign and malignant prostate tissue.

A variety of malignant neoplasms have been shown to induce capillary neovascularization, and in some cases the degree of vascularization appears to correlate with aggressive behavior and risk of metastasis. We hypothesized that carcinoma of the prostate also induces the formation of new capillaries, and we developed a method to quantify the relative density of microscopic vessels in carcinoma of the prostate compared with benign prostatic glandular tissue. The number of microvessel profiles in tissue sections was quantified by marking the vascular endothelial cells with antibodies to factor VIII-related antigen using standard immunohistochemistry techniques and comparing fields of adenocarcinoma with benign glandular tissue in 15 radical prostatectomy specimens. The analysis was facilitated by using the Optimas computerized image analysis system (Bioscan, Seattle, WA) with software written for this investigation. Fourteen of the 15 cases demonstrated significantly higher vascular density in the areas of carcinoma than in the benign tissues. Overall, the ratio of vessels per unit area in sections of carcinoma versus benign tissue was approximately double (ratio = 2.02; P < .001). In benign tissues the capillaries are restricted for the most part to the periglandular stroma immediately adjacent to the epithelium, whereas the distribution in carcinoma appears to be more random. The data demonstrate the increased density of capillaries in prostatic carcinoma when compared with benign prostate tissue.

Sialyl-Lewis(x) and related carbohydrate antigens in the prostate.

Alteration of cell surface carbohydrate antigens during malignant transformation is a well-known phenomenon observed in various tumors. In prostatic carcinoma, nearly total deletion of normally occurring ABO and type I-based Lewis antigens, Le(a) and Leb, has been observed in several studies. We studied expression of the closely related type II antigens Le(x), Le(y), and sialyl-Lewis(x) (SLe(x)) using monoclonal antibodies. Thirty formalin-fixed specimens obtained from radical prostatectomy, containing prostatic carcinoma as well as benign tissue, were evaluated by immunohistochemistry. In both cancer and benign tissue, Le(x) expression was minimal or absent. In benign tissue, Le(y) was expressed in ducts and in the basal layer of glandular epithelium. In tumor tissue, Le(y) expression was greatly increased and extensive staining was observed in 26 of 30 cases. The SLe(x) expression in benign tissue was observed only in larger ducts, never in glandular secretory epithelial cells. In carcinoma, rare cells positive for SLe(x) were present in 8 of 30 cases, and stronger expression with focal to patchy distribution was observed in 14 of 30 cases. The results suggest an alteration in glycosyl transferase activity in prostatic carcinoma, with preserved or increased activity of enzymes responsible for the synthesis of the type II core sequence. This sequence is further glycosylated and expressed as the difucosylated compound Le(y) or the monofucosyl, monosialyl compound SLe(x). For prostate, Le(y) and SLe(x) are the only blood group-related antigens known to be minimal or absent in benign secretory epithelial cells that are more highly expressed in malignant tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of metalloproteinase genes in human prostate cancer.

Twenty-five surgical specimens of malignant human prostate, 3 lymph nodes with metastatic prostate carcinoma, 11 normal human prostates, as well as 3 human prostate cell lines (DU-145, PC3 and LNCaP) were examined for the expression of the human matrix metalloproteinase-7 gene (MMP-7) from the human collagenase family (originally called PUMP-1 for putative metalloproteinase-1) [Quantin et al. (1989) Biochemistry 28:5327-5334; Muller et al. (1988) Biochem J 253:187-192; Matrisian and Bowden (1990) Semin Cancer Biol 1:107-115]. Northern blots were prepared using total RNA extracted from 18 prostate adenocarcinomas, 2 lymph nodes with metastatic prostate carcinoma and 11 normal human prostates. When the northern blots were hybridized with a 32P-labeled MMP-7 cDNA probe, a 1.2-kb mRNA was detected in 14 out of 18 prostate adenocarcinomas, 1 out of 2 metastatic lymph nodes, and 3 out of 11 normal prostates. The 3 human prostate cell lines did not show any evidence of the MMP-7 transcript. In situ hybridization was conducted to localize the MMP-7 mRNA to individual cells using a 35S-labeled MMP-7 cRNA. In situ hybridization was carried out on snap-frozen tissue sections of 7 prostate adenocarcinomas and 3 lymph nodes containing metastatic prostate adenocarcinoma using the same tissues previously probed by northern analysis as well as new samples. In situ hybridization revealed that the MMP-7 gene was expressed in the epithelial cells of primary prostate adenocarcinoma as well as in invasive and metastatic cells. MMP-7 expression was also seen focally in some dysplastic glands but not in stroma. Additional northern blot analysis was performed using probes to human type-IV collagenase, type-I collagenase and stromelysin I in human prostate adenocarcinoma as well as normal prostate tissue. Our results indicated that 6 out of 10 adenocarcinoma samples and none of the 4 normal samples were positive for type-IV collagenase transcripts. Tissue samples were also examined for the expression of type-I collagenase (9 adenocarcinomas and 4 normal) and stromelysin I (13 adenocarcinomas) by northern analysis. None of the tissues was found to express the transcripts of interest at detectable levels. These data suggest that certain metalloproteinases are present in prostatic adenocarcinoma and may play a role in invasion and metastasis.

Serum prostate-specific antigen and prostate pathology in men having simple prostatectomy.

Prostate-specific antigen (PSA) is a sensitive and specific serum marker for monitoring disease activity in men with prostatic carcinoma. Despite reports of elevation of levels of this analyte in men with benign prostatic hyperplasia, no information is available correlating the serum levels with the actual prostatic abnormalities in men having prostatectomy for presumed benign disease. In the present investigation, the authors compared preoperative serum PSA levels with prostate disease in 81 men with bladder outlet obstruction. Five pathologic groups were found: incidental high-grade carcinoma (n = 3), low-grade carcinoma (n = 11), acute inflammation (n = 16) with or without chronic inflammation, Prostatic intraepithelial neoplasia (PIN) (n = 25), and benign hyperplasia (n = 26). Serum PSA levels were significantly elevated in both low- and high-grade carcinoma, acute inflammation, and PIN when compared with the patients with benign hyperplasia with and without chronic inflammation. Within the four groups with elevated levels, use of PSA levels could separate only the high-grade cancer patients who were subsequently shown to have metastatic disease. Only one patient with simple hyperplasia had PSA levels in the abnormal range.

Morphonuclear relationship between prostatic intraepithelial neoplasia and cancers as assessed by digital cell image analysis.

Using digital cell image analysis performed on Feulgen-stained nuclei, the nuclear characteristics of prostatic neoplasia, ranging from benign (benign prostatic hyperplasia [BPH]), through dysplastic (prostatic intraepithelial neoplasia [PIN] 1-3), to carcinoma were studied. Four histopathologic groups were studied: group IA (18 samples) contained BPH, PIN 1, and PIN 2 lesions that were from 9 prostate samples free of cancer. Group IB (23 samples) was identical to group IA, contained also BPH, PIN 1, and PIN 2 lesions, but lesions that were from 7 prostate samples where malignant foci were detected elsewhere. Group II (11 samples) were PIN 3 specimens. Group III (24 samples) were carcinomas. Features of neoplastic nuclei were quantified objectively through morphometric (nuclear size), densitometric (nuclear DNA content), and textural (chromatin organization and heterogeneity) parameters. Cell kinetic parameter, i.e., cell proliferation index, was assessed from the densitometric measurement. The proliferation index was significantly higher in PIN 3 and cancers as compared to BPH, PIN 1, and PIN 2 tissues. Morphonuclear characteristics were also dramatically distinct among the four groups. Indeed, the nuclear size and the hyperchromatism of severe prostatic dysplasia were similar to those of carcinomas, these two lesion types showing mean parameter values that were higher as compared to BPH, PIN 1, and PIN 2 lesions. Finally, benign tissues related to mild or moderate dysplasia taken in histologic material in which cancer was present already share the morphonuclear characteristics of severe dysplasia, although they are nonproliferating.

Endobronchial metastases from prostatic carcinoma.

Prostatic carcinoma presenting with pulmonary symptoms is unusual. We describe the case of a 59-year-old man whose disseminated prostate cancer was diagnosed with bronchoscopy. To our knowledge, this represents the second reported case of prostate cancer that manifested with endobronchial symptoms. The importance of this entity and clinical and therapeutic aspects are also discussed.

Prostate-specific antigen in management of prostatic carcinoma.

In 1979, Wang and associates isolated prostate-specific antigen (PSA). Only recently, however, has the clinical importance of this new tumor marker been recognized. It is now widely accepted that PSA represents a significantly more effective tumor marker than prostatic acid phosphatase (PAP). This article will review the chemistry associated with PSA, the application of PSA in immunohistochemistry, salient features of the two clinically available assays, factors that affect the circulating level of PSA, and the usefulness of PSA in the staging, monitoring, and screening of patients with prostatic carcinoma.

New technique for repair of rectal injury.

Injury to the rectum is a potentially serious complication of pelvic surgery. The management of rectal injury is controversial. We present a technique of using flaps of endopelvic fascia to reinforce the repair and isolate the injury site. We have utilized this approach in 4 men undergoing retropubic prostatectomy without complications.

Papillary adenocarcinoma of ureter.

A well-differentiated papillary adenocarcinoma developed in a ureteral stump thirty-six years after nephrectomy and was associated with a combined transitional-epidermoid carcinoma in the urinary bladder. Carcinoma in a ureteral stump is not uncommon and should be suspected in patients with a ureteral stump and hematuria. The very rare adenocarcinoma of the ureter is typically papillary and is associated with urinary tract infection and stones. At present successful treatment requires the early identification and extirpation of the ureteral tumor and consideration of associated cancer elsewhere in the urinary tract.

How to use prostate-specific antigen.

OBJECTIVE: To determine if prostate-specific antigen (PSA) is the most effective analyte for diagnosing, staging, and monitoring prostatic carcinoma. METHODS: This article reviews what PSA is and how it can be used to detect clinically significant carcinomas as well as its application in managing patients after radical prostatectomy, radiation therapy, and androgen deprivation therapy. RESULTS: PSA screening results in increased detection of localized disease. In individual patients a serum PSA level is not a good indicator of pathologic stage; however, a serum PSA level of greater than 10 ng/mL is associated with a higher incidence of extracapsular disease. Asymptomatic patients with newly diagnosed untreated prostate cancer and a serum PSA level less than 10 ng/mL do not need to undergo staging radionuclide bone scan. Elevated serum PSA is generally the first indicator of "persistent disease" after radical prostatectomy and radiation therapy. In androgen deprivation the PSA nadir is an important indicator of response to therapy. CONCLUSIONS: PSA is the most accurate tumor marker in oncology. This analyte can be successfully used to diagnose, stage, and monitor prostatic carcinoma.

Significance of prostatic intraepithelial neoplasia on prostate needle biopsy.

Prostatic intraepithelial neoplasia (PIN) is a putative premalignant change in the human prostate. Previously, the spatial association of PIN with invasive carcinoma has been described in the study of total prostatectomies. PIN is frequently recognized in prostate needle biopsy specimens in which no carcinoma is apparent. To further define the potential significance of PIN, we performed repeat ultrasound-guided prostate needle biopsy in 21 men who had PIN identified on prostate biopsy performed because of an abnormal finding on digital rectal examination. Twelve patients (57%) had carcinoma identified on their second procedure including all who had intermediate- and high-grade PIN on the initial procedure. Prostate-specific antigen correlated with PIN grade and carcinoma on the secondary procedure, although this did not achieve statistical significance. Men with PIN on prostate needle biopsy should undergo repeat sampling to exclude missed carcinoma.

Morphometric quantitation of stroma in human benign prostatic hyperplasia.

OBJECTIVES: Human benign prostatic hyperplasia (BPH) consists of three major histologic components: stroma, epithelium, and luminal space. For the relief of bladder outlet obstruction caused by BPH, quantitation of the histologic composition of BPH may aid in selecting treatment. To investigate variation between patients in the stromal percentage of BPH, we performed quantitative morphometry on specimens from patients with clinically significant bladder outlet obstruction obtained by three procedures: open prostatectomy, transurethral resection of the prostate (TURP), and prostate needle biopsy (PNB) just prior to TURP. METHODS: Ten specimens obtained by each surgical procedure were analyzed. Specimens were stained with antibody to muscle-specific actin to mark the stroma; quantitation of stroma was accomplished by computer image analysis. RESULTS: The percentage of stroma in all BPH cases ranged from 49.9% to 76.7% (mean, 65.4%, SD = 7.4). No significant difference was observed when comparing samples obtained by the three procedures (p = 0.70). Smooth muscle stromal composition was also quantified in PNB specimens. For these samples, a significant inverse relationship was found between the percentage stroma in the biopsy and the percentage of stroma composed of smooth muscle (r2 = 0.49; p = 0.021). CONCLUSIONS: The data demonstrated that the largest component of BPH was stroma, which comprised approximately 50% to 75% of the total hyperplastic tissue. The mean and range of stromal percentage were similar whether investigating large tissue samples from open prostatectomies or small samples from needle biopsies. PNB data indicated that an increased percentage of stroma may be due to increased nonmuscular elements in the stroma.

Measurement of the proportion of free to total prostate-specific antigen improves diagnostic performance of prostate-specific antigen in the diagnostic gray zone of total prostate-specific antigen.

OBJECTIVES: This study examined the clinical significance of non-complexed (free) prostate-specific antigen (PSA) in the differential diagnosis of prostate cancer with an emphasis on patients with total PSA values between 4.0 and 10.0 ng/mL (the diagnostic gray zone). METHODS: Serum samples were obtained from three specimen banks. Patient samples consisted of 55 untreated histologically confirmed primary cancer, 62 men with untreated benign prostatic disease histologically confirmed by 6 negative sextant biopsies, and 64 asymptomatic healthy male controls with normal digital rectal examinations and PSA values less than 4.0 ng/mL. All patients were between the ages of 50 and 75 years. Total PSA levels were determined using the PA immunoassay performed on the TOSOH AIA-1200 automated immunoassay instrument. Free PSA levels were determined using a monoclonal-polyclonal antibody sandwich radioimmunoassay. The proportion of free to total PSA was calculated by dividing the patient's free PSA value by the total PSA value. RESULTS: When all subjects were included, both total PSA and the proportion of free to total PSA significantly differentiated between patients with prostate cancer and patients with benign histologic conditions (P < 0.0001). However, in men with total PSA values between 4.0 and 10.0 ng/mL, the proportion of free to total PSA significantly differentiated between patients with benign and malignant histologic conditions (P = 0.0004), whereas the total PSA did not (P = 0.13). Among this subgroup of patients, the analysis of sensitivity and specificity showed that the proportion of free to total PSA had a clearly higher specificity compared with that of the total PSA at the same level of sensitivity. CONCLUSIONS: Measurement of the free PSA level in a patient's serum and calculation of the proportion of free to total PSA enhances the ability to distinguish benign histologic conditions from cancer while retaining high sensitivity for detecting cancer in men who present with total PSA levels between 4.0 and 10.0 ng/mL. A large-scale population-based study is currently in progress to confirm this preliminary finding.

Measurement of complexed PSA improves specificity for early detection of prostate cancer.

OBJECTIVES: Prostate-specific antigen (PSA) is the most useful of all tumor markers. Although the sensitivity is impressive, low specificity results in a lack of cancer detection in a significant proportion of patients undergoing prostate biopsy. Several recent studies have addressed the need for improved specificity. Of all these approaches, the free/total PSA ratio appears to be the most promising. Given that most circulating PSA is complexed to alpha1-antichymotrypsin, and that this moiety represents a greater proportion of the total PSA in those men with carcinoma, we set out to determine whether complexed PSA would improve specificity in the detection of men with prostate cancer. METHODS: Archival sera were obtained from 300 men, 75 of whom had biopsy-proved prostate cancer. All sera had been previously stored at -70 degrees C for variable periods. An investigative assay for complexed PSA (Bayer) was used. The Tandem-R free and total PSA assays (Hybritech) were used according to the manufacturer's recommendations. RESULTS: Among all patients, specificities for the total PSA, free/total PSA, and complexed PSA alone were 21.8%, 15.6%, and 26.7%, respectively, at cutoffs yielding 95% sensitivity. Similar equivalence or superior performance, in terms of specificity relative to the free/total PSA ratio, was seen at other sensitivity thresholds and other total PSA ranges. CONCLUSIONS: Complexed PSA alone performs better than total PSA or the free/total PSA ratio and obviates the need for a second analyte determination. We believe this marker may offer significant enhancement in PSA testing with significant economic advantages.

Development of a decision-making tool to predict risk of prostate cancer: the Cancer of the Prostate Risk Index (CAPRI) test.

OBJECTIVES: To provide a simple and reliable clinical prediction for an individual patient's overall risk of cancer at biopsy by deriving an easily implemented test based on a generalizable model. Four variables are analyzed for inclusion in the model: prostate-specific antigen (PSA) level, digital rectal examination (DRE) results, race, and age. METHODS: Two populations were used to develop and validate the test: a model (n = 633) and an independent, geographically separate, external population (n = 766). Pathology records for patients who underwent prostate biopsy between 1991 and 1995 were reviewed and screened for the presence of PSA and DRE results. Records where age and race could be determined were extracted. Multiple logistic regression was used with an iterative approach to optimize each test factor. The Wald chi-square test, receiver operating characteristic (ROC) curve, and Hosmer-Lemingshaw test were used to evaluate the model's predictive capability in the two populations. RESULTS: The model and external populations were significantly different for racial mix, PSA level, age, and biopsy detection rate, providing diverse populations to validate the test. Within a combined model, PSA, DRE, race, and age all demonstrated independent capability to predict cancer at biopsy. Predictive power of the overall test was high within the model population (ROC 80.8%), with minimal loss of power in the external population. The test demonstrated no significant lack of fit in either population. CONCLUSIONS: Within a combined test, PSA, DRE, race, and age all contribute significantly to prediction of prostate cancer at biopsy in an individual patient. The test depicts individual risk in an easily understood, visually provocative manner and should assist the clinician and patient in reaching a decision as to whether biopsy is appropriate.

Multicenter comparison of the diagnostic performance of free prostate-specific antigen.

OBJECTIVES: This study examined the multicenter clinical performance of noncomplexed (free) prostate-specific antigen (PSA) in men presenting with total PSA values between 2.5 to 20 ng/mL. METHODS: Prebiopsy serum samples were obtained from 1,081 consecutively accrued, histologically diagnosed men between the ages of 40 and 75 years with total PSA values falling between 2.5 and 20 ng/mL. Total PSA was determined by either the Tosoh AIA-1200 or Hybritech method. Free PSA values were determined using the Dianon PSA II immunoradiometric method. Free PSA was expressed as a percentage of total PSA. Immunochemistry was performed at each accrual site. RESULTS: Among men diagnosed with prostate cancer (CaP), only 4% (21/520) had proportions of free to total PSA values > 25%. Conversely, among men with benign prostatic disease, only 2% (13/561) had proportions of free to total PSA values < 7%. These results confirm those of previous research. Differences among sites were found in age and prostate volume. CONCLUSIONS: These data confirm that free PSA values < 7% are highly suspicious for CaP whereas free PSA values > 25% suggest absence of malignancy. The data also suggest that age and/or prostate volume influences the serum level of free PSA but does not affect the diagnostic cutoff points of 7% and 25%. Future analysis is needed to confirm that younger men with small prostates are at higher risk for CaP.

Laboratory studies for the detection of carcinoma of the prostate.

Acid phosphatase and prostate-specific antigen are extremely useful markers for the management of patients with prostatic carcinoma. Prostatic acid phosphatase, because of its relatively low sensitivity and specificity, as well as analyte instability and diurnal variability, is unsuitable for prostate cancer screening. Improved performance characteristics, stability, the lesser diurnal variation, and the association of elevated prostate-specific antigen with prostatic intraepithelial neoplasia make prostate-specific antigen possibly a better candidate for early detection of this common malignancy. Further investigations in this area are clearly indicated before we can recommend screening with prostate-specific antigen.