|Year : 2016 | Volume
| Issue : 3 | Page : 172-175
Correlation between prostate specific antigen levels and various prostatic pathologies
Bedarshi Banerjee, Banyameen Mohamad Iqbal, Harsh Kumar, Tushar Kambale, Rupali Bavikar
Department of Pathology, Dr. D.Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||28-Sep-2016|
Banyameen Mohamad Iqbal
Department of Pathology, Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. It is generally increased in diseases such as prostatitis, hyperplasia, and malignancy, but the correlation between various pathologies affecting the prostate gland and their corresponding rise in PSA values is not constant, and exceptions may occur. Aims and Objective: The aim of this study was to find out the spectrum and distribution of various prostatic lesions affecting men, with respect to their age and to find out the correlation between serum total PSA and histological findings. Materials and Methods: This study included a total of eighty samples (both transurethral resection of the prostate and prostatic biopsies) received in the histopathology laboratory, in our tertiary care center over a period of 1 year. All representative tissue sections were taken, and paraffin embedded blocks were made, which were finally sliced in a standard 0.3 mm microtome and stained with hematoxylin and eosin stain. They were finally examined under light microscopy for final evaluation and diagnosis. PSA levels were recorded in all the patients before surgical procedure was undertaken. Statistical analysis was done using Graph Pad in Stat 3 software. Analytical tests done included calculated probability (P value), Chi-squared test, tables containing data distribution in various formats and arithmetic mean. Results: About 51% of subjects studied were in the age group of 61-70 years. Maximum no of subjects had PSA ranging from 0 to 7 ng/ml (37.5%). Benign prostatic hyperplasia was the predominant lesion (38.75%) in the population studied. Chi-Squared distribution yielded a value of 11.49 while P < 0.01 indicating that there exists a positive correlation between the increasing PSA levels and chances of adenocarcinoma, the findings were statistically significant. Conclusion: We were able to determine the spectrum of prostatic lesions in different age groups, and the results indicate that the chances of finding malignancy with increasing values of PSA are more, but not a rule. It can only give a clue to the histopathologist to examine the sections more thoroughly.
Keywords: Benign prostatic hyperplasia, prostate, prostate-specific antigen
|How to cite this article:|
Banerjee B, Iqbal BM, Kumar H, Kambale T, Bavikar R. Correlation between prostate specific antigen levels and various prostatic pathologies. J Med Soc 2016;30:172-5
|How to cite this URL:|
Banerjee B, Iqbal BM, Kumar H, Kambale T, Bavikar R. Correlation between prostate specific antigen levels and various prostatic pathologies. J Med Soc [serial online] 2016 [cited 2020 Oct 31];30:172-5. Available from: https://www.jmedsoc.org/text.asp?2016/30/3/172/191184
| Introduction|| |
The location of the prostate gland is at the neck of the bladder. Its enlargement causes urinary symptoms of static (hesitancy, retention) and dynamic (urgency, dribbling) nature. The incidence of prostatic lesions increases with increasing age.  Due to the influence of pathological processes, the cell integrity is lost leading to the release of prostate-specific antigen (PSA) into circulation, i.e., the processes inside prostate, such as hyperplasia, inflammation, tumors, may lead to the increase of serum PSA value. ,, The increase in PSA values also depends on upon the differentiation of tumor cells. Typically sources for damage can be, cancer, bacterial infection, and prostate infarction and/or destruction of part of the prostate by damage to its blood supply.  Digital rectal examination and transrectal ultrasonography are a preliminary practical diagnostic method but have low specificity and sensitivity.  Various studies done till now have come to various conclusion. While some of them have found positive correlation which is statistically significant, though not highly significant, some of them have not reached the same conclusion. The issue still remains unresolved as to whether thorough sampling should be done in cases where cytomorphologic features favor benignancy, but PSA values are high. Some authors suggested the use of PSA density instead of absolute PSA values while others advocated use of free PSA values which is a more reliable indicator. This study aims to find out the relationship between various prostatic pathology and serum total PSA levels, and whether there exists a positive correlation between increasing PSA levels and neoplastic pathology of prostate.
| Materials and methods|| |
This is a retrospective study carried out in the department of pathology. A period of 1 year ranging from August 2014 to August 2015 was selected, and 80 specimens were received during the aforesaid time frame. Ethical Committee approval for conducting the study was taken. PSA values of the patients were recorded before the surgical process. Serum PSA levels were estimated using chemiluminescent Assay. The histopathology specimens were divided into two categories: Biopsy and transurethral resection of prostate (TURP). Biopsy specimens were sampled into 4-8 representative paraffin blocks and for TURP specimens, entire tissue was submitted (minimum 4 blocks were taken, so that chances of sampling error are reduced). The blocks were sliced using 0.3 mm standard microtome and the sections were further stained with hematoxylin and eosin stain. Sections were examined under light microscopy. Diagnostic criteria followed for diagnosing benign prostatic hyperplasia (BPH), prostatitis, prostatic intraepithelial neoplasia (PIN), and adenocarcinoma were adapted from guidelines laid down by World Health Organization (WHO) 2004.  Gleason's score as laid down by WHO was followed for grading adenocarcinoma.  Statistical analysis of data was calculated using Graph Pad in Stat version 3.0 GraphPad Software, Inc. La Jolla, CA, USA. Analytical tests which were done included calculated probability (P value), Chi-square test, tables containing data distribution in various formats and arithmetic mean.
| Results|| |
Total number of samples received was 80. Of which 41 (51%) were in the age group of 61-70 years. The distribution of lesions with age is shown in [Figure 1].
PSA values were classified into intervals of 7 ng/ml. The number of lesions, when correlated with PSA, showed maximum number of cases (n = 30) in the PSA range of 0-7 ng/ml. The lowest no of cases (n = 2) were seen in the PSA range of 28.1-35 ng/ml. The correlation of number of cases in each PSA range group is shown in [Figure 2].
|Figure 2: Bar diagram showing distribution of prostate specific antigen with age|
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Of 80 cases, 31 (38.75%) were of BPH, which formed the majority of lesions, followed by BPH with prostatitis, 23 (28.75%). The least number of cases were of prostatitis only (7.50%). The distribution of lesions according to their microscopic appearance is shown in detail in [Figure 3].
|Figure 3: Pie diagram showing distribution of lesions as per their microscopic appearance|
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Distribution of lesions depending upon their microscopic appearance and PSA values, it was seen that maximum number of adenocarcinoma lesions was seen to occur between PSA ranges of 14.1-21 ng/ml. Most of the PIN lesions were distributed within the PSA range of 7.1-14 or 14.1-21 ng/ml. Maximum number of BPH lesions was seen in the PSA range of 0-7 ng/ml. Similarly, maximum number of BPH with Prostatitis cases was also seen in the PSA range of 0-7 ng/ml. The detailed results are depicted in [Table 1].
|Table 1: Correlation of prostate specific antigen level and microscopic finding|
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The results of comparison of serum PSA levels in benign and malignant lesions revealed a positive correlation between the increase in PSA levels and malignant lesions, but it was not statistically highly significant (P < 0.01). The rising PSA levels are associated with higher chances of malignant lesions, but it cannot be concluded as a rule as there were four cases of adenocarcinoma with PSA levels in range of 0-7 ng/ml. Chi-square test was done to evaluate the correlation values, and the results are depicted in [Table 2].
|Table 2: Association between prostate specific antigen level and histopathological findings|
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| Discussion|| |
In this study, we found prostatic lesions were mostly associated within the age group of 61-70 years. This study shows 75% of the cases as benign (BPH, BPH with prostatitis, only prostatitis) while 25% of cases were malignant (PIN, adenocarcinoma). In a similar recent study by Puttaswamy et al., a total of 62 prostate biopsies were studied over a 2-year period which included TURP (88.70%) and needle biopsy specimens (11.30%). The most common pathology encountered was benign lesions constituting 80.6% (n = 50). Premalignant and malignant lesions constituted 19.4% (n = 12).  Abdel-Meguid et al. found in their study the prevalence of prostatic inflammation with BPH in about 20.1% cases.  The results in our study were almost comparable with their study as in our study BPH with prostatitis was found in 29% of cases.
In a study by Shakya et al., they found two cases of PIN among 106 cases (1.88%).  In our study, we found 10% cases of PIN lesions. The higher incidence of PIN lesions in our study may be due to the fact that most of the diagnosed lesions were in TURP specimens where the entire part of gland is sampled and examined under microscope thus allowing more chances of diagnosing PIN as it may occur in small foci within a gland, which might go unnoticed in a biopsy, hence limiting the usefulness of prostatic biopsy. In a similar study done by Maru et al., they found 10.99% of cases with PIN. 
In this study, the incidence of prostatic adenocarcinoma was 15% while that of PIN was 10%. This is almost correlating with the findings of the study done by Wadgaonkar et al., where they reported 15% malignant cases in their study of 80 cases of prostatic specimen. 
Anunobi et al., in a study described prostate carcinoma to be prevalent in a mean age of 66 years and peak prevalence in the age group of 60-69 years.  In our study, both the maximum number of cases (51%) and maximum cases of adenocarcinoma were in the age group of 61-70 years.
Levels of serum PSA may vary according to the age of the patient. In several disease processes such as prostate cancer, PIN, and prostatitis, the protective layers between prostatic lumen and capillary may be breached resulting in elevation of serum PSA level. A study by Umbehr et al. showed acute and chronic inflammation of prostate to be more commonly associated with high serum PSA.  Kiehl et al. in their study also concluded that BPH and prostatitis is associated with PSA elevation when glandular epithelium is disrupted.  In our study, most of the patients with benign pathology had PSA in the range of 0-7 ng/ml (43.33%) while only a few (10%) had PSA levels above 21 ng/ml owing to the probable fact of membrane disruption as mentioned above.
A study by Lekili et al. showed 32% of prostate adenocarcinoma patients had serum PSA value >20 ng/ml.  In our study, we found 20% of adenocarcinoma had PSA values in the range of 0-7 ng/ml while 40% of adenocarcinomas had PSA values over 21 ng/ml. In another study done by Kamaleshwaran et al., they found 24% of prostate adenocarcinoma patients with serum PSA >20 ng/ml.  Again slightly higher incidence of adenocarcinoma may be owed to the fact that most of the cases which were diagnosed as adenocarcinoma had been on TURP specimens where entire part of the gland is sampled, compared to biopsy specimens, where chances of missing a small focus of adenocarcinoma is strong as only a small portion of the gland is sampled. It is also to be noted that there is importance in findings of stromal fragments along with atrophic glands, ectatic blood vessels, and arteriosclerosis in BPH and it needs to be analyzed in a study with larger sample size.
The study failed to sub-classify adenocarcinoma of prostate into acinar or ductal type, due to lack of adequate immunohistochemical markers. Second, not a single case of basal cell carcinoma, squamous cell carcinoma, mesenchymal, hematolymphoid, or secondary tumor was recorded; the cause of this could be attributed to observer bias (which was not dealt with in this study) or true rarity of these tumors.
| Conclusion|| |
Thus, we conclude that the most common pathology encountered in prostate specimens is BPH. Most of the diseases of prostate occur in the age group of 61-70 years. Both benign and malignant pathologies can cause an increase in serum PSA levels, but the chances of finding malignancy increases with rising values of PSA, although not highly statistically significant (P < 0.01).
We highly acknowledge the department of Surgery for their kind co-operation in providing us with specimens and case files of the patients whenever needed while performing this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]