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Urologic Clinics of North America

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PROSTATE-SPECIFIC ANTIGEN DENSITY - 11/09/11

Doi : 10.1016/S0094-0143(05)70379-7 
Mario C. Beduschi, MD *, Joseph E. Oesterling, MD *

Resumen

Highly preserved in the evolution chain, prostate-specific antigen (PSA) is a serine protease elaborated, almost exclusively, by the epithelial cells lining the acini and ducts of the prostate gland. Once produced, it is secreted into the prostatic ductal system and is present in high concentrations in the seminal plasma, in which it serves the purpose of liquefying the seminal coagulum.42, 52 Since its isolation and identification in the human serum, prostatic fluid, and tissue nearly 2 decades ago, PSA has been under intensive investigation by the urologic community.34, 39, 58 Today, as a result of such efforts and because of its unique characteristics, PSA has been established as the most clinically useful tumor marker for mass screening, diagnosis, staging, and monitoring of prostate cancer.42, 46

Used classically as a follow-up marker for patients who had undergone treatment for adenocarcinoma of the prostate, measurement of serum PSA in more recent years has been strongly advocated and widely used by some authors as a screening test for this malignancy.17, 25 Though unique, PSA has important shortcomings that prevent it from being the ideal tumor marker.10, 27, 35, 43, 47, 55 Although organ-specific, PSA is not cancer-specific, resulting in a limitation of the marker's ability to differentiate PSA abnormalities owing to prostate malignancy from a series of benign and more prevalent conditions that frequently can produce elevations in serum PSA concentrations, such as benign prostatic hyperplasia (BPH), acute prostatitis, acute urinary retention, and prostatic ischemia.28, 42, 49 Noteworthy also is the finding that serum PSA elevation is not always observed in men with prostate cancer.

Several studies have shown that the median PSA concentration is significantly and consistently higher for men with organ-confined prostate cancer than for men with BPH.44, 53 Using a cut-off point of 4.0 ng/mL, however, most of these studies have shown a considerable overlap in PSA values between these two pathologies. Because of the lack of sensitivity (68% to 80%) and specificity (49% to 90%) well documented by these reports, the value of PSA measurement in routine mass screening and its adequacy as a tumor marker for the early detection of prostate cancer has been questioned.5, 19, 33, 38, 55

This lack of accuracy is most striking for the subgroup of patients whose PSA values lie between 4.1 and 10.0 ng/mL, in which range the aforementioned overlapping results most frequently are found and also many patients with organ-confined disease are likely to be located. Many of these patients undergo prostatic transrectal ultrasonography (TRUS) and prostate biopsy to determine the cause of their PSA elevation.22, 23, 59 For the population whose PSA is 4.0 ng/mL or less, there is a low prevalence of prostate malignancy (1.4%), whereas if PSA is greater than 10.0 ng/mL, a high prevalence is verified (53.3%).5, 21

Researchers have undertaken the task of improving the ability of serum PSA measurement to detect organ-confined prostate cancer. To do so, it is necessary to enhance the capability of this tumor marker to distinguish reliably BPH from clinically significant, nonpalpable prostate cancer, assuming the fact that larger lesions can be detected by digital rectal examination (DRE), and consequently serum PSA is not required for their diagnoses. As a result, in recent years several concepts have been developed and proposed and are being tested clinically with the purpose of optimizing the clinical use of PSA by improving its specificity and preserving its sensitivity. These new techniques include PSA density (PSAD), PSA velocity, age-specific PSA, and percent free PSA.4, 9, 14, 18, 44, 45, 55, 56 Most of these concepts are still under evaluation to determine their true clinical usefulness. Their specific features are discussed separately elsewhere in this issue. In this article PSA density is reviewed in its concept, application, and results in the assessment and management of the male population at risk of harboring prostate cancer.

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Esquema


 Address reprint requests to Joseph E. Oesterling, MD, The Michigan Prostate Institute, The University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109–0330


© 1997  W. B. Saunders Company. Publicado por Elsevier Masson SAS. Todos los derechos reservados.© 1993  © 1993  © 1993  © 1993 
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Vol 24 - N° 2

P. 323-332 - mai 1997 Regresar al número
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  • PROSTATE-SPECIFIC ANTIGEN AS A SCREENING TEST : The Austrian Experience
  • Andreas Reissigl, Georg Bartsch
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  • PROSTATE-SPECIFIC ANTIGEN VELOCITY AND REPEATED MEASURES OF PROSTATE-SPECIFIC ANTIGEN
  • H. Ballentine Carter, Jay D. Pearson

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