Comment to “Relation between prostate gland volume and some histological markers of malignancy”

Vela-Navarrete, R.
doi:10.1016/j.acuroe.2012.04.011
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the diagnostic process of prostate cancer only the positive biopsy confirms the suspicion of tumor&#46; The suspicion of prostatic neoformation may be based on very simple arguments such as prostate palpation&#44; or very elaborate from the total PSA &#40;T<span class="elsevierStyleInf">1c</span>&#41; levels&#44; free and complex PSA&#44; PSA density&#44; PSA velocity&#44; or clinical data&#44; such as ethnic group or family history&#46; In some urological environments&#44; a total PSA greater than 4<span class="elsevierStyleHsp" style=""></span>ng&#47;ml is sufficient grounds to justify the performance of a prostate biopsy&#44; and even to repeat it if negative for malignancy&#44; increasing the number of samples&#46; According to the recommendations contained in different guidelines for action&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and applying more rigor to the interventionist decisions&#44; the prostate biopsy would be justified only when the circumstances are appropriate&#44; matching or separately&#44; of certain analytical or volumetric parameters&#44; such as the percentage of the free PSA &#40;FPSA&#41; or the PSA density &#40;PSA D&#41;&#46; We will refer in the following comments especially to the role played by the total volume of the prostate gland &#40;TVPG&#41; alone or related to the total PSA&#44; i&#46;e&#46;&#44; the PSA density &#40;PSA D&#41; in the indication and justification for prostate biopsy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">When the TPSA is between 4 and 10<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; the most common analytical reference for discussion on the indication for prostate biopsy&#44; the role of the total volume of the prostate gland &#40;TVPG&#41; as a parameter to consider&#44; is an old warning&#46; In 1987&#44; Stamey et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> showed that benign prostatic hyperplasia &#40;BPH&#41; may be associated with elevated PSA levels&#46; In 1992&#44; Babaian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> showed that there was a statistically significant relation between the logarithm of the serum PSA concentration and the total volume of the prostate gland&#44; concluding&#44; categorically&#44; that the total volume of the prostate gland must be considered when trying to understand the meaning of a specific PSA&#46; A subsequent approach to the problem was proposed by Benson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> introducing the concept of PSA density &#40;PSA D&#41;&#44; a concept that consists of the index obtained by dividing the total PSA by the TVGP&#46; However&#44; in the 1990s&#44; there was some lack of interest in prostate volume and PSA density in favor of a new analytical approach based on the so-called complex PSA&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> a lack of interest that continues today&#44; as in some guidelines the value of the PSA D has been excluded as a resource to confirm the need for biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Since there is evidence that the cancer cell increases the serum concentration of the PSA 12 times more than the benign prostatic cell&#44; it was proposed&#44; to have a more precise idea of the origin of the elevated PSA&#44; to more rigorously determine the volume of the adenoma&#44; which was called &#8216;volume of the transition zone&#8217;&#44; erroneously&#44; because of this determination being performed by transrectal ultrasound using the old terminology&#46; Thus&#44; there was a new PSA density index referred to the transition area and known as TPSA &#40;total PSA&#47;volume of the adenoma&#41;&#44; whose predictive value for cancer was investigated by Djavan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> identifying a predictive value greater than the total PSA D&#44; especially in patients with prostate volume greater than 30<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The correlation between the total volume of the prostate gland and free PSA was investigated by Catalona et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> in 1995&#44; confirming that there is a positive correlation&#44; so large prostates are associated with a higher percentage of free PSA than those of small size&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which is why the debate on the usefulness of this index is still controversial&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Another way to assess the role of the prostate gland volume in the biopsy result is when&#44; in homogeneous populations of PSA and biopsy method&#44; we compare the successes obtained in different volume glands&#46; In 1995&#44; Uzzo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> showed that more positive results were obtained in small prostates than in prostates with a volume greater than 50<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> &#40;38&#37; vs&#46; 23&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; in a series of 1021 prostate biopsies performed following the sextant model proposed by Hodge&#46; Other studies demonstrated the certainty of this finding&#44; that the total prostate volume is an important parameter for the biopsy result&#44; but simultaneously suggested that these differences could be due to other variants more than to the volume factor and&#44; in particular&#44; to the direction given to the biopsy needle&#46; Thus&#44; the discussion of region vs&#46; number began&#44; formulated by Stamey&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> who suggested that biopsies had to be taken more laterally than the original model proposed by Hodge&#46; Other authors who proposed increasing the number of doses or including some of the transition zone followed&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Given this strategy of &#8216;the larger the number of samples&#44; the more positive findings&#8217;&#44; a paradoxical but very interesting factor from a biological standpoint was made evident&#59; the prostate glands with a volume greater than 50<span class="elsevierStyleHsp" style=""></span>g usually have unifocal and small volume &#40;&#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41; tumors with remarkable greater frequency than small volume glands&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Therefore&#44; the reason for the recognition of fewer tumors in high-volume prostate glands may simply be because they harbor tumors of smaller volume&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This interesting statement has been amply confirmed in studies performed in samples of radical prostatectomy&#44; comparing the weight of those with the tumor volume&#44; in some cases&#44; and with other markers of malignancy&#44; such as multifocality and Gleason grade&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a>&#46; Certainly&#44; the argument that emerges from these studies can be summarized by the title that heads one of them&#58; the high-volume prostate glands harbor low-grade&#44; small-volume&#44; unifocal&#44; or no tumor&#46; This is an argument that invalidates the indication for prostate biopsy in patients with bulky adenomas and&#44; above all&#44; the repetition of the biopsies in these patients&#46; More so&#44; when considering the convenience&#44; by reason of age or health&#44; watchful waiting&#44; or the opportunity to perform desobstructive surgery due to the coincidence of symptoms motivated by BPH&#46; The response to corrector medical treatment of symptoms and reducing of the prostate volume and PSA &#40;alpha-blocker combination therapy with inhibitors of 5-alpha reductase&#41; can help assess the final decision and avoid many unnecessary biopsies&#46;</p></span>"
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