Prognostic Significance of Prostate Specific Antigen in Comparison with Histological Grade of Prostatic Adenocarcinoma: A Hospital Based Study

Background: Prostate gland disease causes significant morbidity in elderly males. Our objective of the study was to evaluate the histopathological spectrum of prostatic lesions in correlation with prostate specific antigen and compare the prostate specific antigen with histological grade of prostatic adenocarcinoma. Methods: The present retrospective study was carried in the department of pathology, Narayana Medical College & Hospital, Nellore, and Andhra Pradesh, India from January 2015 to December 2015. 119 Prostatic biopsy specimens were analyzed histopathologically for diagnosis of types of prostatic lesion and correlated with serum PSA level. Prostatic adenocarcinomas were graded according to Gleason histological grading. Gleason’s grading of tumors was correlated with serum PSA levels Result: Out of 119 patients, 95 cases had benign prostatic hyperplasia, 17 cases had prostatic adenocarcinoma, 7 cases had prostatitis. In our study, the maximum number of BPH cases (51.58%) showed PSA levels < 4ng/ml. Most of prostatic adenocarcinoma (82.35%) displayed PSA levels >10ng/ml. 5 cases (71.43%) of prostatitis showed PSA levels of 4 to 10ng/ml. Maximum cases of grade 2 and grade 3 prostatic adenocarcinoma had PSA range of 20-49.99 ng/ml. Conclusion: Benign prostatic hyperplasia is the most commonly diagnosed prostatic lesions. Investigation like serum PSA level detection can aid in the diagnosis, but accurate diagnosis of non-neoplastic and neoplastic lesions of prostate can be made by histopathological study of prostate biopsy.There is a positive relation was seen between higher levels of PSA and Gleason histopathological grade.

Statistical analysis: Data collected was entered in MS Excel and analyzed using SPSS-Version 22.0 Percentages and chi-square values were calculated. A P value of 0.05 was taken as significance.

Results
During the period of one year from January 2015 to December 2015, 119 prostatic biopsy specimens were received. The age ranges of patients were 31-90 years.

Discussion
The prostate is a pear -shaped glandular organ that weighs up to 20g in the normal adult male and it has been divided into anterior, middle, posterior and two lateral lobes by drawing divergent lines from the centrally located urethra. The prostate can be divided into four biological and anatomical zones, peripheral zone, central zone, transitional zone and periurethral gland regions. The transitional zone and periurethral regions are the exclusive sites of origin of nodular hyperplasia, whereas the peripheral zone is the one most susceptible to prostatitis and carcinoma. The glandular component of the organ is composed of acini and ducts, the latter subdivided into large (primary, major, excretory) and peripheral (secretory, minor). Both acini and ducts contain secretory cells, basal cells and scattered neuroendrocine cells. The secretory cells which are located in the luminal side of the gland, contribute a wide variety of products of the seminal fluid. They produce prostatic acid phosphate (PAP) and prostate specific antigen (PSA). PSA is glycoprotein that has been identified as a kallikrein like protease. In the present study most common lesion is BPHwith mean age 63.67±11.29 and BPH is more common between 51-80 years of age. Prostatic adenocarcinoma ( Figure 2) is second most common lesion in our study. Prostatic adenocarcinoma mean age is 68.88±6.49 and more common between 61to 80 years of age in this study. In our study prostatic adenocarcinoma mean age figure are comparable with finding from other studies which report the mean age of 69 years by Thompson IM et al, [7] mean age of 65 years by Lyn et al, [8] and mean age of 68 years by H A Mwakyoma et al . [9] In the present study BPH cases are 79.83% which is nearby comparable with Kshitij et al, [10] Jeven et al, [12] Arunchitale et al [13] and Janardan et al studies. [13] In our study prostatic adenocarcinoma incidence was 14.28% which is nearby comparable with Jevan et al [12] and Arun Chitale et al studies. [13] (Table 3) .In our study BPH cases are most commonly present between PSA level 0-4.0ng/ml (51.58%) Which is compared with study of Khitij et al, [10] and prostatic adenocarcinoma cases are more commonly present with PSA level >10.0ng/ml (82.35%) and it is nearly compared with Walyomaet al [9] Kshitij et al [10] and Sladana Zivkovic et al studies . [15] (Table 4).
In the present study we evaluated the prognostic importance of serum PSA levels with grades of adenocarcinoma prostate. In our study maximum number of malignancies (58.82%) has serum PSA value of more than 20 ng/ml which coincided with study done by Sladana Zivkovic et al study (52.25%) [15] and lower than Shanthi V et al study (80.95%). [16] 2 cases (11.76%) of prostatic adenocarcinoma was detected with PSA values in the range of 4-9.99 ng/ml which is higher than the Shanthi V et al study (4.76%) [16] and lower than the Sladana Zivkovic et al study (27.5%). [15] 4 cases of (23.53%) prostatic adeno carcinoma was detected with PSA values in the range of 10-19.99 ng/ml which is higher than the SladanaZivkovic et al study (17.5%) [15] and Shanthi V et al study (14.29%). [16] (Table 5).
In the present study, one case (5.88%) of grade 2 prostatic adenocarcinoma was noted with serum PSA range of 0-3.99 ng/ml. One case (5.88%) of grade 1 prostatic adenocarcinoma are noted with serum PSA range of 4-9.99 ng/ml which is slightly higher than Shanthi V et al study (4.76%). [16] One case (5.88%) of grade 2 prostatic adeno carcinoma . 3 cases(17.65%) of grade 2 prostatic adenocarcinoma were noted with serum PSA range of 10-19.99 ng/ml which is higher than the Shanthi V et al study (11.9%) . [16] One case (5.88% ) of grade 3 prostatic adeno carcinoma , 3 cases (17.65%) of grade 2 prostatic adeno carcinomas were noted with serum PSA range of 20-49.99 ng/ml which is slightly higher than Shanthi V et al study (16.67%). [16] 3 cases (17.65%) of grade 3 prostatic adeno carcinoma , 4 cases of (23.53%) grade 2 prostatic adeno carcinoma were noted with serum PSA range of 50-99.99 ng/ml which is similar to Shanthi V et al study (23.8%). [16] In our study histopathological grade 2 prostatic adeno carcinoma were restricted to PSA levels of 10ng/ml and above ,but grade 1 prostatic adeno carcinomas was restricted to PSA levels of < 10 ng/ml and grade 3 carcinomas were not having any correlation with specific PSA levels ( Table 6).
In studies done by Shanthi V et al (2012Shanthi V et al ( -2015 [16] and Lennox Anderson Jackson et al (2012), [15] histopathological grade 3 adeno carcinomas had a PSA range of 50-149.99ng/ ml and 76-190 ng/ml respectively . Our study coincided with the conclusion drawn from the studies of Shanthi V et al (2012-2015) [16] and Lennox Anderson Jackson et al (2012) [17] that histological higher grades of prostatic carcinomas are associated with higher PSA levels.

Conclusion
Benign prostatic hyperplasia was the most frequent lesion encountered followed by adenocarcinoma prostate . Prostatic adenocarcinomas were associated with raised prostate specific antigen more than 10ng/ml. In our study, there was a positive relation between higher levels of serum PSA and Gleason's histopathological grade of prostatic adenocarcinoma. But poorly differentiated prostatic adenocarcinomas (higher grade) did not show correlation with serum PSA levels indicating that as the tumor becomes poorly differentiated, tumor cell production of PSA is reduced.