Serial serum prostate specific antigen measurements over time in a patient presenting with a metastatic adenocarcinoma of unknown origin.Abstract
A 60-year male presented with a mass in the lower abdomen and was referred to the Biochemistry department, Nizam's Institute of Medical Sciences, Hyderabad, India for serum prostate specific antigen PSA (Prostate specific antigen)
A tumor marker associated with prostate cancer.
Mentioned in: Tumor Markers (PSA (Professional Services Automation) An information system designed to organize, track and manage all opportunities, work, resources, costs, revenues and invoices to improve the productivity and efficiency of the workforce. ) estimation. The referring physician had made the following differential diagnoses: non-Hodgkin's lymphoma, prostate carcinoma, and cancer with unknown primary. A very high serum PSA was the only indicator of prostatic malignancy, histopathology his·to·pa·thol·o·gy
The science concerned with the cytologic and histologic structure of abnormal or diseased tissue.
The study of diseased tissues at a minute (microscopic) level. being inconclusive.
The patient was treated for prostate cancer. The PSA concentration declined to normal levels as the patient responded to treatment. He was in remission for seven years but later developed bone metastases. In total the patient was followed up over a period of eight years with serial PSA measurements. The PSA correlated well with the clinical stage of the patient during stable course and recurrent stage of the disease.
Key words: prostate specific antigen, prostate carcinoma, unknown primary cancer unknown primary cancer See Occult primary malignancy.
Prostate cancer is the second most common malignancy in men globally. It is known to have increased prevalence with advancing age. Prostate specific antigen (PSA) was discovered in 1979 and by the late 1980's its prognostic importance and role in monitoring prostate cancer was established (1,2). However, the role of PSA in screening remains controversial (3-6). In this paper a case study is presented in which PSA established the diagnosis of metastatic Metastatic
The term used to describe a secondary cancer, or one that has spread from one area of the body to another.
Mentioned in: Coagulation Disorders
pertaining to or of the nature of a metastasis. prostatic cancer and provided information on the course of the disease and response to treatment, between 1995 and 2003.
A 60- year old male presented with a mass in the lower abdomen and was referred by the physician to the biochemistry department at the Nizam's Institute of Medical Sciences Hyderabad, India for serum PSA estimation. Serum PSAwas measured with a one step double monoclonal antibody enzyme immuno-adsorbent assay (ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.
n. ), using the Enzymun-Test Kit PSA on the Boehringer Mannheim ES300 immunoassay Immunoassay
An assay that quantifies antigen or antibody by immunochemical means. The antigen can be a relatively simple substance such as a drug, or a complex one such as a protein or a virus. batch analyser. The reference interval for PSA in our laboratory was 0.3 to 4.0 ng/ml.
Ultrasound of the abdomen had suggested bilateral iliac and pelvic lymph adenopathy. A CT scan confirmed huge pelvic and lower para aortic aortic
pertaining to or emanating from the aorta. See also aortic arch.
occurs most often in dogs, where it is caused by Spirocerca lupi larvae, turkeys and primates, causing dyspnea, cyanosis and coughing. lymphadenopathy lymphadenopathy /lym·phad·e·nop·a·thy/ (-op´ah-the) disease of the lymph nodes.
angioimmunoblastic lymphadenopathy , angioimmunoblastic lymphadenopathy with dysproteinemia . The physician made three differential diagnoses: non-Hodgkin's lymphoma, prostate carcinoma, and cancer with unknown primary. The serum PSA analysis revealed a very high value of 825 ng/ml, although histopathological examination showed only metastatic adenocarcinoma with unknown primary. In April 1995, the patient underwent bilateral orchidectomy orchidectomy /or·chi·dec·to·my/ (or?ki-dek´tah-me) orchiectomy.
see orchiectomy. as an appropriate treatment for prostatic cancer. In May 1995 and August 1995 PSA values were 34 ng/ml and 22ng/ml respectively.
A further decline in PSA to 4.2 ng/ml and then to 0.8 ng/ml was noticed between October 1995 and April 1996. However, in August 1996 the patient presented with pain near the left pelvic girdle and the PSA had increased to 32 ng/ml. He was treated with Flutamide (a potent anti-androgen). From November 1996 to January 2002 normal PSA levels (2.8ng/ml, 0.4 ng/ml, 0.5 ng/ml, 0.8 ng/ml, 0.6 ng/ml and 0.08 ng/ml) were observed and the patient was clinically stable during this period (Figure 1).
In May 2002 the patient complained of weakness and leg pain and the PSA had increased to 19 ng/ml. He was started on Cytomid (an anti-inflammatory and anti-androgen). A bone scan revealed multiple skeletal metastases Metastasis (plural, metastases)
A tumor growth or deposit that has spread via lymph or blood to an area of the body remote from the primary tumor.
Mentioned in: Malignant Melanoma . During July 2002 and September 2002 a progressive rise in PSA levels was observed (22 ng/ml and 49 ng/ml). The total alkaline phosphatase (ALP (language) ALP - A list processing extension of Mercury Autocode.
["ALP, An Autocode List-Processing Language", D.C. Cooper et al, Computer J 5:28-31, 1962]. ) was borderline elevated at 132 U/L U/L Upload
U/L Units/Litre while the ALP bone fraction was elevated at 77%. ALP was estimated on a Merck Micro lab 200 semi auto analyzer using the manufacturer's reagents. The reference interval for ALP is 38 to 126 U/L. ALP iso-enzymes (bone and liver) were separated by electrophoresis and the fractions were quantitated by scanning of the electrophoresed gels with a Helena densitometer A device that calibrates the relative strength of a color using complementary filters. Contrast with colorimeter. at 595nm, using the ALP isoenzymes kit supplied by the manufacturer. The reference interval for the bone fraction is 23-67%.
The patient had swelling in the inguinal region and bone pain. The patient was subjected to 25 exposures of radiation therapy as well as hormone therapy consisting of Cytomid. In December 2002 his PSA slightly declined to 19.5 ng/ml. In January 2003 swelling in the inguinal region was reduced but the PSA rose to 40 ng/ml along with a rise in total ALP (641 U/L) and bone ALP fraction (80%).
Although the patient's prostate cancer could have been detected earlier by a screening program, there is a considerable debate regarding the necessity or even desirability of screening to detect prostate cancer in cases of asymptomatic individuals (3-6). PSA is considered as an ideal tumor marker for monitoring prostate cancer and assessing response to treatment (7,8). A study by Malati and colleagues during a screening programme in India on South Indian males aged between 40 to 80 years emphasized the importance of a multidisciplinary approach using digital rectal examination Digital rectal examination
A routine screening test that is used to detect any lumps in the prostate gland or any hardening or other abnormality of the prostate tissue. , ultrasound and PSA measurement but did not recommend for or against screening (9).
This case study clearly indicates the importance of PSA estimation as a preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
the preparation of a patient before operation. marker as well as a marker for follow-up during different stages of the cancer such as remission, stable course of the disease, and recurrence. This patient's clinical presentation was unusual and histology was unhelpful in reaching a diagnosis. The high PSA confirmed the presence of prostatic cancer and was very useful in monitoring successful treatment and the course of the disease over a seven year period.
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Rajani K Gutha (1) PhD, Medical Laboratory Scientist
Malati Tangirala (2), PhD, Professor and Head
(1) Core Laboratory, Wellington Hospital, Wellington
(2) Department of Riocheffistry Nizam's Institute of Medical Sciences, Hyderabad, India
Figure 1. PSA levels over 8 years Duration (years) PSA ng/ml Mar '95 825 May '95 34 Aug '95 22 Oct '95 4.2 Jan '96 2.1 Apr '96 0.8 Aug '96 32 Nov '96 2.8 Feb '98 0.4 Oct '98 0.5 Aug '99 0.8 Feb '00 0.5 Jun '00 0.4 Nov '00 0.6 Jan '02 0.08 May '02 19 Jul '02 22 Sep '02 49 Dec '02 19.5 Jan '03 40 Note: Table made from line graph.