European Journal of Cardiovascular Medicine

The prostate gland is located at the neck of bladder. Its enlargement causes urinary symptoms of static (hesitancy, retention) and dynamic (urgency, dribbling) nature. (1,2) Prostatic carcinoma is at present the second leading cancer among males in the urban Indian population. It is also the most common malignant tumor in elderly males over the age of 65 years. The prevalence of prostate cancer rises with age, and can reach up to 60% in men at the age of 80.(3) Prostate cancer is encountered as the second most common cancer and the fifth leading cause of cancer-associated mortality among men worldwide. (3)

PSA is normally formed as a pro-enzyme, secreted primarily by the secretory acinar cells that line the prostate and are secreted into the lumen. (4) PSA level in blood rises when barrier between blood and epithelium is disturbed by cancer, infection, infarction.(5,6) Gleason's microscopic grading is a paramount feature and with PSA are important for diagnosis, management and prognosis of carcinoma. (7,8,9)

This study was conducted to study the various histomorphological spectrum of prostatic lesions, assess the prostatic carcinoma according to modified Gleason grading system and correlate the serum prostatic antigen levels in prostatic lesions.

This is a 2-year prospective study from October 2019 to September 2021 and was carried out on 70 prostate specimens by doing histopathological examination & their total PSA values were correlated.

Inclusion criteria(s)-

• All prostatic biopsies.
• Transurethral resection of prostate (TURP) chips.
• Prostatectomy specimens.

Exclusion Criteria (s)-

• Prostatic lesions secondary to other primary neoplasms
• Poorly fixed/unfixed specimens.
• Inadequate prostatic biopsies for histopathological reporting

Histopathological diagnosis was achieved using the microscopic examination of slides stained with Haematoxylin and Eosin and serum prostate specific antigen correlation was done. Postoperative histopathology specimens were fixed in 10% formalin. Appropriate number of 5mm to maximum 2cm sections was submitted for processing. 4-to-5-micron thick section were cut with microtome and stained with haematoxylin and eosin (H&E) stain. The stained sections were studied by light microscopy. Total PSA was estimated by using chemiluminescent immunoassay method. It was done by using mindray TPSA kit. Gleason’s grading system was used for grading the cases of adenocarcinoma.

Total 70 cases were prospectively examined for various prostatic pathologies by doing histopathological examination & their total PSA values were correlated. Among 70 cases selected, 23 cases were benign prostatic hyperplasia(Image 1), 8 cases were benign prostatic hyperplasia with chronic prostatitis (Image 2), 1 case of prostatic intraepithelial neoplasm (Image 3)& 38 cases were of prostate adenocarcinoma(Image 4). ( Table 1)

The most common symptom encountered in prostatic lesions was increased frequency of micturition followed by dysuria which accounts 24% and 22% respectively. Least common symptom was acute retention of urine in 1.42% cases.

Most of the prostatic lesions were in the age group of 61-70 years, comprising (42.85%) of total case percentage. Mean age of prostatic lesions was 65.95±15.49 (61-70) years. ( Table 2)

Table 1: Distribution of Prostatic lesions

Table 2: Age wise distribution of various prostatic lesions

A difference in serum tPSA level in prostate cancer patients compared to patients with benign prostate changes was found, i.e. the all patients with prostate adenocarcinoma and PIN 39 cases(100%), had a t PSA level >10.0 ng/ml, unlike patients without carcinoma whose t PSA level was predominantly between 0-4.0 ng/ml, 15 cases (21.42%). ( Table 3)

Table 3: Comparison of PSA levels with various prostatic lesions

Among all the 38 prostatic adenocarcinoma cases studied the most common Gleason score was 7a in 20 cases and 7b in 8 cases constituting 52.61% and 21.05% respectively, followed by score 8b in 5 cases constituting 13.15 %, followed by score 8a in 2 cases constituting 5.26 %, followed by score 9 in 1 case constituting 2.63 %. Gleason score 6 was in 5.26 % and Gleason score ≥ 8 in 21.05% of cases. There were (n=2), 2 cases of gleason score 3+3(6) ,20 cases (n=20) of gleason score 3+4(7a), 8 cases (n=8) gleason score 4+3(7b) ,2 cases (n=2) of gleason score 4+4(8a), 5 cases (n=5) of gleason score 5+3(8b), 1 cases (n=1) of gleason score 4+5(9). ( Table 4)

Table 4: Incidence of different Gleason scores with different total prostate specific antigen levels (tPSA):

Gleason score was analyzed in the grade groups of patients with prostatic adenocarcinoma with respect to increased tPSA .In the group of patients with Gleason score 7, mean value of t PSA was 49.12 (range 12.31-92.2 ng/ml), while in patients with Gleason score 8 it was 30.13 (range 62.4- 192.4). Gleason score 3+4=7 was the most represented score with 20 cases having t PSA most commonly between(10.1-20) ng/ml, while higher Gleason score 4+5=9, was dominantly represented in the group of patients with t PSA level ≥100.0 ng/ml. An increase of t PSA level with the increase of prostate carcinoma Grade Group (GG) was not found: the highest percentage of GG 5 (100%)carcinomas had t PSA level greater than 20 ng/ml, while of GG 4 (31.57%) carcinomas also had t PSA level >100.0 ng/ml.

MICROSCOPIC IMAGES:

Image 1: Benign prostatic hyperplasia showing bland appearing glands lined by double layered lining with infolding of columnar epithelium surrounded by fibromuscular stromal hyperplasia. (H and E, 40X)

Image 2: Benign prostatic hyperplasia with prostatitis showing bland appearing glands & hyperplastic stroma with chronic inflammatory cells. (H and E, 10X)

Image 3: Prostate intraepithelial neoplasm low grade showing glands with crowding, stratification and anisonucleosis. (H and E, 40X)

Image 4: Cribriform pattern adenocarcinoma (H and E, 40X)

The present study entitled “Correlation of prostate specific antigen levels with histomorphological spectrum of prostatic lesions,” was conducted in department of pathology tertiary care center and attached cancer hospital within period of 2 years from October 2019 to September 2021. A total sample size of 70 cases were analyzed for prostatic lesions and correlated with serum prostate specific antigen levels . The study was conducted after taking ethical clearance from the institute. These prostatic specimens obtained, constituted 0.40 % of 17498 total specimens received in the department during the same period.

The histopathological diagnosis of different cases of prostate in various studies is shown in Table 5-

Table 5: Histopathological diagnosis in various studies

The incidence of benign prostatic lesions in our study was 44.28% which was lower than other studies of Pudasaini et al 70.6%, Yelave et al 89%,Jasani et al 56% and Kusauma et al 80.6%.

The incidence of prostatic intraepithelial lesion in our study was 1.42% which was similar to studies of Kusauma et al 1.6% and Yelave et al 0.67%102 while incidence was lower than studies of Pudasaini et al 5.9% and Jasani et al 7.22%.

The incidence of malignant lesions in our study was 54.28% which was higher than other studies of Pudasaini et al 17.6%,Yelave et al 10%,Jasani et al 32% and Kusauma et al 17.7%.

Recently, higher incidence of neoplastic lesion was observed due to diagnosis of prostate carcinoma at an early stage. Moreover, our study was carried out at tertiary health care health center and tertiary care cancer hospital.

Table 6: PSA Correlation of prostatic lesions in various studies

In our study out of total 31 cases of benign lesions of prostate, 15 cases (48.38%) showed tPSA levels <4ng/ml which were comparable with studies of Parvathaneni S. et al (50.66%) and were lower than study of Kshitij et al 71.6%. 9(29.03%) cases showed tPSA level between 4.1-10ng/ml which were comparable with studies of Parvathaneni S. et al (25.33%), Kshitij et al 22.6% and lower than study of Ishtiaq Ali khan et al (85.0%). 7(22.58%) cases showed tPSA level >10ng/ml which were comparable with study of Parvathaneni S. et al 24.0%, and higher than the study of Kshitij et al 3.0% and Ishtiaq Ali khan et al 15.0%.

All malignant lesions of prostate 39 cases including PIN and adenocarcinoma showed t PSA values >10ng/ml which were comparable with studies of 105 ParvathaneniS. et al 100% and Deepika Gurumurthy et al 84.31%, and higher thanthe studies of Sladana Zivkovic et al 70.0% and Kshitij et al. ( Table 6)

Table 7: Comparison of tPSA with Gleason score and other studies

PSA levels in prostatic carcinoma were compared with Gleason’s histopathological grade of the tumors. In our study most commonly,represented grade was grade 2, 20(52.63%) which was lower than the study of Nandam M et al . Grade 3 in our study 8(21.05%) which was comparable with the study of Namdam M etal 4(23.53). Grade 1 in our study 2(5.26%) was also comparable with the study of Nandam M et al 1(5.88%). (Table 7)

As prostate disease is common, more research is needed for prevention, early diagnosis and giving therapeutic options for both patients and clinicians. The commonest pathology encountered in our study was of adenocarcinoma of prostate. Serum PSA emerged as an important tumor marker and it can be used for screening of carcinoma prostate cases for early detection and better patient management.

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