Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : February | Volume : 3 | Issue : 1 | Page : 1274 - 1284

Significance Of Prostate Specific Antigen And Prostate Volume In The Diagnosis Of Prostatic Diseases

TAURO LF #, RAO K **, SHETTY M **** , RAO BSS *, SHENOY DH.***

# (M.S),Addl.Prof,*(M.S),Assoc.Prof,**(M.B.B.S),PGResident,***(M.S),Prof&HOD,Dept.of GeneralSurgery,****M.S,D.N.B.(Uro)Asso.Prof&Head of Urology.Fr. Muller Medical College Hospital Kankanady,Mangalore–575002(D.K.),Karnataka,(India)

Correspondence Address :
Dr. Leo Francis Tauro Dept of General Surgery,Fr. Muller Medical College Hospital Kankanady,Mangalore–575002(D.K.),Karnataka.Ph.No:Hosp:(0824)2436301,Res:(0824)2224911,E-Mail:drlftauro@rediffmail.com

Abstract

Background and Objectives: Prostate Specific Antigen (PSA) has been used as a screening tool for prostate cancer. Controversies exist with studies showing significant prostate cancer in men with normal PSA. The objective is to study the role of PSA in differentiating benign and malignant diseases of prostate and Prostate Specific Antigen Density (PSA-D) in prostate diseases.
Methods:This is a prospective study of data from 100 patients in our Medical College Hospital from July 2005-May 2007. All patients with lower urinary tract symptoms (LUTS), suggestive of prostate enlargement, were included. Patients with urethral strictures, calculi or with a previous history of surgeries and procedures on the prostate were excluded. All patients underwent digital rectal examination, serum PSA measurement and transrectal ultrasonography to measure prostate volume. Prostatic pathology was confirmed by biopsy in all patients after obtaining informed written consent.
Results:The mean age was 68.05 ± 8.27 (SD) years. 40% of the patients had PSA values between 4-10ng/ml. There was no statistical correlation between age and PSA. Digital rectal examination had a sensitivity of 65.5% for detection of prostate cancer. Prostatic volume, as an independent variable, was not significant in predicting malignancy. Total PSA done in all cases was significant for the detection of cancer at levels >10ng/ml. PSA-D improved the sensitivity to detect malignancy.
Conclusion: PSA is significant in detecting prostate cancer at values >10ngm/ml. Prostate volume is not significant for diagnosis of prostatic diseases but PSA-D has a high sensitivity (96.55%) in detecting prostate cancer.

Keywords

Prostate Specific Antigen (PSA); Prostate Volume; Digital rectal Examination (DRE); PSA density (PSA-D)

Introduction
The burden of prostate diseases on Health Departments throughout the world is on the rise, as a consequence of the improved survival rate of the population. Benign Prostatic Hyperplasia (BPH) accounts for the majority of bladder outflow obstructions in men >50 years of age, with prostate cancer being an important differential diagnosis. Therefore, it is necessary to investigate the patient thoroughly before planning the management.

Prostate Specific Antigen (PSA) has been used as a screening tool for cancer. But controversies exist (1),(2),(3) regarding its usefulness, with studies showing significant prostate cancer in men with normal PSA. PSA and prostate volume have an age dependant log linear relationship (4).Studies have shown that prostate volume with PSA correlation is a better indicator for prostate diseases (5), (6). This study aims to correlate PSA levels and PSA Density in prostate diseases in our clinical set up, for diagnostic accuracy and for planning further management.

Objectives Of The Study:
1. To study the role of PSA in differentiating benign and malignant diseases of prostate.
2. To study Prostate Specific Antigen Density (PSA-D) in prostate diseases.

Material and Methods

This study consecutively included one hundred patients with symptoms suggestive of prostate diseases, registered at our Medical College Hospital from July 2005 to May 2007. Ethical committee clearance was obtained prior to the study. All patients were admitted and underwent a standard evaluation of digital rectal examination, serum PSA measurement and transrectal ultrasonography (done by a single sonologist) to measure prostate volume. Serum PSA was estimated on the day of admission before any procedures on the prostate or urethra. Patients were prepared with proctoclysis enema in the night and early morning, and a transrectal ultrasound was performed on all patients to measure the prostate volume and to calculate the prostate specific antigen density. Prostatic pathology was confirmed by transrectal biopsy (was done by a single urologist, uniform technique) in all patients after obtaining informed written consent. The histopathology report was confirmed by a single pathologist. Collected data were tabulated and analyzed for possible association using Chi-square Test, along with sensitivity, specificity and predictive values.

Inclusion Criteria
All patients were admitted to our Medical College Hospital with lower urinary tract symptoms (LUTS) suggestive of prostate pathology.
Exclusion Criteria:
1. Patients with other causes of LUTS like urethral strictures or calculi.
2. Previous history of surgeries or procedures on the prostate.
PSA blood test: After the generation of specific anti-PSA antiserum, it is used to identify the presence of PSA in the sera of metastatic prostate cancer patients by rocket-immunoelectrophoresis (IEP). PSA values obtained from the patient’s sera and from prostate tissues proved to be immunologically identical. These significant findings provided the basis for the development of an enzyme-linked immunosorbent assay (ELISA).
It has been observed that when sera from metastatic prostate cancer patients were examined by gel filtration, the reactive antigen or the circulating PSA antigen eluted as a peak at a molecular weight of 96,000, while the antigen isolated from prostate tissues eluted at 34,000. Additional studies with immunoprecipitation and two-dimensional IEP revealed that in addition to PSA, the serum PSA peak contained "normal serum protein contaminants." This was the first report concerning complexed PSA, as it is called today.

Results

The mean age in our patient group was 68.05 years, with a standard deviation of 8.27 and 81% of the patients were in the age group between 56 to 75 years.(Table/Fig 1)

A majority of patients in the study had serum PSA values between 4.01-10ng/ml (Table/Fig 2).

P value 0.107
In our study, there was no log linear increase of PSA values with age. The correlation was not significant (Table/Fig 3).

The correlation between Digital rectal examination and Histopathology, revealed the following: (Table/Fig 4)
Sensitivity for detection of prostate cancer = 65.5%
Specificity for detection of prostate cancer = 91.5%
Positive predictive value = 76%
Negative predictive value = 86.7%

In our study, prostate volume was found to be insignificant in differentiating the benign from the malignant disease of the prostate (Table/Fig 5).

Twenty nine cases were detected to have prostate cancer, among which 27 patients had a PSA value more than 10 ng/ml and 2 patients had a PSA value within the range of 4.01-10ng/ml (Table/Fig 6).


Hence, the correlation of the PSA value range of more than 10ng/ml to the histopathology was done and the cross tabulation result is as shown in (Table/Fig 7).

When PSA values were more than 10ng/ml, our study was found to have a sensitivity of 93.1%; a specificity of 90.1%; a positive predictive value of 79.41% and a negative predictive value of 96.97% for the detection of prostate cancer.

PSA Density is the ratio of Total Serum PSA (ng/ml) to the Prostatic Gland Volume (ml). PSA-D had a sensitivity of 96.55%; specificity of 87.3%; positive predictive value of 75.67% and negative predictive value of 98.4% (Table/Fig 8).


Discussion

The first tumour marker for prostate cancer was Acid Phosphatase which was described by Gutman and Gutman (7) in 1938, but lost its importance as it was not very prostate specific. The search for a tumour marker which was more sensitive and specific for prostate cancer led to the discovery of several prostate antigens that subsequently came to be known as Prostate Specific Antigen. While many have claimed to be the first to discover PSA in seminal plasma, most authorities credit Wang and associates who were working at the Roswell Park Cancer Institute in Buffalo, New York, in conjunction with Murphy et al, also at Roswell Park at that time, as having clearly described this protein on gel electropheresis. (8),(9) Prostate-specific antigen testing was introduced into clinical use in the mid-1980s.(10) PSA is a glycoprotein which is secreted by prostatic epithelial cells, and its serine protease activity lyses the clotted ejaculate to enhance sperm motility. It belongs to the Human Kallikrein (HK) family of proteins, i.e., HK3, and is under tight androgen regulation.

The advent and refinement of ultrasound technology has provided a new and important method to examine the prostate. Prostatic volume estimation by transrectal ultrasound is a common clinical procedure. It’s uses include the pre-treatment assessment of prostate size and interpretation of elevated prostate specific antigen (PSA) levels. Transrectal ultrasound (TRUS) was initially described as a technique to evaluate rectal pathology. In 1963, Takahashi and Ouchi (11), (12), (13) were the first to describe the use of TRUS to evaluate the prostate. The first clinically applicable images of the prostate obtained with TRUS, were described in 1967 by Watanabe et al.(13).

Prostate growth appears to be related to prostate volume. Numerous studies have confirmed that prostate volume is an important predictor of BPH progression(14),(15). These studies confirmed that the risk of acute urinary retention increased with increased prostate size, as measured by transrectal ultrasound (a 3-fold increased risk for prostates >30 ml). Roehrborn CG et al.(16) focused on a database of 4627 patients from either BPH or safety trials, for whom baseline data regarding age, prostate volume, and serum prostate-specific antigen (PSA) level were available. Overall, the results suggested that while prostate size increases throughout adulthood, PSA levels do not tend to increase with age until after age 40.

Pauler DK et al (17) investigated the prevalence of prostate cancer among men in the Prostate Cancer Prevention Trial, who had a PSA level of 4.0ng per milliliter or less. They concluded that biopsy-detected prostate cancer including high-grade cancers is not rare among men with PSA levels of 4.0ng per milliliter or less--levels generally thought to be in the normal range.

Sang Eun Lee et al (18) studied 755 patients with a serum PSA level of 2.0–10.0ng/ml, who underwent TRUS guided systematic biopsy. Patients were divided into low (PSA 2.0–4.0ng/ml, n = 144) and intermediate (PSA 4.1–10.0ng/ml, n = 611) PSA groups. Patients in the low PSA group had significantly smaller prostates and lower PSA density. The rate of cancer detection was 16.7% in the low PSA group and 23.7% (145 of 611) in the intermediate PSA group. In a study conducted by Babain et al.(19), 151 men who had serum PSA values between 2.5 and 4.0ng/ml, underwent prostate biopsy. Cancer was identified in 24.5% of the patient’s biopsies. The median age of the men with cancer was 62 years.

In prostate cancers, a study by Stephen JF(20)] concluded that men with smaller prostates had more high-grade cancers and more advanced disease, and suggested that prostate size may be an important prognostic variable that should be evaluated to predict biochemical progression pre- and postoperatively.

PSA Density
It enhances PSA performance. Babain et al (21) were the first to describe the relationship between prostate size and PSA. PSA density is calculated as the ratio of Total Serum PSA (ng/ml) to the Prostatic Gland Volume (ml). Isikay et al(22) studied the role of prostate-specific antigen density in the early detection of prostate cancer and assessed the hypothesis that PSAD offers significant advantages over prostate-specific antigen (PSA) alone in the evaluation of patients with benign (BPH), pre-malignant (PIN) and malignant prostatic diseases. They concluded that the information provided by PSAD is superior to absolute PSA values in the differentiation between BPH and carcinoma prostate, but PSAD was not able to add more information on differentiating BPH from pre-malignant conditions. Klingler et al(23) studied the use of PSAD in enhancing the specificity of PSA in detecting prostate cancer. They studied 77 patients and concluded that PSAD does not significantly identify patients at the risk of prostate cancer, at levels of PSA between 4-10ng/ml.

Iwaki et al(24) studied the predictive value of prostate specific antigen density in the detection of prostate cancer in patients with elevated prostate specific antigen levels and normal digital rectal findings. For all patients with PSA levels of 4.1-10.0 ng/ml, a PSAD cutoff value of 0.1 reduced the number of biopsies 22.5% (16 of 71 cases). These results suggested that by the measurement of PSAD, some patients with benign disease could be spared a biopsy which would have been performed, based on the PSA results alone.

Modification of the PSA-D is the PSA transition zone density, defined as the serum PSA that is divided by the volume of the transition zone. But the effectiveness of the latter has yet to be proved (25),(26). Substantial cost is added to early detection by using PSA density instead of the raw PSA level, and measuring PSA density is not practical in primary care settings(27).
Total serum PSA and Prostate volume were the two main indices taken into consideration in our study. A majority of patients were in the age group of 56-75 years in our study, which corresponds to extensive studies done by other researchers (28),(29).The relatively higher percentage of patients in the PSA range between 4-10ng/ml, when compared to larger studies (30), may be attributed to the other associated features like urinary tract infection and acute retention of urine, as many patients presented to the emergency set up with the above complaints. In the present study, there was no significant rise in serum PSA values with age. This is in contrary to the findings in other larger study populations (28), (29) and may be attributed to the relatively small sample size.

The first clue to a malignant prostate disease is digital rectal examination. In our study, DRE had a sensitivity of 65.5% in detecting prostate cancer (31). In a rare study that reported long-term outcome, Gerber et al. (32) and Chodak et al (33) found that men who had cancer that was discovered on a serial digital rectal examination, seemed to have a more favourable stage shift than men who had cancer that was discovered on initial examination. So, in spite of being a subjective finding in the diagnosis of prostate diseases, it gives the examiner a useful insight to the pathology that he is dealing with.

Prostate volume as an independent modality for diagnosing prostate diseases, has no statistically significant role, as is indicated in this study, which is in concurrence of the observations made by Mcconnel et al (34).Total serum PSA has a significant role to play in prostate cancer detection, as shown in our study, that at PSA levels of more than 10 ng/ml, sensitivity was 93.1%; specificity was 90.1%; positive predictive value was 79.41% and negative predictive value was 96.97%. These results are comparable to the studies of Cooner et al [13, 35] (sensitivity 65.7% and specificity 82%) and Brawer et al (25) (sensitivity 75% and specificity 94.1%). While correlating PSA levels >4 and cancer, our study had a positive predictive value of 40.8% and is in concurrence with other larger study series as shown in the table (Table/Fig 9).

The PSA density had a high sensitivity (96.55%) and specificity (87.3%) in our study. This is comparable to the larger study done by Van Iersel et al. (37), who had a sensitivity of 92% for the detection of prostatic malignancy at PSAD values >0.15.

Limitations Of The Study
Our study includes patients with acute retention of urine. This causes elevation of PSA, which might have changed our results. We have taken biopsies from all patients, including those with a PSA value of less than 4 and normal DRE. We could have avoided biopsies in these patients. However, we have obtained informed written consent and ethical committee clearance. A similar study has been reported by Pauler DK et al (17). It would have been good if we had analyzed the sensitivity and specificity of both DRE and PSA values of less than 4, 4-10 and more than 10 alone and in combination.

Conclusion

Undiagnosed prostate cancer is highly prevalent, especially among older men. Although many of these cancers may be considered incidental, evidence suggests that consideration of screening is warranted, because earlier diagnosis of clinically significant cancers often has the potential to improve outcome. (39) Serum PSA estimation is a useful tool to detect prostate cancer at values >10ngm/ml. Prostate volume, as an independent entity, is not significant for the diagnosis of prostate diseases. When prostate specific antigen density is calculated, it has a high sensitivity (96.55%) for the diagnosis of prostate cancer. But undoubtedly, new approaches to interpreting PSA values in individual patients will be discovered and new markers will be identified to aid clinicians who deal with one of the most common neoplasm in men.

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