0022-534 7/92/14 73-0810$03.

00 /0
THE JOURNAL OF UROLOGY Vol. 147, 810-814, March 1992
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC, Printed in U.S.A.

Diagnosis

EFFECTS OF RECTAL EXAMINATION, PROSTATIC MASSAGE,

ULTRASONOGRAPHY AND NEEDLE BIOPSY ON SERUM PROSTATE
SPECIFIC ANTIGEN LEVELS
JERRY J. J. YUAN, DOUGLAS E. COPLEN, JOHN A. PETROS, ROBERT S. FIGENSHAU,
TIMOTHY L. RATLIFF, DEBORAH S. SMITH AND WlLLlAM J. CATALONA*
From the Division of Urologic Surgery and Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri

ABSTRACT

Measurement of serum prostate specific antigen (PSA) is commonly used to evaluate the prostate
gland in a variety of clinical settings. We examined the effects of pro static manipulations, including
digital rectal examination, prostate massage, transrectal ultrasonography and transrectal needle
biopsy, on serum PSA levels in 199 men. We detected no clinically significant difference between
serum PSA levels obtained immediately before and at 5 or 90 minutes after rectal examination in
43 men. We observed falsely increased PSA levels (to greater than 4 ng.fml., Tandem-R) in 1 of 17
men (6%) following prostatic massage and in 3 of 27 men (11%) following ultrasonography.
Transrectal needle biopsy caused an immediate increase in serum PSA in 92 of 100 men. In 29 of
these 92 men (32%) when followed weekly serum PSA levels did not return to baseline as expected
according to the published serum PSA half-life of 2 to 3 days. Biopsies taking 3 or fewer cores (7
patients) resulted in a smaller increase in serum PSA (mean 1.63 ± 1.12 times the baseline level
versus 6.24 ± 1.10 times baseline, p <0.03) and a proportionally shorter duration of PSA elevation
(mean 1.43 ± 0.48 weeks versus 2.13 ± 0.14 weeks, p = 0.20) than those taking 4 or more cores (93
patients). Prostate size and the presence of cancer had no influence on the duration of PSA elevation
following biopsy.
We conclude that digital rectal examination, prostatic massage and ultrasonography have minimal
effects on serum PSA levels in most patients. However, prostatic needle biopsy usually causes
marked elevations of serum PSA levels with a persistent PSA leak into the blood stream lasting
longer than expected from the serum half-life of PSA in approximately 25% of the patients.
KEY WORDS: prostate; massage; ultrasonic diagnosis; biopsy, needle; antigens, differentiation

Prostate specific antigen (PSA) is a serine protease of the
kallikrein family with a molecular weight of 35,000 daltons
which serves to liquefy the seminal coagulum. PSA is produced
exclusively by the prostatic ductal and acinar epithelium, and
it is composed of a single polypeptide chain of 240 amino
acids. 1- 3 Elevated serum PSA levels have been associated with
benign prostatic hyperplasia (BPH), prostatitis and prostate
cancer. The role of serum PSA as a tumor marker has yet to
be fully defined. Serum PSA is useful in monitoring the re-
sponse to treatment in patients with prostate cancer. 4- 9 The
usefulness of serum PSA in the preoperative staging of cases
of clinically localized prostate cancer is controversial. Stamey
et al reported that a preoperative serum PSA level of greater
than 50 ng./ml. (Yang Pros-Check polyclonal radioimmuno-
assay) is a reliable predictor of extracapsular tumor extension. 5
In contrast, Partin et al suggested that serum PSA failed to
reflect accurately tumor burden and final pathological stage in
individual patients. 10 Our previous experience using the Tan-
dem-R (Hybritech) monoclonal immunoradiometric assay re-
Accepted for publication October 18, 1991.
Editor's note. This paper was awarded a prize in the 1990 essay
contest sponsored by the American Urological Association.
Supported in part by Hybritech, San Diego, California.
* Requests for reprints: 4960 Audubon Ave., St. Louis; Missouri
63110.
810
vealed that despite a direct relationship between serum PSA
level and pathological tumor stage, substantial overlap of PSA
levels existed among patients with different tumor stages, thus
rendering serum PSA less useful as a staging tool. 4 Similar
results were reported by others. 8
We are conducting an ongoing study of PSA as a first-line
screening test for prostate cancer and we have observed recently
that in surgically staged cases a baseline serum PSA level of
greater than 10 ng./ml. (Tandem-R) was a surprisingly good
predictor of extracapsular tumor extension when there had
been no recent prostate manipulation. 11 This prompted a ret-
rospective review of 30 patients who had been evaluated before
the screening study. These patients had pathologically organ-
confined prostate cancer but serum PSA levels greater than 10
ng./ml. preoperatively. We found that 75% of these patients
had had either prostate biopsies or transurethral resections
performed within 30 days before the PSA levels were drawn, or
they had rectal examinations performed on the same day that
the PSA levels were measured, which suggests that prior pros-
tatic manipulations may have spuriously increased the serum
PSA levels in some of the patients with organ-confined cancer.
To examine this issue further, we conducted the present study
on the effects of digital rectal examination, prostate massage,
transrectal ultrasonography and transrectal needle biopsy of
the prostate on serum PSA levels.
 EFFECTS OF PROSTATl:C MANIPULATIONS ON SERUM: PROSTATE SPECIF'IC ANTIGEN LEVELS
MATERIALS AND METHODS
We used the Tandem-R monoclonal i:mmunoradiometric
PSA assay (Hybritech). The normal range recom~ende·d· by
the manufacturer is Oto 4 ng./ml. We performed routme d1g1tal
rectal examination to define prostate size and asymmetry, and
to evaluate induration or fixation. One of us (J. J. J. Y.)
performed prostate massage for 30 seconds. as previously de-
scribed. 12 We performed ultrasonography w1~h 7 MHz. tra~s-
ducer scanning in the transverse and the sag1ttal planes, usmg
either the Bruel and Kjaer model 1846 or the Teknar Proscan.
We used an automatic biopsy gun fitted with an 18 gauge needle
for transrectal biopsy under sonographic guidance. We studied
199 ambulatory men who were evaluated at our outpatient
office. We excluded those with known or subsequently proved
metastatic prostate cancer and suspected acute bacterial pros-
tatitis and those who had undergone prostatic needle biopsy
or tra~surethral surgery within 6 months, or rectal examination
within 7 days.
PSA is known to fluctuate spontaneously from day to day, a
phenomenon that we called biological variation in this study.
We calculated the biological variation in 2 ways. We selected
100 biopsied cases for this analysis; for each patient we per-
formed at least 2 pre-biopsy PSA levels (PSAl and PSA2) on
different days approximately 2 weeks apart. We separ~ted them
into 3 groups: normal PSA (O to 4 ng./ml.), low titer P?A
elevation (4.01 to 10 ng./ml.) and high titer PSA elevat10n
(greater than 10 ng./ml.). In the first calculation, called the
difference :score, for each PSA pair (PSAl and PSA2) we
calculated the individual difference score (PSA2 minus PSAl)
and then the mean group difference score and the correspond-
ing 99% confidence interval for each PSA group. We used the
formula: confidence interval = mean group difference score ±
t 0.01 (standard deviation/-Jsample size -1 ). Confidence inter-
vals were based upon the t distribution due to small sample
sizes. We defined the allowable biological variation as the upper
limit of the appropriate confidence interval. In t~e ~e?ond
calculation of biological variation we calculated the md1v1dual
coefficient of variation for each PSA pair and then the mean
coefficient of variation for each PSA group. Two times. the
mean coefficient of variation times baseline was then defmed
as allowable biological variation for each group. The biologi.cal
variations based on the difference score and the correspondmg
mean group coefficients of variation. are sh~wi:i in t.able 1. The
2 methods for calculating the biological vanat10n yielded com-
parable results. . .
We defined an elevation of serum PSA followmg pros ta tic
manipulation as a PSA increase exceeding. the allowable bio-
logical variation; we defined return to baselme as. the ~eturn ~f
an elevated serum PSA to within the allowable b10log1cal ".an-
ation over baseline. In this report we included only elevat10ns
and returns to baseline fulfilling difference score and the coef-
ficient of variation criteria.
Serum PSA levels were obtained in 43 men immediately
before rectal examination. We measured post-rectal examina-
tion levels 5 minutes after examination in 23 men and 90
minutes after rectal examination in the remaining 20. Serum
PSA levels were obtained in 20 men immediately before pros-
tatic massage. We measured post-massage levels 5 m~nutes
after massage in 10 men and 90 minutes after massage m. the
remaining 10. Two ambulatory serum PSA levels were obtamed
TABLE 1. Biological variation of serum PSA levels calculated by the
difference score and coefficient of variation determined in 100 study
patients
Baseline PSA Difference Score Coefficient of
No.
(ng./ml.) (ng./ml.) Variation(%)
0-4 27 0.5 6.8
4.01-10 58 1.3 12.1
Greater than 10 15 5.8 9.7
811
in 36 men. We selected the highest pre-uitrasonography serum
PSA level as the baseline. Serum PSA levels were obtained 5
minutes after ultrasonography and we took additional meas-
urements in 12 of these 36 men 24 hours later to assess a
possible delayed increase. We established baseline seru~ PSA
levels in 100 men according to the same procedure used m the
ultrasonography group. Serum PSA levels were obtained 5
minutes after needle biopsies and then at weekly intervals until
the PSA levels had returned to baseline. We applied the same
criterion to subjects with normal baseline PSA levels (4 ng./
ml. or less), even if the returned serum PSA was greater than
4 ng./ml. For the first 23 men we per.formed.~u.ltiple determi-
nations at 48 to 72-hour intervals durmg the m1tial 7 to 10 days
following biopsies. These multiple determinations added ~o
further information to this study and were subsequently drn-
continued.
We used the 2-sample t test and paired t test for statistical
analysis. All values were given as mean ± 1 standard error.
RESULTS
Rectal examination had no clinically significant effect on
serum PSA levels either immediately or 90 minutes after the
examination. Three men in the 5-minute group had PSA ele-
vations from baselines of 0.8 to 1.6 ng./ml., 1.5 to 2.2 ng./ml.
and 2.9 to 3.6 ng./ml., respectively, while 1 man in the 90-
minute group had an increase from 4.9 to 7.9 ng./ml. Of. 20
men 3 (15%) had elevations in serum PSA levels followmg
prostatic massage from 3.6 to 4.8 ng./ml., l.~ to 3.3 ng./ml. ~nd
1.5 to 2.2 ng./ml., respectively. Of 17 men with normal baselme
PSA levels 1 (6%) had an abnormal level following prostatic
massage.
Of 36 men 4 (11 %) had elevations of PSA levels following
ultrasonography. The first 3 men all coincidentally had baseline
PSA levels of 3.8 ng./ml. with subsequent increases to 6, 13.9
and 14.1 ng./ml., respectively. In 2 men 24-hour measurements
were available: the PSA level in 1 patient had normalized and
the level in the other patient remained elevated at 4.7 ng./ml.
The fourth patient had an increase from 9.1 to 11.5 ng./ml. No
significant change occurred in the remaining 32 men following
ultrasonography. None of the 12 men from whom additional
24-hour post-ultrasonography measurements were obtained
had a delayed increase in PSA level. Overall 3 of 27 men (11.%)
with normal baseline PSA levels had abnormal levels followmg
ultrasonography.
Table 2 summarizes the clinical information on the biopsied
patients. In 92 of 100 men (92%) PSA levels were elevated
immediately following transrectal biopsy. The immediate in-
crease of serum PSA following needle biopsies varied from none
to 52-fold, with a mean of 5.91 times the baseline leveL Biopsies
taking 3 or fewer cores caused a smaller initial increase in the
serum PSA level than those taking 4 cores or more (1.63 ± 1.12
times the baseline level versus 6.24 ± 1.10 times baseline, p
<0.03). The immediate post-biopsy serum PSA level repre-
sented the highest overall post-biopsy level in the great majority
of men studied. Following needle biopsies we performed serial
PSA measurements at 48 to 72-hour intervals in 23 men, of
whom 1 had an additional increase surpassing the immediate
post-biopsy value (22.3 ng./ml. at 48 hours versus 14 ng./ml. 5
minutes after biopsy). Of 77 men who were tested on a weekly
schedule 2 (3%) had delayed increases 1 week after biopsy. We
TABLE 2. Clinical data on biopsied patients
Baseline PSA level (ng./ml.):
0 to 4 27
4.01 to 10 58
Greater than 10 15
Mean No. biopsies (range)
4.8 (2-8)
Mean age (range) 64 (51-78)
Biopsy result:
Ca 33
Benign 67
-----
812 YUAN AND ASSOCIATES

separately studied 10 men with daily PSA levels for 2 to 3 days
following transrectal biopsy and found no additional increase
in serum PSA level surpassing the immediate post-biopsy value.
Of the 92 men with PSA elevations immediately following
biopsy 29 (32%) had persistent serum PSA elevations 2 weeks
after biopsy (tables 3 and 4). Biopsies taking 3 or fewer cores
resulted in proportionally shorter duration of PSA elevations
than those taking 4 or more cores (1.43 ± 0.48 weeks versus
2.13 ± 0.14 weeks, p = 0.20). Prostate size (less than 30 cc, 30
to 60 cc and greater than 60 cc) had no apparent influence on
the duration of PSA elevation (2.15 ± 0.32 weeks, 2.26 ± 0.21
weeks and 2.01 ± 0.17 weeks, respectively, p >0.20); neither
did the presence of carcinoma (2.00 ± 0.27 weeks with carci-
noma versus 2.42 ± 0.35 weeks with benign biopsy, p = 0.35).
The_ figure illustrates deJay_ed PSAreturn to baseline following
biopsy (patient J. G., table 4). The serum half-life of PSA has
been reported to be 2.2 days and 3.15 days following total
prostatectomy. 9 • 12 We used the latter half-life in this report.
DISCUSSION
Serum PSA levels are measured to monitor prostate cancer
after therapy. Currently, many urologists believe that this is
the extent of the usefulness of this serum marker. Thus, the
use of serum PSA level in the preoperative staging of clinically
TABLE 3. PSA return to baseline following biopsy
No, Men
No elevation 8 those of Brawer et al who found that digital rectal examination
Time to baseline (wks.):
1 35
2 28
3 14
4 or more 15
Total 100
localized prostate cancer is controversial. Although it is gener-
ally agreed that a direct correlation exists between increasing
serum PSA levels and higher pathological tumor stages, many
investigators have reported that the PSA levels for different
pathological stages can overlap to a significant degree. Because
investigators were unable to isolate an exact relationship be-
tween a given PSA level and a given tumor stage, many believe
that serum PSA was not accurate enough to be clinically useful
in preoperative staging. 4 • 3- 10 However, we have observed that
in the absence of recent prostate manipulation a baseline serum
PSA level of greater than 10 ng./ml. predicts extracapsular
tumor extension or positive surgical margins in two-thirds of
prostate cancer cases. These findings contradict most previ-
ously published reports, 3- 10 including our own. 4 The discrepancy
may be due to the IH'_e&nce of spuriously high_ PSa _levels in
blood samples that were drawn too soon after prostatic biopsy
in previous studies. To provide an overview of previous findings,
table 5 summarizes the available studies on the effects of
various prostatic manipulations on serum PSA levels.
Serum PSA levels have been reported to have no diurnal
variation. 13• 14 Schifman et al reported a 6.2% variation ex-
pressed as the coefficient of variation (standard deviation/
mean) in 10 cases sampled twice daily for 3 days. 13 El-Shirbiny
et al noted a 9.9% variation in 16 men with hourly serum PSA
measurements for 24 hours. 14 These studies suggest that the
biological variation of PSA measurements is approximately
10%, which parallels our calculation of 6.8 to 12.1 %, depending
upon the baseline PSA level. Our results are in agreement with
has minimal effects on serum PSA levels. 15 In a study involving
24 men they detected no significant difference among serum
PSA levels obtained 40 and 10 minutes before and those ob-
tained 5 and 30 minutes after rectal examination. Similarly,
using a sample of 43 men we detected no clinically significant

TABLE 4. Followup summary in 29 men with persistently elevated serum PSA following needle biopsy
Wks. of PSA (ng./ml.)
Pt. No. Biopsies Biopsy Results
Elevation* Baseline Post-Biopsy 1 Wk. 2Wks. 3 Wks. 4 Wks. 5 Wks. 6 Wks.

Normal baseline PSA

CM 5 Prostate Ca 4 3.0 18.9 14.3 6.1 8.6 4.9 3.5t
OA 5 Benign 4+ 3.0 56.4 6.1 4.8 4.1 4.0
JT 4 Benign 6+ 3.1 26.8 7.0 5.9 5.7 5.6 5.4 4.4
PHe 3 Prostate Ca 3 3.2 4.8 4.7 4.1 3.4t
KN 5 Benign 3 3.3 32 12 5.7 3.4t
CV 4 Benign 3 3.5 46.4 7.0 5.6 4.1
RW 6 Benign 5+ 3.6 164 13.6 11.0 7.3 7.3 5.5
GLe 4 Benign 4+ 3.8 46.7 7.0 6.9 5.9 5.6
PHi 6 Prostate Ca 3+ 3.9 30.5 8.2 6.2 7.8
RF 6 Prostate Ca 5 3.9 13.1 8.5 6.2 7.0 4.7 4.2t
ER 4 Benign 4 3.9 21.5 12.3 9.8 6.2 3.8t
FB 4 Benign 4+ 3.9 34 9.4 8.2 5.3 4.7
Baseline PSA 4.01-10 ng./ml.
GLa 5 Prostate Ca 3 4.4 22.7 11.5 7.0 5.6t
RM 6 Benign 4 4.4 23.8 34.3 22.2 12 4.4t
GT 6 Benign 3+ 4.5 25.0 10.2 7.1 6.1
DM 6 Benign 3 4.7 39.5 8.5 6.8 4.8t
JE 4 Prostate Ca 4 4.8 13 6.9 7.0 10 4.9t
AL 4 Prostate Ca 3 4.9 13 7.2 7.0 5.0t
JG 4 Benign 5+ 5.0 20.4 19.1 20.3 12.1 9.5 7.2
RSi 5 Prostate Ca 3 5.3 30.1 10.1 6.9 4.lt
AP 4 Benign 4 5.4 22.1 7.5 11.5 8.5 6.lt
WH 4 Prostate Ca 3 5.8 24.8 9.2 7.9 6.3t
FV 4 Benign 3 5.9 33.0 93.4 12.0 6.6t
RSt 3 Prostate Ca 4 5.9 47.9 21.2 9.0 7.8 6.2t
WK 4 Benign 3 6.1 14.4 18 10.9 6.3t
SSig 5 Benign 3+ 6.6 41.6 12.5 8.7 8.0
GF 6 Benign 3 6.8 44 13.5 11.0 6.5t
cw 6 Benign 4+ 7.3 63.3 13.7 10.2 10.9 9.6
Baseline PSA greater than 10 ng./ml.
KJ 6 Benign 4 16.3 44 32.8 Not available 24.2 22.4t
* Week + indicates continuously elevated PSA at last available followup.
t Return to baseline.
 EFFECTS OF PROSTATIC MANIPULATIONS ON SERUM PROSTATE SPECIFIC ANTIGEN LEVELS 813
PSA
25~-----------------------------~

20

15

10

a~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

BIBX 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

DAYS

--¾- ACTUAL -6 -- THEORETICAL

Elevation of serum PSA level following prostatic biopsy and delayed return to baseline level

TABLE 5. Summary of published reports on various prostate manipulations and serum PSA levels
Procedure Pt. Group No. Men Effect on PSA Reference
Rectal examination Prostate Ca/BPH/prostatitis 24 None Brawer et al 15
Ultrasonography Prostate Ca/BPH 64 None Hughes et al 17
Ultrasonography Prostatitis 21 1.3 X increase
Massage Urinary calculi 13 Minimum or no EI-Shirbiny et al 14
increase in 12
Massage BPH 16 1.9 ± 0.88 x increase Stamey et al 16
Massage + cystoscopy Unspecified 7 4.1 ± 2.2 X increase
Perinea! biopsy Unspecified 7 57 x increase
Transurethral resection of prostate BPH 8 53 X increase

difference among serum PSA levels taken immediately before
and those taken 5 or 90 minutes after rectal examinations.
Prostate massage causes an appreciable increase of serum
PSA levels in a small proportion of patients. Stamey et al found
that serum PSA levels (Yang, Pros-Check) increased nearly 2-
fold in 16 men immediately following prostate massage. 16 El-
Shirbiny et al found minimal or no increase of serum PSA in
12 of 13 men, while the remaining man had a 5.5-fold increase
(1.7 to 9.3 ng./ml., Tandem-R) when measured 60 minutes
following prostatic massage, 14 Our experience suggests that
prostatic massage has a more pronounced effect on serum PSA
level than rectal examination; however, we observed a clinically
significant elevation in only 1 of 20 men following massage.
We were unable to verify the nearly 2-fold increase in serum
PSA levels found by Stamey et al1 3 following prostatic massage
in any patient. The different PSA assays used (Tandem-R
versus Pros-Check) and the vigor of prostatic massage may
partially account for this difference.
The effect of transrectal ultrasonography on serum PSA
levels paralleled that of prostate massage. In a study of 64 men
with prostate cancer (treated and untreated) and BPH Hughes
et al found no significant difference between serum PSA levels
obtained immediately before and 30 minutes after transrectal
ultrasonography; however, in the same study following ultra-
sonography they observed a small (1.5 to 2.10 ng./ml., Tandem-
R) but statistically significant increase of 1.3-fold in 21 men
with prostatitis. 17 We found that 4 of 36 men (11%) had
elevations in serum PSA levels following ultrasonography but
no effect was observed in the remaining 32 men. Therefore, our
findings support, at least in part, the previous observations of
Hughes et al. 17
To our knowledge no study has been conducted to examine
the overall effects of prostate biopsy on serum PSA levels.
Stamey et al reported a 57-fold increase in serum PSA imme-
diately following transperineal needle biopsy and recommended
postponing PSA measurement for 2 weeks following the pro-
cedure.18 We found that 92 of 100 men (92%) had elevated
serum PSA levels following biopsy and in 29 of these 92 men
(32%) serum PSA levels failed to return to baseline within 2
weeks, as would be expected according to the published serum
PSA half-life of 2 to 3 days. Clearance of PSA from the plasma
is unpredictable in patients with a traumatized prostate and
PSA clearance does not always follow the decline slope estab-
lished after total prostatectomy. Biopsy causes anatomical dis-
ruption that leads to continuous leakage of PSA into prostatic
stroma and circulation, which results in a post-traumatic in-
flammatory response within the prostate, These are 2 possible
explanations for our observations. Vv e encountered a greater
than 50-fold increase of serum PSA levels that was reported
Stamey et al1 3 infrequently, which may be accounted for in a
number of ways, including we used a different method of biopsy
(transrectal versus transperineal) and different PSA assay, and
we took a different number of tissue cores from the patients.
To minimize over-interpretation of our data we selected the
highest pre-biopsy serum PSA value as the baseline, we calcu-
lated the biological variation based on different baseline PSA
ranges (normal, low and high titer elevation) and we used the
longest reported serum half-life of PSA. Our own calculations
based on serial PSA measurements in 10 patients following
radical prostatectomy reveal a somewhat shorter serum half-
life of approximately 2 days.
The desirability of obtaining serum PSA measurements be-
fore prostatic manipulation cannot be overemphasized, al-
though this may not always be possible. Despite the fact that
we found no instances of a clinically significant increase in
serum PSA after rectal examination, 4 of 43 men (9%) had
sufficient increases that could possibly result in falsely abnor-
mal serum PSA levels in patients with high normal baseline
814 YUAN AND ASSOCIATES
PSA levels (for example 3 to 4 ng./ml.). Falsely abnormal serum
PSA levels following prostatic massage (1 of 17, 6%) and
ultrasonography (3 of 27, 11 %) pose more of a problem. One
should consider postponing PSA measurements for 1 week
following prostatic massage, ultrasonography or rectal exami-
nation. Alternatively, one may draw the PSA level immediately
after rectal examination as long as one realizes that any bor-
derline elevation may be iatrogenic and require a repeat meas-
urement. A waiting period of 4 weeks after prostatic biopsy
should be allowed before the PSA determination can be consid-
ered valid. Based on our results, the likelihood of a persistently
elevated PSA at 4 weeks is 7% while measurement 2 or 3 weeks
following biopsy has a chance of 29% and 19%, respectively
(table 4).
Thus, premature sampling of spuriously elevated serum PSA
levels in patients with organ-confined tumors may have re-
sulted in erroneous conclusion as to the nature and usefulness
of serum PSA levels as a staging tool. This may partially
account for the frequent overlap of serum PSA levels that was
previously reported in patients with these organ-confined tu-
mors and in patients with extracapsular extension; it may also
be the reason for the reputed inaccuracy of serum PSA as an
indicator of pathological tumor stages. Pre-biopsy serum PSA
levels may be more useful in preoperative staging than previ-
ously believed. In all future reports investigators should con-
sider the timing of the PSA levels with respect to any prostatic
manipulations.
In conclusion, we have verified previous reports that digital
rectal examination causes minimum changes in serum PSA
levels, and that prostatic massage and ultrasonography may
cause clinically significant elevations in approximately 10% of
individuals. More importantly, we report that needle biopsy of
the prostate may elevate PSA levels for longer intervals than
predicted by published half-life determinations based on meas-
urements obtained following total prostatectomy. Our data
suggest that the half-life of PSA clearance is variable and
unpredictable in patients with an intact prostate gland that
has been traumatized by needle biopsy.
Linda Black, Cindy Heidorn, Mary Lynn and Cindy
Gebhardt obtained the PSA samples and Tracy Lewis per-
formed the PSA assay.
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