Histological Characteristics of Radical Prostatectomy Specimens in Men with a Serum Prostate Specific Antigen of 4 ng./ml. or Less

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Abstract
Of most reported radical prostatectomy series 20 percent consist of men with a serum prostate specific antigen (PSA) of 4.0 ng./ml. or less. Since our series is not only prospective but all prostates are reconstructed at 3 mm. intervals, we determined the clinical and histological findings in this important subset of men undergoing radical prostatectomy. Of 911 consecutive men undergoing radical prostatectomy 187 (21 percent) had a preoperative serum PSA of 4.0 ng./ml. or less (values equivalent to those of the Hybritech Tandem-R assay). Mean tumor volume was 2.3 cc. Of the 187 cancers 156 (83 percent) were in the peripheral zone and 31 (17 percent) in the transition zone, while 137 (73 percent) were organ-confined and 50 (27 percent) showed capsular penetration. No patient had positive pelvic lymph nodes, only 5 had seminal vesicle invasion and positive surgical margins were present in 14 percent. Cancer volumes less than 0.5 cc were noted in 9 percent of the patients and were probably insignificant. At an average followup of 37 months, only 16 men (9 percent) had a detectable serum PSA. These 16 patients had a larger tumor volume (3.7 cc versus 2.2 cc, p less than 0.05), and a greater percent of Gleason grade 4 and/or 5 disease than the 171 with undetectable PSA. Men with prostate cancer and a serum PSA of 4.0 ng./ml. or less are excellent candidates for radical prostatectomy if the 9 percent with clinically insignificant tumors can be avoided. Since 70 percent of all men had a suspicious prostate on digital rectal examination, this evaluation is important for men with a serum PSA of 4.0 ng./ml. or less.