Fig 1: sEV protein CAIX can be used to predict diagnosis in the initial PCa biopsies. (A, B) In the training cohort, sEV protein CAIX is significantly upregulated in both PCa (P = 1.8e−15) and csPCa patients (P = 1.3e−13). (C, D) The validation cohort confirms the sEV CAIX findings. (E, F) In the training cohort, tPSA is upregulated in both PCa (P = 1.5e−18) and csPCa (P = 1.1e−08). (G, H). In the validation cohort, tPSA upregulation is observed in PCa (p = 0.0021) and csPCa (P = 8.6e−05). (I, J) The ROC analysis shows the diagnostic power of the sEV protein CAIX score in PCa (AUC: 0.873) and the Model in csPCa (AUC: 0.909) in the training cohort. Comparison of ROC analysis shows that the sEV protein CAIX expression (assay) had a better diagnostic performance than blood tPSA, f/tPSA, and PSAD test in PCa. The Model (CAIX + PSAD) had a better diagnostic performance than sEV protein CAIX, tPSA, f/tPSA and PSAD tests in csPCa alone. (K, L) Similar results were obtained in the validation cohort. Abbreviations: AUC, area under the curve; CAIX, carbonic anhydrase IX; csPCa, clinically significant PCa; f/t PSA, free prostate‐specific antigen/total prostate‐specific antigen; nsPCa, nonsignificant PCa; PCa, prostate cancer; PSAD, prostate‐specific antigen density; ROC, receiver operating characteristic; tPSA, total prostate‐specific antigen. [Color figure can be viewed at wileyonlinelibrary.com]
Fig 2: Characterization of sEVs isolated from human PCa plasma samples. (A) NTA shows the modal sizes of sEV particles in the plasma of patients with negative and positive biopsies (B) Representative TEM images show sEVs (white arrows) isolated from biopsy‐negative (Left image) and biopsy‐positive (Right image) patients, with visible lipid bilayers and cup‐shaped structures, scale bar‐200 nm. (C) Representative Western blots demonstrating the expression of CD9, calnexin, syntenin‐1, TSG101, and CAIX in sEV preparations isolated from plasma samples of patients with negative and positive biopsies, compared to whole cell lysates from DU145 prostate cancer cells. (D) Comparison of protein expression (ApoA1, LDHB, HBG1) in hemolyzed plasma, non‐hemolyzed plasma, and sEVs isolated from non‐hemolyzed plasma samples from PCa patients (n = 3 each). (E) The hemolyzed and non‐hemolyzed plasma samples exhibited distinct color differences upon visual inspection(n = 3). Abbreviations: ApoA1, Apolipoprotein A1; CAIX, carbonic anhydrase IX; HBG1, Hemoglobin subunit gamma 1; LDHB, Lactate Dehydrogenase B; NTA, nanoparticle tracking analysis; PCa, prostate cancer; sEV, small extracellular vesicle; TEM, transmission electron microscopy; WCL, whole cell lysate. [Color figure can be viewed at wileyonlinelibrary.com]
Fig 3: The clinical utility of the sEV protein CAIX test assay. (A, B) DCA shows that the CAIX assay demonstrates the highest net benefit across 0.2–0.8 threshold probabilities for PCa in the training and validation cohort. The horizontal black lines parallel to the x‐axis represent no patient undergoing a biopsy (Treat None). The gray line indicates that all the patients will have PCa (Treat All). (C) The waterfall plot of the sEV protein CAIX test assay scores is related to the prostate biopsy results (n = 230). Each bar represents an individual. Red indicates the ISUP grade ≥ two tumors (Gleason score ≥ 7); dusty blue indicates the ISUP grade of one tumor (Gleason score = 6); green indicates the negative biopsies. Two black horizontal lines represent the cutoff points of 0.454 at the sensitivity of 90% and 0.376 at the sensitivity of 95%. Abbreviations: AUC, area under the curve; CAIX, carbonic anhydrase IX; f/t PSA, free prostate‐specific antigen/total prostate‐specific antigen; ISUP, International Society of Urological Pathology; PCa, prostate cancer; PSAD, prostate‐specific antigen density; tPSA, total PSA. [Color figure can be viewed at wileyonlinelibrary.com]
Fig 4: Nomograms can predict the probability of csPCa. A Nomogram was established based on sEV protein CAIX test assay and PSAD. (A) Nomogram for diagnosis of csPCa. Higher total points indicate a higher prevalence for csPCa. (B) Nomogram‐predicted probability of csPCa in the training cohort. (C) DCA of the sEV protein CAIX test, tPSA, f/t PSA, PSAD and prediction models for csPCa. DCA shows that the model presents the highest net benefit across 0.2 to 0.8 threshold probabilities for csPCa in the training cohort. The horizontal black lines parallel to the x‐axis represent no patient undergoing a biopsy (Treat None). The gray line indicates that all the patients will have csPCa (Treat All). Abbreviations: CAIX, carbonic anhydrase IX; CsPCa, clinically significant PCa; DCA, decision curve analysis; Predicted Pr, predicted probability; PSAD, PSA density; sEV, small extracellular vehicle; tPSA, total PSA; f/tPSA, free prostate‐specific antigen/total prostate‐specific antigen. [Color figure can be viewed at wileyonlinelibrary.com]
Fig 5: Clinical association of sEV protein CAIX biomarker identified with human PCa tissue. The expression of CAIX protein in adjacent normal tissue and PCa tissue was examined using a TMA including PCa tissue (n = 94) and normal prostate control tissue (n = 47). (A) Typical images show a high expression of CAIX in PCa tissue compared to normal prostate tissue, with the predominant localization observed in the cytoplasm. Brown color indicates positive staining while blue color indicates nuclei. Magnification x 20, scale bar = 100 um. (B) Quantitative analysis indicates distinct expression of CAIX (***p < 0.001) between PCa tissue and adjacent normal prostate tissue. (C) Comparison of CAIX protein IHC staining scores between cancerous and adjacent noncancerous tissues in the same PCa patients (n = 44, paired two‐tailed t‐test, p < 0.001). Abbreviations: CAIX, carbonic anhydrase IX; IHC, immunohistochemistry; PCa, prostate cancer. [Color figure can be viewed at wileyonlinelibrary.com]
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