Large acinar atypical hyperplasia and carcinoma of the prostate

Intraprostatic ethanol diffusion: comparison of two injection methods using ex vivo human prostates

BACKGROUND

Intraprostatic injection of ethanol has been previously tested in clinical trials as a potential treatment of BPH, with variable outcomes. As evident from animal studies, the inconsistency was owing to various degrees of ethanol backflow along the needle tract. In acute canine experiments, we previously documented that using convection enhanced delivery (CED) eliminates backflow and improves ethanol distribution. The goal of this study was to compare the diffusion pattern between a microporous hollow fiber catheter (MiHFC) and a standard needle in human prostates from organ donors.

METHODS

Prostates were harvested from cadaveric organ donors immediately after removal of organs for transplant. After trimming off excess fat and weighing, prostates were injected with absolute ethanol. The total injected volume was 25% of the calculated prostate volume. One lateral lobe was injected using a single lumen 21-gauge control needle. The contralateral lobe was injected with the same volume but using a MiHFC. Immediately after injection, prostates were fixed en bloc in 10% neutral-buffered formalin, and then sectioned. Three-dimensional reconstruction was performed to determine lesion volume based on hematoxylin- and eosin-stained cross-sections.

RESULTS

Three fresh human prostates were harvested and injected. The time from harvest to intraprostatic injection was 15-35 min. The lesion created by the MiHFC was 1.14±0.52 cm(3), whereas that from the control needle was 0.28±0.10 cm(3) (P=0.038). No backflow was observed along the needle tract of the MiHFC.

CONCLUSIONS

This study shows that freshly harvested human prostates can be used to evaluate new treatments using intraprostatic injection. Similar to in vivo canine experiments, the ethanol lesion sizes were significantly bigger with the use of a MiHFC when compared with a standard single lumen needle.

Concomitant high-grade prostatic intraepithelial neoplasia is associated with good prognosis factors and oncologic outcome after radical prostatectomy

OBJECTIVES

To assess correlations between concomitant high-grade prostatic intraepithelial neoplasia (HGPIN), pathological features and oncologic outcomes after radical prostatectomy (RP).

MATERIAL AND METHODS

We prospectively collected a single-institution database of 2,351 patients who underwent RP between 1998 and 2011.

RESULTS

1,272 (54.1%) patients had HGPIN on specimens. The mean follow-up was 28 months. Presence of HGPIN was significantly associated with a favorable preoperative risk status and with pathological factors of poor prognosis in RP specimens. Patients without HGPIN had a worse biochemical recurrence-free survival compared with those with HGPIN in RP specimen (log-rank test: p = 0.015). The 3-year RFS rate was 73.9% for the HGPIN group versus 67.2%. The absence of HGPIN was also significantly correlated with the use of androgen deprivation treatment during the follow-up (p < 0.001). In Cox multivariate analysis, taking into account the other prognostic pathological factors, HGPIN was not an independent predictive factor for PSA failure (p = 0.868).

CONCLUSION

HGPIN is associated with factors of good prognosis but fails to show independent significance when classical pathological prognostic factors are taken into account.

Implication of high grade intraepithelial neoplasia in adverse pathology after radical prostatectomy

The implication of high grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer aggressiveness and prognosis is conflicted. The aim of the present study was to evaluate the role of HGPIN in prediction of adverse pathology in patients undergoing a radical prostatectomy. We retrospectively analysed patients who underwent a radical prostatectomy between January 2005 and December 2010. The relationship between HGPIN and the presence of upgrade, positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and lymph node invasion (LNI) was analysed. HGPIN predictive ability was estimated by using receiver operating characteristic curves. HGPIN was found in 160 (53.3%) specimens. A statistically significant correlation was found between HGPIN and preoperative prostate specific antigen (p=0.020) and patients' age (p=0.025). No significant differences were found, regarding the presence of adverse pathological findings, between the patients with or without HGPIN, irrespective of the preoperative risk stratification. HGPIN did not reach significance for the prediction of upgrade, PSM, ECD, SVI and LNI. The presence of concomitant HGPIN and prostate cancer found not to be related with tumor aggressiveness in patients undergoing a radical prostatectomy and should not be considered as a parameter for the operative outcome prediction.

Independent predictors of biochemical recurrence after radical prostatectomy: a single center experience

Introduction

The aim of study was to establish pretreatment and postoperative factors which could predict the early biochemical recurrence after radical prostatectomy.

Materials and method

754 patients had undergone radical prostatectomy since January 2002 to December 2008 in our department and were included in this prospective study. Exclusion criteria were: neoadjuvant or adjuvant treatment (radiation or hormonal treatment) and N+. Following parameters were evaluated: age, PSA at time of biopsy, time period from biopsy to operation, biopsy and postoperative Gleason score, stage, high grade intraepithelial neoplasias, perineural invasion. Biochemical recurrence was detected if PSA value after radical prostatectomy was ≥0.2 ng/ml. All factors likely to be predictive were evaluated by univariate analysis (Log-rank test). Multivariate analysis using Cox model was completed for all factors with p value <0.1 at univariate analysis.

Results

Final analysis was done using data of 496 patients. We detected 53 (10.7%) biochemical recurrences. Calculated actuarial biochemical recurrence free survival reached 64%. Multivariate analysis highlighted that PSA >10 ng/ml (HR 2.45, p = 0.008), pathological stage ≥pT3 (HR 2.371, p = 0.02), postoperative Gleason score ≥7 (HR 2.149, p = 0.049), positive surgical margins (HR 2.482, p = 0.014) and absence of high grade intraepithelial neoplasia in removed prostate (HR 0.358, p = 0.006) are independent factors influencing biochemical recurrence after radical prostatectomy.

Conclusion

Patients with higher PSA, locally advanced disease, positive surgical margins, and Gleason score ≥7 are at the highest risk for biochemical recurrence.

High-grade prostatic intraepithelial neoplasia is an independent predictor of outcome after radical prostatectomy

OBJECTIVE

To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer.

PATIENTS AND METHODS

The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS.

RESULTS

In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum.

CONCLUSIONS

In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.

Prostatic intraepithelial neoplasia: recent advances

CONTEXT

There have been 2 putative prostatic cancer precursors, prostatic intraepithelial neoplasia (PIN) and atypical adenomatous hyperplasia (adenosis), but PIN remains as a well-known precancerous condition.

OBJECTIVE

To describe recent advances in knowledge of PIN and to better define the diagnostic criteria and differential diagnosis of PIN.

DATA SOURCES

Review of the pertinent literature and our experience.

CONCLUSIONS

The presence of ductal/acinar epithelial changes including nuclear enlargement, prominent nucleoli, chromatin alterations, and luminal complexity is an easy way to identify the disorder. Four main patterns of high-grade PIN (HGPIN) have been described: tufting, micropapillary, cribriform, and flat. In addition, variants of HGPIN have also been described. Both HGPIN and prostatic carcinoma share an increased incidence and severity with advancing age and with high rates of occurrence in the peripheral zone of the prostate. Furthermore, HGPIN and prostate cancer share genetic and molecular markers as well, with PIN representing an intermediate stage between benign epithelium and invasive carcinoma. The clinical significance of HGPIN is that it identifies patients at risk for prostatic carcinoma. With the increased use of extended biopsy protocols, clinicians are more likely to identify HGPIN and less likely to miss concurrent carcinoma.

The ABCA5 protein: a urine diagnostic marker for prostatic intraepithelial neoplasia

PURPOSE

To develop a urine diagnostic test for preneoplastic intraepithelial neoplasia of the prostate.

EXPERIMENTAL DESIGN

We have used a DNA-binding assay and electrophoretic mobility shift assays (EMSA) to screen for novel duplexed DNA-binding sequences, which bind protein(s) overexpressed in crude protein extracts from high-grade prostatic intraepithelial neoplasia (HGPIN). EMSAs, immunohistochemistry, and ELISAs were used to measure expression of the ABCA5 protein identified as a specific marker in prostate tissue and patient urine.

RESULTS

Following screening of 4,096 sequences, an 8-bp dsDNA sequence (i.e., TCCAGCGA) was identified, which binds the ABCA5 protein, a member of the ATP-binding cassette multidrug resistant family. EMSAs showed that ABCA5 was overexpressed in HGPIN tissue (n=11/11) and in the urine of patients with HGPIN (n=18/18) but was not expressed in prostate cancer, benign prostatic hyperplasia, or stroma. Immunohistochemistry indicated that ABCA5 was overexpressed in foci of intermediate basal cells in normal glands and in HGPIN. ABCA5 was faintly expressed in prostate cancer glands. ELISAs showed in 'blinded studies' that ABCA5 was a highly sensitive (>98% sensitivity) urine diagnostic marker for HGPIN in biopsy-positive patients (n=107) at a 'cutoff' of 25 ng/mL. ABCA5 was present at very low levels (i.e., <25 ng/mL) in the urine of patients diagnosed with benign prostatic hyperplasia (n=79) or prostatitis or kidney and bladder cancer (>86% specificity).

CONCLUSIONS

The data indicate that ABCA5 might be a specific urine marker for diagnosis of patients with HGPIN.

Incidence of impalpable carcinoma of the prostate and of non-malignant and precarcinomatous lesions in Greek male population: an autopsy study

OBJECTIVE

The present study investigates the incidence of impalpable carcinoma of the prostate and the pathological findings of impalpable prostate carcinoma (PC) detected in autopsy material. The frequency of pre-carcinomatous and non-carcinomatous lesions as well as their relationship to the impalpable PC, were also examined.

MATERIALS AND METHODS

Data were obtained from 212 autopsy specimens of the prostate gland, of men aged above 30 and under 98 years of age, born and living in Greece, who died (between 8/2002 and 8/2004), of causes other than carcinoma of the prostate.

RESULTS

The age-independent frequency of histological PC in our study's population is 18.8% (ranging from 0% to 56.2% according to different age groups), whereas the age-independent frequency of histological benign prostate hyperplasia is 65.5% (ranging from 27.7% to 90.6%), of atypical adenomatous hyperplasia 15.5% (ranging from 5.5% to 25%), of prostatic intraepithelial neoplasia (PIN) 26.4% (ranging from 5.5% to 47.2%) and of prostate atrophy (PA) 10.3% (ranging from 0% to 43.7%). There was a statistically significant correlation between PIN and PC volume. Most impalpable carcinomas found within necropsy material were characterized by small volume, favorable histological type, and relatively low aggressiveness. The prevalence of PC and pre-carcinomatous lesions in our study population appears to be lower than that of most autopsy studies.

CONCLUSIONS

The frequency of clinical PC in a certain population could be related to the frequency and prevalent model of impalpable carcinoma as well as to the frequency of pre-carcinomatous lesions.

Monofocal and plurifocal high-grade prostatic intraepithelial neoplasia on extended prostate biopsies: factors predicting cancer detection on extended repeat biopsy

OBJECTIVES

To evaluate factors predicting cancer detection by extended repeat prostate biopsies in patients with an initial, isolated, monofocal or plurifocal, high-grade prostatic intraepithelial neoplasia (HGPIN) diagnosis.

METHODS

From 1995 to 2002, after a first set of 10 to 12 systematic biopsy cores, 47 patients with an initial HGPIN diagnosis underwent repeat biopsy using the same technique (mean repeat biopsy cores 11.5) after a median follow-up of 11.4 months (range 3 to 24).

RESULTS

Cancer was detected at the second biopsy in 21 patients (44.6%). Cancer detection was significantly greater in patients with plurifocal HGPIN than in those with monofocal HGPIN (70% vs. 10%, respectively; P <0.005) and in patients who underwent repeat biopsy more than 6 months after the first biopsy set (65%) compared with patients who underwent repeat biopsy within 6 months (25%; P <0.01; mean follow-up 15.5 and 3.8 months, respectively). Multivariate analysis showed that prostate-specific antigen, prostate-specific antigen density, digital rectal examination, and transrectal ultrasound findings were not statistically significant predictors of prostate cancer, and HGPIN multifocality and interval between biopsies (more than a 6-month follow-up interval) were independent prognostic factors (odds ratio 4.65 and 2.65, respectively). After radical prostatectomy (14 patients), no statistically significant differences were found in the pathologic stage between patient groups stratified by repeat biopsy interval (within or after 6 months).

CONCLUSIONS

After a 10 to 12-core biopsy, patients with initial, isolated monofocal or plurifocal HGPIN diagnoses had an overall cancer detection rate of 45% on repeat extended biopsies. Plurifocal HGPIN on the first biopsy set was the strongest independent predictive factor in cancer detection. A 12 to 18-month interval before repeat biopsy could permit a significantly greater cancer detection rate, with no apparent likelihood of clinical cancer progression.

An investigation into the spatial relationship between prostate intraepithelial neoplasia and cancer

The distribution of high grade prostate intraepithelial neoplasia (PIN) and cancer was analysed in 18 separate areas from 89 radical prostatectomy specimens that had been sectioned and digitally imaged. When the occurrence of each type of pathology was summated a predilection was demonstrated for both pathologies in the apex of the prostate and a linear relationship was found between the frequency of cancer and high grade PIN (r(2)=0.744, P<0.05). This relationship was strongest at the apex (r(2)=0.621, P<0.005), lower in the midgland (r(2)=0.828, P<0.05) and bordered on significance at the base (r(2)=0.621, P<0.063). These results support the theory that cancer could obliterate high grade PIN as it over grows the areas once occupied by PIN.Prostate Cancer and Prostatic Diseases (2001) 4, 97-100

Will the experience with tamoxifen in breast cancer help define the role of antiandrogens in prostate cancer?

Breast and prostate cancers are the two predominant hormone-responsive tumours. The use of the antioestrogen tamoxifen in the treatment of breast cancer has evolved over the past 30 y from treatment for advanced breast cancer to prevention. Tamoxifen is currently the endocrine treatment of choice for advanced breast cancer and for adjuvant therapy in a broad spectrum of women whose primary tumours have functional oestrogen receptors. It has also been shown to reduce the incidence of breast cancer in high-risk women. Non-steroidal antiandrogen therapy is used in the treatment of prostate cancer, but its role is still being defined. The clinical development of tamoxifen and that of the antiandrogens are reviewed and parallels are uncovered which provide insight into contemporary and future management of hormone-responsive prostate cancer.Prostate Cancer and Prostatic Diseases (2001) 4, 72-80

[Prostatic intraepithelial neoplasm diagnosed with transrectal biopsy. Overall review]

OBJECTIVE

To review the incidence, clinical features and management guidelines for patients with isolated prostatic intraepithelial neoplasia (PIN) diagnosed through prostate transrectal biopsy.

METHODS AND RESULTS

Search in Medline database for papers published between 1990 and 2000 based on the following key words: "prostatic intraepithelial neoplasia and needle biopsy". Nineteen papers fulfilling the search criteria were selected.

CONCLUSIONS

The incidence of PIN in patients seen as part of an early diagnosis program is much lower than in patients attending standard Urology practices. PSA level and ultrasound changes are poor predictors of PIN presence in the biopsy. Prostate cancer incidence in successive biopsies ranges between 13.3% and 100%. None of the clinical variables used to diagnose prostate cancer (DRE, PSA and transrectal ultrasound) can predict accurately the existence of cancer associated to PIN, and only prostatic intraepithelial neoplasia grading is considered a good cancer predictor. There is no consensus with regard to diagnostic and therapeutic management in these patients.

Epidemiology of high-grade prostatic intraepithelial neoplasia

This review summarizes published data dealing with the prevalence of high-grade prostatic intraepithelial neoplasia (HGPIN) in a variety of prostate tissue samples. Additionally, we have attempted to document the relationship between HGPIN and the pathological parameters of prostate cancer in autopsy and radical prostatectomy specimens. Studies reporting the prevalence of HGPIN in needle biopsies, transurethral resection specimens and radical prostatectomy specimens, and those documenting the lesion in postmortem settings are compared. We also summarize studies in which the distribution and/or extent of HGPIN was correlated with prostate cancer stage, grade and volume. There is significant variation in the reported frequency of HGPIN, particularly in needle biopsy specimens, with a range of 0.8-23.9%. The factors responsible for these discrepancies include the population studied, the limited sample size that needle biopsies represent, diagnostic inconsistencies and, possibly, tissue preparation/staining variables. Because of the important implications a diagnosis of HGPIN carries, there is a pressing need to achieve greater consistency in diagnosing and reporting the lesion. Better targeted educational efforts, including teaching courses, websites with illustrations and the possibility of teleconsultations, are among possible means to attain this goal. Better documentation of the evolution of HGPIN to cancer through clinical follow-up is also recommended.

Morphological identification of the patterns of prostatic intraepithelial neoplasia and their importance

High grade prostatic intraepithelial neoplasia (PIN) is the most likely precursor of prostatic carcinoma. PIN has a high predictive value as a marker for carcinoma, and its identification in biopsy specimens warrants repeat biopsy for concurrent or subsequent carcinoma. The only methods of detection are biopsy and transurethral resection; PIN does not greatly raise the concentration of serum prostate specific antigen (PSA) or its derivatives, does not induce a palpable mass, and cannot be detected by ultrasound. Androgen deprivation decreases the prevalence and extent of PIN, suggesting that this form of treatment might play a role in chemoprevention. Radiotherapy is also associated with a decreased incidence of PIN.

[Incidence of high grade prostatic intraepithelial neoplasia in urologic practice]

High grade (PIN AG) intraepithelial neoplasia of the prostate is a likely precursor of prostate adenocarcinoma (PA) because of their association. Since the risk to suffer PA increases in patients with no previous PIN AG, its finding requires an arduous search for PA. This paper reviews the incidence of PIN AG in 499 histological studies in prostate transrectal biopsies, prostate TUR and adenomectomy specimens and radical prostatectomy (RP) sections. Evaluation of data obtained, type of presentation and association to prostate carcinoma, indicating the approach taken in the various cases.

Retrovesical mass in men: pitfalls of differential diagnosis

PURPOSE

We review the differential diagnosis and treatment of retrovesical masses in men.

MATERIALS AND METHODS

During the last 8 years 21 male patients 3 to 79 years old (mean age 47.1) presented with symptoms or signs of a retrovesical mass. Clinical features and diagnostic findings were reviewed, and related to surgical and histopathological findings.

RESULTS

The retrovesical masses included prostatic utricle cyst in 3 cases, prostatic abscess in 1, seminal vesicle hydrops in 6, seminal vesicle cyst in 2, seminal vesicle empyema in 3, large ectopic ureterocele in 1, myxoid liposarcoma in 1, malignant fibrous histiocytoma in 1, fibrous fossa obturatoria cyst in 1, hemangiopericytoma in 1 and leiomyosarcoma in 1. In 17 patients various symptoms were seen and in 4 the mass was incidentally detected. A mass was palpable on digital rectal examination in 16 cases and visible on sonography in 20. For a cystic mass medial location relative to the bladder neck was suggestive of prostatic abscess or utricle cyst, while lateral location was suggestive of seminal vesicle cyst/hydrops or empyema, ectopic ureter or ureterocele. In 6 patients diagnosis was established only by exploratory laparotomy and histopathological examination.

CONCLUSIONS

Digital rectal examination and sonography reliably detect a retrovesical mass. Nevertheless, clinical signs and median or lateral location relative to the bladder neck on ultrasound are diagnostic only for cystic lesions. Computerized tomography and magnetic resonance imaging are useful for staging malignant tumors. However, needle or open biopsy is required in most cases to establish a histopathological diagnosis. Exploratory laparotomy and histopathological examination are the procedures of choice when other findings are equivocal.

Digital image analysis of proliferative index: two distinct populations of high-grade prostatic intraepithelial neoplasia in close proximity to adenocarcinoma of the prostate

A considerable amount of data has been collected showing the association of high-grade prostatic intraepithelial neoplasia (HGPIN) with adenocarcinoma of the prostate, and many studies have yielded results that suggest that HGPIN is a precursor of carcinoma. A few studies have indicated that HGPIN may, in some cases, be a sequela of prostatic adenocarcinoma. We examined the proliferative indices of HGPIN, carcinoma, and benign prostatic epithelium by computer-aided counting of Ki-67-positive nuclei in 15 cases in which HGPIN and carcinoma were in close proximity. There were 13 radical prostatectomy specimens with prostate cancer and two cystoprostatectomy specimens with both transitional cell carcinoma and prostatic adenocarcinoma. First, we showed the accuracy of the computer-aided counting method compared with direct counting through the binoculars of the microscope. Then proliferative activity was assessed for each case by picking the two areas of carcinoma, the two areas of HGPIN, and the one area of benign epithelium with the greatest density of carcinomatous, dysplastic, and benign Ki-67-positive nuclei, respectively. The total number of nuclei and the number of positive nuclei were counted. Basal cells were not counted. The mean proliferative index was higher for cancer (caindex, average 0.054) than for HGPIN (pinindex, average 0.048) (P < .05). We found that the 15 cases fell into two distinct groups. The average ratio of pinindex to caindex (pinindex/caindex) was lower in group 1 (0.72) than in group 2 (1.54) (P=.17), and when the results were corrected for the nonzero gamma-intercepts of the regression lines of pinindex versus caindex, the ranges were widely separated, and the difference between the means was statistically significant (0.15 v 0.62; P < .0001). A greater subjective similarity between the nuclear features in the HGPIN and those of the corresponding carcinoma was noted for the cases in group 2. The average value of bngnindx was 0.014. The value of bngnindx did not correlate with either caindex or pinindex. We conclude that there may be two types of lesions with the morphological appearance of HGPIN and that they may have different relationships to carcinoma. Computer-aided counting of digitized microscopic images is both labor-saving and as accurate as enumeration directly through the binoculars of the microscope.

Incidence of prostatic intra-epithelial neoplasia in Osaka, Japan

High-grade prostatic intra-epithelial neoplasia (HGPIN) is the most likely precancerous lesion for prostatic carcinoma. A high incidence of its association with cancer has been reported in Western countries. On the other hand, information regarding its incidence is limited in Japan, where the mortality due to prostate cancer is much lower. We reviewed 53 clinical stage T2 or T3 prostatic cancers of Japanese patients living in Osaka, Japan (mean age, 67.2 years). These cases were subdivided into a pre-operatively non-castrated group (34 cases) and a medically or surgically castrated group (19 cases). HGPIN was found in 27 cases. The incidence of HGPIN was significantly lower in the castrated group (21.0%) compared with the non-castrated group (67.6%). In the non-castrated group, patient age, pathological stage, Gleason score, tumor size and serum prostate-specific antigen showed no significant correlation with HGPIN. Advanced pathological stage and tumor size tended to decrease the incidence of HGPIN, although this was not statistically significant. When the study group was limited to stage T2 tumors of the non-castrated group, the incidence of HGPIN was 81.0%. HGPIN in Japan may also be clinically and etiologically significant as a precursor of clinical cancer.

The relationship between prostatic intraepithelial neoplasia and prostate cancer: critical issues

PURPOSE

Prostatic intraepithelial neoplasia (PIN) is often considered to be a premalignant lesion and the main precursor of invasive carcinoma of the prostate. We evaluated the evidence for and against PIN as a premalignant lesion and determined guidelines for the clinical management of PIN.

MATERIALS AND METHODS

Literature analysis of histopathological, morphometric, phenotypic and molecular genetic evidence of progression and of clinical findings regarding PIN was done. Literature searches were performed on MEDLINE with relevant key words.

RESULTS

PIN, like prostate cancer, occurs most frequently in the peripheral zone of the prostate and is usually located in close proximity to prostate cancer. The relative PIN and prostate cancer volumes vary inversely. Prostate specific antigen in cases of PIN appears to be intermediate between prostate cancer and normal levels, although this elevation may be explained by concomitant prostate cancer or benign prostatic hyperplasia. Deoxyribonucleic acid ploidy in PIN follows the aneuploid proportion as in the concomitant prostate cancer. Prostate cancer and PIN show evidence of loss of putative tumor suppressor genes on chromosome 8p. The clinical relevance of PIN biopsy findings is based on the association of neoplasia and prostate cancer. High grade PIN in core biopsies without concomitant prostate cancer has a substantial risk for prostate cancer in subsequent biopsies (24 to 73%, up to 100% when the digital rectal examination is suspicious) and should cause further biopsy sampling.

CONCLUSIONS

There is convincing evidence that PIN is a precursor lesion to prostate cancer, with a close association of PIN and prostate cancer in biopsy and prostatectomy specimens. A biopsy finding of high grade PIN necessitates further investigation in patients who are candidates for radical treatment for localized prostate cancer.

Incidence and clinical significance of high-grade prostatic intraepithelial neoplasia in TURP specimens

OBJECTIVES

To determine the incidence and clinical significance of high-grade prostatic intraepithelial neoplasia (PIN) in specimens obtained from transurethral resection of the prostate (TURP).

METHODS

All TURP specimens accessioned to the general surgical pathology service of the Johns Hopkins Hospital (JHH) from March 1984 through December 1987 that did not contain adenocarcinoma of the prostate were reviewed for the presence of high-grade PIN (PIN 2 and PIN 3). These cases were supplemented with cases from the consultation files of the JHH, the Armed Forces Institute of Pathology, and the University of Michigan Hospitals. In total, 85 cases of high-grade PIN in TURP specimens were identified.

RESULTS

The mean age of the patients at the time of TURP was 70 years and the median age was 71 years (range 50 to 89). Sixty-three patients (74%) were 65 years of age or older, 45 patients (53%) were at least 70 years of age, and 14 patients (16%) were 60 years of age or younger. Adenocarcinoma of the prostate was discovered in 9 (22%) of 41 patients with follow-up information. Based on material from JHH, the incidence of high-grade PIN was 2.3% in all TURP specimens and 3.2% in those without invasive carcinoma.

CONCLUSIONS

High-grade PIN on TURP is relatively uncommon and is diagnosed in an elderly population. Patients with high-grade PIN on TURP appear to be at increased risk of developing prostatic carcinoma, although not to the same degree as patients with high-grade PIN on needle biopsy.

Prostatic intraepithelial neoplasia in surgical resections: relationship to coexistent adenocarcinoma and atypical adenomatous hyperplasia of the prostate

BACKGROUND

High grade prostatic intraepithelial neoplasia (PIN) is associated with coincident prostate carcinoma, and has been considered to be a precursor of prostate carcinoma. Most studies on PIN have been performed on total prostatectomy or core needle biopsy specimens. Few reports deal with the occurrence of PIN in consecutive surgical resections, which is the objective of the current study.

METHODS

A total of 1135 nonselected surgical specimens from the prostate, examined during 1974 and 1975, underwent blind review by 2 experienced pathologists. There were 79 core needle biopsies, 731 transurethral resections of the prostate and 325 transvesical prostatic enucleations. The kappa coefficient for interobserver reproducibility was 0.66 for PIN and 0.86 for carcinoma.

RESULTS

Grade 1 PIN was found in 9%, Grade 2 PIN in 32%, and Grade 3 PIN in 20% of the total cases. Atypical adenomatous hyperplasia (AAH) was found in 11% and adenocarcinoma in 27% of the cases. Grade 3 PIN was associated with coincident adenocarcinoma in 39% of the cases. The prevalence of carcinoma for cases with Grade 1 and 2 PIN did not exceed that of those with Grade 0 PIN. PIN was most commonly found in association with small carcinomas. The mean age of the entire group of patients was 70.0 years, and was 69.4 years for patients with PIN without coincident carcinoma. Patients with PIN and coincident carcinoma had a mean age of 71.7 years, similar to all PIN grades, but patients with carcinoma without PIN had the highest mean age, 73.3 years.

CONCLUSIONS

PIN is a common histologic finding in tissues from prostatic resections. In this study, Grade 3 PIN was strongly associated with coincident carcinoma, but lower grade PIN was not. There was no association between PIN and AAH. Patients with PIN did not appear to have a higher mean age than corresponding patients without PIN.

The extent and multicentricity of high-grade prostatic intraepithelial neoplasia in clinically localized prostatic adenocarcinoma

High-grade prostatic intraepithelial neoplasia (PIN) is considered the most likely precursor of invasive prostatic adenocarcinoma, and is characterized by cellular proliferations within preexisting ducts and glands with cytological changes mimicking cancer. The extent and multicentricity of this clinically important histopathologic lesion have not been fully defined. We sought to determine whether the extent and zonal distribution of PIN are related to prostate cancer. A total of 195 whole-mounted radical prostatectomy specimens were evaluated. All patients had clinically localized cancer, and none had received preoperative therapy. The zonal location and multicentricity of PIN were recorded, and the volume of PIN was measured using a grid-counting method according to pattern (tufting, micropapillary, cribriform, and flat) and spatial proximity to cancer (less than or equal to 2 mm from cancer, and greater than 2 mm from cancer). The results were correlated with patient age, prostate volume, cancer volume, pathological stage, and Gleason grade. High-grade PIN was identified in 86% of cases, usually with multiple architectural patterns of PIN in each positive case: tufting (97% of cases), micropapillary (66% of cases), cribriform (19% of cases), and flat (21% of cases). The mean volume of PIN was 1.32 cm3 (standard error [SE], 0.10; range, 0 to 8.12 cm3), and was greater for PIN within 2 mm of cancer (mean, 1.0 cm3) than for PIN more than 2 mm from cancer (mean, 0.3 cm3). PIN was usually multicentric (64.5% of cases) and located in the nontransition zone (63%) or all zones (36%) of the prostate. There was a positive correlation of total volume of PIN and volume of cancer, but this correlation was significant only for PIN within 2 mm of cancer. The volume of PIN was positively correlated with age, pathological stage, and Gleason score; most of these positive correlations were caused by PIN within 2 mm of cancer rather than that greater than 2 mm from cancer. Our results indicate that the extent and zonal distribution of high-grade PIN and carcinoma are strongly associated, and that PIN is frequently multicentric. This supports the hypothesis that PIN is a premalignant lesion.

Platelet-derived growth factor A and B chains and the alpha and beta receptors in prostatic intraepithelial neoplasia

BACKGROUND

The objective of this study was to evaluate the expression of platelet-derived growth factor (PDGF A, PDGF B) and their receptors (PDGF alpha, PDGF beta) in prostatic intraepithelial neoplasia (PIN) and adenocarcinoma.

METHODS

Peroxidase-antiperoxidase immunoperoxidase labeling was used to detect the extent of antibody labeling in 29 different high grade PIN specimens.

RESULTS

PDGF A and PDGF alpha were uniformly expressed in glandular epithelial and stromal cells, whereas PDGF B was not expressed by either tissue. However, PDGF beta was lightly expressed in a uniform manner by both the glandular epithelial and stromal cells.

CONCLUSIONS

The data suggest that an autocrine loop may exist in which the epithelial cells of high-grade PIN express PDGF AA and PDGF alpha to modulate growth of precancerous lesions.

Repeat biopsy strategy in men with isolated prostatic intraepithelial neoplasia on prostate needle biopsy

PURPOSE

Isolated high grade prostatic intraepithelial neoplasia on needle biopsy of the prostate is a strong predictor of malignancy on repeat biopsy. However, the optimal repeat biopsy technique for these patients has not been defined.

MATERIALS AND METHODS

We reviewed the records of 66 men in whom isolated prostatic intraepithelial neoplasia was found on needle biopsy of the prostate. We evaluated the side and/or quadrant and grade of prostatic intraepithelial neoplasia on initial biopsy, and compared the findings to the location of cancer on repeat biopsy.

RESULTS

Of 66 men 31 (47%) had cancer on repeat biopsy, with disease on the same side of the prostate as prostatic intraepithelial neoplasia in 20 (64%). The quadrant locations of prostatic intraepithelial neoplasia and cancer matched in 6 of 12 cases (50%). Low and high grade prostatic intraepithelial neoplasia predicted the side of cancer on repeat biopsy in 3 of 5 (60%) and 17 of 26 (65%) cases, respectively.

CONCLUSIONS

Directing repeat biopsy solely to the side with prostatic intraepithelial neoplasia will miss cancer in approximately 35% of cases. The optimal repeat biopsy technique for patients with high grade prostatic intraepithelial neoplasia should include systematic biopsy of the prostate.

Numerical chromosomal changes in high-grade prostatic intraepithelial neoplasia (PIN) and concomitant invasive carcinoma

Prostatic intraepithelial neoplasia (PIN) is regarded as a precursor lesion of at least some prostatic cancers. Using interphase cytogenetics, an in situ hybridization technique with chromosome specific probes, we investigated 15 prostatectomy specimens containing both invasive carcinoma and PIN for the presence of numerical changes of chromosomes 7, 8, 10, 17 and X. The results were correlated with tumor stage and Gleason grade as well as with morphological features of PIN. Of the 15 carcinomas, four were disomic, five displayed at least focal chromosomal gains and six were found to be aneusomic. A non-disomic chromosomal status correlated well with a higher tumor stage and grade. Although the majority of PIN glands showed an eusomy, focal chromosomal gains within single glands or parts of a gland could be observed in 12 of the 15 cases. All but one specimen with non-disomic carcinomas also harboured areas of PIN with numerical chromosomal aberrations, often laying directly adjacent to tumorous glands. Additionally, focal non-disomies of PIN could also be detected in two cases with eusomic cancer. With regard to numerical changes in PIN and cancer, no significant preponderance could be observed for the five chromosomes tested. We conclude that numerical chromosomal aberrations are a frequent, but mostly focal event in PIN. This karyotypic instability is further evidence for the premalignant nature of this lesion.

Experimental research on the morphofunctional differentiation of the rat ventral prostate: roles of the gonads at birth

In the male rat, a dramatic increase in serum testosterone (T) of testicular origin occurs during the first few hours of postnatal life. This experiment sought to determine whether this increase affects the physiology of the adult rat ventral prostate. Male rats were castrated at the time of caesarean delivery performed at different precise stages between 21 days and 22 days of gestation (0h males). Newborn male rats were castrated after spontaneous delivery at 22 days of gestation at 6, 12, 24 or 48 h after birth. Some male rats were castrated at fetal stage 21 days 13-15 h and injected at the time of surgery with 1, 2.5 or 5 micrograms of testosterone propionate (TP). Control males were sham operated at fetal stage 21 days 13-15 h and castrated at 23 days postnatal. At 30 days of age, each male was given T replacement therapy through a T filled silastic capsule until the time of sacrifice at 100 days of age. Before T implantation at 30 days of age, castration at 0 h or 48 h after birth does not impair neither branching morphogenesis nor the organization of the prostatic acinus. In contrast, the histological structure of the ventral prostate of the 0 h males implanted with T from puberty on is greatly disturbed. Cribriform and severe atypic hyperplastic acini with various epithelial cell arrangements are common. The alveolar sheath of the prostatic glands and the interacinar stroma are enlarged. In acini with severe intraepithelial hyperplasia, the disorganized epithelium rests over a thick basement membrane that stains strongly for laminin. In some 0 h males, epithelial cells break through the periacinar fibromuscular sheath and invade the interacinar stroma. It is as though all the categories of cells comprising the ventral prostate were not programmed in the absence of neonatal androgens. The secretory activity and the expression of Prostate Binding Protein (PBP) are impaired in the ventral prostate of the 0 h males. Castration performed after 12 h after birth has no deleterious effect on either secretory activity or PBP expression. The critical period during which perinatal T affects the histological structure and the functional differentiation of the ventral prostate extends from fetal stage 21 days up to 1 or 2 days postnatal. A single injection of 2.5 micrograms TP, a dose which mimicks the postpartum T surge is sufficient for programming the histological structure and the functional differentiation of the adult ventral prostate.

Neoplastic and borderline lesions of the prostate: autopsy study and epidemiological data

Early detection and management of prostatic cancer (PC) is an important public health problem in all industrialized countries, where the relative rate of the elderly population is rapidly increasing. We examined the epidemiology of PC in the province of Trieste, Italy and studied the relationship between prostatic intraepithelial neoplasia (PIN) and PC. The average annual incidence of PC was 99.3 per 100,000 (1,739 new prostatic cancer cases were histologically diagnosed at autopsy or in surgical specimens between 1980 and 1993). In patients over 85 years of age, the incidence rate was 1,209 per 100,000 compared with 64 per 100,000 in the 55-64 age group. Trends in PC incidence rates showed a significant increase among men under 64 years of age and those between 65-74 years. Survival analysis showed that 94% of the patients with well differentiated PC were alive at 5 years, compared with 80% and 40% of those with moderately differentiated and poorly differentiated cancer, respectively. We studied 130 whole autopsy prostates, 70 radical prostatectomies with carcinoma, 63 transurethral resections or adenomectomies without cancer from patients who later developed PC and 94 transurethral resections or adenomectomies from patients who did not develop PC. The 102 prostatic cases with cancer had a high rate of PIN, and the relative frequency of PIN 3 was high (almost 70%, versus almost 0% in benign prostates). In addition, the frequency of PIN was higher in benign prostates of patients who later developed PC (almost 50% of the cases) than in benign autopsy and surgical prostates. PIN was spatially associated with cancer in 75% of the cases. This study confirms the strong relationship between PIN and PC.

The extent and zonal location of prostatic intraepithelial neoplasia and atypical adenomatous hyperplasia: relationship with carcinoma in radical prostatectomy specimens

High grade prostatic intraepithelial neoplasia (PIN) and atypical adenomatous hyperplasia (AAH) are considered putative precursors of prostatic adenocarcinoma. We determined the extent and zonal distribution of PIN and AAH in totally-embedded radical prostatectomies with prostate cancer, including 195 cases with PIN and 217 with AAH. PIN was identified in 86% of the cases. The mean volume of PIN was 1.32 cc (range, 0-8.12 cc), and was greater for PIN within 2 mm of cancer (mean, 1.0 cc) than for PIN more than 2 mm from cancer (mean, 0.3 cc). PIN was usually multicentric (64.5% of cases) and located in the non-transition zone (63%) or all zones (36%). The volume of PIN was positively correlated with the volume of cancer, patient age, pathologic stage and Gleason score. AAH was identified in 23.0% of the cases, and was more frequent in the transition zone (19.8% of cases) than in the non-transition (peripheral and central) zone (6.0%). The number of foci of AAH in the transition zone was always greater than that in the non-transition zone. AAH was frequently multicentric (46% of cases), especially in the transition zone (47% of transition zone cases) compared with the non-transition zone (23% of non-transition zone cases). The mean volume of AAH was 0.029 cc (range, 0-1.29 cc), and was much higher in the transition zone than in the non-transition zone. AAH was more common in older patients and those with greater prostatic weight, higher prostatic volume, greater percent of nodular hyperplasia, greater volume of cancer, greater percent of Gleason patterns 4 and 5 cancer, higher volume of prostatic intraepithelial neoplasia and higher serum prostate specific antigen concentration. Our results indicate that the extent and zonal distribution of high grade PIN and carcinoma are strongly associated, and that PIN is frequently multicentric; this supports the hypothesis that PIN is a premalignant lesion. AAH and carcinoma show a weak but significant association; if AAH is a premalignant lesion, it probably is associated with a subset of cancers arising in the transition zone.

Morphometric analysis and clinical followup of isolated prostatic intraepithelial neoplasia in needle biopsy of the prostate

PURPOSE

We evaluate the significance of grade and extent of isolated prostatic intraepithelial neoplasia in prostate needle biopsies as a predictor of cancer on repeat biopsy.

MATERIALS AND METHODS

We reviewed our experience with 58 men 50 years or older who had isolated prostatic intraepithelial neoplasia on initial prostate needle biopsy during a prostate specific antigen (PSA) based screening trial for prostate cancer. All 58 men underwent repeat biopsy to follow the initial findings of prostatic intraepithelial neoplasia. We assessed the relationship of patient age, digital rectal examination, serum PSA concentration, PSA density, prostatic intraepithelial neoplasia grade, number of foci of neoplasia and linear extent of prostatic intraepithelial neoplasia in the initial biopsy specimen to the finding of cancer on the repeat biopsy. We also compared the cancer detection rate in the 58 men with and 427 without prostatic intraepithelial neoplasia in the same screening trial.

RESULTS

Of 21 men with low grade and 37 with high grade prostatic intraepithelial neoplasia 4 (19%) and 19 (51%), respectively, had cancer on repeat biopsy (p < 0.02), compared to 82 of 427 (19%) without cancer or prostatic intraepithelial neoplasia on the initial biopsy. High grade prostatic intraepithelial neoplasia was a significant predictor of malignancy on repeat biopsy (p < 0.05). The number of foci of neoplasia and the linear extent of prostatic intraepithelial neoplasia on initial biopsy were not predictive of cancer on repeat biopsy.

CONCLUSIONS

Our results demonstrate that the presence of high grade prostatic intraepithelial neoplasia is a strong predictor of prostate cancer in men with elevated serum PSA concentrations and they should be followed with repeat biopsy.

Pathology review in an early prostate cancer detection program: results from the American Cancer Society-National Prostate Cancer Detection Project

Biopsy materials obtained in the American Cancer Society National Prostate Cancer Detection Project were reviewed at the Central Pathology Laboratory at the Armed Forces Institute of Pathology. Of 265 cases submitted, 177 were diagnosed as prostatic carcinoma, 7 as prostatic intraepithelial neoplasia (PIN), 13 as atypical glands or atypical hyperplasia, and the remaining 68 were benign hyperplasias. Irrespective of the means of detectin or the grading system used (Gleason or WHO-Mostofi), a large majority of the cancers were detected as low-grade tumors. Of 27 cases of PIN reported, 20 were associated with cancer, leaving 7 cases with the sole diagnosis of PIN. These data may indicate the increased use of prostate-specific antigen (PSA), digital rectal examination (DRE), and transrectal ultrasound (TRUS) in the United States is shifting the spectrum of prostate cancer pathology toward early low-grade tumors.

Comparison of DNA ploidy in prostatic intraepithelial neoplasia and invasive carcinoma of the prostate: an image cytometric study

Prostatic intraepithelial neoplasia (PIN) is regarded as the most important premalignant lesion of prostatic epithelium. The aim of this investigation was to find clues to formal pathogenesis of prostatic cancer. For this purpose DNA ploidy (determined by means of image cytometry [ICM] using 4-microns-thick Feulgen-stained paraffin sections) of PIN and invasive carcinoma was compared. Prostatic tissue of 72 patients (mean age, 67.5 years; 82 areas with carcinoma and 71 areas with PIN) was examined. In 44 cases PIN and carcinoma were coexistent in the same prostates, the PIN grade being high in 77% of these cases (P < .05). In higher-grade PIN and higher-grade carcinoma the c-values, 2.5c-exceeding-rate, and aneuploidy rate increased (P < .01). Carcinomas associated with diploid PIN (either low or high grade) showed diploidy and aneuploidy in an equal number of cases, whereas 70% of aneuploid PIN cases (all high grade) were associated with aneuploid invasive carcinomas (P < .01). Conversely, in 71% of the cases with aneuploid carcinoma the coexistent PIN (either low or high grade) was diploid. Our findings show that aneuploidy can be acquired at a preinvasive stage of carcinogenesis in the prostate and suggest that aneuploid high-grade PIN might be regarded as a precursor of some but not all aneuploid prostatic carcinomas. Image cytometry analysis seems to be a promising method for further subclassification of high-grade PIN lesions into groups with putatively lower or higher risk. However, further investigation is necessary to confirm the clinical importance of these results.

Developmental estrogenization and prostatic neoplasia

The association of estrogens with benign prostatic hyperplasia and prostatic cancer has been widely studied, but no conclusive evidence exists for a role of estrogens in prostatic disease. This paper reviews the literature and describes studies which have sought to show a correlation of estrogens and alterations in the prostates of humans and experimental animal models. Using the developmentally estrogenized mouse model, we propose an alternative role for estrogens as a predisposing factor for prostatic diseases: estrogen exposure during development may initiate cellular changes in the prostate which would require estrogens and/or androgens later in life for promotion to hyperplasia or neoplasia. Thus, the critical time for estrogen action would be during the development of the prostatic tissue. We further suggest that estrogen-sensitive cells may remain in the prostate and be more responsive to estrogens later in life or less responsive to the normal controlling mechanisms of prostatic growth.