The association of selected pathological features with prostate cancer in a single-needle biopsy accession

Prostatic chronic inflammation and prostate cancer risk at baseline random biopsy: Analysis of predictors

Objective

To evaluate predictors of prostatic chronic inflammation (PCI) and prostate cancer (PCa) in patients undergoing transperineal baseline random prostatic needle biopsies (BNB).

Patient and methods

According to BNB outcomes, patients were divided into four groups: cases without PCI or PCa (Control group), cases with PCI only (PCI group), cases with PCa and PCI (PCa+PCI group) and cases with PCa only (PCa group). A multinomial logistic regression model was used to evaluate the association of clinical factors with BNB outcomes. Additionally, clinical factors associated with the risk of PCa in the overall population were investigated using a multivariable logistic regression model (univariate and multivariate analysis).

Results

Overall, 945 patients were evaluated and grouped as follows: Control group, 308 patients (32.6%); PCI group, 160 (16.9%); PCa+PCI group, 45 (4.8%); and PCa group, 432 (45.7%). Amongst these, PCa was independently predicted by age (odds ratio [OR] 1.081), prostate specific-antigen level (PSA; OR 1.159), transition zone volume (TZV; OR 0.916), and abnormal digital rectal examination (DRE; OR 1.962). PCa and PCI (4.8%) were independently predicted by age (OR 1.081), PSA level (OR 1.122) and TZV (OR 0.954). In the group without PCa, the PSA level was the only factor associated with the risk of PCI when compared to the control group (OR 1.051, P = 0.042). Among patients with PCa, independent factors associated with the risk of only PCa compared to cases with PCA+PCI were TZV (OR 0.972) and number of positive cores (OR 1.149). In the overall population, PCI was the strongest predictor of a decreased risk of PCa (multivariate model, OR 0.212; P < 0.001)

Conclusions

At BNB, PCI was associated with both a decreased risk of PCa and less aggressive tumour biology amongst patients with PCa. The presence of PCI on biopsy cores should be reported because of its implications in clinical practice.

Abbreviations

BGG: biopsy Gleason Group; BPC: biopsy positive (cancer) cores; BMI: body mass index; FGF-2: fibroblast growth factor 2; IL: interleukin; ISUP: International Society of Urologic Pathology; NIH: National Institutes of Health; OR: odds ratio; PCa: prostate cancer; PCI: prostatic chronic inflammation; TGF: transforming growth factor; TPV: total prostate volume; TZV: transition zone volume

Inflammation on Prostate Needle Biopsy is Associated with Lower Prostate Cancer Risk: A Meta-Analysis

PURPOSE

We performed a comprehensive literature review and meta-analysis to evaluate the association of inflammation on prostate needle biopsies and prostate cancer risk.

MATERIALS AND METHODS

We searched Embase®, PubMed® and Web of Science™ from January 1, 1990 to October 1, 2016 for abstracts containing the key words prostate cancer, inflammation and biopsy. Study inclusion criteria were original research, adult human subjects, cohort or case-control study design, histological inflammation on prostate needle biopsy and prostate cancer on histology. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. Combined ORs and 95% CIs of any, acute and chronic inflammation were calculated using the random effects method.

RESULTS

Of the 1,030 retrieved abstracts 46 underwent full text review and 25 were included in the final analysis, comprising a total of 20,585 subjects and 6,641 patients with prostate cancer. There was significant heterogeneity among studies (I² = 84.4%, p <0.001). The presence of any inflammation was significantly associated with a lower prostate cancer risk in 25 studies (OR 0.455, 95% CI 0.337-0.573). There was no evidence of publication bias (p >0.05). When subanalyzed by inflammation type, acute inflammation in 4 studies and chronic inflammation in 15 were each associated with a lower prostate cancer risk (OR 0.681, 95% CI 0.450-0.913 and OR 0.499, 95% CI 0.334-0.665, respectively).

CONCLUSIONS

In a meta-analysis of 25 studies inflammation on prostate needle biopsy was associated with a lower prostate cancer risk. Clinically the presence of inflammation on prostate needle biopsy may lower the risk of a subsequent prostate cancer diagnosis.

Impact of the Pathologist on Prostate Biopsy Diagnosis and Immunohistochemical Stain Usage Within a Single Institution

OBJECTIVES

To determine whether pathologists in a tertiary care institution vary in diagnosis and immunohistochemical stain usage in prostate biopsy specimens.

METHODS

Men who underwent prostate needle biopsies between 2008 and 2013 were included.

RESULTS

In total, 1,777 prostate biopsy specimens diagnosed by nine pathologists showed variation in diagnostic reporting (atypical small acinar proliferation, 2.0%-8.0%; high-grade prostatic intraepithelial neoplasia, 2.0%-8.5%; nonneoplastic, 30.2%-48.3%; adenocarcinoma, 46.2%-55.3%; P < .001). Variation in Gleason scoring was observed (P < .001), with the 4 + 3 = 7 category having the greatest variability (6.9%-30.3%). A blinded review from the most outlying pathologist in this category revealed 45% grading discrepancies. The mean number of immunostains performed per case (0.3-1.2) differed between pathologists (P < .001), and one pathologist used immunostains at twice the rate of the remaining cohort.

CONCLUSIONS

Case pathologist significantly affects prostate biopsy diagnosis and immunohistochemical workup. We recommend evaluation for outlying practice patterns to provide consistent and efficient patient care.

Clinical significance of proliferative inflammatory atrophy finding in prostatic biopsies

BACKGROUND

Proliferative inflammatory atrophy (PIA) has been involved in prostatic carcinogenesis. However, little is known about the clinical significance of a PIA finding in prostatic biopsies (PBs). The aim of this study is to determine the incidence of prostate inflammatory atrophy (PIA) in prostate biopsies (PBs), its association to high-grade prostatic intraepithelial neoplasia (HGPIN), prostate cancer (PCa), and tumor aggressiveness.

METHODS

Prospective and observational study of PIA lesion in 528 extended PBs and 200 radical prostatectomy specimens (RPS).

OUTCOME MEASUREMENTS

PIA, HGPIN, PCa incidence, Gleason score, clinical and pathologic tumor stage and insignificant tumor rate. Univariate and multivariate analysis.

RESULTS

Overall incidence of PIA and HGPIN was 30.3% and 54%. In RPS, the incidence was 30.5% and 72%, respectively. No significant association was found between PIA and HGPIN. Overall PCa detection rate in PBs was 38.1%. PCa was found in 27.5% PBs with PIA and 42.7% of those without PIA, P < 0.001. In contrast, PCa was detected in 50.9% of PBs with HGPIN and 23% of those without HGPIN, P = 0.001. Multivariate analysis revealed that PIA decreased the risk of PCa, OR:0.59 (95%CI:0.37-0.95), P = 0.029, while HGPIN increased OR:3.16 (95%CI:2.04-4.90), P = 0.001. PIA was not related to Gleason grade and clinical stage, however it was associated to an insignificant tumors increase, OR:3.08 (95%CI:1.09-8.7), P = 0.033. The information in RPS suggests that PIA is associated with less aggressive tumors and a higher probability of insignificant tumors.

CONCLUSIONS

PIA is present in one third of PBs, HGPIN in one half of them, and no association exists between both lesions. Contrary to HGPIN, PIA finding is associated to lower risk of PCa detection. Tumors accompanying PIA seem to be less aggressive and have a greater probability of being insignificant.

Contemporary clinical management of isolated high-grade prostatic intraepithelial neoplasia

High-grade prostatic intraepithelial neoplasia (HGPIN) is a premalignant lesion associated with increased risk of coexistent cancer or delayed progression to carcinoma. Extended biopsy schemes have improved the ability to rule out concurrent cancers, increased the detection of isolated HGPIN and removed the routine necessity for immediate repeat biopsy. As the natural history of HGPIN is poorly defined, and no non-invasive marker allows monitoring of progression to cancer, routine delayed interval biopsy should be considered in all patients. In this article, we present an overview of the existing literature on HGPIN and a proposed strategy for clinical management.

Prostate needle biopsies containing prostatic intraepithelial neoplasia or atypical foci suspicious for carcinoma: implications for patient care

PURPOSE

We identified information critical for patient treatment on prostate needle biopsies diagnosed with prostatic intraepithelial neoplasia or atypical foci suspicious for carcinoma.

MATERIALS AND METHODS

A search was performed using the MEDLINE database and referenced lists of relevant studies to obtain articles addressing the significance of finding PIN or atypical foci suspicious for carcinoma on needle biopsy.

RESULTS

There were certain results concerning PIN. 1) Low grade PIN should not be documented in pathology reports due to poor interobserver reproducibility and a relatively low risk of cancer following re-biopsy. 2) The expected incidence of HGPIN on needle biopsy is between 5% and 8%. 3) Although the diagnosis of HGPIN is subjective, interobserver reproducibility for its diagnosis is fairly high among urological pathologists, and yet only moderate among pathologists without special expertise in prostate pathology. 4) The median risk recorded in the literature for cancer following the diagnosis of HGPIN on needle biopsy is 24.1%, which is not much higher than the risk reported in the literature for repeat biopsy following a benign diagnosis. 5) The majority of publications that compared the risk of cancer in the same study following a needle biopsy diagnosis of HGPIN to the risk of cancer following a benign diagnosis on needle biopsy show no differences between the 2 groups. 6) Clinical and pathological parameters do not help stratify which men with HGPIN are at increased risk for a cancer diagnosis. 7) A major factor contributing to the decreased incidence of cancer following a diagnosis of HGPIN on needle biopsy in the contemporary era is related to increased needle biopsy core sampling, which detects many associated cancers on initial biopsy, such that re-biopsy, even with good sampling, does not detect many additional cancers. 8) It is recommended that men do not need routine repeat needle biopsy within the first year following the diagnosis of HGPIN, while further studies are needed to confirm whether routine repeat biopsies should be performed several years following a HGPIN diagnosis on needle biopsy. There were certain results concerning atypical glands suspicious for carcinoma. 1) An average of 5% of needle biopsy pathology reports are diagnosed as atypical glands suspicious for carcinoma. 2) Cases diagnosed as atypical have the highest likelihood of being changed upon expert review and urologists should consider sending such cases for consultation in an attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy. 3) Ancillary techniques using basal cell markers and AMACR (alpha-methyl-acyl-coenzyme A racemase) can decrease the number of atypical diagnoses, and yet one must use these techniques with caution since there are numerous false-positive and false-negative results. 4) The average risk of cancer following an atypical diagnosis is approximately 40%. 5) Clinical and pathological parameters do not help predict which men with an atypical diagnosis have cancer on repeat biopsy. 6) Repeat biopsy should include increased sampling of the initial atypical site, and adjacent ipsilateral and contralateral sites with routine sampling of all sextant sites. Therefore, it is critical for urologists to submit needle biopsy specimens in a manner in which the sextant location of each core can be determined. 7) All men with an atypical diagnosis need re-biopsy within 3 to 6 months.

CONCLUSIONS

It is critical for urologists to distinguish between a diagnosis of HGPIN and that of atypical foci suspicious for cancer on needle biopsy. These 2 entities indicate different risks of carcinoma on re-biopsy and different recommendations for followup.

WITHDRAWN:Epidemiology of prostate cancer and its precursors

Ahead of Print article withdrawn by publisher.

Pathologic features the urologist should expect on a prostate biopsy

In recent years, the pathological evaluation of prostate biopsy specimens has made great improvements in diagnostic accuracy and comprehensiveness. In this article, we review major pathological findings on prostate biopsy, their interpretation and reporting, as well as their clinical significance and utility. We discuss especially the clinically relevant histological features in either a positive or negative biopsy. We emphasize that both Gleason score and extent of cancer involvement in a needle core biopsy are important predictors of clinical outcome after either radical prostatectomy or radiation. Special issues regarding diagnosis and grading of minimal cancer on needle core biopsies are discussed. We also highlight the current standards on high-grade prostatic intraepithelial neoplasia and atypical small acinar proliferation on needle core biopsies. In summary, the pathology reports on needle biopsies are far beyond the simple presence or absence of cancer; they contain invaluable information to clinicians on patient management and counseling.

Significance of high-grade prostatic intraepithelial neoplasia on prostate biopsy

The early diagnosis of prostate cancer has been facilitated by the development of serum prostate-specific antigen (PSA) testing and evolution in transrectal ultrasound-guided biopsy of the prostate. Over a decade has passed since the initial recommendations for systematic sextant sampling of the prostate to increase the accuracy of cancer detection. Subsequently, variations in the number and location of biopsies have been proposed to maximize prostate cancer detection and obtain more complete information regarding tumor grade, tumor volume, and local stage. Although current biopsy strategies provide a wide sampling of the prostate gland, biopsy histology may not be conclusive for either the presence or absence of adenocarcinoma. High-grade prostatic intraepithelial neoplasia (HGPIN) is found in a significant fraction of patients undergoing transrectal prostate biopsies. In this article, we discuss the significance of high-grade prostatic intraepithelial neoplasia and other abnormal histology findings and current evidence addressing the presence of cancer and need for additional prostate biopsies.

Morphologic criteria for the diagnosis of prostatic adenocarcinoma in needle biopsy specimens. A study of 250 consecutive cases in a routine surgical pathology practice

CONTEXT

The diagnosis of prostate adenocarcinoma in needle core biopsy specimens is based on multiple diagnostic criteria and supportive features, most of which have been defined mainly from observations in transurethral resection and prostatectomy specimens. There is little information on the frequency with which diagnostic and supportive features of prostate cancer occur within benign glands. The few reports dealing with diagnostic criteria of cancer in needle biopsies have been largely confined to analysis of selected cases that posed particular diagnostic difficulty.

OBJECTIVE

To analyze the frequency with which numerous diagnostic or supportive features of prostate cancer occur in an unselected, consecutively performed series of 18-gauge prostate needle biopsy specimens.

DESIGN

Two hundred fifty consecutive 18-gauge prostate needle biopsy specimens (150 malignant and 100 benign) were evaluated, using hematoxylin-eosin-stained histologic sections.

RESULTS

The frequency of the histologic features in malignant and benign glands was as follows: prominent nucleoli (94% and 25% of malignant and benign specimens, respectively), marginated nucleoli (88% and 7%), multiple nucleoli (64% and 0%), blue-tinged mucinous secretions (52% and 0%), intraluminal crystalloids (40.6% and 1%), intraluminal amorphous eosinophilic material (86.7% and 2%), collagenous micronodules (2% and 0%), glomerulations (15.3% and 0%), perineural invasion (22% and 0%), retraction clefting (38.6% and 7%), and invasion of fat (0.7% and 0%).

CONCLUSIONS

Since not all diagnostic or supportive features of cancer are evident in any single case of cancer, particularly in needle biopsy specimens in which sampling is limited, awareness of these data would be helpful in the assessment of small foci of atypical glands being considered for cancer.

Histological markers of risk and the role of high-grade prostatic intraepithelial neoplasia

The marked discrepancy between the prevalence of preclinical prostate cancer and the incidence of clinically manifest disease indicates a long latency phase and significant heterogeneity in the progression potential of early neoplastic lesions. There are a variety of histologic changes within prostatic epithelium that have been termed atypical or dysplastic. The 2 most widely studied of these lesions are prostatic intraepithelial neoplasia (PIN) and atypical adenomatous hyperplasia (AAH). Although associations between AAH and adenocarcinoma are spurious, those linking high-grade PIN (HGPIN) to cancer are far more established. There is a significantly increased risk for patients with isolated HGPIN to have prostate cancer confirmed on subsequent biopsy, suggesting that HGPIN is a marker for prostate carcinoma in addition to its potential role as a premalignant lesion. Autopsy studies reveal that HGPIN is found in association with cancer in 63% to 94% of malignant and 25% to 43% of benign prostates. Data on age and race reveal that African American men develop more extensive HGPIN at a younger age than white men. A wide spectrum of molecular/genetic abnormalities appears to be common to both HGPIN and prostate cancer. Data loss of 8p, 10q, 16q, 18q, and gain of 7q31, 8q, multiple copies of the c-myc genes, along with changes in chromatin texture, telomerase activity, cell cycle status, and proliferative indices collectively suggest that HGPIN is intermediate between benign epithelium and prostatic carcinoma with respect to these markers. These data indicate that HGPIN is important in neoplastic progression, and may present an appropriate target/marker for chemoprevention.

High-grade prostatic intraepithelial neoplasia with adjacent atypia is associated with a higher incidence of cancer on subsequent needle biopsy than high-grade prostatic intraepithelial neoplasia alone

OBJECTIVES

High-grade prostatic intraepithelial neoplasia (HGPIN) is often considered a premalignant lesion of the prostate. Its incidence ranges from 0.7% to 20% in all prostate biopsies, and patients with HGPIN on initial biopsy are reportedly found to have a higher risk of cancer on subsequent biopsy. The purpose of our study was to determine the incidence of HGPIN in our patients who underwent prostate biopsy and to determine whether a further pathologic subclassification of HGPIN between HGPIN alone and HGPIN with adjacent atypical glands has any prognostic value in predicting the rate of prostate cancer on subsequent prostate biopsy.

METHODS

A total of 485 patients who underwent prostate biopsy between January 1998 and October 1999 were included in the study. Each set of slides was reviewed by a single urologic pathologist to determine the presence of HGPIN alone or HGPIN with adjacent atypical glands. If any HGPIN was identified, a repeat biopsy was performed, and the presence of cancer was recorded.

RESULTS

The overall incidence of HGPIN alone and HGPIN with adjacent atypical glands on initial biopsy was 33 (6.8%) of 485. Of these 33 patients, 21 (64%) had HGPIN alone and 12 (36%) had HGPIN with adjacent atypical glands. Three (14%) of 21 patients with HGPIN alone were found to have cancer on subsequent biopsy compared to 9 (75%) of 12 patients with HGPIN with adjacent atypia on initial biopsy. This difference is statistically significant (P <0.005).

CONCLUSIONS

The incidence of HGPIN alone in our experience is 4.3% (21 of 485). Patients with HGPIN with adjacent atypical glands suspicious for cancer have a significantly higher incidence of cancer on subsequent biopsy than patients with HGPIN alone.