Risk of concurrent prostate cancer in cystoprostatectomy specimens is related to volume of high-grade prostatic intraepithelial neoplasia

ERG and PTEN status of isolated high-grade PIN occurring in cystoprostatectomy specimens without invasive prostatic adenocarcinoma

High-grade prostatic intraepithelial neoplasia (HGPIN) is widely believed to represent a precursor to invasive prostatic adenocarcinoma. However, recent molecular studies have suggested that retrograde spread of invasive adenocarcinoma into pre-existing prostatic ducts can morphologically mimic HGPIN. Thus, previous molecular studies characterizing morphologically identified HGPIN occurring in radical prostatectomies or needle biopsies with concurrent invasive carcinoma may be partially confounded by intraductal spread of invasive tumor. To assess ERG and PTEN status in HGPIN foci likely to represent true precursor lesions in the prostate, we studied isolated HGPIN occurring without associated invasive adenocarcinoma in cystoprostatectomies performed at Johns Hopkins between 2009 and 2014. Of 344 cystoprostatectomies, 33% (115/344) contained invasive prostatic adenocarcinoma in the partially submitted prostate (10 blocks/case on average) and were excluded from the study. Of the remaining cases without sampled cancer, 32% (73/229) showed 133 separate foci of HGPIN and were immunostained for ERG and PTEN using genetically validated protocols. Of foci of HGPIN with evaluable staining, 7% (8/107) were positive for ERG. PTEN loss was not seen in any HGPIN lesion (0/88). Because these isolated HGPIN foci at cystoprostatectomy are unlikely to represent retrograde spread of invasive tumor, our study suggests that ERG rearrangement, but not PTEN loss, is present in a minority of potential neoplastic precursor lesions in the prostate.

Positive predictive value of high-grade prostatic intraepithelial neoplasia in initial core needle biopsies of prostate adenocarcinoma--a study with complete sampling of hemi-prostates with corresponding negative biopsy findings

OBJECTIVES

High-grade prostatic intraepithelial neoplasia (HGPIN) is a putative premalignant lesion of prostate adenocarcinoma (PCa). The significance of isolated HGPIN in initial biopsy cores as a marker of PCa in repeat biopsies has been extensively investigated, but little is known of the true occurrence of PCa in this setting, because repeat biopsies can miss the focus of cancer. In this study, a hemi-prostate model was used to define the true positive predictive value of HGPIN in core biopsies in predicting PCa.

METHODS

From 132 consecutive resected prostate specimens, 70 hemi-prostates with all corresponding biopsy cores negative for PCa were thoroughly examined.

RESULTS

Of the 70 hemi-prostates, 38 had PCa (including 8 with clinically significant PCa), and 11 had HGPIN. In the group of 38 hemi-prostate with PCa, 7 were associated with HGPIN-positive biopsies. No statistically significant difference was found between the hemi-prostates with or without PCa, regarding the presence, microscopic pattern, or multiple core involvement of HGPIN in the biopsies. The positive predictive value of HGPIN in predicting for clinically significant PCa was 27%, the negative predictive value was 87%, the sensitivity was 38%, and the specificity was 91% (P = 0.04, statistically significant). In addition, the positive predictive value of multiple cores with HGPIN in predicting for clinically significant PCa was 75% (negative predictive value 92%).

CONCLUSIONS

The results of the present study have failed to support HGPIN as a statistically significant predictor for the occurrence of PCa. More importantly, however, HGPIN and multiple core involvement did seem to be a useful marker for clinically significant PCa.

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.

Clinicopathologic Features of Prostate Adenocarcinoma Incidentally Discovered at the Time of Radical Cystectomy: An Evidence-Based Analysis

OBJECTIVES

To review all relevant features of incidentally discovered prostate cancer (PCa) in patients undergoing radical cystectomy for bladder cancer: incidence, pathologic characteristics, clinical significance, and implications for its management.

METHODS

A structured literature review through a MEDLINE search was performed.

RESULTS

The frequency of incidentally discovered PCa in cystoprostatectomy specimens is extremely variable because of several factors, particularly the pathology sampling. The relationship among clinically, incidentally, and autopsy-detected cancer is uncertain. The definition of clinically significant cancer varies among published reports and remains inadequate for clinical application. High-grade prostatic intraepithelial neoplasia is a marker for concurrent PCa and the risk depends more on the volume than on its absolute presence. Outcome of patients with unsuspected PCa after cystoprostatectomy relies mostly on the bladder tumor.

CONCLUSIONS

Incidental PCa in patients with bladder cancer is highly variable and with an unclear clinical significance. For those who are candidates for prostate-sparing surgery, it seems reasonable to include a routine prostate biopsy in the standard preoperative work-up irrespective of prostate-specific antigen values. In the absence of sufficient data to make firm recommendations, when PCa is incidentally discovered, PCa surveillance should be part of the follow-up scheme after radical cystectomy.

Clinically significant prostate cancer found incidentally in radical cystoprostatectomy specimens

OBJECTIVE

To review the incidence, histopathological features and clinical outcomes of patients with incidental prostate cancer found in radical cystoprostatectomy (RCP) specimens excised for bladder cancer, to determine if these cancers affected the follow-up strategy and if prostate-sparing cystectomy would be appropriate for these patients.

PATIENTS AND METHODS

We retrospectively reviewed the charts of men who had a RCP for transitional cell carcinoma (TCC) of the bladder, at our institution between 1987 and 2003. Patients with a preoperative diagnosis or clinical suspicion of prostate cancer were excluded from further analysis. We identified those men with incidental prostate cancer in the RCP specimens. The patients' demographic, histopathological and clinical outcome data were collected.

RESULTS

In all, 217 men had RCP for TCC between 1987 and 2003; 13 were excluded from the study due to a preoperative diagnosis or clinical suspicion of prostate cancer, and 58 (28%) were found to have incidental prostate cancer. The mean (range) follow-up was 47 (6-157) months. Of these prostate cancers, 20% were of Gleason score > or = 7 and two patients developed local and metastatic prostate cancer recurrences.

CONCLUSION

Incidental prostate cancer is a relatively common finding in RCP specimens, with a significant proportion having the characteristics of clinically relevant prostate cancer. The follow-up for prostate cancer should be incorporated with that for TCC and adapted according to the grade and stage of the prostate cancer. Preserving the prostate in an attempt to decrease the morbidity after RCP carries a high risk of significant prostate cancer in the residual prostatic tissue, suggesting that prostate-sparing cystectomy should only be reserved for a highly selected group of patients.

Incidentally Detected Prostate Cancer in Cystoprostatectomy Specimens

OBJECTIVES

Bladder and prostate cancers occur with increasing prevalence in the ageing population. Our study aims to quantify the incidence of prostate cancer in patients undergoing cystoprostatectomy for bladder cancer and assess the impact of that incidental prostate cancer on oncological outcome.

METHODS AND MATERIALS

We retrospectively reviewed the pathology reports of 128 men who underwent cystoprostatectomy for bladder cancer.

RESULTS

Twenty-three men (18%) were found to have incidental prostate cancer. All incidental prostate cancers were organ confined and 91% were well or moderately differentiated. At a mean follow-up of 55 months the prostate cancer-free survival was 96%.

CONCLUSION

The incidence of prostate cancer in cystoprostatectomy specimens is high. When the prostate is removed completely the presence of incidental prostate cancer does not influence the overall oncological outcome.

Incidentally detected prostate cancer in cystoprostatectomies: pathological and morphometric comparison with clinically detected cancer in totally embedded specimens

There are limited data regarding the pathological features of incidentally detected prostate cancer. Examination of cystoprostatectomy specimens obtained during bladder cancer treatment affords a unique opportunity to examine incidentally detected prostate cancer and determine its relationship with clinically detected prostate cancer obtained during radical prostatectomy. We compared the pathological findings of incidentally detected prostate cancer in 132 consecutive cystoprostatectomy specimens from patients treated for bladder cancer with a consecutive series of 228 radical prostatectomy specimens from patients treated for prostate cancer. All specimens were totally embedded and whole-mounted. Karyometry was evaluated in select subsets of patients from the study groups. Incidentally detected cancer was found in 42% of cystoprostatectomy specimens, and the cancers were of lower Gleason score and lower pathological stage with fewer positive surgical margins than in clinically detected cancers in age-matched radical prostatectomies. High-grade prostatic intraepithelial neoplasia (PIN) was present in 82% of radical prostatectomy specimens, in 70% of cystoprostatectomies with incidentally detected prostate cancer, and in 54% of cystoprostatectomies without prostate cancer. Mean nuclear and nucleolar area was lower in incidentally detected cancer and PIN when compared with clinically detected cancer and PIN, respectively, similar to the results with proliferative indices. We conclude that incidentally detected cancer is less aggressive than clinically detected cancer.

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.

WITHDRAWN:Epidemiology of prostate cancer and its precursors

Ahead of Print article withdrawn by publisher.

Pathologic evaluation of radical cystectomy specimens

BACKGROUND

The authors evaluated the pathology of radical cystectomy and pelvic lymph node specimens from patients with bladder carcinoma who were enrolled in a cooperative group trial. Their objective was to determine whether current practices conform to suggested pathology practice guidelines for reporting on radical cystectomy and pelvic lymph node specimens.

METHODS

Overall, 268 patients underwent radical cystectomy with pelvic lymph node dissection over 11 years in a total of 109 diverse geographic locations and types of institutions. Institutions included 50 community hospitals, 36 academic hospitals, and 23 Veterans Administration (VA)/military hospitals, which evaluated 84, 137, and 47 patients, respectively. The quality of pathology examination was assessed based on the original pathology reports of specimens that were submitted according to published practice guidelines.

RESULTS

Among all types of institutions, pathologic evaluation of radical cystectomy specimens generally was complete for tumor histology, grade, size, location, pathologic stage, lymph node status, prostate involvement, and associated mucosal abnormalities, including ureters and urethra. Perivesical fat (soft tissue) margins were not recorded in 10% of specimens, and 18% of patients did not mention either the presence or the number of lymph nodes. These deficiencies were observed primarily at community and VA hospitals.

CONCLUSIONS

The overall quality of pathologic examination of radical cystectomy specimens is high. Better reporting of soft tissue margin status and pelvic lymph node counts is needed to achieve compliance with the standards published by evolving practice protocols. Standardized pathologic evaluation and reporting of radical cystectomy specimens will optimize important prognostic information and foster better communication between the pathologist, surgeon, and interested oncologists to benefit patients.

Did the rate of incidental prostate cancer change in the era of PSA testing? A retrospective study of 1127 patients

OBJECTIVES

To evaluate, in a retrospective study, the impact of routine prostate-specific antigen (PSA) testing on the rate of incidental prostate cancer in patients undergoing surgery for obstructive symptoms caused by presumed benign prostatic enlargement (BPE) and to investigate the indication of a routine biopsy before alternative treatment procedures for BPE. In the pre-PSA era, the diagnosis of incidental carcinoma was exclusively based on normal digital rectal examination (DRE) findings.

METHODS

Since January 1993, 2422 operations (2283 transurethral resection of the prostate, 139 retropubic adenoma enucleations) for BPE were performed at our institution. The preoperative DRE findings and PSA level were evaluated, and patients with any suspicion for cancer were excluded. The pathologic reports of all patients were reviewed. A diagnosis of incidental carcinoma of the prostate required histologic evidence of cancer and negative DRE findings and a PSA level within age-specific reference ranges preoperatively.

RESULTS

Of 2422 patients, 1127 (46.5%) had both negative DRE findings and an age-specific PSA level and were evaluated for our study. Overall, prostate cancer was diagnosed by surgery in 314 (13%) of 2422 patients. The rate of incidental prostate cancer in patients with both negative age-specific PSA levels and negative DRE findings was 6.4% (72 of 1127).

CONCLUSIONS

In our series, the likelihood of detecting incidental prostate cancer by surgery was 6.4%. In the PSA era, the rate of incidental prostate cancer has been decreased by more than 50%. Today, the low rate of incidental carcinoma does not warrant routine histologic evaluation of the prostate if PSA testing and DRE are negative when alternative treatment modalities without tissue sampling are offered for the treatment of BPE.

Prevalence of prostate cancer and prostatic intraepithelial neoplasia in Caucasian Mediterranean males: an autopsy study

BACKGROUND

The prevalence of carcinoma of the prostate gland (CaP) and high-grade prostatic intraepithelial neoplasia (HGPIN) was assessed in a Spanish population, representative of the Caucasian Mediterranean (CM) ethnic group. Data were compared with those described in populations from other geographical regions and in other ethnic groups.

METHODS

CaP and HGPIN were evaluated in a consecutive series of prostatic glands collected at the post-mortem examination of 162 male patients born and living in Spain, aged 20-80 years, and dying from trauma. The glands were sliced every 2-3 mm. All slices were paraffin embedded and sectioned to obtain 5 microm whole-mount sections. To compare the prevalence rate in our series and in other Caucasian populations with that from other geographical areas and other ethnic groups, we used data from the autopsy study performed at the Wayne State University.

RESULTS

Prevalence of CaP is 3.58, 8.82, 14.28, 23.80, 31.7, and 33.33% in the 3rd, 4th, 5th, 6th, 7th, and 8th decades, respectively. The rates of HGPIN were 7.14, 11.75, 35.71, 38.06, 45.40, and 48.15% at the 3rd, 4th, 5th, and 8th decades of life. Both CaP and HGPIN are located preferentially at the peripheral zone of the gland and in 21/27 cases (77.7%), an association between CaP and HGPIN was found. The prevalence of both lesions in CM males is significantly lower than in Caucasian American (CA) and Afro-American (AA) males in all the age groups evaluated.

CONCLUSIONS

Microscopic foci of CaP and HGPIN can be documented in CM males from the 3rd decade of life onwards. The lesions become more frequent and extensive as age increases. The prevalence of both lesions seems to be significantly lower in the CM population than in CA and AA males in all the age groups evaluated.

Morphologic and clinical significance of multifocal prostate cancers in radical prostatectomy specimens

OBJECTIVES

To examine the histologic details of small, independent cancers compared with the largest (index) tumor and their impact on prostate-specific antigen (PSA) failure in 486 men treated only by radical retropubic prostatectomy (RRP).

METHODS

The tumor volume and percentage of Gleason grade 4/5 carcinoma were recorded in 3-mm step sections. Univariate statistics were calculated for the largest, total (largest plus smaller cancers), and smaller tumor volumes, number of independent foci, patient age, and follow-up. Cox hazards model determined the relative importance of all variables in relation to failure.

RESULTS

The mean index tumor volume was 4.16 cm3; smaller cancer volumes averaged 0.63 cm3. The index cancer volume was gaussian in distribution; smaller tumor volumes were highly skewed toward 234 carcinomas less than 0.5 cm3. Only 17% of all cases had one carcinoma. The Cox model showed similar hazard rates of PSA failure for both the index (3.43) and the total cancer (3.74) volumes. The hazard rate for the presence of any Gleason grade 4/5 carcinoma was 6.5. As the numbers of smaller tumors increased, the PSA cure rates improved.

CONCLUSIONS

The PSA failure rates (hazard ratios) were similar for the index tumor and the index plus smaller cancers, confirming that predictive estimates only need to measure the largest carcinoma. The greater the number of lesser cancers, the smaller the size of the index cancer. The extraordinary multiplicity of these small independent cancers in 3-mm step sections may explain the poor correlation between six or more biopsies with the index cancer in radical prostatectomy specimens.

Prostate cancer: management and controversies

Advances in the management of prostate cancer are associated with uncertainties and controversies in screening, who and when to treat, the best treatment option for localized disease and what to do with biochemical relapse after presumed curative treatment.

Analysis of intraprostatic failures in patients treated with hormonal therapy and radiotherapy: implications for conformal therapy planning

PURPOSE

Conformal therapy of prostate cancer is based on high-dose irradiation to the entire prostate gland. The aim of this study was to analyze the pattern of intraprostatic recurrence in patients undergoing external beam radiotherapy (EBRT) at a dose of 65-70 Gy to evaluate whether conventional radiotherapy doses are adequate to control microscopic disease outside the primary tumor and therefore whether high-dose irradiation can be exclusively focused on the macroscopic disease.

METHODS AND MATERIALS

The clinical and radiologic reports of 118 patients with prostate cancer undergoing EBRT (64.8-70.2 Gy) combined with hormonal therapy were evaluated. In all patients, before and after therapy, the size and site of the primary neoplasm within the prostate were assessed by clinical examination and imaging studies.

RESULTS

With a median follow-up of 45 months (range 14-119), the 5-year actuarial local control rate was 83.9%. Twelve patients had an intraprostatic recurrence, with the appearance of a new nodule (in 5 patients with a complete response after therapy) or increased nodular size compared with the minimal size (in the 7 other patients). In all patients, on the basis of a semiquantitative evaluation of the site of recurrence, this was shown to originate within the initial tumor volume.

CONCLUSION

The results of this analysis seem to confirm some histologic findings observed in patients undergoing prostatectomy for local recurrence after radiotherapy that suggest that local recurrence usually originates in the primary tumor rather than in focal prostatic intraepithelial neoplasia. This observation might justify the application of conformal therapy procedures aimed at identifying the gross tumor volume, in the phase of boost, exclusively with the primary tumor.

Prostate cancer detection in men with prior high grade prostatic intraepithelial neoplasia or atypical prostate biopsy

PURPOSE

We used clinical variables to predict prostate cancer detection on re-biopsy among patients diagnosed with high grade prostatic intraepithelial neoplasia (PIN) or atypia on initial prostate biopsy.

MATERIALS AND METHODS

A total of 45 men with atypia and 43 with high grade PIN were eligible for our study. Clinical variables were tested with univariate and multivariate logistic regression to predict who would have cancer on re-biopsy. We also calculated the odds of detecting cancer with various repeat sampling strategies and determined whether the location of initial atypia or high grade PIN is correlated to that of cancer on re-biopsy.

RESULTS

Of the patients in the atypia and high grade PIN groups 51% had cancer on re-biopsy. Cancer was diagnosed significantly earlier in the high grade PIN than in the atypia cohort (average 7.5 versus 22.9 months, respectively, p = 0.005). Multivariate logistic modeling showed that digital rectal examination and patient age were independent predictors of cancer in atypia, whereas no variables were significantly predictive for high grade PIN. Of cancers in the atypia and high grade PIN 65% and 74%, respectively, would have been detected if re-biopsy was focused only at the initial site of disease.

CONCLUSIONS

Men with atypia or high grade PIN merit close followup because 50% will have cancer on re-biopsy as will those who are older with an abnormal digital rectal examination. Although re-biopsy should focus primarily on the original site of atypia or high grade PIN, cancer detection significantly increases with the sampling of adjacent sites.

Chemoprevention for prostatic carcinoma: The role of flutamide in patients with prostatic intraepithelial neoplasia

High-grade prostatic intraepithelial neoplasia (HGPIN) is believed to be a precursor for prostatic adenocarcinoma. The prevalence of prostatic intraepithelial neoplasia (PIN) increases with advancing age. Autopsy studies suggest that PIN may precede the development of prostatic adenocarcinoma by up to 10 years. As such, HGPIN is believed to be a marker of increased risk. This provides a potential opportunity for chemoprevention. Flutamide is 1 agent with potential activity and limited side effects that may act to prevent or delay the onset of prostatic adenocarcinoma in men with HGPIN. A clinical trial is currently underway to assess the efficacy of flutamide.

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.

Significance of high-grade prostatic intraepithelial neoplasia in needle biopsy specimens

OBJECTIVES

To examine the significance of high-grade prostatic intraepithelial neoplasia (HGPIN) in biopsy specimens.

METHODS

We performed sextant biopsies on a series of 83 cystoprostatectomy specimens removed for bladder cancer. For each case the number of foci and volume of both HGPIN and prostate cancer were assessed in the prostatectomy specimens and compared with the number of biopsy specimens involved by HGPIN.

RESULTS

We identified HGPIN in 82 (99%) of 83 prostatic glands, whereas prostate cancer was found in 41 cases (49%). Corresponding sextant biopsies harbored both HGPIN and prostate cancer in 6 cases (7%), whereas only HGPIN was diagnosed in 29 sextant biopsies (35%). There was a positive correlation between the number of biopsy specimens containing HGPIN and the volume and multifocality of HGPIN in the corresponding prostatic glands. Prostates with HGPIN on sextant biopsy contained prostate cancer significantly more often when compared to cases with no HGPIN on sextant biopsy. Frequency of concurrent prostate cancer was higher in cases with two or more biopsy specimens containing HGPIN than in cases with only one such biopsy specimen, but case numbers of these categories were too small to render this difference statistically significant.

CONCLUSIONS

The presence of HGPIN in sextant biopsies is a significant predictor of concurrent prostate cancer. Multifocality of HGPIN is a useful parameter in assessing the extent of HGPIN in the corresponding prostates. Its value in predicting a significantly increased risk of concurrent prostate cancer needs to be further investigated in larger case studies.

[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.

Extent and zonal distribution of prostatic intraepithelial neoplasia in patients with prostatic carcinoma in Japan: analysis of whole-mounted prostatectomy specimens

BACKGROUND

Prostatic intraepithelial neoplasia (PIN), an intraluminar proliferation of epithelial cells in ducts and acini, is divided into high-grade (HGPIN) and low-grade (LGPIN), based on morphologies. HGPIN is considered to be a putative precursor of prostatic adenocarcinoma (PCA). Information on PIN has been limited in Japan, because PIN had not been regarded as a precursor lesion for PCA.

METHODS

In this study, extent and zonal distribution of PIN together with its relationship with PCA were examined in totally embedded radical prostatectomy specimens obtained from 70 patients with PCA. Fifty-three patients received androgen deprivation therapy (castrated) and remaining 17 did not (noncastrated).

RESULTS

Frequency of HGPIN in noncastrated cases (76%) was much higher than that in castrated cases (26%) (P < 0.001). LGPIN showed the same tendency, but the difference was smaller. Difference in mean number of HGPIN in noncastrated and castrated cases (12.0 and 6.4, respectively) was more marked than in LGPIN (6.4 and 5.1, respectively). Reduction rate of mean size in HGPIN (26%) by the androgen deprivation therapy was larger than in LGPIN. When evaluated in noncastrated cases, the coexistence of PCA and HGPIN was found in 76% of cases in the nontransition and 53% in the transition zone. Close association of PCA and PIN (</=2 mm distance between lesions) was more frequently found in HGPIN (55% of lesions) than in LGPIN (37%) (P < 0.05). Frequency of close association of HGPIN with PCA was 65% in the nontransition and 35% in transition zone.

CONCLUSIONS

The present study from Japan supports the etiological importance of HGPIN in the development of PCA. The effect of androgen deprivation therapy is much more marked in HGPIN than in LGPIN.

Sensitivity and specificity of sextant biopsies in the detection of prostate cancer: preliminary report

OBJECTIVES

To determine the true-negative and false-negative rates of sextant prostate biopsies, the most common method of prostate cancer diagnosis.

METHODS

Forty-three men scheduled for prostatectomy as part of a surgical procedure for bladder pathologic findings agreed to participate in this study. All patients had normal digital rectal examination findings. Immediately before prostatectomy all patients underwent sextant biopsies. The location, amount, and Gleason grade of any cancer identified on the biopsies were recorded. After surgery, the prostate was serially sectioned. The location, grade, and volume of any prostatic adenocarcinoma identified was recorded and compared with the results of the biopsy specimens.

RESULTS

There were 33 patients without prostate cancer in either the biopsies or the prostatectomy specimen. No patients had cancer on the biopsies and no cancer in the prostatectomy specimen. In 6 patients, cancer was found in both the biopsies and the prostatectomy specimens; these cancers were 0.9, 2.1, 2.8, 3. 1, 4.2, and 6.5 cc in volume. In the remaining 4 patients, there was no cancer on the biopsies but the prostatectomy specimen revealed cancers of 0.05, 0.1, 0.3, and 2.5 cc. The overall sensitivity for sextant biopsies was 60.0%, with a specificity of 100%. When only cancers greater than 2 cc or cancers in the peripheral zone were considered, the sensitivity rose to 83.3% and 71.4%, respectively, with a minimal decrease in specificity (97.3% and 97.2%, respectively). In contrast, when transition zone cancers were evaluated, the sensitivity fell to 33.3%.

CONCLUSIONS

Sextant biopsies are fairly sensitive for the detection of tumors greater than 2 cc and those in the peripheral zone; however, repeat biopsies should be strongly considered in patients with a high clinical suspicion for prostate cancer and negative initial sextant biopsies.

Prevalence and distribution of prostatic intraepithelial neoplasia in salvage radical prostatectomy specimens after radiation therapy

High-grade prostatic intraepithelial neoplasia (PIN) is the most likely precursor of prostate cancer. The effect of radiation therapy (RT) on the prevalence of PIN is uncertain. We studied 86 patients who underwent salvage radical prostatectomy after irradiation failure at the Mayo Clinic. The prevalence, volume, multicentricity, spatial proximity to cancer, and architectural patterns of PIN were evaluated. High-grade PIN was identified in 53 (62%) of 86 prostatectomy specimens. Multiple architectural patterns were usually observed, including tufting in 87%, micropapillary in 66%, cribriform in 38%, and flat in 17%. The mean volume of PIN was 0.12 cm3 (range, 0.05-1.20 cm3). PIN was usually multicentric (70%), with a mean number of PIN foci of 2.5 (range, 1-10). Ninety-four percent of PIN foci were located within 2 mm of invasive cancer. There was no correlation between PIN and pathologic stage, surgical margin, tumor size, DNA ploidy, post-RT Gleason score, time interval from RT to biopsy-proven recurrence, postoperative prostate-specific antigen level, distant metastasis-free survival, or cancer-specific survival. Our examination of salvage radical prostatectomy specimens indicated that the prevalence and extent of PIN appeared to be reduced after RT compared to published studies of prostatectomies without prior RT.

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.