Epidemiology of high grade prostatic intraepithelial neoplasia

Importance of Estrogenic Signaling and Its Mediated Receptors in Prostate Cancer

Prostate cancer (PCa) treatment was first established by Huggins and Hodges in 1941, primarily described as androgen deprivation via interference of testicular androgen production. The disease remains incurable with relapse of hormone-refractory cancer after treatments. Epidemiological and clinical studies disclosed the importance of estrogens in PCa. Discovery of estrogen receptor ERβ prompted direct estrogenic actions, in conjunction with ERα, on PCa cells. Mechanistically, ERs upon ligand binding transactivate target genes at consensus genomic sites via interactions with various transcriptional co-regulators to mold estrogenic signaling. With animal models, Noble revealed estrogen dependencies of PCa, providing insight into potential uses of antiestrogens in the treatment. Subsequently, various clinical trials were conducted and molecular and functional consequences of antiestrogen treatment in PCa were delineated. Besides, estrogens can also trigger rapid non-genomic signaling responses initiated at the plasma membrane, at least partially via an orphan G-protein-coupled receptor GPR30. Activation of GPR30 significantly inhibited in vitro and in vivo PCa cell growth and the underlying mechanism was elucidated. Currently, molecular networks of estrogenic and antiestrogenic signaling via ERα, ERβ and GPR30 in PCa have not been fully deciphered. This crucial information could be beneficial to further developments of effective estrogen- and antiestrogen-based therapy for PCa patients.

Primary and metastatic tumor dormancy as a result of population heterogeneity

Existence of tumor dormancy, or cancer without disease, is supported both by autopsy studies that indicate presence of microscopic tumors in men and women who die of trauma (primary dormancy), and by long periods of latency between excision of primary tumors and disease recurrence (metastatic dormancy). Within dormant tumors, two general mechanisms underlying the dynamics are recognized, namely, the population existing at limited carrying capacity (tumor mass dormancy), and solitary cell dormancy, characterized by long periods of quiescence marked by cell cycle arrest. Here we focus on mechanisms that precede the avascular tumor reaching its carrying capacity, and propose that dynamics consistent with tumor dormancy and subsequent escape from it can be accounted for with simple models that take into account population heterogeneity. We evaluate parametrically heterogeneous Malthusian, logistic and Allee growth models and show that 1) time to escape from tumor dormancy is driven by the initial distribution of cell clones in the population and 2) escape from dormancy is accompanied by a large increase in variance, as well as the expected value of fitness-determining parameters. Based on our results, we propose that parametrically heterogeneous logistic model would be most likely to account for primary tumor dormancy, while distributed Allee model would be most appropriate for metastatic dormancy. We conclude with a discussion of dormancy as a stage within a larger context of cancer as a systemic disease.

Reviewers: This article was reviewed by Heiko Enderling and Marek Kimmel.

Multiparametric MR can identify high grade prostatic intraepithelial neoplasia (HGPIN) lesions and predict future detection of prostate cancer in men with a negative initial prostate biopsy

PURPOSE

This study aims to determine the pre-biopsy diffusion-weighted imaging (DWI) and magnetic resonance spectroscopic imaging (MRSI) characteristics of patients with high-grade prostatic intraepithelial neoplasia (HGPIN) and perform follow-up studies in these patients to assess the clinical implications.

MATERIALS AND METHODS

One hundred sixteen men with prostate specific antigen between 4 and 10ng/ml underwent pre-biopsy MR examinations. Nine of them had HGPIN lesions without concomitant prostate cancer (PCa) on biopsy. Apparent diffusion coefficient (ADC) and metabolite ratio [Citrate/(Choline+Creatine)] were calculated and these 9 patients were followed to determine the clinical outcomes.

RESULTS

Mean ADC for HGPIN foci was 1.01±0.16×10(-3)mm(2)/s while for the normal peripheral zone it was 1.69±0.25×10(-3)mm(2)/s (p<0.005). Mean metabolite ratio for voxels in the HGPIN region of initial biopsy was 0.24±0.16 while for the normal peripheral zone the value was 2.66±1.57 (p<0.005). Four of 5 patients who were available for follow-up were detected to have prostate cancer on repeat biopsy. No significant change in metabolite ratio and PSA was observed while ADC showed further reduction on follow-up.

CONCLUSION

HGPIN foci have ADC and metabolite ratio values similar to adenocarcinoma prostate, indicating that such patients have a high likelihood of developing cancer. DWI may help identify such men who may be candidates for close follow-up.

Metastatic mechanisms in follicular cell-derived thyroid cancer

Thyroid cancer incidence is rising annually largely related to enhanced detection and early stage well-differentiated primary tumors. The prognosis for patients with early stage thyroid cancer is outstanding with most patients being cured with surgery. In selected cases, I-131 is administered to treat known or suspected residual or metastatic disease. Even patients with loco-regional metastases typically have an outstanding long-term prognosis, albeit with monitoring and occasional intervention for residual or recurrent disease. By contrast, individuals with distant metastases from thyroid cancer, particularly older patients with larger metastatic burdens and those with poorly differentiated tumors, have a poor prognosis. Patients with metastatic anaplastic thyroid cancer have a particularly poor prognosis. Published clinical trials indicate that transient disease control and partial remissions can be achieved with kinase inhibitor therapy directed toward angiogenic targets and that in some cases I-131 uptake can be enhanced. However, the direct targets of activity in metastatic lesions are incompletely defined and clear evidence that these treatments increase the duration or quality of life of patients is lacking, underscoring the need for improved knowledge regarding the metastatic process to inform the development of new therapies. In this review, we will focus on current data and hypotheses regarding key regulators of metastatic dormancy, metastatic progression, and the role of putative cancer stem cells.

Preneoplasia in the prostate gland with emphasis on high grade prostatic intraepithelial neoplasia

There are a variety of morphological patterns and processes that have been implicated in the pathogenesis of prostate cancer. Prostatic intraepithelial neoplasia (PIN), inflammation with or without atrophy, and adenosis (atypical adenomatous hyperplasia) have all been given candidate status as precursor lesions of prostatic adenocarcinoma. Based on decades of research, high grade prostatic intraepithelial neoplasia (HPIN), a proliferative lesion of prostatic secretory cells, has emerged as the most likely morphological pre-invasive lesion involved in the evolution of many but not all prostatic adenocarcinomas. In this manuscript, we briefly discuss other proposed precursors of prostatic adenocarcinoma and then focus on the history, diagnostic criteria and morphology of HPIN. The incidence of HPIN and its relationship to prostate cancer is reviewed. The differential diagnosis of large glandular patterns in the prostate is discussed in depth. Finally, we summarise the recent clinicopathological studies evaluating the clinical significance of HPIN and discuss follow-up strategies in men diagnosed with HPIN.

cGMP-dependent protein kinase Iβ interacts with p44/WDR77 to regulate androgen receptor-driven gene expression

The androgen receptor (AR) pathway plays critical roles in controlling differentiation and proliferation of prostate epithelial cells. We previously identified a novel AR cofactor, p44/WDR77, which specifically enhances AR transcriptional activity in the prostate gland and prostate cancer. To further elucidate p44/WDR77's role in the AR signaling pathway, we conducted a yeast two-hybrid screening and identified cGMP-dependent protein kinase (PKG) as a p44/WDR77-interacting protein. Further investigation by lusiferase assay and kinase assay demonstrated that PKG-Iβ physically interacted with and phosphorylated both p44 and AR and enhanced AR transactivity in synergy with p44 in an androgen- and cGMP-dependent manner. Furthermore, PKG1β expression promoted p44/WDR77 nuclear translocation and inhibited prostate cancer cell growth via G1 cell cycle arrest. Our findings characterize PKG as a novel regulator of AR-mediated transcription by enhancing AR cofactor p44/WDR77's function, which provide a novel mechanism for the growth regulation of prostate cancer cells by the androgen signaling.

High grade prostate intraepithelial neoplasia (PIN) is a PSA-independent risk factor for prostate cancer in African American men: results from a pilot study

African American men (AAM) demonstrate increased prostate cancer incidence and mortality rates. We investigated known prostate cancer risk factors in AAM. Prostate specific antigen (PSA) and diagnosis of high grade prostatic intraepithelial neoplasia (PIN) were significant prostate cancer predictors. However, even including AAM with low PSA (<4ng/ml), those with PIN had significantly elevated risk, compared to men without PIN (83.3% vs. 6.9%, p<0.0001). In AAM diagnosed with PIN, PSA level was no longer significant (83.3% vs. 92.3%, p=0.593 respectively). Our results suggest that a history of PIN is highly predictive of prostate cancer in AAM, and help provide PSA-independent venues for screening.

Molecular Targeted Therapies Using Botanicals for Prostate Cancer Chemoprevention

In spite of the large number of botanicals demonstrating promise as potential cancer chemopreventive agents, most have failed to prove effectiveness in clinical trials. Critical requirements for moving botanical agents to recommendation for clinical use include adopting a systematic, molecular-target based approach and utilizing the same ethical and rigorous methods that are used to evaluate other pharmacological agents. Preliminary data on a mechanistic rationale for chemoprevention activity as observed from epidemiological, in vitro and preclinical studies, phase I data of safety in suitable cohorts, duration of intervention based on time to progression of pre-neoplastic disease to cancer and using a valid panel of biomarkers representing the hypothesized carcinogenesis pathway for measuring efficacy must inform the design of clinical trials. Botanicals have been shown to influence multiple biochemical and molecular cascades that inhibit mutagenesis, proliferation, induce apoptosis, suppress the formation and growth of human cancers, thus modulating several hallmarks of carcinogenesis. These agents appear promising in their potential to make a dramatic impact in cancer prevention and treatment, with a significantly superior safety profile than most agents evaluated to date. The goal of this paper is to provide models of translational research based on the current evidence of promising botanicals with a specific focus on targeted therapies for PCa chemoprevention.

Prostate cancer aggressiveness: in vivo assessment of MR spectroscopy and diffusion-weighted imaging at 3 T

PURPOSE

To determine the individual and combined performance of magnetic resonance (MR) spectroscopic imaging and diffusion-weighted (DW) imaging at 3 T in the in vivo assessment of prostate cancer aggressiveness by using histopathologically defined regions of interest on radical prostatectomy specimens to define the prostate cancer regions to be investigated.

MATERIALS AND METHODS

The local institutional ethics review board approved this retrospective study and waived the informed consent requirement. Fifty-four patients with biopsy-proved prostate cancer underwent clinical MR spectroscopic imaging followed by prostatectomy. Guided by the histopathologic map, all spectroscopy voxels that contained tumor tissue were selected, and metabolite ratios (choline [Cho] plus creatine [Cr]-to-citrate [Cit] and Cho/Cr ratios) were derived. For each spectroscopic voxel, 25th percentile apparent diffusion coefficient (ADC) of the region corresponding to that voxel was determined, representing the most aberrant tumor part on the ADC map, which was often smaller than spectroscopic imaging voxels. Maximum metabolic ratios and minimum 25th percentile ADC of each tumor were related to tumor aggressiveness and were used to differentiate aggressiveness classes. A logistic regression model (LRM) was used to combine data from both modalities.

RESULTS

Significant correlation was found between aggressiveness classes and maximum Cho+Cr/Cit ratio (ρ=0.36), maximum Cho/Cr ratio (ρ=0.35), and minimum 25th percentile ADC (ρ=-0.63) in the peripheral zone (PZ). In the transition zone (TZ), the correlation was significant for only Cho+Cr/Cit and Cho/Cr ratios (ρ=0.58 and ρ=0.60, respectively). For differentiation between aggressiveness classes, LRM use did not result in significantly improved differentiation over any individual variables.

CONCLUSION

These findings enabled confirmation that MR spectroscopic imaging and DW imaging offer potential for in vivo noninvasive assessment of prostate cancer aggressiveness, and both modalities have comparable performance. The combination did not result in better performance. Nonetheless, the better performances of metabolite ratios in the TZ and of ADCs in the PZ suggest that they have complementary value.

Emergent trends in the reported incidence of prostate cancer in Nigeria

BACKGROUND

To date there has not been any nationwide age-standardized incidence data reported for prostate cancer in Nigeria. We examined and integrated diverse trends in the age-specific incidence of prostate cancer into a comprehensive trend for Nigeria, and examined how best the existing data could generate a countrywide age-standardized incidence rate for the disease.

METHODS

Data were obtained from studies undertaken between 1970 and 2007 in referral hospital-based cancer registries. Records from at least one tertiary hospital in each of the six geopolitical zones of Nigeria were examined retrospectively. Data were also reported for the rural population in cross-sectional prospective studies. Age-standardized incidence rates and the annual incidence of disease were calculated.

RESULTS

Higher incidence rates for prostate cancer during this period were recorded for patients aged 60-69 years and 70-79 years, with a lower incidence rate for patients aged younger than 50 years. An exponential annual incidence rate of disease was observed in the 50-79 year age group and peaked at 70-79 years before dropping again at age 80 years. The results showed metastasis in more than half of these hospital-based prostate tumors.

CONCLUSION

Our results suggest that prostate cancer occurs at a relatively young age in Nigerians and that hospital-based registry reports may not appropriately reflect the incidence of the disease in Nigeria. A countrywide screening program is urgently needed. Finally, the difference in reported stages of disease found in Nigerians and African-Americans versus Caucasians suggests biological differences in the prognosis. Nigeria may thus typify one of the ancestral populations that harbor inherited genes predisposing African-Americans to high-risk prostate cancer.

Tomato-based food products for prostate cancer prevention: what have we learned?

Evidence derived from a vast array of laboratory studies and epidemiological investigations have implicated diets rich in fruits and vegetables with a reduced risk of certain cancers. However, these approaches cannot demonstrate causal relationships and there is a paucity of randomized, controlled trials due to the difficulties involved with executing studies of food and behavioral change. Rather than pursuing the definitive intervention trials that are necessary, the thrust of research in recent decades has been driven by a reductionist approach focusing upon the identification of bioactive components in fruits and vegetables with the subsequent development of single agents using a pharmacologic approach. At this point in time, there are no chemopreventive strategies that are standard of care in medical practice that have resulted from this approach. This review describes an alternative approach focusing upon development of tomato-based food products for human clinical trials targeting cancer prevention and as an adjunct to therapy. Tomatoes are a source of bioactive phytochemicals and are widely consumed. The phytochemical pattern of tomato products can be manipulated to optimize anticancer activity through genetics, horticultural techniques, and food processing. The opportunity to develop a highly consistent tomato-based food product rich in anticancer phytochemicals for clinical trials targeting specific cancers, particularly the prostate, necessitates the interactive transdisciplinary research efforts of horticulturalists, food technologists, cancer biologists, and clinical translational investigators.

Null activity of selenium and vitamin e as cancer chemopreventive agents in the rat prostate

To evaluate the potential efficacy of selenium and vitamin E as inhibitors of prostate carcinogenesis, four chemoprevention studies using a common protocol were done in a rat model of androgen-dependent prostate cancer. After stimulation of prostate epithelial cell proliferation by a sequential regimen of cyproterone acetate followed by testosterone propionate, male Wistar-Unilever rats received a single i.v. injection of N-methyl-N-nitrosourea (MNU) followed by chronic androgen stimulation via subcutaneous implantation of testosterone pellets. At 1 week post-MNU, groups of carcinogen-treated rats (39-44/group) were fed either a basal diet or a basal diet supplemented with l-selenomethionine (3 or 1.5 mg/kg diet; study 1), dl-alpha-tocopherol (vitamin E, 4,000 or 2,000 mg/kg diet; study 2), l-selenomethionine + vitamin E (3 + 2,000 mg/kg diet or 3 + 500 mg/kg diet; study 3), or selenized yeast (target selenium levels of 9 or 3 mg/kg diet; study 4). Each chemoprevention study was terminated at 13 months post-MNU, and prostate cancer incidence was determined by histopathologic evaluation. No statistically significant reductions in prostate cancer incidence were identified in any group receiving dietary supplementation with selenium and/or vitamin E. These data do not support the hypotheses that selenium and vitamin E are potent cancer chemopreventive agents in the prostate, and when considered with the recent clinical data reported in the Selenium and Vitamin E Cancer Prevention Trial (SELECT), show the predictive nature of this animal model for human prostate cancer chemoprevention.

Novel biomarkers for prostate cancer including noncoding transcripts

Levels of 27 transcripts were investigated as potential novel markers for prostate cancer, including genes encoding plasma membrane proteins (ADAM2, ELOVL5, MARCKSL1, RAMP1, TMEM30A, and TMEM66); secreted proteins (SPON2, TMEM30A, TMEM66, and truncated TMEFF2 (called POP4)); intracellular proteins (CAMK2N1, DHCR24, GLO1, NGFRAP1, PGK1, PSMA7, SBDS, and YWHAQ); and noncoding transcripts (POP1 (100 kb) from mRNA AK000023), POP2 (4 kb from mRNA AL832227), POP3 (50 kb from EST CFI40309), POP5 (intron of NCAM2, accession DO668384), POP6 (intron of FHIT), POP7 (intron of TNFAIP8), POP8 (intron of EFNA5), POP9 (intron of DSTN), POP10 (intron of ADAM2, accession DO668396), POP11 (87kb from EST BG194644), and POP12 (intron of EST BQ226050)). Expression of POP3 was prostate specific, whereas ADAM2, POP1, POP4, POP10, ELOVL5, RAMP1, and SPON2 had limited tissue expression. ELOVL5, MARCKSL1, NGFRAP1, PGK1, POP2, POP5, POP8, PSMA7, RAMP1, and SPON2 were significantly differentially expressed between laser microdissected malignant versus benign clinical samples of prostate tissue. PGK1, POP2, and POP12 correlated to clinical parameters. Levels of CAMK2N1, GLO1, SDBS, and TMEM30A transcripts tended to be increased in primary prostate cancer from patients who later had biochemical failure. Expression of GLO1, DHCR24, NGFRAP1, KLK3, and RAMP1 were significantly decreased in metastatic castration-recurrent disease compared with androgen-dependent primary prostate cancer. These novel potential biomarkers may therefore be useful in the diagnosis/prognosis of prostate cancer.

Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair

BACKGROUND

Preperitoneal placement of mesh during herniorraphy has been shown to complicate future extirpative prostate surgery. We investigated the value of a prostate cancer screening program in patients considering laparoscopic inguinal herniorrhaphy to identify men at risk of prostate cancer.

STUDY DESIGN

A prospective cohort study was conducted in men 30 years of age or older presenting with inguinal hernia. All patients were counseled on prostate cancer risk and the potential for herniorrhaphy with mesh placement to complicate future pelvic surgery. Serum prostate specific antigen (PSA) values were obtained, and patients determined to be at increased relative risk of prostate cancer were referred for urologic evaluation. Transrectal ultrasonography-guided biopsy was performed if clinically indicated, and operative data for patients undergoing prostate cancer treatment were retrospectively reviewed.

RESULTS

There were 1,324 patients who presented for management of inguinal hernia; 814 of these (median age 60 years) consented to screening. Overall, 259 (32%) had an increased relative risk of prostate cancer based on PSA 1.0 to 2.49 ng/mL, and 152 (19%) had PSA > or = 2.5 ng/mL. Transrectal ultrasonography-guided biopsy was performed in 86 patients. Prostate cancer was identified on initial or repeat biopsy in 31 patients (3.8%), including 1 patient (0.7%) younger than 50 years of age.

CONCLUSIONS

We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Does race affect postoperative outcomes in patients with low-risk prostate cancer who undergo radical prostatectomy?

OBJECTIVES

To assess the magnitude of racial disparities in prostate cancer outcomes following radical prostatectomy for low-risk prostate cancer.

METHODS

We retrospectively reviewed our database of 2407 patients who under went radical prostatectomy and isolated 2 cohorts of patients with low-risk prostate cancer. Cohort 1 was defined using liberal criteria, and cohort 2 was isolated using more stringent criteria. We then studied pre- and postoperative parameters to discern any racial differences in these 2 groups. Statistical analyses, including log-rank, chi(2), and Fisher's exact analyses, were used to ascertain the significance of such differences.

RESULTS

Preoperatively, no significant differences were found between the white and African-American patients with regard to age at diagnosis, mean prostate-specific antigen, median follow-up, or percentage of involved cores on prostate biopsy. African-American patients in cohort 1 had a greater mean body mass index than did white patients (26.9 vs 27.8, P = .026). The analysis of postoperative data demonstrated no significant difference between white and African-American patients in the risk of biochemical failure, extraprostatic extension, seminal vesicle involvement, positive surgical margins, tumor volume, or risk of disease upgrading. African-American patients in cohort 2 demonstrated greater all-cause mortality compared with their white counterparts (9.4% vs 3.1%, P = .027).

CONCLUSIONS

In patients with low-risk prostate cancer treated with radical prostatectomy, there exist no significant differences in surrogate measures of disease control, risk of disease upgrading, estimated tumor volume, or recurrence-free survival between whites and African-Americans.

Precursor Lesions of Prostate Cancer

Several morphological lesions have been proposed that may act as potential precursor lesions of prostate cancer. These are the morphologically distinct entities of focal atrophy or post-atrophic hyperplasia (PAH), atypical adenomatous hyperplasia (AAH) or adenosis, and prostatic intraepithelial neoplasia (PIN). The diagnostic criteria of low-and high-grade PIN (LGPIN and HGPIN, respectively) and of lesions suspicious for cancer (LSC) have been established. In the present review, we present the current knowledge about the precursor lesions of prostate cancer. We focus on the epidemiology, pathogenesis, clinical markers, and differential diagnosis of PIN. The similarities between HGPIN and prostate cancer are also discussed. Furthermore, potential markers and management strategies (that is, repeat biopsy, chemoprevention, radical prostatectomy, radiotherapy) are outlined along with updated recommendations.

The ratio of matrix metalloproteinase to E-cadherin expression: a pilot study to assess mRNA and protein expression among African American prostate cancer patients

BACKGROUND

We assessed the expression of Matrix Metalloproteinase (MMP) to E-cadherin (M/E ratio) to determine the correlation of gene expression with pathologic variables and outcome in a cohort of African American (AA) prostate cancer patients.

METHODS

Tumors from formalin-fixed, paraffin embedded RP specimens were examined. Gleason scores were 6, 7, and >or=8 in 7, 16, 13 tumors, respectively. Pathologic stage was organ confined (pT2) in 18 and advanced (>pT2) in 18 tumors. A colorimetric mRNA in situ hybridization (ISH) assay was performed using biotinylated anti-sense oligonucleotide probes for MMP 2 and 9, as well as for E-cadherin gene transcripts. Immunohistochemistry (IHC) was performed utilizing specific monoclonal antibodies to detect the above genes. Image analysis was performed to determine the intensity of both mRNA and protein expression. Two reviewers analyzed ISH gene expression independently.

RESULTS

The M/E expression ratio was significantly increased at the invasive edge (but not the center) of tumors of higher Gleason score (P = 0.02 and 0.0008) and pathologic stage (P = 0.0001 and <0.0001) when examined by both ISH and IHC. Significant variability in ISH staining interpretation was noted within and among the two study reviewers. An M/E ratio >2.5 was associated with biochemical recurrence after radical prostatectomy in addition to tumor pathologic stage subsequent to univariate statistical analysis.

CONCLUSIONS

The M/E ratio characterizes an important aspect of the molecular phenotype associated with the histologic progression of prostate cancer among African American prostate cancer patients. A larger comparative study is required to determine potential racial variation and prognostic significance of gene expression.

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 adenocarcinoma detected after high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation

OBJECTIVE

To review specific histological variables in patients with prostate cancer who previously had diagnoses of high-grade prostatic intraepithelial neoplasia (HGPIN) and/or atypical small acinar proliferation (ASAP), compared with those who had no such diagnoses.

PATIENTS AND METHODS

The histological characteristics of prostate cancers which were detected after a previous diagnosis of HGPIN and/or ASAP during 1998-2005 were investigated and correlated with the biopsies from patients with prostate cancer but with no such previous diagnoses.

RESULTS

HGPIN was followed by prostate cancer on repeat biopsy in 16.8% of patients, and ASAP in 26.7%. The mean age of patients with HGPIN or ASAP was higher than in those with no such diagnoses (P < 0.001). Similarly, patients with these previous diagnoses had a lower Gleason score (P = 0.017 and <0.001, respectively) and lower tumour volume variables (fewer tumour foci, P = 0.033 and 0.041, respectively) and shorter cancer (P = 0.048 and 0.030) in core biopsies than those without.

CONCLUSIONS

Patients with prostate cancer who had previous biopsies with HGPIN or ASAP were older and has lower grade- and volume-cancers than those who had not.

The proportion of cores with high-grade prostatic intraepithelial neoplasia on extended-pattern needle biopsy is significantly associated with prostate cancer on site-directed repeat biopsy

OBJECTIVE

To determine whether the predictive value of isolated high-grade prostatic intraepithelial neoplasia (HGPIN) for an unsampled prostate cancer on an extended biopsy is lower due to more thorough prostate sampling, and whether the proportion of cores with HGPIN is associated with prostate cancer, as isolated HGPIN on sextant prostate biopsy is associated with a 27-57% risk of prostate cancer on repeat biopsy.

PATIENTS AND METHODS

All extended prostate biopsies taken by one urologist over 6 years were reviewed for patients with isolated HGPIN on initial biopsy. Biopsies were evaluated for histological features and the proportion of cores with HGPIN. The clinical characteristics and pathological findings from subsequent biopsies were determined.

RESULTS

Of 577 men having extended biopsies, 48 had isolated HGPIN, followed by one to four site-directed repeat biopsies. Although only 10 (21%) had cancer on the first repeat biopsy, overall 15 (31%) had cancer. Those with cancer on repeat biopsy had a significantly higher proportion of cores with HGPIN, i.e. 29% vs 15%, cancer vs no cancer, respectively (P = 0.04).

CONCLUSIONS

Isolated HGPIN on extended biopsy conferred a 31% risk of unsampled prostate cancer. The proportion of cores with HGPIN on initial biopsy was significantly associated with the risk of cancer. The same was not true for age, race, prostate-specific antigen level, or the findings on digital rectal examination. The significant association between the proportion of cores with HGPIN and the risk of cancer suggests that patients with unifocal HGPIN on extended biopsy be managed expectantly, whereas those with multifocal HGPIN be re-biopsied.

Widespread High-grade Prostatic Intraepithelial Neoplasia on Prostatic Needle Biopsy: A Significant Likelihood of Subsequently Diagnosed Adenocarcinoma

In comparison with earlier studies, recent reports have demonstrated a lower incidence of prostate carcinoma after an initial diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN). The latter has led to a general tendency to reconsider the absolute need for a rebiopsy in this setting. The current retrospective study assesses the subsequent likelihood of identifying prostatic adenocarcinoma (PCa) in 41 patients with an initial diagnosis of "widespread" HGPIN defined as HGPIN present in 4 or more biopsy cores. All patients underwent at least 1 follow-up (F/U) sampling procedure in a period of 1 to 41 months. PCa was found in 16/41 patients (39%), all except 1 identified on the first F/U biopsy with the remaining patients diagnosed on a transurethral resection after a negative first F/U biopsy. All but 1 prostatic carcinoma diagnoses were obtained within 2 years from initial biopsy with 10 rendered within the first year. On average, prostate cancer was identified at 10.4 months (range: 1 to 36). One-fourth of all identified prostatic carcinomas were of Gleason score 7 or more. In 4 additional patients (9.7%), F/U biopsy revealed HGPIN with adjacent atypical small glands suspicious but not diagnostic of carcinoma (PINATYP). Of 41 patients, 10 (24.3%) continued to show HGPIN with the remaining 11/41 patients (26.8%) showing benign prostatic tissue. Patients >or=70 years of age at the time of initial biopsy had a statistically significant higher rate of PCa or HGPIN/PINATYP diagnosis on repeat biopsy compared with younger patients (P=0.02), with 55% of older men being diagnosed with cancer as compared with 33% in younger men. Patients with fewer cores sampled on initial biopsy were more likely to be diagnosed with carcinoma as opposed to HGPIN/PINATYP on F/U (P=0.015). Other factors such as the number of F/U procedures, serum prostate-specific antigen level before initial HGPIN biopsy, number of cores per F/U biopsy, and F/U interval length did not affect the likelihood of finding carcinoma. In summary, our study reveals a 39% risk of finding PCa on repeat biopsies obtained after an initial diagnosis of widespread HGPIN. Our findings support the need for a repeat biopsy in this subset of patients.

African-American men with nonpalpable prostate cancer exhibit greater tumor volume than matched white men

BACKGROUND

Although prostate cancer (PC) mortality disproportionately affects African-American (AA) men, limited data exist comparing the pathologic characteristics of white and AA patients with nonpalpable PC (clinical stage T1c).

METHODS

The authors reviewed the radical prostatectomy (RP) specimens from 37 consecutive AA men with clinical stage T1c PC and 35 white men who were matched for age, clinical stage, serum prostate-specific antigen (PSA) level, year of surgery, prostate weight, and prostate biopsy strategy. Pathologic characteristics were compared after mapping tumor foci and calculating tumor volumes by using computer software.

RESULTS

For AA men, the median age (57.7 years), mean serum PSA level (9.3 ng/mL), mean prostate weight (43 g), and biopsy strategy (73% sextant) were matched with the cohort of 35 white men (median age, 57.1 years; mean PSA, 9.3 ng/mL;, mean prostate weight, 43 g; biopsy strategy, 66% sextant). Despite similar biopsy characteristics between the 2 groups (Gleason score > or =7 in 43% of AA men vs. 37% of white men), AA men exhibited significantly higher prostatectomy Gleason scores (> or =7 in 76% of AA men vs. 34% of white men; P = .01). AA men also had a higher mean tumor volume (1.82 cm3 vs. 0.72 cm3; P = .001) and had 2.8 times more tumor per ng/mL of serum PSA (0.22 cm3 per ng/mL vs. 0.079 cm3 per ng/mL; P = .001).

CONCLUSIONS

Compared with a cohort of white men with similar clinical features at the time of biopsy, AA men with nonpalpable PC had higher prostatectomy Gleason scores, greater cancer volume, and greater tumor volume per ng/mL of serum PSA. These data provide additional support for the concept of early PC detection using a serum PSA threshold of 2.5 ng/mL for biopsy among AA men.

Bicalutamide 50 mg monotherapy in patients with isolated high-grade PIN: findings in repeat biopsies at 6 months

OBJECTIVES

To evaluate morphological findings in repeat biopsies in patients with isolated high-grade prostatic intraepithelial neoplasia (HGPIN) after a 6-month course of bicalutamide (Casodex) 50 mg/day.

METHODS

20 consecutive patients with isolated HGPIN in prostate biopsies were treated for 6 months with bicalutamide 50 mg/day. After treatment, the patients were resubmitted to prostate biopsy mapping. The control group included 22 untreated consecutive patients with isolated high-grade PIN with repeat biopsies taken 6 months after the initial biopsies.

RESULTS

In the initial biopsies of the treated group, HGPIN was monofocal in 12 patients and plurifocal in 8. In the repeat biopsies HGPIN was present in 2 patients, monofocal in both, whereas prostate adenocarcinoma (PCa) was discovered in one. In the control group, HGPIN was monofocal in 15 and plurifocal in 7. In the repeat biopsies HGPIN was present in six patients, being monofocal in three and plurifocal in the other three. PCa was present in one.

CONCLUSIONS

There was a lower incidence of HGPIN (treated group vs control: 10% vs 27.2%) after 6 months of bicalutamide. Reduction in its extent was also observed (treated group vs control: monofocal 100% vs 50%). Treatment did not affect the incidence of cancer (treated vs control: 5% vs 4.5%).

Dealing with non-cancerous findings on prostate biopsy

Most prostate biopsies do not show malignancy. The proper management of non-cancerous pathologic findings of the prostate is controversial. For this article, we reviewed the current literature for indications for repeat prostate biopsy after initial biopsies demonstrated non-cancerous prostatic tissue or benign prostatic hyperplasia. This review includes discussions of management of asymptomatic prostatitis and how it may affect prostate-specific antigen, and also the management of several potentially premalignant lesions such as atrophy, atypical small acinar proliferation, and high-grade prostatic intraepithelial neoplasia. There is a paucity of randomized trials in this area and, considering the high number of biopsies with non-malignant findings, we conclude that more investigation is warranted in this area.

Histopathology reporting of prostate needle biopsies. 2005 update

This report reviews the diagnostic and prognostic importance of the pathologic findings in prostate needle biopsies. The morphological findings of the needle biopsy may be placed into one of the following five categories: prostate cancer, atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, inflammation, and benign prostatic tissue. While the prime goal of the biopsy is to diagnose prostatic adenocarcinoma, once carcinoma is detected, further descriptive information regarding the type, amount of cancer, and grade forms the cornerstone for contemporary management of the patient and for assessment of the potential for local cure and the risk for distant metastasis. The information provided in the needle biopsy report regarding the attributes of carcinoma is used depending on the individual patient's medical condition and preference and on the treating physician's evaluation to determine whether any form of treatment is indicated and, if so, the type of therapy.

Phytoestrogen tissue levels in benign prostatic hyperplasia and prostate cancer and their association with prostatic diseases

OBJECTIVES

To compare phytoestrogen tissue levels in men with small-volume benign prostatic hyperplasia (BPH), large-volume BPH, and prostate cancer (PCa).

METHODS

Prostatic tissue samples of men consuming a Western diet who underwent surgery for BPH (n = 63) or PCa (n = 31) were collected and frozen at -40 degrees C. In the tissue samples, the enterolactone and genistein levels were determined in duplicate by monoclonal antibody-based immunoassays. We subsequently compared the tissue levels in patients with BPH and PCa and studied the impact of enterolactone and genistein on prostate volume.

RESULTS

The enterolactone tissue levels were comparable in patients with BPH and PCa and revealed no correlation to prostate volume. The genistein tissue levels tended to be lower in patients with PCa (median 8.4 ng/g dry weight) compared with the entire BPH group (11.0 ng/g dry weight; P = 0.072). In addition, the genistein tissue levels were significantly greater in men with small-volume BPH (median 20.9 ng/g dry weight) compared with those with large-volume BPH (8.8 ng/g dry weight; P = 0.023).

CONCLUSIONS

Our data suggest an involvement of genistein in the pathogenesis of BPH and, possibly, of PCa. The impact of enterolactone is currently unknown.

Prostate cancer screening parameters in a high-risk African-Caribbean population

OBJECTIVES

To estimate the prostate cancer screening parameters in a population-based study of African-Caribbean men from the Island of Tobago.

METHODS

A total of 2582 men aged 40 to 79 years (50% of all Tobago men in this age group) were screened using both serum prostate-specific antigen (PSA) and digital rectal examination (DRE). Men with an elevated PSA level (4 ng/mL or greater) or abnormal DRE findings were referred for ultrasound-guided sextant biopsy.

RESULTS

The screening results for one or both tests were abnormal in 32% of men. The prevalence of prostate cancer was 10.7 of 100 screened men. The positive predictive value for PSA was 56% compared with 39% for DRE. The positive predictive value for PSA ranged from 6% for those aged 40 to 49 years to 59% for those aged 70 to 79 years. The sensitivity was 71% and the specificity 86% for DRE. The sensitivity for PSA was 80%. The sensitivity was low among men aged 40 to 49 years (20%) and 50 to 59 years (66%). The specificity for PSA declined across age groups from 98% for those aged 40 to 49 years to 70% for those 70 to 79 years.

CONCLUSIONS

The screening parameters in this African-Caribbean population were similar to the sparse data available from other populations of African descent. The screening was highly efficacious, with a positive predictive value of 56% for an elevated PSA level and 40% for an elevated PSA level and/or abnormal DRE findings.

Can the number of cores with high-grade prostate intraepithelial neoplasia predict cancer in men who undergo repeat biopsy?

OBJECTIVES

To evaluate whether the presence of, or the number of cores containing, high-grade prostatic intraepithelial neoplasia (PIN) found in men who underwent initial extended multisite biopsy could predict which men would have prostate cancer on subsequent repeat biopsies.

METHODS

Between June 1997 and January 2003, 1086 men underwent initial prostate biopsy for early detection of prostate cancer using an extended multisite biopsy scheme. Of these, 175 men without cancer underwent at least one repeat biopsy (range one to three; median interval between biopsies, 3 months). Among these 175 patients, 47 had high-grade PIN on initial biopsy.

RESULTS

The initial extended biopsy identified cancer in 33.8% (367 of 1086) and high-grade PIN in 20.8% (226 of 1086). The incidence of high-grade PIN only in patients found to have cancer on initial biopsy was 29.7% (109 of 367). The presence of high-grade PIN was associated with concurrent prostate cancer at the initial biopsy (P <0.0001). Overall, repeat biopsy identified cancer in 18.3% of the 175 men. Of the 47 men with high-grade PIN, 5 (10.6%) were found to have cancer on repeat biopsy. The number of biopsy specimens positive for high-grade PIN on initial biopsy was not associated with the likelihood of prostate cancer on repeat biopsy. Multivariate logistic regression analysis showed that neither the presence of high-grade PIN nor the number of cores containing high-grade PIN on initial biopsy were predictors for prostate cancer on repeat biopsy.

CONCLUSIONS

The number of cores positive for high-grade PIN was not predictive for cancer on repeat biopsy.

High-grade prostatic intraepithelial neoplasia

High-grade prostatic intraepithelial neoplasia (PIN) is now accepted as the most likely preinvasive stage of adenocarcinoma, almost two decades after its first formal description. PIN has a high predictive value as a marker for adenocarcinoma, and its identification warrants repeat biopsy for concurrent or subsequent invasive carcinoma. The only method of detection is biopsy; PIN does not significantly elevate serum prostate-specific antigen (PSA) concentration or its derivatives and cannot be detected by current imaging techniques, including ultrasound. Most patients with PIN will develop carcinoma within 10 years. PIN is associated with progressive abnormalities of phenotype and genotype, which are similar to cancer rather than normal prostatic epithelium, indicating impairment of cell differentiation with advancing stages of prostatic carcinogenesis. Androgen deprivation therapy decreases the prevalence and extent of PIN, suggesting that this form of treatment may play a role in chemoprevention.

Phase IIA Clinical Trial to Test the Efficacy and Safety of Toremifene in Men with High-Grade Prostatic Intraepithelial Neoplasia

Men with high-grade prostatic intraepithelial neoplasia (PIN) evident on prostate biopsy are at high risk for the eventual development of prostate cancer. The ability to reverse high-grade PIN may reduce the incidence or delay the development of prostate cancer. Toremifene (GTx-006, Acapodene trade mark ) is a selective estrogen receptor modulator that has been shown in the transgenic mouse model of prostate cancer to eliminate high-grade PIN and reduce the incidence of prostate cancer. This study was aimed at the evaluation of the safety and efficacy of toremifene in men diagnosed with high-grade PIN. This was an open-label, phase IIA clinical trial that enrolled 21 men (mean age, 64.7 years) with evidence of high-grade PIN on biopsy within 6 months of entry into the study. Eighteen of these men (86%) completed toremifene treatment (60 mg/day orally for 4 months) and then underwent follow-up prostate biopsy (8 cores) to determine high-grade PIN status. The effect of the drug on serum prostate-specific antigen (PSA), percentage of free PSA, testosterone, estradiol, and quality of life was also measured. After toremifene treatment, 72% of these 18 men (vs. 17.9% of historical controls) had no high-grade PIN on subsequent prostate biopsies. Mean PSA trended higher, and percentage of free PSA was increased. Quality of life was not significantly affected by treatment. There were 3 mild adverse events, and no serious adverse events. Toremifene appeared to reduce high-grade PIN in this small, exploratory trial. The drug was well tolerated. A double-blind, dose-finding, randomized, placebo-controlled phase IIB/III study is currently open to further study toremifene's activity against high-grade PIN and prostate cancer incidence.

High-grade prostatic intraepithelial neoplasia and prostate cancer risk reduction

High-grade prostatic intraepithelial neoplasia (PIN) is the earliest accepted stage in carcinogenesis, possessing most of the phenotypic and biochemical changes in cancer without invasion of the basal membrane of the acini. The support for high-grade PIN as the main premalignant lesion of prostate cancer is based on several lines of evidence derived from prostate cancer animal models, epidemiological, morphological, genetic, and molecular studies. The incidence of high-grade PIN averages 9% (range 4-16%) in prostate biopsies, representing 115,000 new cases of high-grade PIN diagnosed each year in the United States. Performing saturation prostate biopsies to rule out any coexistent prostate cancer followed by every 3-6 month serial repeated prostate biopsies is currently the only way in which to manage patients found to have high-grade PIN. Medical therapy for high-grade PIN may easily become the mainstay treatment for high-grade PIN. Treatment of high-grade PIN appears to be of clinical benefit notwithstanding the potential for prostate cancer risk reduction. These clinical benefits would reduce morbidity, enhance quality of life, delay surgery or radiation, and increase the interval for surveillance requiring invasive procedures.

Evidence of multifocality of telomere erosion in high-grade prostatic intraepithelial neoplasia (HPIN) and concurrent carcinoma

Mechanisms underlying prostate cancer (CaP) initiation and progression are poorly understood. A chromosomal instability mechanism leading to the generation of numerical and structural chromosomal changes has been implicated in the preneoplastic and neoplastic stages of CaP. Telomere dysfunction is one potential mechanism associated with the onset of such instability. To determine whether there was alteration in telomere length and chromosome number, 15 paraffin-embedded prostatectomy specimens were investigated using quantitative peptide nucleic acid (PNA) FISH analysis of representative foci of carcinoma, putative precancerous lesions (high-grade prostatic intraepithelial neoplasia, HPIN) and nondysplastic prostate epithelium. A significant decrease in telomere length was shown in both HPIN and CaP in comparison with normal epithelium. In addition, elevated rates of aneusomy suggested that increased levels of chromosomal aberrations were associated with decreased telomere length. Moreover, multiple foci of HPIN were shown to have a heterogeneous overall reduction of telomere length. This reduction was more evident in the histologic regions of the prostate containing CaP. Such observations lend support to the hypothesis that telomere erosion may be a consistent feature of CaP oncogenesis and may also be associated with the generation of chromosomal instability that characterizes this malignancy.

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.

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.

Impact of race on prostate-specific antigen outcome after radical prostatectomy for clinically localized adenocarcinoma of the prostate

PURPOSE

To compare prostate-specific antigen (PSA) outcome after radical prostatectomy (RP) for prostate cancer in African-American and white men using previously established risk groups.

PATIENTS AND METHODS

Between 1989 and 2000, 2,036 men (n = 162 African-American men, n = 1,874 white men) underwent RP for clinically localized prostate cancer. Using pretreatment PSA, Gleason score, clinical T stage, and percentage of positive biopsy specimens, patients were stratified into low- and high-risk groups. For each risk group, PSA outcome was estimated using the actuarial method of Kaplan and Meier. Comparisons of PSA outcome between African-American and white men were made using the log-rank test.

RESULTS

The median age and PSA level for African-American and white men were 60 and 62 years old and 8.8 and 7.0 ng/mL, respectively. African-Americans had a statistically significant increase in PSA (P =.002), Gleason score (P =.003), clinical T stage (P =.004), and percentage of positive biopsy specimens (P =.04) at presentation. However, there was no statistical difference in the distribution of PSA, clinical T stage, or Gleason score between racial groups in the low- and high-risk groups. The 5-year estimate of PSA outcome was 87% in the low-risk group for all patients (P =.70) and 28% versus 32% in African-American and white patients in the high-risk group (P =.28), respectively. Longer follow-up is required to confirm if these results are maintained at 10 years.

CONCLUSION

Even though African-American men presented at a younger age and with more advanced disease compared with white men with prostate cancer, PSA outcome after RP when controlled for known clinical predictive factors was not statistically different. This study supports earlier screening in African-American men.

Prostate specific antigen progression after radical prostatectomy in African-American men versus white men

BACKGROUND

It is well established that African-American men (AAM) have a worse mortality from prostate carcinoma (PC) than White men (WM). Outcome data for men treated with radical prostatectomy for clinically localized PC demonstrate more advanced tumors and higher biochemical recurrence rates among AAM compared with WM. The objective of the current study was to characterize the pattern of prostate specific antigen (PSA) progression by race in patients experiencing disease recurrence after undergoing radical prostatectomy. Racial differences in the pattern of rising PSA would warrant different intervention strategies for reducing the disproportionality in survival outcomes between the two racial groups.

METHODS

Between 1991-1996, 1080 consecutive men underwent radical prostatectomy for clinically localized PC at Wayne State University-affiliated Harper Hospital. Two hundred forty-one patients developed a biochemical recurrence on or before January, 1, 1999. The median follow-up was 39 months. Longitudinal PSA profiles of 77 men who met the study inclusion criteria were analyzed. Average relative velocities of PSA were compared between AAM and WM. Linear mixed effects regression was used to test the hypothesis that, after adjusting for age, preoperative PSA, stage and grade of disease, PSA levels increase at a faster rate in AAM compared with WM.

RESULTS

The mean average relative velocity for AAM and WM experiencing a disease recurrence was 0.25 ng/mL and 0.11 ng/mL per month, respectively (P = 0.21). The relative rate of PSA increase in patients who developed a disease recurrence after radical prostatectomy was 18.9% per month for AAM and 16.3% per month for WM (P = 0.73).

CONCLUSIONS

AAM and WM appear to have similar rates of PSA progression after undergoing radical prostatectomy.

Racial differences in prostate carcinogenesis. Histologic and clinical observations

Racial differences in the prevalence of HGPIN and in the Gleason score of local stage cancers indicate that clinically observed racial differences in cancer incidence and stage at diagnosis reflect racial variability in prostate carcinogenesis. Exploration of genetic, hormonal, nutritional, and behavioral differences in black and white men may provide insight into the fundamental mechanisms of prostatic carcinogenesis and cancer progression.

Is repeat prostate biopsy for high-grade prostatic intraepithelial neoplasia necessary after routine 12-core sampling?

OBJECTIVES

To determine whether repeat biopsy is necessary when the diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) is made with a 12-core biopsy. Repeated biopsy has been recommended for individuals with HGPIN noted on sextant prostate biopsy because of the high likelihood of cancer detection. Recently, we have recommended the routine use of 12 cores, rather than 6, to improve cancer detection.

METHODS

The charts of all patients undergoing prostate biopsy during a 2-year period at the Manhattan Veterans Administration Medical Center were reviewed. Patients diagnosed with HGPIN on a 12-core biopsy were identified, and those undergoing a repeat 12-core biopsy within 1 year of the initial biopsy were evaluated to determine the rate of cancer detection.

RESULTS

A total of 619 men underwent biopsy during the study period. Of 103 men diagnosed with HGPIN, 43 underwent a repeat biopsy within 1 year at the discretion of the managing urologist. The mean age and median prostate-specific antigen level of those undergoing a repeat biopsy was 65.5 years and 5.37 ng/mL, respectively. At the time of the repeat biopsy, 1 patient was found to have cancer (2.3%), 20 had HGPIN (46.5%), 20 had benign pathologic findings (46.5%), and 1 patient (2.3%) had atypical small acinar proliferation.

CONCLUSIONS

A repeat biopsy after the diagnosis of HGPIN on 12-core prostate biopsy rarely results in cancer detection. In the absence of other factors increasing the suspicion of cancer, immediate repeat biopsy for HGPIN diagnosed on a 12-core biopsy is unnecessary.