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

[Prostate cancer detection rates: comparison of standard biopsy with prompt rebiopsy and a one-time extended biopsy]

INTRODUCTION

Prostate biopsy is the gold standard for the detection of prostate cancer (PCA). While national and international guidelines recommend the extraction of 10-12 cores at initial biopsy, some authors plead to initially perform more extensive biopsy protocols. We assessed the PCA detection and complication rates of different biopsy schemes.

MATERIALS AND METHODS

We relied on the data of 425 men who underwent their first prostate biopsy from April 2005 to May 2013. Exclusion criteria consisted of PSA > 20 ng/ml, prior surgery of the prostate, or intake of 5-α-reductase inhibitors. Overall 357 underwent a 10- to 12-core biopsy, while 68 patients underwent 20-core biopsy. In case of a negative biopsy in the 10-12 cohort, rebiopsy was performed within 6 months, while in the 20-core group clinical follow-up determined further course of action. Endpoints of the study were the overall PCA detection rate and the rate of severe complications, which were defined as complications requiring hospital admission. The effect of the respective biopsy scheme on the PCA detection rate was assessed using uni- and multivariable logistic regression analysis. In the subanalysis, the PCA detection rates between the two groups were compared solely in patients with PSA values ≤10 ng/ml.

RESULTS

At initial biopsy, the overall PCA detection rate was 50.4% (214/425). In the 10-12 core group, the PCA detection rate at first biopsy was 52.4% (187/357) and rebiopsy detected a further 19 (11.2%) PCA cases, resulting in a cumulative PCA detection rate of 57.7% (206/357). In the 20-core group, the PCA detection rate was 39.7% (27/68). While the different PCA detection rates were not statistically different when the initial biopsies were compared, biopsy scheme reached independent predictor status when the cumulative PCA detection rate of the 10- to 12-core scheme was compared to the 20-core scheme (p=0.01). Comparable results were obtained only when patients with PSA ≤10 ng/ml were considered. The rate of severe complications was statistically higher in the 20-core group (6.1 vs. 2.4%; p=0.01).

CONCLUSION

Our data indicate that an initial 20-core biopsy does not lead to a higher PCA detection rate compared to an initial 10- to 12-core biopsy. Moreover, the cumulative PCA detection rate of a 10- to 12-core biopsy and prompt repeat biopsy was significantly higher compared to a single 20-core biopsy.

The use of matrix coating assisted by an electric field (MCAEF) to enhance mass spectrometric imaging of human prostate cancer biomarkers

In this work, we combined a newly developed matrix coating technique - matrix coating assisted by an electric field (MCAEF) and matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) to enhance the imaging of peptides and proteins in tissue specimens of human prostate cancer. MCAEF increased the signal-to-noise ratios of the detected proteins by a factor of 2 to 5, and 232 signals were detected within the m/z 3500-37500 mass range on a time-of-flight mass spectrometer and with the sinapinic acid MALDI matrix. Among these species, three proteins (S100-A9, S100-A10, and S100-A12) were only observed in the cancerous cell region and 14 proteins, including a fragment of mitogen-activated protein kinase/extracellular signal-regulated kinase kinase kinase 2, a fragment of cAMP-regulated phosphoprotein 19, 3 apolipoproteins (C-I, A-I, and A-II), 2 S100 proteins (A6 and A8), β-microseminoprotein, tumor protein D52, α-1-acid glycoprotein 1, heat shock protein β-1, prostate-specific antigen, and 2 unidentified large peptides at m/z 5002.2 and 6704.2, showed significantly differential distributions at the p < 0.05 (t-test) level between the cancerous and the noncancerous regions of the tissue. Among these 17 species, the distributions of apolipoprotein C-I, S100-A6, and S100-A8 were verified by immunohistological staining. In summary, this study resulted in the imaging of the largest group of proteins in prostate cancer tissues by MALDI-MS reported thus far, and is the first to show a correlation between S100 proteins and prostate cancer in a MS imaging study. The successful imaging of the three proteins only found in the cancerous tissues, as well as those showing differential expressions demonstrated the potential of MCAEF-MALDI/MS for the in situ detection of potential cancer biomarkers. Copyright © 2015 John Wiley & Sons, Ltd.

GOLPH3 and YB-1 Are Novel Markers Correlating With Poor Prognosis in Prostate Cancer

Background

Prostate cancer is a common and aggressive cancer among men. Despite advances in the treatment, the mechanisms involved in progression are still unclear. New prognostic markers should be explored for better design of patient-specific therapeutic regimens.

Methods

This study was performed on 120 patients stratified as 76 with prostatic carcinoma, 12 with low-grade prostate intraepithelial lesion, 12 with high-grade prostate intraepithelial lesion and 20 with benign prostate hyperplasia. Immunohistochemical study was done for Golgi phosphoprotein 3 (GOLPH3) and Y-box binding protein-1 (YB-1) analysis. Correlation with clinicopathological data and overall survival was analyzed.

Results

Both GOLPH3 and YB-1 showed increased expression from benign to malignant tumors. In prostatic carcinoma, cytoplasmic GOLPH3 was associated with Gleason score, stage and androgen receptor (P = 0.034, P < 0.001, and P = 0.008 respectively). Nuclear YB-1 expression was associated with Gleason score and androgen receptor (P = 0.018 and P = 0.024 respectively). Cytoplasmic YB-1 expression was associated with Gleason score, stage and androgen receptor (P = 0.008, P = 0.027, and P < 0.001 respectively). High Gleason score (P = 0.004), high stage (P < 0.001) and androgen receptor (P = 0.006) were the only detected adverse prognostic clinicopathological factors. Moderate/intense GOLPH3 and high nuclear and cytoplasmic YB-1 expression were correlated with shorter overall survival (P < 0.001, P = 0.020, and P < 0.001 respectively). In the multivariate analysis, moderate/intense GOLPH3 expression was the only predictor of overall survival (P = 0.025).

Conclusions

High GOLPH3 and nuclear/cytoplasmic YB-1 expression correlated with poor prognosis in prostate cancer. Both markers can be promising targets for new treatment strategies.

Inverted (hobnail) high-grade prostatic intraepithelial neoplasia and invasive inverted pattern

High-grade prostatic intraepithelial neoplasia (HGPIN) is considered to be an important precursor for prostatic adenocarcinoma. The present study aimed to investigate the histological features of the uncommon inverted (hobnail) pattern of HGPIN in transrectal ultrasonographic (TRUS) prostatic needle biopsies from 13 cases. These 13 diagnosed cases of inverted HGPIN were identified out of a total of 2,034 TRUS biopsies (0.63%), obtained from patients suspected to have prostate cancer. The hobnail pattern is comprised of secretory cell nuclei, which are histologically localized at the luminal surface of the prostate gland, rather than the periphery, and exhibit reverse polarity. Histological examinations were performed and the results demonstrated that 5 of the 13 cases exhibited pure inverted histology, while HGPIN was observed to be histologically associated with other patterns in the remaining 8 patients. In addition, an association with adenocarcinoma was identified in 7 of the 13 cases. All 7 carcinomas accompanied by inverted HGPIN were conventional acinar adenocarcinoma cases; of note, for these 7 cases, the Gleason score was 7 for each. One acinar adenocarcinoma case accompanying inverted HGPIN demonstrated hobnail characteristics in large areas of the invasive component. It was observed that nuclei were proliferated in the invasive cribriform glands, which was comparable to that of inverted HGPIN, and were located on the cytoplasmic luminal surface; a similar morphology was also observed in individual glands. In conclusion, the results of the present study suggested that the hobnail HGPIN pattern may be of diagnostic importance due to its high association with adenocarcinoma and the high Gleason scores in the accompanying carcinomas.

ERG overexpression and multifocality predict prostate cancer in subsequent biopsy for patients with high-grade prostatic intraepithelial neoplasia

PURPOSE

The most important clinical significance of an isolated high-grade prostatic intraepithelial neoplasia (HGPIN) diagnosis is the risk of missed prostate cancer (PCa) in subsequent biopsies. Because most patients with HGPIN do not harbor or develop PCa, clinical, pathological, or molecular markers that predict of PCa risk are of clinical significance.

MATERIALS AND METHODS

Overall, 155 men with a diagnosis of isolated HGPIN, which was based on the results of extended biopsy, and who underwent at least one repeat biopsy were analyzed for ERG oncoprotein (ERG) expression and clinicopathological parameters to determine the risk of finding PCa in subsequent biopsies.

RESULTS

Of 155 patients diagnosed with HGPIN on initial biopsy, 39 (25%) had PCa on subsequent biopsies. For men with only one repeat biopsy, the cancer detection rate was 22%. Most (54%) PCas were detected in≤6 months of rebiopsy. ERG expression was present in 15 patients with HGPIN (9.6%). Patients with ERG expression in HGPIN were more likely to have PCa in repeat biopsy, with 9 (60%) ERG-positive and 30 (21%) of ERG-negative patients having PCa (P = 0.001). Multifocal involvement (P = 0.0001), cribriform morphology (P = 0.004), and bilaterality (P = 0.0075) of HGPIN were other significant risk factors. On multivariable analysis, only the presence of ERG positivity and multifocality remained significant parameters in detecting PCa on a repeat biopsy. The presence of ERG-negative focal HGPIN involving one core, which accounted for 46% of patients, had minimal (16%) PCa risk on subsequent biopsy. In total, 8 patients (89%) ERG-positive HGPIN had PCa identified at identical sites on subsequent biopsy, of which 5 (71%) were ERG positive.

CONCLUSIONS

The status of ERG expression in HGPIN along with other histological parameters stratifies patients into low- and high-risk groups for having PCa on subsequent biopsy. Our results further support molecular characterization of HGPIN as a means to improve risk stratification and optimize surveillance strategies.

Gleason Score 6 - Prostate Cancer or Benign Variant?

The leading motivation behind wanting to call a 'malignant' prostate lesion 'benign' is the evidence of indolent prostate cancer that is not associated with a fatal outcome and in part makes therapeutic measures such as surgery and radiotherapy appear like overtreatment for some or possibly the majority of such patients. The present article reviews the definitions of 'precancerous lesion' and 'cancer' from a histopathologic point of view as the basis and gold standard for diagnosis. It is clear that with the 2 modifications implemented since its first publication, the Gleason score as the grading system for prostate cancer has shifted towards a low malignant subgroup diagnosed as Gleason 6. The recommendation of the International Society of Urological Pathology to change the Gleason score to a 5-tiered system, starting with grade group 1, is presented here, and may help doctor-patient communication especially in the active surveillance setting.

Atypical diagnosis in prostate needle biopsies from a developing country (Philippines): The essential role of a urological pathologist

Purpose

Borderline prostatic lesions, with insufficient histomorphologic features, to be definitely diagnosed as prostatic adenocarcinoma (PCa) are often signed out as “atypical glands suspicious for carcinoma” or atypical small acinar proliferation (ASAP). These findings that eventually warrant either immunohistochemical (IHC) studies or a repeat biopsy, prove to be more burdensome to patients in developing countries (such as the Philippines), where health care is not as progressive nor is it an utmost priority. At the same time, in countries like the Philippines, there is a shortage of urological pathologists.

Methods

In this study, we compared the transrectal ultrasound-guided prostate (TRUS) biopsies signed out by general surgical pathologists in St. Luke's Medical Center Quezon City from 2008–2010, and the TRUS Biopsies primarily signed out by a urologic pathologist in both St. Luke's Medical Center Quezon City and Global City from July 2013 to July 2014, and from September 2013 to July 2014, respectively.

Results

From 2008 to 2010, 30.6% (129 of 421) of the cases were signed out as atypical. Of these, 79 underwent IHC staining, 21 (26.6%) of which were eventually signed out as PCa. Compared to those signed out in 2013 to 2014 by our genitourinary pathologist, only 16.6% (39 of 235) of the cases were signed out as atypical. Of these, 16 underwent IHC staining, with 15 (93%) of them being definitively diagnosed as PCa. Among the 21 cases wherein a repeat biopsy was recommended, only three followed and two of these had findings of PCa on repeat biopsy. Looking at our 16.6% rate of atypicals and subtracting those that were eventually established as PCa after IHCs, our atypicals would be down to 10% (24/235) in 2013–2014 compared to 25.7% (108/421) in 2008–2010.

Conclusions

These results highlight the critical role a specialist has in the field of urological pathology, especially in developing countries. It is in the diagnosis of PCa in needle biopsies that a urological pathologist impacts the use of an atypical diagnosis, by ensuring its judicious use. This ultimately benefits the patients, by lessening unwarranted expenses through the decreased dependence on IHC staining and if necessary, a repeat biopsy.

Randomized, Placebo-Controlled Trial of Green Tea Catechins for Prostate Cancer Prevention

Preclinical, epidemiologic, and prior clinical trial data suggest that green tea catechins (GTC) may reduce prostate cancer risk. We conducted a placebo-controlled, randomized clinical trial of Polyphenon E (PolyE), a proprietary mixture of GTCs, containing 400 mg (-)-epigallocatechin-3-gallate (EGCG) per day, in 97 men with high-grade prostatic intraepithelial neoplasia (HGPIN) and/or atypical small acinar proliferation (ASAP). The primary study endpoint was a comparison of the cumulative one-year prostate cancer rates on the two study arms. No differences in the number of prostate cancer cases were observed: 5 of 49 (PolyE) versus 9 of 48 (placebo), P = 0.25. A secondary endpoint comparing the cumulative rate of prostate cancer plus ASAP among men with HGPIN without ASAP at baseline, revealed a decrease in this composite endpoint: 3 of 26 (PolyE) versus 10 of 25 (placebo), P < 0.024. This finding was driven by a decrease in ASAP diagnoses on the Poly E (0/26) compared with the placebo arm (5/25). A decrease in serum prostate-specific antigen (PSA) was observed on the PolyE arm [-0.87 ng/mL; 95% confidence intervals (CI), -1.66 to -0.09]. Adverse events related to the study agent did not significantly differ between the two study groups. Daily intake of a standardized, decaffeinated catechin mixture containing 400 mg EGCG per day for 1 year accumulated in plasma and was well tolerated but did not reduce the likelihood of prostate cancer in men with baseline HGPIN or ASAP.

Atypical Small Acinar Proliferation: Repeat Biopsy and Detection of High Grade Prostate Cancer

Purpose. Atypical small acinar proliferation (ASAP) is diagnosed in 1-2% of prostate biopsies. 30–40% of patients with ASAP may be diagnosed with prostate cancer (PCa) on repeat biopsy. Our objective was to examine the association between ASAP and subsequent diagnosis of intermediate/high risk PCa. Materials and Methods. Ninety-six patients who underwent prostate biopsy from 2000 to 2013 and were diagnosed with ASAP were identified. Clinicopathologic features were analyzed. Comparison was made between those with subsequent PCa on repeat biopsy and those with benign repeat pathology. Results. 56/96 (58%) patients had a repeat biopsy. 22/56 (39%) were subsequently diagnosed with PCa. There was no significant difference in patients' characteristics. Presence of HGPIN on initial biopsy was associated with a benign repeat biopsy (68% versus 23%). 17/22 (77%) had Gleason grade (GG) 3+3 disease and only 5/22 (23%) had GG 3+4 disease. Conclusions. 22/56 patients (39%) of patients who underwent a subsequent prostate biopsy following a diagnosis of ASAP were found to have PCa. 77% of these men were diagnosed with GG 3+3 PCa. Only 23% were found to have intermediate risk PCa and no high risk PCa was identified. Immediate repeat prostate biopsy in patients diagnosed with ASAP may be safely delayed. A multi-institutional cohort is being analyzed.

Clinical features and prognosis of prostate cancer with high-grade prostatic intraepithelial neoplasia

Purpose

To evaluate the clinical features and biochemical recurrence (BCR) in prostate cancer (PCa) with high-grade prostatic intraepithelial neoplasia (HGPIN).

Materials and Methods

We retrospectively analyzed the medical records of 893 patients who underwent a radical prostatectomy for PCa between 2011 and 2012 at Asan Medical Center; 752 of these patients who did not receive neoadjuvant or adjuvant therapy and were followed up for more than 1 year were included. The cohort was divided into two groups-patients with and without HGPIN-and their characteristics were compared. The Cox proportional hazards model was used to analyze factors affecting BCR.

Results

In total, 652 study patients (86.7%) had HGPIN. There were no significant differences in preoperative factors between the two groups, including age (p=0.369) and preoperative prostate-specific antigen concentration (p=0.234). Patients with HGPIN had a higher Gleason score (p=0.012), more frequent multiple tumor (p=0.013), and more perineural invasion (p=0.012), but no other postoperative pathologic characteristics were significantly different between the two groups. There were no significant differences in BCR (13.0% vs. 11.5%, p=0.665) and HGPIN was not associated with BCR (p=0.745). In multivariate analysis, only the T stage (p<0.001) was associated with BCR.

Conclusions

PCa patients with HGPIN have a higher Gleason score, more frequent multiple tumors, and more perineural invasion than those without HGPIN. The presence of HGPIN is not an independent predictor of BCR.

Urinary biomarkers for the detection of prostate cancer in patients with high-grade prostatic intraepithelial neoplasia

INTRODUCTION

High-grade prostatic intraepithelial neoplasia (HGPIN) is a recognized precursor stage of PCa. Men who present HGPIN in a first prostate biopsy face years of active surveillance including repeat biopsies. This study aimed to identify non-invasive prognostic biomarkers that differentiate early on between indolent HGPIN cases and those that will transform into actual PCa.

METHODS

We measured the expression of 21 candidate mRNA biomarkers using quantitative PCR in urine sediment samples from a cohort of 90 patients with initial diagnosis of HGPIN and a posterior follow up of at least two years. Uni- and multivariate statistical analyses were applied to analyze the candidate biomarkers and multiplex models using combinations of these biomarkers.

RESULTS

PSMA, PCA3, PSGR, GOLM, KLK3, CDH1, and SPINK1 behaved as predictors for PCa presence in repeat biopsies. Multiplex models outperformed (AUC = 0.81-0.86) the predictive power of single genes, including the FDA-approved PCA3 (AUC = 0.70). With a fixed sensitivity of 95%, the specificity of our multiplex models was of 41-58%, compared to the 30% of PCA3. The PPV of our models (30-38%) was also higher than the PPV of PCA3 (27%), suggesting that benign cases could be more accurately identified. Applying statistical models, we estimated that 33% to 47% of repeat biopsies could be prevented with a multiplex PCR model, representing an easy applicable and significant advantage over the current gold standard in urine sediment.

DISCUSSION

Using multiplex RTqPCR-based models in urine sediment it is possible to improve the current diagnostic method of choice (PCA3) to differentiate between benign HGPIN and PCa cases.

Prostate atypia: does repeat biopsy detect clinically significant prostate cancer?

BACKGROUND

While the treatment pathway in response to benign or malignant prostate biopsies is well established, there is uncertainty regarding the risk of subsequently diagnosing prostate cancer when an initial diagnosis of prostate atypia is made. As such, we investigated the likelihood of a repeat biopsy diagnosing prostate cancer (PCa) in patients in which an initial biopsy diagnosed prostate atypia.

METHODS

We reviewed our prospectively maintained prostate biopsy database to identify patients who underwent a repeat prostate biopsy within one year of atypia (atypical small acinar proliferation; ASAP) diagnosis between November 1987 and March 2011. Patients with a history of PCa were excluded. Chart review identified patients who underwent radical prostatectomy (RP), radiotherapy (RT), or active surveillance (AS). For some analyses, patients were divided into two subgroups based on their date of service.

RESULTS

Ten thousand seven hundred and twenty patients underwent 13,595 biopsies during November 1987-March 2011. Five hundred and sixty seven patients (5.3%) had ASAP on initial biopsy, and 287 (50.1%) of these patients underwent a repeat biopsy within one year. Of these, 122 (42.5%) were negative, 44 (15.3%) had atypia, 19 (6.6%) had prostatic intraepithelial neoplasia, and 102 (35.6%) contained PCa. Using modified Epstein's criteria, 27/53 (51%) patients with PCa on repeat biopsy were determined to have clinically significant tumors. 37 (36.3%) proceeded to RP, 25 (24.5%) underwent RT, and 40 (39.2%) received no immediate treatment. In patients who underwent surgery, Gleason grade on final pathology was upgraded in 11 (35.5%), and downgraded 1 (3.2%) patient.

CONCLUSIONS

ASAP on initial biopsy was associated with a significant risk of PCa on repeat biopsy in patients who subsequently underwent definitive local therapy. Patients with ASAP should be counseled on the probability of harboring both clinically significant and insignificant prostate cancer.

Rate of Gleason 7 or higher prostate cancer on repeat biopsy after a diagnosis of atypical small acinar proliferation

BACKGROUND

Limited information is known about the clinical significance of cancers diagnosed upon repeat biopsy for the indication of atypical small acinar proliferation (ASAP). With increasing concern regarding overdiagnosis and overtreatment of prostate cancer, and the reported rise in infectious complications related to prostate biopsy, we examined the outcomes of patients rebiopsied for a diagnosis of ASAP.

METHODS

Clinical, pathologic and outcomes data of patients diagnosed with ASAP on prostate biopsy at our institutions between 2000 and 2010 were abstracted through chart review. Statistical analyses included Fisher's exact and the two-sample Wilcoxon rank sum tests. Logistic regression evaluated risk factors for the probability of cancer following a diagnosis of ASAP.

RESULTS

A total of 349 patients met the inclusion criteria with median follow-up of 4.4 years. Median age was 65.3 years with a median PSA of 5.3 ng ml(-1). Of men diagnosed with ASAP, 250/349 (71.6%) had a repeat biopsy within 1 year with 94/246 (38.2%) demonstrating prostate cancer; only 26/245 (10.6%) had ⩾Gleason 7 disease. Of men diagnosed with ASAP, 284/349 (81.4%) underwent biopsy at some time during follow-up. Prostate cancer was diagnosed in 132/279 (47.3%) of these men, 48/278 (17.3%) with ⩾Gleason 7 disease. Multivariate analyses suggested that older age, no previous biopsy and PSA density were predictive of cancer on repeat biopsy within 1 year from ASAP. Univariate analysis revealed PSA density was associated with the presence of ⩾Gleason 7 disease at 1 year and any time after a diagnosis of ASAP.

CONCLUSIONS

The overall rate of intermediate- and high-grade prostate cancer found on repeat biopsy for ASAP is low. Further investigation into ways to further risk stratify these men may be warranted. However, until such tests become available, repeat biopsy of men diagnosed with ASAP remains prudent.

Role of PCA3 test in clinical decision making for prostate cancer diagnosis

AIM: To assess the role of PCA3 urine test in the management of patients with suspected prostate cancer after repeat negative prostate biopsies.

METHODS: Patients with suspected prostate cancer either due to high or rising prostate specific antigen (PSA) levels and with a history of prostate biopsy who were candidates for repeat procedure were prospectively recruited to undergo PCA3 urine test. The recommendations on further management including the decision whether to proceed or not to the biopsy were made based on the PCA3 score. Patients’ adherence with the recommendations and influence of the PCA3 test on clinical decision making were assessed. The contribution of the multivariate model was measured with a decision curve analysis.

RESULTS: Three hundred and fifty-six patients were recruited to the study and underwent the PCA3 test. Twenty-six percent of 263 patients underwent prostate biopsy despite the low risk designation by PCA3 and 30% of 93 men did not proceed to biopsy despite a high risk result, rendering overall adherence of 73%. The variables that significantly correlated with adherence were positive family history of prostate cancer and PSA more than 10 ng/mL. Pre-test clinical stage, the number and the results of previous biopsies were not associated with the adherence. The decision curve analysis gave identical results for cut-off points of 25 and 35. On multivariate analysis the model that included PCA3 score, serum PSA, family history and result of the previous biopsy best performed with Area Under the Curve of 0.77.

CONCLUSION: PCA3 urine test markedly outperforms PSA in a repeat biopsy setting. Urologists and patients demonstrate substantial confidence in this analysis and tend to follow its recommendations.

[Distribution of intraductal carcinoma of the prostate and associated lesions in the cancer foci on radical prostatectomy specimens]

OBJECTIVE

The distribution of intraductal carcinoma of the prostate (IDC-P) and other intraductal lesions associated with IDC-P was evaluated in the cancer foci on radical prostatectomy specimens.

MATERIALS AND METHODS

We reviewed slide in 412 cases treated by radical prostatectomy without neoadjuvant therapy. Mapping study was performed with regard to IDC-P, other intraductal lesions associated with IDC-P and invasive carcinoma.

RESULTS

We identified 98 cases (23.8%) and 102 cancer foci associated with IDC-P. In these all cancer foci, IDC-P was associated with invasive carcinoma and other intraductal neoplastic lesions with tufting, micropapillary and loose cribriform patterns were contiguous and admixed with IDC-P in 83 cancer foci (81.4%). There were lesions with invasive carcinoma around the IDC-P in 95 cancer foci (93.1%) and lesions without invasive carcinoma around IDC-P in 66 foci (64.7%). The latter lesions existed in the marginal areas of the cancer foci in 63 (61.8%) and in the central areas of the cancer foci in 14 (13.7%). In 5 cancer foci (4.9%), volume of IDC-P was larger than that of invasive carcinoma.

CONCLUSIONS

The distribution of IDC-P with dense cribriform and solid patterns varied in cancer foci, and intraductal lesions with tufting, micropapillary and loose cribriform patterns were frequently seen in area contiguous and admixed with IDC-P. The latter lesion may be low grade morphology of IDC-P, although the lesions could not be distinguished from high grade prostatic intraepithelial neoplasia.

Utility of PTEN and ERG immunostaining for distinguishing high-grade PIN from intraductal carcinoma of the prostate on needle biopsy

Intraductal carcinoma of the prostate and high-grade prostatic intraepithelial neoplasia (PIN) have markedly different implications for patient care but can be difficult to distinguish in needle biopsies. In radical prostatectomies, we demonstrated that PTEN and ERG immunostaining may be helpful to resolve this differential diagnosis. Here, we tested whether these markers are diagnostically useful in the needle biopsy setting. Separate or combined immunostains were applied to biopsies containing morphologically identified intraductal carcinoma, PIN, or borderline intraductal proliferations more concerning than PIN but falling short of morphologic criteria for intraductal carcinoma. Intraductal carcinoma occurring with concurrent invasive tumor showed the highest rate of PTEN loss, with 76% (38/50) lacking PTEN and 58% (29/50) expressing ERG. Of biopsies containing isolated intraductal carcinoma, 61% (20/33) showed PTEN loss and 30% (10/33) expressed ERG. Of the borderline intraductal proliferations, 52% (11/21) showed PTEN loss and 27% (4/15) expressed ERG. Of the borderline cases with PTEN loss, 64% (7/11) had carcinoma in a subsequent needle biopsy specimen, compared with 50% (5/10) of PTEN-intact cases. In contrast, none of the PIN cases showed PTEN loss or ERG expression (0/19). On needle biopsy, PTEN loss is common in morphologically identified intraductal carcinoma yet is very rare in high-grade PIN. Borderline intraductal proliferations, especially those with PTEN loss, have a high rate of carcinoma on resampling. If confirmed in larger prospective studies, these results suggest that PTEN and ERG immunostaining may provide a useful ancillary assay to distinguish intraductal carcinoma from high-grade PIN in this setting.

Nuclear Ep-ICD expression is a predictor of poor prognosis in "low risk" prostate adenocarcinomas

INTRODUCTION

Molecular markers for predicting prostate cancer (PCa) that would have poor prognosis are urgently needed for a more personalized treatment for patients. Regulated intramembrane proteolysis of Epithelial cell adhesion molecule results in shedding of the extracellular domain (EpEx) and release of its intracellular domain (Ep-ICD) which triggers oncogenic signaling and might correlate to tumor aggressiveness. This study aimed to explore the potential of Ep-ICD and EpEx to identify PCa that have poor prognosis.

METHODS

Immunohistochemical analysis of Ep-ICD and EpEx was carried out in normal prostate tissues (n = 100), benign prostate hyperplasia (BPH, n = 83), and prostate cancer (n = 249) using domain specific antibodies. The expression of Ep-ICD and EpEx was correlated with clinico- pathological parameters and disease free survival (DFS).

RESULTS

Reduced expression of nuclear Ep-ICD and membrane EpEx was observed in PCa in comparison with BPH and normal prostate tissues (p = 0.006, p < 0.001 respectively). For patients who had PCa with Gleason Score less than 7, preserved nuclear Ep-ICD emerged as the most significant marker in multivariate analysis for prolonged DFS, where these patients did not have recurrence during follow up of up to 12 years (p = 0.001).

CONCLUSION

Reduced expression of nuclear Ep-ICD was associated with shorter disease free survival in patients with a Gleason Score less than 7 and may be useful in identifying patients likely to have aggressive tumors with poor prognosis. Furthermore, nuclear Ep-ICD can differentiate between normal and prostate cancer tissues for ambiguous cases.

The role of image guided biopsy targeting in patients with atypical small acinar proliferation

PURPOSE

Men diagnosed with atypical small acinar proliferation are counseled to undergo early rebiopsy because the risk of prostate cancer is high. However, random rebiopsies may not resample areas of concern. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy offers an opportunity to accurately target and later retarget specific areas in the prostate. We describe the ability of magnetic resonance imaging/transrectal ultrasound fusion guided prostate biopsy to detect prostate cancer in areas with an initial diagnosis of atypical small acinar proliferation.

MATERIALS AND METHODS

Multiparametric magnetic resonance imaging of the prostate and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy were performed in 1,028 patients from March 2007 to February 2014. Of the men 20 met the stringent study inclusion criteria, which were no prostate cancer history, index biopsy showing at least 1 core of atypical small acinar proliferation with benign glands in all remaining cores and fusion targeted rebiopsy with at least 1 targeted core directly resampling an area of the prostate that previously contained atypical small acinar proliferation.

RESULTS

At index biopsy median age of the 20 patients was 60 years (IQR 57-64) and median prostate specific antigen was 5.92 ng/ml (IQR 3.34-7.48). At fusion targeted rebiopsy at a median of 11.6 months 5 of 20 patients (25%, 95% CI 6.02-43.98) were diagnosed with primary Gleason grade 3, low volume prostate cancer. On fusion rebiopsy cores that directly retargeted areas of previous atypical small acinar proliferation detected the highest tumor burden.

CONCLUSIONS

When magnetic resonance imaging/transrectal ultrasound fusion guided biopsy detects isolated atypical small acinar proliferation on index biopsy, early rebiopsy is unlikely to detect clinically significant prostate cancer. Cores that retarget areas of previous atypical small acinar proliferation are more effective than random rebiopsy cores.

Biopsy sampling and histopathological markers for diagnosis of prostate cancer

Prostate cancer is one of the most common malignant tumors and a leading cause of cancer-related morbidity and mortality. Irrespective of the method that allows for risk stratification of prostate cancer suspects, diagnosis relies on tissue sampling through prostate biopsy and subsequent histopathological evaluation. This provides critical information about disease aggressiveness, which is required for adequate patient management. Prostate biopsy methods have significantly evolved over the years, including the definition of indications, sampling schemes and use of imaging techniques (ultrasound and MRI) that allow for more accurate tissue sampling. In response to the challenges emerging from more precise collection of minute prostate tissue samples for analysis, histopathological assessment should include not only the observation of routinely stained sections, but also, and increasingly so, a series of ancillary techniques, especially immunohistochemistry, which increment the accuracy of prostate cancer diagnosis and may provide relevant information to guide patient management.

The critical role of the pathologist in determining eligibility for active surveillance as a management option in patients with prostate cancer: consensus statement with recommendations supported by the College of American Pathologists, International Society of Urological Pathology, Association of Directors of Anatomic and Surgical Pathology, the New Zealand Society of Pathologists, and the Prostate Cancer Foundation

CONTEXT

Prostate cancer remains a significant public health problem. Recent publications of randomized trials and the US Preventive Services Task Force recommendations have drawn attention to overtreatment of localized, low-risk prostate cancer. Active surveillance, in which patients undergo regular visits with serum prostate-specific antigen tests and repeat prostate biopsies, rather than aggressive treatment with curative intent, may address overtreatment of low-risk prostate cancer. It is apparent that a greater awareness of the critical role of pathologists in determining eligibility for active surveillance is needed.

OBJECTIVES

To review the state of current knowledge about the role of active surveillance in the management of prostate cancer and to provide a multidisciplinary report focusing on pathologic parameters important to the successful identification of patients likely to succeed with active surveillance, to determine the role of molecular tests in increasing the safety of active surveillance, and to provide future directions.

DESIGN

Systematic review of literature on active surveillance for low-risk prostate cancer, pathologic parameters important for appropriate stratification, and issues regarding interobserver reproducibility. Expert panels were created to delineate the fundamental questions confronting the clinical and pathologic aspects of management of men on active surveillance.

RESULTS

Expert panelists identified pathologic parameters important for management and the related diagnostic and reporting issues. Consensus recommendations were generated where appropriate.

CONCLUSIONS

Active surveillance is an important management option for men with low-risk prostate cancer. Vital to this process is the critical role pathologic parameters have in identifying appropriate candidates for active surveillance. These findings need to be reproducible and consistently reported by surgical pathologists with accurate pathology reporting.

ERG protein expression as a biomarker of prostate cancer

TMPRSS2-ERG is a recurrent rearrangement specific for prostate cancer, leading to the overexpression of a truncated ERG protein product that is amenable to immunohistochemical detection. Two monoclonal anti-ERG antibodies have currently been validated, with comparable sensitivity and specificity for detecting ERG rearrangement. ERG immunostaining has been applied in different settings to elucidate the role of ERG rearrangement and overexpression in prostate cancer tumorigenesis and progression, as well as to investigate potential diagnostic and prognostic applications. In this article we review the literature on the topic and suggest potential future applications.

Significance of atypical small acinar proliferation and extensive high-grade prostatic intraepithelial neoplasm in clinical practice

INTRODUCTION

Prostate cancer (PCa) is one of the most commonly diagnosed neoplasms in elderly men. The precancerous lesion of PCa is considered a high-grade prostate intraepithelial neoplasm (HG-PIN), while atypical small acinar proliferation (ASAP) is commonly considered as an under-diagnosed cancer. The aim of the study was to establish the impact of ASAP and extensive HG-PIN on pre-biopsy prostate-specific antigen (PSA) levels and the risk of cancer development in subsequent biopseis.

MATERIAL AND METHODS

The 1,010 men suspected for PCa were included in the study based on elevated PSA, and/or positive rectal examination. Transrectal ultrasound (TRUS) guided 10 core biopsy was performed. In those with extensive HG-PIN or ASAP on the first biopsy, and/or elevated PSA value, a second biopsy was performed.

RESULTS

In the second biopsy, PCa was diagnosed in 6 of 19 patients (31.57%) with extensive HG-PIN, in four of 40 (10%) with BPH, and in 4 of 18 (22.22%) with ASAP. There was a statistically significant difference between the values of PSA in the group of patients with ASAP in comparison to those with benign prostate hyperplasia (BPH) (p = 0.005) as well as in patients with HG-PIN in comparison to BPH (p = 0.02).

CONCLUSIONS

A precancerous lesion diagnosed upon biopsy causes a statistically significant increase in the values of PSA in relation to BPH, as well as in the case of ASAP and extensive HG-PIN. The estimate of risk of PCa diagnosis in patients with ASAP and those with extensive HG-PIN in the first biopsy is comparable, which is why there are no reasons for different treatment of patients with the above-mentioned diagnoses. Both should be subjected to urgent second biopsy in around the 4-6 weeks following the initial biopsy.

Optimization of prostate biopsy: review of technique and complications

A 12-core systematic biopsy that incorporates apical and far-lateral cores in the template distribution allows maximal cancer detection and avoidance of a repeat biopsy while minimizing the detection of insignificant prostate cancers. Magnetic resonance imaging-guided prostate biopsy has an evolving role in both initial and repeat prostate biopsy strategies, potentially improving sampling efficiency, increasing the detection of clinically significant cancers, and reducing the detection of insignificant cancers. Hematuria, hematospermia, and rectal bleeding are common complications of prostate needle biopsy, but are generally self-limiting and well tolerated. All men should receive antimicrobial prophylaxis before biopsy.

Intraductal carcinoma of the prostate: the whole story

Intraductal carcinoma of the prostate (IDC-P) is characterised by proliferation of malignant secretory cells that markedly expand prostatic ducts and acini. Its morphological features and diagnostic criteria have been refined in recent studies. Its molecular characteristics have also been increasingly elucidated. IDC-P is strongly associated with high grade and high volume invasive prostate cancer and unfavourable clinical outcomes. Therefore, it is critical to recognise and report IDC-P, especially in prostate biopsies where the clinical implications of the diagnosis are greatest. IDC-P has to be distinguished from several other prostate lesions with similar histological appearance. The distinction between IDC-P and high grade prostatic intraepithelial neoplasia is most important as they have drastically different implications for patient management. IDC-P is an uncommon finding in prostate biopsies, and is even rarer as an isolated finding without concomitant prostate cancer in biopsies. However, patients with isolated IDC-P in biopsies are recommended for either definitive treatment or immediate repeat biopsy. This article will review the historical aspect, diagnostic criteria, molecular genetics, and clinical significance of IDC-P.

Transrectal electrical impedance tomography of the prostate: spatially coregistered pathological findings for prostate cancer detection

PURPOSE

Prostate cancer ranks as one of the most common malignancies and currently represents the second leading cancer-specific cause of death in men. The current use of single modality transrectal ultrasound (TRUS) for biopsy guidance has a limited sensitivity and specificity for accurately identifying cancerous lesions within the prostate. This study introduces a novel prostate cancer imaging method that combines TRUS with electrical impedance tomography (EIT) and reports on initial clinical findings based on in vivo measurements.

METHODS

The ultrasound system provides anatomic information, which guides EIT image reconstruction. EIT reconstructions are correlated with semiquantitative pathological findings. Thin plate spline warping transformations are employed to overlay electrical impedance images and pathological maps describing the spatial distribution of prostate cancer, with the latter used as reference for data analysis. Clinical data were recorded from a total of 50 men prior to them undergoing radical prostatectomy for prostate cancer treatment. Student's t-tests were employed to statistically examine the electrical property difference between cancerous tissue and benign tissue as defined through histological assessment of the excised gland.

RESULTS

Example EIT reconstructions are presented along with a statistical analysis comparing EIT and pathology. An average transformation error of 1.67% is found when 381 spatially coregistered pathological images are compared with their target EIT reconstructed counterparts. At EIT signal frequencies of 0.4, 3.2, and 25.6 kHz, paired-testing demonstrated that the conductivity of cancerous regions is significantly greater than that of benign regions ( p < 0.0304).

CONCLUSIONS

These preliminary clinical findings suggest the potential benefits electrical impedance measurements might have for prostate cancer detection.

TMPRSS2:ERG gene fusion predicts subsequent detection of prostate cancer in patients with high-grade prostatic intraepithelial neoplasia

PURPOSE

High-grade prostatic intraepithelial neoplasia (HGPIN) is considered a precursor lesion of prostate cancer (PCa). The predictive value of ERG gene fusion in HGPIN for PCa was interrogated as a post hoc analysis in the context of a randomized clinical trial.

PATIENTS AND METHODS

The GTx Protocol G300104 randomly assigned 1,590 men with biopsy-diagnosed HGPIN to receive toremifene or placebo for 3 years or until a diagnosis of PCa was made on prostate biopsy. As part of this phase III clinical trial, a central pathologist evaluated biopsies of patients with isolated HGPIN at baseline and 12, 24, and 36 months of follow-up. ERG immunohistochemistry was performed on biopsies from 461 patients and evaluated for protein overexpression.

RESULTS

ERG expression was detected in 11.1% of patients (51 of 461 patients) with isolated HGPIN. In the first year and during the 3-year clinical trial, 14.7% and 36.9% of 461 patients were diagnosed with PCa, respectively. Patients with ERG expression were more likely to develop PCa, with 27 (53%) of 51 ERG-positive and 143 (35%) of 410 ERG-negative patients experiencing progression to PCa (P = .014, Fisher's exact test). ERG expression was not associated with age, baseline PSA, Gleason score, or tumor volume.

CONCLUSION

This study underscores the necessity of more stringent follow-up for men with HGPIN that is also positive for ERG overexpression. Clinicians should consider molecular characterization of HGPIN as a means to improve risk stratification.

Prostate cancer chemoprevention

Prostate cancer is a leading cause of morbidity and mortality in men and has significant treatment-associated complications. Prostate cancer chemoprevention has the potential to decrease the morbidity and mortality associated with this disease. Chemoprevention research to date has primarily focused on nutrients and 5 alpha-reductase inhibitors (5ARIs). A large randomized trial (SELECT) found no favorable effect of selenium or vitamin E on prostate cancer prevention. Two large randomized placebo controlled trials (the PCPT and REDUCE trials) have been published and have supported the role of 5ARIs in prostate cancer chemoprevention; however, these trials also have prompted concerns regarding the increase in high-grade disease seen with treatment and have not been approved by the US Food and Drug Administration (FDA) for chemoprevention. Conclusive evidence for the chemopreventive benefit of nutrients or vitamins is lacking, whereas the future role of 5ARIs remains to be clarified.

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.

Intraductal carcinoma of prostate: a comprehensive and concise review

Intraductal carcinoma of the prostate (IDC-P) is defined as a proliferation of prostate adenocarcinoma cells distending and spanning the lumen of pre-existing benign prostatic ducts and acini, with at least focal preservation of basal cells. Studies demonstrate that IDC-P is strongly associated with high-grade (Gleason grades 4/5), large-volume invasive prostate cancers. In addition, recent genetic studies indicate that IDC-P represents intraductal spread of invasive carcinoma, rather than a precursor lesion. Some of the architectural patterns in IDC-P exhibit architectural overlap with one of the main differential diagnoses, high-grade prostatic intraepithelial neoplasia (HGPIN). In these instances, additional diagnostic criteria for IDC-P, including marked nuclear pleomorphism, non-focal comedonecrosis (>1 duct showing comedonecrosis), markedly distended normal ducts/acini, positive nuclear staining for ERG, and cytoplasmic loss of PTEN by immunohistochemistry, can help make the distinction. This distinction between IDC-P and HGPIN is of critical importance because IDC-P has an almost constant association with invasive carcinoma and has negative clinical implications, including shorter relapse-free survival, early biochemical relapse, and metastatic failure rate after radiotherapy. Therefore, IDC-P should be reported in prostate biopsies and radical prostatectomies, regardless of the presence of an invasive component. This article will review the history, diagnostic criteria, molecular genetics, and clinical significance of IDC-P.

[Benign mimickers of the prostate cancer. Diagnostic challenges]

The diagnosis of prostate cancer (PCa), especially limited adenocarcinoma on needle biopsy, is often challenging. Before making diagnosis of PCa, it is prudent for the pathologist to consider different benign patterns that may lead to a false positive interpretation. Histoanatomic structures such as seminal vesicles, Cowper's glands and paraganglia along with hyperplasia, atrophy with its different patterns and adenosis may generate difficulties in differential diagnosis. Furthermore, inflammatory processes and post-treatment changes may cause problems. The above entities can in some instances simulate low-grade and less commonly high grade PCa. Knowledge of these patterns and application of appropriate immunohistochemistry will lead the pathologist to a correct diagnosis.

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

[Diagnostic histopathology of prostate cancer]

Even though the principal criteria for the diagnosis of adenocarcinoma of the prostate have remained unchanged for more than 60 years, the diagnostic pathology of prostate cancer, its mimicking and precursor lesions, grading and processing have undergone an immense development in diagnostic precision and differentiation. This article presents the major aspects of prostate diagnostics, Gleason grading and processing of prostatectomy specimens according to the TNM system.

Cytoplasmic PTEN protein loss distinguishes intraductal carcinoma of the prostate from high-grade prostatic intraepithelial neoplasia

Intraductal carcinoma of the prostate is a marker of aggressive disease. However, intraductal carcinoma exists on a morphologic continuum with high-grade prostatic intraepithelial neoplasia (PIN) and distinguishing intraductal carcinoma from PIN is a common diagnostic dilemma with significant clinical implications. We evaluated whether immunostains for PTEN and ERG can sensitively identify intraductal carcinoma and accurately distinguish it from high-grade PIN. A combined immunostain for PTEN, ERG, p63 and CK903 was developed and validated. Radical prostatectomy specimens with lesions meeting criteria for intraductal carcinoma (n=45), intraductal cribriform proliferations falling short of intraductal carcinoma (n=15), and PIN lesions (n=39) were retrospectively identified and assessed for PTEN and ERG. Cytoplasmic PTEN loss was identified in 84% (38/45) of the intraductal carcinoma and 100% (15/15) of intraductal cribriform proliferation cases. In contrast, cytoplasmic PTEN loss was never observed in PIN (0/39; P<0.0001). Of the 53 cases of intraductal carcinoma or intraductal cribriform proliferation with cytoplasmic PTEN loss, it was homogeneously lost in 42 cases (79%). Weak, focal nuclear positivity for PTEN was retained in 31 of these 42 cases (74%). ERG expression was identified in 58% (26/45) of intraductal carcinoma and 67% (10/15) of intraductal cribriform proliferations compared with 13% (5/39) of PIN. Concordance between the PTEN/ERG status of the intraductal carcinoma lesions and the concurrent invasive carcinoma was high (>95% and P<0.0001 for each), and substantially less for PIN and the concurrent invasive tumor (83% for PTEN and 67% for ERG; P=NS for each). Cytoplasmic PTEN loss occurs in the majority of intraductal carcinoma and intraductal cribriform proliferation cases. Cytoplasmic PTEN loss was never observed in PIN (100% specificity). Our study identifies PTEN loss as a potentially useful marker to distinguish intraductal carcinoma from PIN and provides a plausible molecular explanation for why intraductal carcinoma is associated with poor prognosis.

Histopathologic features of atypical glands on prostate biopsy: nucleolar size is a predictor of subsequent detection of prostatic adenocarcinoma

BACKGROUND

Patients whose prostate biopsy reveals the presence of atypical glands suspicious for carcinoma (AGSC) are subject to close monitoring and repeat biopsies, perhaps unnecessarily, as clinicians do not have a clear basis for understanding and stratifying the significance of these findings.

METHODS

In a retrospective, blinded manner, we histopathologically examined initial biopsies reported as AGSC (82 patients, 93 foci). On subsequent biopsies, 31 (38%)/5 (6%) patients were found to have prostate cancer (PCA)/AGSC, respectively, while no carcinoma (NOCA) was identified in the remainder (56%) of cases.

RESULTS

Nucleolar grade (on a scale of 1-4 with "1" denoting small, inconspicuous nucleoli and "4" denoting macronucleoli) was significantly higher in PCA cases than in NOCA cases whether comparing all AGSC foci (P = 0.006) or when considering the highest grade in each patient (P = 0.009). However, the number of AGSC per focus was similar (P = 0.926) between PCA (mean ± SD: 7.03 ± 5.35) and NOCA (mean ± SD: 7.13 ± 4.44). Adjacent (P = 0.117) and separate (P = 0.457) high-grade prostatic intraepithelial neoplasia was found in 8/37 (22%) foci and 12/31 (39%) cases in PCA, respectively, and in 4/48 (8%) foci and 13/46 (28%) cases in NOCA, respectively. The presence of intraluminal dense secretion, crystalloid, or mucin in AGSC did not show a statistically significant correlation between PCA [5/37 (14%)] and NOCA [10/48 (21%)] (P = 0.567).

CONCLUSIONS

Our study may thus clarify the significance of AGSC on prostate biopsy and suggests that the size of nucleoli in AGSC is a positive predictor of subsequent detection of prostatic adenocarcinoma.

Clinical applications of novel ERG immunohistochemistry in prostate cancer diagnosis and management

TMPRSS2:ERG gene fusions, the most common molecular subtype of ETS family gene fusions occur in ~50% of prostate carcinomas (PCas) and ~20% of high-grade prostatic intraepithelial neoplasia (HGPIN) intermingled with adjacent PCa demonstrating identical gene fusions. ERG gene fusions have not yet been demonstrated in isolated benign prostate tissue, isolated high-grade prostatic intraepithelial neoplasia, or benign cancer mimics. Taken together, ERG gene fusions are the most prostate cancer-specific biomarker yet identified and define a specific molecular subtype of PCa with important clinical and biological implications. ERG gene fusions result in the overexpression of a chimeric fusion transcript that encodes a truncated ERG protein product. Recently, N-terminal epitope-targeted mouse (9FY) and C-terminal-targeted rabbit monoclonal (EPR 3864) ERG antibodies are commercially available and are increasingly utilized as a surrogate for TMPRSS2:ERG gene fusions. Until recently, because of lack of availability of reliable ERG antibody, the most commonly utilized methods for studying ERG aberrations in PCa specimens included fluorescence in situ hybridization or reverse transcriptase polymerase chain reaction. The knowledge gleaned from these studies has significantly improved our understanding of molecular biology of ERG gene fusions. With availability of highly specific anti-ERG monoclonal antibodies, there are now unprecedented opportunities to explore and validate clinical applications of ERG antibody in routine pathology practice, which has just started. This review provides a brief background of molecular biology of ERG gene fusions in PCa and focuses on characterizing the current state of ERG oncoprotein and determining the role of ERG immunohistochemistry in the diagnosis and biological stratification of prostate cancer.

Prostate cancer diagnosis among men with isolated high-grade intraepithelial neoplasia enrolled onto a 3-year prospective phase III clinical trial of oral toremifene

PURPOSE

Prostate cancer (PCa) prevention remains an appealing strategy for the reduction of overtreatment and secondary adverse effects. We evaluated the efficacy of toremifene citrate 20 mg in PCa prevention among men with isolated high-grade prostatic intraepithelial neoplasia (HGPIN) on biopsy.

PATIENTS AND METHODS

One thousand five hundred ninety men with HGPIN, or HGPIN and atypia, and no PCa on prostate biopsy were randomly assigned 1:1 to receive toremifene citrate 20 mg or placebo in a 3-year phase III, double-blind, multicenter trial. Men underwent annual biopsy until cancer detection or study end. Efficacy analysis was performed in 1,467 men who underwent at least one on-study biopsy. Baseline risk factors were evaluated to determine influence on cancer detection.

RESULTS

Cancer was detected in 34.7% and 32.3% of men in the placebo and treatment groups, respectively, with no observed difference (P = .39, log-rank test) in PCa-free survival. The 3-year Kaplan-Meier PCa-free survival estimate was 54.9% (99% CI, 43.3% to 66.5%) in the placebo group and 59.5% (99% CI, 48.1% to 70.9%) in the treatment group. Exploration of baseline risk factors demonstrated no subset in which a risk reduction was observed. In the placebo group, 17.9%, 12.9%, and 13.6% of men at risk at the beginning of years 1, 2, and 3, respectively, were diagnosed with PCa.

CONCLUSION

Although toremifene 20 mg did not lower the PCa detection rate, men with isolated HGPIN have a high likelihood of eventual PCa diagnosis, demonstrating they are ideal candidates for inclusion in chemoprevention trials and require surveillance by periodic prostate biopsy.

Gradient field microscopy for label-free diagnosis of human biopsies [Invited]

We introduce a label-free method for detecting high-grade prostatic intraepithelial neoplasia (HGPIN) in unstained biopsies. We image this condition based on the identification of basal cells in biopsies that otherwise would resemble prostate cancer by unassisted histologic examination. Gradient field microscopy (GFM) is used as a label-free imaging method which increases the contrast of a transparent sample by taking the first-order phase derivative that is very sensitive to rapid refractive index changes. GFM is able to image the basal cell layers in HGPIN biopsies because of their rapid refractive index changes at the periphery of small glandular structures.