Multifocal High Grade Prostatic Intraepithelial Neoplasia is a Significant Risk Factor for Prostatic Adenocarcinoma

The current recommendation for the management of isolated high-grade prostatic intraepithelial neoplasia

OBJECTIVE

To analyse the current predictive value of isolated high-grade prostatic intraepithelial neoplasia (HGPIN) for clinically significant prostate cancer (csPCa) detection in repeat biopsies.

PATIENTS AND METHODS

A cohort of 293 men with isolated HGPIN detected in previous biopsies performed without multiparametric magnetic resonance imaging (mpMRI), and who underwent repeat biopsy within 1 to 3 years, was analysed. Pre-repeat biopsy mpMRI and guided biopsies to suspicious lesions (Prostate Imaging - Reporting and Data System [PI-RADS] ≥3) and/or and systematic biopsies were performed. Persistent prostate cancer (PCa) suspicion, defined as sustained serum prostate-specific antigen level >4 ng/mL and/or abnormal digital rectal examination, was present in 248 men (84.6%), and was absent in 45 men (15.4%). A control group of 190 men who had no previous HGPIN, atypical small acinar proliferation or HGPIN with atypia who were scheduled to undergo repeat biopsy due to persistent PCa suspicion were also analysed. csPCa was defined as tumours of Grade Group ≥2.

RESULTS

In the subset of 45 men with isolated HGPIN, in whom PCa suspicion disappeared, only one csPCa (2.2%) and one insignificant PCa (iPCa) were detected. csPCa was detected in 34.7% of men with persistent PCa suspicion and previous HGPIN, and in 28.4% of those without previous HGPIN (P =0.180). iPCa was detected in 12.1% and 6.3%, respectively (P =0.039). Logistic regression analysis showed that the risk of csPCa detection was not predicted by previous HGPIN: odds ratio (OR) 1.369 (95% confidence interval [CI] 0.894-2.095; P =0.149); however, previous HGPIN increased the risk of iPCa detection: OR 2.043 (95% CI 1.016-4.109; P =0.006).

CONCLUSION

The risk of csPCa in men with isolated HGPIN, in whom PCa suspicion disappears, is extremely low. Moreover, in those men in whom PCa suspicion persists, the risk of csPCa is not influenced by the previous finding of HGPIN. However, previous HGPIN increases the risk of iPCa detection. Therefore, repeat prostate biopsy should not be recommended solely because of a previous HGPIN.

Glyoxalase 1 Expression as a Novel Diagnostic Marker of High-Grade Prostatic Intraepithelial Neoplasia in Prostate Cancer

Glyoxalase 1 (GLO1) is an enzyme involved in the detoxification of methylglyoxal (MG), a reactive oncometabolite formed in the context of energy metabolism as a result of high glycolytic flux. Prior clinical evidence has documented GLO1 upregulation in various tumor types including prostate cancer (PCa). However, GLO1 expression has not been explored in the context of PCa progression with a focus on high-grade prostatic intraepithelial neoplasia (HGPIN), a frequent precursor to invasive cancer. Here, we have evaluated GLO1 expression by immunohistochemistry in archival tumor samples from 187 PCa patients (stage 2 and 3). Immunohistochemical analysis revealed GLO1 upregulation during tumor progression, observable in HGPIN and PCa versus normal prostatic tissue. GLO1 upregulation was identified as a novel hallmark of HGPIN lesions, displaying the highest staining intensity in all clinical patient specimens. GLO1 expression correlated with intermediate-high risk Gleason grade but not with patient age, biochemical recurrence, or pathological stage. Our data identify upregulated GLO1 expression as a molecular hallmark of HGPIN lesions detectable by immunohistochemical analysis. Since current pathological assessment of HGPIN status solely depends on morphological features, GLO1 may serve as a novel diagnostic marker that identifies this precancerous lesion.

The clinical predictive factors and postoperative histopathological parameters associated with upgrading after radical prostatectomy: A contemporary analysis with grade groups

BACKGROUND AND AIM

Upgrading after radical prostatectomy (RP) is an ongoing problem since first description of Gleason score. In this retrospective study, our aim is to investigate upgrading after RP in grade groups (GG) and clinical predictive, and postoperative histopathological factors associated with GG upgrading (GGU).

PATIENTS AND METHODS

A total of 753 patients undergoing RP between January 2006 and June 2019 at our institution were investigated. Overall cohort were divided into two groups according to GGU status after RP as nonupgrading and upgrading. Retrospectively documented preoperative clinical and postoperative histopathological parameters were compared between two groups. Furthermore, we investigated a subgroup of institutional cohort (n = 398) whose prostate biopsy (Pbx) and RP were performed in our institution and we also divided this cohort into two groups according to GGU status. χ² and Mann-Whitney U tests were used for comparative analyses. The independent preoperative predictive and postoperative histopathological factors associated with GGU were investigated using multivariate logistic regression analysis.

RESULTS

The total GGU was 55.8% in overall cohort and 45.2% in institutional cohort. The GGU was found as the most common in bioptic GG1 group in both overall (64.0%), and institutional (54.5%) cohorts. In multivariate analyses, the noninstitutional Pbx (odds ratio [OR] = 2.56; 95% confidence interval [CI]: 1.86-3.51; P < .001), tumor positive core numbers in Pbx (OR = 1.11; 95%CI: 1.04-1.19; P = .003), increased prostate specific antigen (PSA) density (OR = 3.59; 95%CI: 1.03-12.52, P = .045) and age (OR = 1.03; 95%CI: 1.00-1.05, P = .046) were independent clinical predictors of GGU in overall cohort whereas only increased PSA density (OR = 5.94; 95%CI: 1.28-27.50; P = .023) was independent predictor in institutional cohort. Among postoperative histopathological factors, perineural invasion (OR = 1.57; 95%CI: 1.70-3.87; P < .001 and OR = 2.53; 95%CI: 1.46-4.40; P = .001, respectively), increased maximum tumor diameter (OR = 1.46; 95%CI: 1.23-1.73; P < .001 and OR = 1.33; 95%CI: 1.07-1.66; P = .010, respectively), and high-grade prostatic intraepithelial neoplasia (HGPIN) existence at tumor surrounding tissue (OR = 1.96; 95%CI: 1.32-2.90; P = .001 and OR = 1.87; 95%CI: 1.10-3.21; P = .022, respectively) were independently associated with GGU after RP, in both of overall and institutional cohorts.

CONCLUSIONS

Noninstitutional prostate biopsy, increased PSA density, higher tumor positive cores in Pbx and older age are the clinical predictors of upgrading after RP in contemporary GG. Perineural invasion, increased maximum tumor diameter, and HGPIN existence at tumor surrounding tissue are postoperative histopathological factors associated with GGU.

Clinical significance of the De Ritis ratio for detecting prostate cancer in a repeat prostate biopsy

Purpose

We evaluated factors predicting a positive repeat biopsy result in patients with an initial negative prostate biopsy result.

Materials and Methods

This study included 124 patients in whom prostate cancer (PCa) was not detected in the initial transrectal ultrasound-guided prostate biopsy and who underwent repeat biopsy from January 2011 to December 2017. Patients without PCa in both initial and repeat prostate biopsies were designated as group 1 (n=82), and those in whom PCa was detected on a repeat prostate biopsy were designated as group 2 (n=42). Among group 2 patients, 6 had insignificant PCa according to the Epstein criteria and were combined with group 1 patients to make up group A (n=88). Patients with significant PCa were categorized as group B (n=36). We compared clinicopathologic characteristics between the groups.

Results

Multivariate analysis showed that age (p=0.018) and detection of atypical small acinar proliferation (ASAP) or ≥3 cores of high-grade prostatic intraepithelial neoplasia (HGPIN) (p=0.011) on the initial biopsy were predictive factors for a positive result on a repeat biopsy. When we compared group A and group B, age (p=0.004) and the De Ritis ratio (p=0.024) were significantly higher in group B in the multivariate analysis.

Conclusions

Age and the detection of ASAP or ≥3 cores of HGPIN on the initial biopsy were associated with detection of PCa on a repeat biopsy. Age and the De Ritis ratio were found to be predictive factors for the detection of clinically significant PCa on a repeat biopsy.

A 12-year follow-up of ANNA/C-TRUS image-targeted biopsies in patients suspicious for prostate cancer

PURPOSE

PSA screening has been rehabilitated. PSA is not specific and can be elevated by benign reasons. Additionally, a subgroup of patients with prostate hyperplasia may harbor prostate cancer (PCa). During monitoring, the clinician aims to detect significant tumors in time, submitting patients to minimal psychological and physical burden, especially in men with high serum PSA and repeat biopsies. We aimed to determine long-term outcomes with respect to ANNA/C-TRUS ability to detect PCa with six targeted biopsies.

METHODS

A subset of 71 patients were enrolled. During monitoring, they were subjected to primary, secondary, or even multiple prostate biopsies when needed. Protocol monitoring included PSA measurements, digital rectal examination (DRE) and imaging.

RESULTS

The median follow-up was 12 years. Forty-one patients had a history of negative systematic random biopsies (1-3 sessions). Their age ranges 62-85 years, PSA 0.5-47.3 ng/ml, and the median prostate volume 11-255 cc. During monitoring, 15 patients were diagnosed with PCa. Only two harbored aggressive tumors. The median time to diagnosis was 6 years. All PCa patients are free from biochemical relapse. From the remaining 56 patients, 11 did not have any biopsies, 12 had one, 13 had two, and 20 had three or more biopsy sessions.

CONCLUSIONS

ANNA/C-TRUS is a useful method monitoring patients with a risk of PCa. 50-75% of the usually performed biopsy cores could be spared and, after 12 years, 97% of the patients were either without evidence of a PCa or were diagnosed with a good prognosis tumor.

Atypical small acinar proliferation and two or more cores of high-grade intraepithelial neoplasia on a previous prostate biopsy are significant predictors of cancer during a transperineal template-guided saturation biopsy aimed at sampling one core for each 1 mL of prostate volume

Objective

The objective of this study was to evaluate whether high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP) predict prostate cancer (PCa) during repeat transperineal template saturation biopsy with a high number of cores per prostate volume in patients with persistent clinical suspicion of PCa who underwent at least one previous negative transrectal ultrasound (TRUS)-guided biopsy.

Methods

We retrospectively evaluated 135 consecutive patients with persistent clinical suspicion of PCa, despite a set of negative TRUS-guided biopsies and increasing prostate-specific antigen levels; abnormal findings on digital rectal examination, TRUS, or magnetic resonance imaging; previous biopsy showing HGPIN; and previous biopsy showing atypical glands. Transperineal template saturation biopsy (TTSB) was performed at 5mm intervals to sample one core for each 1 mL of prostate volume.

Results

The median rate of biopsy cores per prostate volume was 1.00 (range: 0.75–1.39). The PCa detection rates in patients who were diagnosed with HGPIN, or had two or more cores of HGPIN or ASAP, were 53% (9/17), 89% (8/9), and 83% (10/12), respectively. Two or more HGPIN cores and ASAP were positive predictors of PCa on TTSB. The high-grade cancer rates (Gleason score [GS] ≥7) in patients with ASAP and two or more cores of HGPIN were 20% and 80%, respectively. The cancer detection rate represented by a GS score ≥8 in patients with ASAP or two or more cores of HGPIN at a previous TRUS-guided biopsy was 5.5% (1/18).

Conclusion

ASAP or two or more cores of HGPIN at a previous TRUS-guided biopsy strongly indicated the presence of PCa on TTSB.

Precursor Lesions of Urologic Malignancies

CONTEXT

- Precursor lesions of urologic malignancies are established histopathologic entities, which are important not only to recognize for clinical purposes, but also to further investigate at the molecular level in order to gain a better understanding of the pathogenesis of these malignancies.

OBJECTIVE

- To provide a brief overview of precursor lesions to the most common malignancies that develop within the genitourinary tract with a focus on their clinical implications, histologic features, and molecular characteristics.

DATA SOURCES

- Literature review from PubMed, urologic pathology textbooks, and the 4th edition of the World Health Organization Classification of Tumours of the Urinary System and Male Genital Organs. All photomicrographs were taken from cases seen at Weill Cornell Medicine or from the authors' personal slide collections.

CONCLUSIONS

- The clinical importance and histologic criteria are well established for the known precursor lesions of the most common malignancies throughout the genitourinary tract, but further investigation is warranted at the molecular level to better understand the pathogenesis of these lesions. Such investigation may lead to better risk stratification of patients and potentially novel treatments.

Differential Diagnosis of Intraductal Lesions of the Prostate

The category of intraductal lesions of the prostate includes a range of primary prostatic and nonprostatic processes with wide variation in prognosis and recommended follow-up. Studies have shown that pathologists are uncomfortable with the diagnosis of these lesions and that the diagnostic reproducibility is low in this category. Despite the diagnostic difficulty, their accurate and reproducible diagnosis is critical for patient management. This review aims to highlight the diagnostic criteria, prognosis, and treatment implications of common intraductal lesions of the prostate. It focuses on the recognition of intraductal carcinoma of the prostate (IDC-P) in prostate needle biopsies and how to distinguish it from its common mimickers, including high-grade prostatic intraepithelial neoplasia, invasive cribriform prostatic adenocarcinoma, urothelial carcinoma extending into prostatic ducts, and prostatic ductal adenocarcinoma. IDC-P is independently associated with higher risk disease, and its identification in a needle biopsy, even in the absence of invasive carcinoma, should compel definitive treatment. Conversely, high-grade prostatic intraepithelial neoplasia has a much better prognosis and in limited quantities does not even warrant a repeat biopsy. IDC-P must be distinguished from urothelial carcinoma involving prostatic ducts, as recommended treatment varies markedly. Ductal adenocarcinoma may confuse the pathologist and clinician by overlapping terminology, and morphology may also mimic IDC-P on occasion. The use of ancillary testing with immunohistochemistry and molecular markers has also been reviewed.

Current concepts in the diagnosis and pathobiology of intraepithelial neoplasia: A review by organ system

Answer questions and earn CME/CNE In this report, a team of surgical pathologists has provided a review of intraepithelial neoplasia in a host of (but not all) anatomic sites of interest to colleagues in various medical specialties, namely, uterine cervix, ovary, breast, lung, head and neck, skin, prostate, bladder, pancreas, and esophagus. There is more experience with more readily accessible sites (such as the uterine cervix and skin) than with other anatomic sites, and the lack of uniform terminology, together with divergent biology in various sites, makes it difficult to paint a unifying, relevant portrait. The authors' aim was to provide a framework from which to move forward as we care for patients with such precancerous lesions. CA Cancer J Clin 2016;66:408-436. © 2016 American Cancer Society.

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.

Metabolic syndrome diagnosis and widespread high grade prostatic intraepithelial neoplasia significantly increase prostate cancer risk: results from a multicenter biopsy study

Background

To test in multicenter setting if patients affected of metabolic syndrome (MetS) and initial widespread high grade prostatic intraepithelial neoplasia (wHGPIN) diagnosis are at higher risk of prostate cancer (PCa) on repeat biopsy.

Methods

Patients clinical charts from three European Academic Hospital were reviewed in order to identify patients with initial diagnosis of HGPIN undergone to repeat biopsy. Inclusion and exclusion criteria were adopted to minimize patient heterogeneity. MetS was defined according to Word Heart Organization criteria while initial wHGPIN when ≥4 cores biopsy were involved. A multivariate logistic model was computed to assess the association between PCa and clinical-pathological variables.

Results

Overall 283 patients were scheduled. Median age was 67 years (IQR 62–72). MetS was diagnosed in 116/283 (41 %) patients and PCa was detected in 84/283 (29.7 %) patients.

In particular, PCa was more frequently diagnosed in patients affected of wHGPIN and MetS (45/86, 52.3 %) than in patients with wHGPIN and normal metabolic profile (28/95, 29.5 %), p = 0.002. The multivariate logistic model confirmed that wHGPIN and MetS are independent risk factors for following PCa diagnosis, respectively OR 2.4 (95 % CI 1.01–5.71, p = 0.04), OR 2.79 (95 % CI 1.49–5.22, p = 0.01) while total PSA and DRE findings are not able to predict PCa at repeat biopsy, OR 1.05 (95 % CI 0.98–1.03 p = 0.69) and OR 1.01 (95 % CI 0.55–1.84, p = 0.96) respectively.

Conclusions

wHGPIN is positively associated to PCa; assessing metabolic profile and repeat prostate biopsy is advisable in patients with initial diagnosis of wHGPIN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2085-8) contains supplementary material, which is available to authorized users.

Incidental prostate cancer in transurethral resection of prostate specimens in men aged up to 65 years

Background

The identification of prostate cancer (PC) is important in men aged ≤ 65 years. We examined complete transurethral resection of prostate (TURP) specimens to quantify the incidence and nature of PC in men aged ≤ 65 years.

Methods

A prospective multi-institutional database included TURP specimens. The cohort was stratified into two groups according to age. For men aged ≤ 65 years, the entire specimen was submitted for histological analysis, while the TURP specimens from men aged > 65 years were sampled following standard guidelines.

Results

A total of 923 men were included, with 224 in the younger group. PC was identified in 13.4% in men aged ≤ 65 years, compared with 28.7% the older group. The younger group had a lower proportion of Gleason score ≥ 7 (30% compared with 40%) and higher rates of pT1a (57% compared with 43%). In men aged ≤ 65 years with cancer, tumor was identified in one block in 15 of 30 cases (50%). Following diagnosis, 4/30 underwent radical prostatectomy, 5/30 underwent curative radiotherapy, 10/30 androgen deprivation, and 1/30 received palliative radiotherapy.

Conclusion

Incidental PC in men aged ≤ 65 years is not uncommon. Our results suggest that TURP specimens in men aged ≤ 65 years should be completely assessed. Underidentification of cancer may occur as a result of increasing use of laser prostatectomy and the consequent loss of tissue for pathological examination.

Is histological prostate inflammation in an initial prostate biopsy a predictor of prostate cancer on repeat biopsy?

PURPOSE

To investigate whether histological inflammation detected in an initial prostate biopsy can predict the risk of prostate cancer on a repeat biopsy.

METHODS

This was a retrospective study of 171 patients who underwent repeat prostate biopsy for persistently elevated prostate-specific antigen after an initial negative biopsy result. The enrolled patients were divided into two groups according to the results of the repeat biopsy: the noncancer group (n = 126) and the cancer group (n = 45). Multivariate regression analysis was used to determine the effect of inflammation grade, aggressiveness, and prostate-related parameters on the detection of prostate cancer at the repeat biopsy.

RESULTS

Prostate inflammation grade (p = 0.005) and aggressiveness (p = 0.001) in the initial biopsy were significantly different between the cancer and noncancer groups. Factors associated with the risk of prostate cancer at the repeat biopsy were age [odds ratio (OR) 1.08; 95 % confidence interval (CI) 1.03-1.14], prostate-specific antigen density (OR 24.30; 95 % CI 9.3-62.9), prostate-specific antigen velocity (OR 1.05; 95 % CI 1.01-1.09), and inflammation aggressiveness (OR 0.05; 95 % CI 0.01-0.27).

CONCLUSIONS

A histological inflammatory finding at the initial prostate biopsy was negatively associated with prostate cancer detection in repeat biopsy. This result could be useful to determine the need for repeat prostate biopsy in patients with persistently elevated prostate-specific antigen.

Estrogen receptor beta in prostate cancer: friend or foe?

Prostate cancer is the commonest, non-cutaneous cancer in men. At present, there is no cure for the advanced, castration-resistant form of the disease. Estrogen has been shown to be important in prostate carcinogenesis, with evidence resulting from epidemiological, cancer cell line, human tissue and animal studies. The prostate expresses both estrogen receptor alpha (ERA) and estrogen receptor beta (ERB). Most evidence suggests that ERA mediates the harmful effects of estrogen in the prostate, whereas ERB is tumour suppressive, but trials of ERB-selective agents have not translated into improved clinical outcomes. The role of ERB in the prostate remains unclear and there is increasing evidence that isoforms of ERB may be oncogenic. Detailed study of ERB and ERB isoforms in the prostate is required to establish their cell-specific roles, in order to determine if therapies can be directed towards ERB-dependent pathways. In this review, we summarise evidence on the role of ERB in prostate cancer and highlight areas for future research.

Reducing prostate cancer racial disparity: evidence for aggressive early prostate cancer PSA testing of African American men

BACKGROUND

There is continuing controversy about prostate cancer testing and the recent American Urological Association guidelines. We hypothesize that the reduction and elimination of racial survival disparity among African American men (AAM; high-risk group) compared with European American men (EAM; intermediate-risk group) during the PSA testing era compared with the pre-PSA era strongly supports the use of PSA testing in AAM.

METHODS

We used Surveillance, Epidemiology, and End Results (SEER) data to investigate relative survival disparities between AAM and EAM. To evaluate pre-PSA testing era, we selected malignant first primary prostate cancer in AAM and EAM, all stages, diagnosed during 1973-1994. To evaluate relative survival disparities in the current PSA testing era, we selected malignant first primary local, regional, and distant stage prostate cancers diagnosed during 1998-2005 to calculate 5-year relative survival rates.

RESULTS

Age-adjusted 5-year relative survival of prostate cancer diagnosed during 1973-1994 in the national SEER data revealed significantly shorter survival for AAM compared with EAM (P < 0.0001). The SEER-based survival analysis from 1995 to 2005 indicated no statistical difference in relative survival rates between AAM and EAM by year of diagnosis of local, regional, or distant stage prostate cancer.

CONCLUSION

We conclude that the elimination of prostate cancer racial disparity of local, regional, and metastatic prostate cancer relative survival in the current PSA testing era compared with pre-PSA era as an endpoint to test PSA efficacy as a marker for prostate cancer diagnosis is evidence for aggressive testing of AAM.

IMPACT

Evidence for screening AAM.

[Prostate biopsy. Update for indication, procedure, and future developments]

Transrectal ultrasound-guided prostate biopsy is considered the gold standard in the primary investigation of a suspicious prostate-related finding. The procedure can be carried out with ten probes or more on the lateral side of the prostate, after administering antibiotic prophylaxis and applying local anesthesia. The indication for a biopsy depends on the results of the digitorectal examination, on the serum prostate-specific antigen level, on the individual patient's wish and on his comorbidities. Whether multiparametric imaging should be used before or during the course of a primary or repeated biopsy in order to identify suspicious prostate lesions is the subject of current investigations. Extended biopsy protocols require further clinical investigations before they can become the new standard in the diagnostic work-up. This review delivers an update on the indication for, and technique of, prostate biopsies.

EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013

CONTEXT

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011.

OBJECTIVE

To present a summary of the 2013 version of the EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined PCa.

EVIDENCE ACQUISITION

A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group. The guidelines have been updated, and levels of evidence and grades of recommendation have been added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

EVIDENCE SYNTHESIS

A full version of the guidelines is available at the EAU office or online (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. A biopsy progression indicates the need for active intervention, whereas the role of PSA doubling time is controversial. In men with locally advanced PCa for whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT), with equivalent oncologic efficacy. Active treatment is recommended mostly for patients with localized disease and a long life expectancy, with radical prostatectomy (RP) shown to be superior to WW in prospective randomized trials. Nerve-sparing RP is the approach of choice in organ-confined disease, while neoadjuvant ADT provides no improvement in outcome variables. Radiation therapy should be performed with ≥ 74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa. For locally advanced disease, adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice. Follow-up after local therapy is largely based on PSA and a disease-specific history, with imaging indicated only when symptoms occur.

CONCLUSIONS

Knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice.

PATIENT SUMMARY

A summary is presented of the 2013 EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined prostate cancer (PCa). Screening continues to be done on an individual basis, in consultation with a physician. Diagnosis is by prostate biopsy. Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to androgen-deprivation therapy in locally advanced PCa not requiring immediate local treatment. Radical prostatectomy is the only surgical option. Radiation therapy can be external or delivered by way of prostate implants. Treatment follow-up is based on the PSA level.

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.

[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.

Small cell-like change in prostatic intraepithelial neoplasia, intraductal carcinoma, and invasive prostatic carcinoma: a study of 7 cases

Small cell carcinoma of the prostate is associated with poor prognosis and different treatment from conventional acinar adenocarcinoma. Given the important clinicopathologic implications of a diagnosis of small cell carcinoma, we report 7 cases showing unusual, extensive small cell-like change in intraductal carcinoma and invasive carcinoma. Prostatic biopsies from 3 patients and radical prostatectomy specimens from 4 patients showed variably extensive small cell-like high-grade prostatic intraepithelial neoplasia and intraductal carcinoma. Five cases were associated with conventional acinar adenocarcinoma (2 cases with Gleason score 4 + 3 = 7; 3 cases with Gleason 3 + 4 = 7). No small cell carcinoma was seen. Small and large ducts with small cell-like change showed solid and cribriform proliferations of atypical cells with abrupt transition between centrally located populations of small cells and more typical large dysplastic cells at the duct periphery. Rosette-like formations were noted within some involved ducts. Small cell-like change was characterized by crowded cells with uniformly bland vesicular nuclei and minimal cytoplasm and no significant mitotic or apoptotic activity. In 3 cases, similar small cell-like morphology was noted focally in invasive carcinoma. The small cell-like areas were negative for synaptophysin and chromogranin, focally positive for TTF-1, and weakly positive for racemase. Ki-67 labeled less than 5% with predominant labeling of the larger atypical cells and minimal reactivity in the small cell-like population. In summary, small cell-like change in prostatic intraepithelial neoplasia, intraductal carcinoma, and invasive carcinoma is not associated with small cell carcinoma; shows no immunohistochemical evidence of neuroendocrine differentiation; and likely is not an adverse prognostic feature.

Inflammation and preneoplastic lesions in benign prostate as risk factors for prostate cancer

Benign changes ranging from atrophy and inflammation to high-grade prostatic intraepithelial neoplasia (HGPIN) are common findings on prostate core needle biopsies. Although atrophy and inflammation may be precursors of prostate cancer, only HGPIN is currently recommended to be included in surgical pathology reports. To determine whether these benign findings increase prostate cancer risk, we conducted a case-control study nested within a historical cohort of 6692 men with a benign prostate specimen collected between 1990 and 2002. The analytic sample included 574 case-control pairs comprised of cases diagnosed with prostate cancer a minimum of 1 year after cohort entry and controls matched to cases on date and age at cohort entry, race, and type of specimen. The initial benign specimen was reviewed for presence of HGPIN, atrophy (simple, lobular, and partial) and inflammation (glandular and/or stromal). HGPIN significantly increased risk for prostate cancer (odds ratio (OR)=2.00; 95% confidence interval (CI)=1.25-3.20). Inflammation within the stromal compartment was associated with decreased risk (OR=0.66; CI=0.52-0.84), and diffuse stromal inflammation of severe grade had the strongest inverse association with risk (OR=0.21; CI=0.07-0.62). In a model adjusted for prostate-specific antigen (PSA) level at cohort entry and inflammation, simple atrophy was associated with a 33% increased prostate cancer risk that was marginally significant (P=0.03). Clinicians should consider patterns and extent of inflammation when managing high-risk patients with negative biopsy results. Identifying benign inflammatory processes that underlie high PSA levels would help to reduce the number of unnecessary repeated prostate biopsies.

Phase III trial of selenium to prevent prostate cancer in men with high-grade prostatic intraepithelial neoplasia: SWOG S9917

The threat of prostate cancer and the significant and often negative impact of its treatment underscore the importance of prevention. High-grade prostatic intraepithelial neoplasia (HGPIN) has been identified as a potential premalignant lesion marking an increased risk of prostate cancer and substantial evidence suggests that men with HGPIN are in need of prostate cancer prevention. In vitro, in vivo, epidemiologic, and clinical trial evidence that selenium supplementation protects against prostate cancer motivated the study we report here: a double-blind, randomized, placebo-controlled trial of selenium 200 (μg/d) as selenomethionine in men with HGPIN. The primary endpoint was progression of HGPIN to prostate cancer over a 3-year period. This National Cancer Institute Intergroup trial was coordinated by the Southwest Oncology Group (SWOG). Of 619 enrolled patients, 423 randomized men with HGPIN (212 selenium and 211 placebo) were eligible (by central pathology review) and included in the primary analysis. Three-year cancer rates were 36.6% (placebo) versus 35.6% (selenium; P = 0.73, adjusted). The majority of patients who developed cancer on trial (70.8%, selenium and 75.5%, placebo) had a Gleason score of 6 or less than 6; there were no differences in Gleason scores between the two arms. Subset analyses included the finding of a nonsignificantly reduced prostate cancer risk (relative risk = 0.82; 95% CI: 0.40-1.69) in selenium versus placebo patients in the lowest quartile of baseline plasma selenium level (<106 ng/mL). Overall, and in all other subsets defined by baseline blood selenium levels, selenium supplementation had no effect on prostate cancer risk. The 36% prostate cancer rate in men with HGPIN indicates the association of this lesion with an elevated prostate cancer risk. Future study in this setting should focus on selenium-deficient populations and selenium pharmacogenetics.

[EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Initial high-grade prostatic intraepithelial neoplasia with carcinoma on subsequent prostate needle biopsy: findings at radical prostatectomy

There are only a few small studies on men with an initial biopsy showing high-grade prostatic intraepithelial neoplasia (HGPIN) who later have cancer on repeat biopsy and then undergo radical prostatectomy. It is unknown whether this scenario impacts the prognosis of subsequent radical prostatectomy. We compared radical prostatectomy findings in 45 men with an initial diagnosis of HGPIN who subsequently were diagnosed with cancer with 18,494 men diagnosed with cancer who lacked an earlier diagnosis of HGPIN. All cases were retrieved from our institution between 1993 and 2008. The mean patient age was 60.2 years, and the mean serum prostate-specific antigen value was 9.0 ng/mL. For the 45 men with an initial HGPIN diagnosis, 21 of 45 (46.7%) men were found to have cancer within 6 months and 29 of 45 (64.4%) within 1 year after the diagnosis of HGPIN. Cancer involved a single core in 32 of 45 (71.1%) cases, and the maximum tumor volume was ≤5% in 57.8% of the 45 cases. Men with initial HGPIN had 84.4% organ-confined cancer, whereas cases without HGPIN had 65.4% organ-confined cancer (P=0.007) at radical prostatectomy. For the RPs performed in men with an earlier diagnosis of HGPIN followed by cancer on biopsy, the mean and median tumor volumes were 0.3 cm³ and 0.12 cm³ (0.003 cm³ to 1.46 cm³). Favorable pathologic stage was maintained even when we restricted the analysis to men with only Gleason score 6 cancer on biopsy. In men with Gleason score 6 cancer on biopsy, men with an initial diagnosis of HGPIN had 88.9% organ confined versus 73.2% for men with no earlier biopsy diagnosis of HGPIN, (P=0.03). At radical prostatectomy, although men with an earlier HGPIN diagnosis had less adverse findings in terms of Gleason score, surgical margin involvement, seminal vesicle involvement, and lymph node metastasis, the differences did not reach statistical significance. This was possibly due to the relatively small number of positive events in the men with no earlier HGPIN and due to the relatively small number of cases with earlier HGPIN. Prostatic adenocarcinomas discovered after an initial HGPIN diagnosis on biopsy are more likely to be organ confined, yet of similar grade, compared with cases diagnosed as cancer on the first biopsy. These findings likely reflect cancers associated with HGPIN, in which the cancers were missed on the initial biopsy as a result of smaller size.

Diagnosis of isolated high-grade prostatic intra-epithelial neoplasia: proposal of a nomogram for the prediction of cancer detection at saturation re-biopsy

Study Type--Diagnostic (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Multifocality, age, PSA values, and biopsy protocols regarding the predictive value of high grade PIN have been discussed extensively in the literature. Our study developed for the first time a predictive nomogram that could be helpful for patient counselling and to guide the urologist to perform rPBX after an initial diagnosis of isolated HGPIN.

OBJECTIVE

• To evaluate factors that may predict prostate cancer (PCa) detection after the initial diagnosis of high-grade prostatic intra-epithelial neoplasia (HGPIN) on prostate biopsy (PBx) with six to 24 random cores.

PATIENTS AND METHODS

• We retrospectively evaluated 262 patients submitted from 1998 to 2007 to prostate re-biopsy (rPBx) after an initial HGPIN diagnosis in tertiary academic centres. • HGPIN diagnosis was obtained on initial systematic PBx with six to 24 random cores. • All patients were re-biopsied with a 'saturation' rPBx with 20-26 cores, with a median time to rPBx of 12 months. • All slides were reviewed by expert uropathologists.

RESULTS

• Plurifocal HGPIN (pHGPIN) was found in 115 patients and monofocal HGPIN (mHGPIN) was found in 147 patients. • In total, 108 and 154 patients, respectively, were submitted to >12-core initial PBx and ≤12-core initial PBx. • Overall PCa detection at rPBx was 31.7%. PSA level (7.7 vs 6.6 ng/mL; P= 0.031) and age (68 vs 64 years; P= 0.001) were significantly higher in patients with PCa at rPBx. • PCa detection was significantly higher in patients with a ≤12-core initial PBx than in those with a >12-core initial PBx (37.6% vs 23.1%; P= 0.01), as well as in patients with pHGPIN than in those with mHGPIN (40% vs 25.1%; P= 0.013). • At multivariable analysis, PSA level (P= 0.041; hazards ratio, HR, 1.08), age (P < 0.001; HR, 1.09), pHGPIN (P= 0.031; HR, 1.97) and ≤12-core initial PBx (P= 0.012; HR, 1.95) were independent predictors of PCa detection. • A nomogram including these four variables achieved 72% accuracy for predicting PCa detection after an initial HGPIN diagnosis.

CONCLUSIONS

• PCa detection on saturation rPBx after an initial diagnosis of HGPIN is significantly higher in patients with a ≤12-core initial PBx than those with a >12-core initial PBx and in patients with pHGPIN than in those with mHGPIN. • We developed a simple prognostic tool for the prediction of PCa detection in patients with initial HGPIN diagnosis who were undergoing saturation rPBx.

Neoplastic disorders of prostate glands in the light of synchrotron radiation and multivariate statistical analysis

The prostate gland is the most common site of neoplastic disorders in men. The pathogenesis of inflammatory cells, prostatic intraepithelial neoplasia (PIN) lesions, and prostate cancer is still under investigation. Inflammatory cells by producing free radicals are considered as major and universal contributors to cancerogenesis. PIN is regarded as a precursor lesion to prostate cancer or a marker signaling the vulnerability of the epithelium to neoplastic transformation [1]. Differentiation markers that are frequently changed in early invasive carcinoma are also changed in PIN lesions. In this study, prostate tissue samples obtained during surgical operation and classified as various disease states (inflammation, PIN lesions, and cancer) were examined. The samples were measured by means of microbeam synchrotron-radiation-induced X-ray emission (micro-SRIXE). Special attention was paid to examine the relationship between the earlier-mentioned disorders and changes in relative concentrations of S, K, Ca, Fe, Cu, and Zn. Applying the image-processing program ImageJ enabled us to select the areas of interest from two-dimensional maps of various prostate samples according to the histopathologist's evaluation. Detailed analysis of micro-SRIXE spectra based on multivariate methods shows significant differences between elemental concentrations in inflammatory cells, PIN lesions, and cancerous tissues, which confirms that this method can be used to distinguish various pathological states in prostate tissues. Information obtained in this way may provide better understanding of the biochemistry of unhealthy prostate tissues, thus opening the way to find new medicines/treatments to prevent or slow down some harmful intracellular processes.

Prostate cancer detection after a negative prostate biopsy: lessons learnt in the Cleveland Clinic experience

Urologists are often faced with the dilemma of managing patients with a negative initial prostate biopsy in whom clinical or pathological risk for prostate cancer still exists. Such real-life challenging scenarios might raise questions such as: Who should undergo further biopsies? What are the optimal predictors for prostate cancer on subsequent biopsies? What is the optimal biopsy protocol that should be used? When to stop the biopsy cascade? The last decade has witnessed numerous studies that have analyzed factors conferring a significant risk for cancer discovered on repeat biopsies. We and others have developed predictive models to aid decision-making regarding pursuing further biopsies. For decades, high-grade prostatic intraepithelial neoplasia has been considered a strong risk indicator for subsequent cancer. However, it has been recently shown that only through segmentation of this heterogeneous population does the real risk profile emerge. Biopsy templates underwent modification regarding the number and location of cores with emergence of the transrectal or brachytherapy grid transperineal saturation biopsy. However, the best biopsy protocol remains controversial. We have refined the initial biopsy template to a 14 core initial biopsy template that optimizes cancer detection, and have shown that transrectal saturation biopsy significantly improves cancer detection for repeat biopsy. Another concern is the overdiagnosis of clinically insignificant cancer on repeat biopsies, so we explored ways to limit this, and to deal with its ramifications. Through carrying out a Medline literature search, we critically evaluated pertinent articles together with emphasis of our own journey in this arena to assist in the decision-making process for repeat biopsy population.

Predicting prostate cancer at rebiopsies in patients with high-grade prostatic intraepithelial neoplasia: a study on 546 patients

The aim of this study was to analyse the factors that predict the diagnosis of prostate cancer (PCa) after high-grade prostatic intraepithelial neoplasia (HGPIN). Data from 546 patients with HGPIN submitted up to a 6-month series of three rebiopsies, according to an institutional protocol, were reviewed. PCa has been found in 174 cases (31.8%), in 116 cases at the first and in 58 cases at a further rebiopsy. The risk of finding PCa at the first rebiopsy was correlated with the PSA value and with an anomalous digital rectal examination (DRE) at the time of the initial biopsy; the risk at a subsequent rebiopsy was correlated to the number of cores with HGPIN, with a cutoff of four, and to the ratio with the total number of cores ('PIN density'), with a cutoff of 50%, at the time of initial biopsy. A tailored protocol of controls can be suggested: (a) higher PSA value and/or anomalous DRE: early extended or saturation rebiopsy; (b) number of cores with HGPIN ≥4 and/or PIN density ≥50%: delayed rebiopsy; and (c) no risk factors: PSA and DRE controls.

A model to predict prostate cancer after atypical findings in initial prostate needle biopsy

PURPOSE

Atypical small acinar proliferation can occur alone or with high grade prostatic intraepithelial neoplasia in either a discontinuous or contiguous pattern in a prostate needle biopsy. We assessed whether different subgroups of atypical small acinar proliferation and high grade prostatic intraepithelial neoplasia denote a differing risk of detecting subsequent prostate cancer.

MATERIALS AND METHODS

We reviewed the pathological findings in 12,304 men who underwent initial prostatic needle biopsy during May 1999 to June 2007. Patients were included in the study if the initial diagnosis was atypical small acinar proliferation alone or combined with high grade prostatic intraepithelial neoplasia, or a benign diagnosis, and if followup prostatic needle biopsy was done.

RESULTS

Prostate cancer developed in 22%, 27% and 49% of patients in the benign, high grade prostatic intraepithelial neoplasia and atypical small acinar proliferation groups, respectively (p <0.0005). In all subgroups there was a 35% to 57% rate of prostate cancer detection. The prostate cancer risk increased in the atypical small acinar proliferation subgroups according to the extent of high grade prostatic intraepithelial neoplasia in the initial sample, with atypical small acinar proliferation associated with multifocal high grade prostatic intraepithelial neoplasia carrying a 71% prostate cancer risk.

CONCLUSIONS

Atypical small acinar proliferation combined with high grade prostatic intraepithelial neoplasia, particularly when associated with multifocal high grade prostatic intraepithelial neoplasia, is associated with a significant risk of prostate cancer detection on followup biopsy.

Tumor focality in prostate cancer: implications for focal therapy

In recent years, there has been a growing interest in focal treatment for prostate cancer. Although widely used for the treatment of tumors of the breast and kidney, focal treatment for prostate cancer remains a controversial area. Criticism of focal prostate therapy has been based on the fact that prostate cancer is a multifocal disease. Until now, little attention has been paid to distinguishing between men with unifocal and those with multifocal disease because such information has little clinical relevance when treatment is aimed at the whole gland irrespective of the volume or number of cancers in the prostate. In this Review, we summarize existing knowledge and examine the issue of prostate cancer focality in the context of focal treatment.

EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature

CONTEXT

The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate.

OBJECTIVE

Our aim was to review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy.

EVIDENCE ACQUISITION

A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS), nomogram, and diagnosis. Results were restricted to the English language, with preference given to those published within the last 3 yr.

EVIDENCE SYNTHESIS

At initial biopsy, a minimum of 10 but not >18 systematic cores are recommended, with 14-18 cores in glands ≥ 50 cm³. Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (≥ 20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3-6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound-guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative.

CONCLUSIONS

The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.

Impact of prostate cancer multifocality on its biology and treatment

Any focal therapy requires correct localization of the lesion; consequently, much effort is now devoted to accurate characterization of the spatial distribution of the tumor within the prostate. One of the greatest difficulties in the localization of prostate cancer is its frequent multifocality, but prostate cancer is unifocal in 13% to 43.7% of cases and unilateral in 19.2%. In cases of multifocality, it seems that the index tumor is the biologic driving force behind the malignant potential of prostate cancer. Not only is the Gleason score of the secondary nodes lower than that of the index node, but 80% of the secondary nodes are smaller than 0.5 cc and almost all extraprostatic extensions are associated with the largest cancers. While current evaluation with 12 to 18 core biopsies may be adequate to determine the index lesion, transperineal three-dimensional mapping biopsy of the prostate should be undertaken if greater accuracy is needed.