THE PATHOLOGICAL INTERPRETATION AND SIGNIFICANCE OF PROSTATE NEEDLE BIOPSY FINDINGS: IMPLICATIONS AND CURRENT CONTROVERSIES

Biomarkers in previous histologically negative prostate biopsies can be helpful in repeat biopsy decision-making processes

To evaluate whether the addition of biomarkers to traditional clinicopathological parameters may help to increase the accurate prediction of prostate re‐biopsy outcome. A training cohort with 98 patients and a validation cohort with 72 patients were retrospectively recruited into our study. Immunohistochemical analysis was used to evaluate the immunoreactivity of a group of biomarkers in the initial negative biopsy normal‐looking tissues of the training and validation cohorts. p‐STAT3, Mcm2, and/or MSR1 were selected out of 10 biomarkers to construct a biomarker index for predicting cancer and high‐grade prostate cancer (HGPCa) in the training cohort based on the stepwise logistic regression analysis; these biomarkers were then validated in the validation cohort. In the training cohort study, we found that the biomarker index was independently associated with the re‐biopsy outcomes of cancer and HGPCa. Moreover supplementing the biomarker index with traditional clinical‐pathological parameters can improve the area under the receiver operating characteristic curve of the model from 0.722 to 0.842 and from 0.735 to 0.842, respectively, for predicting cancer and HGPCa at re‐biopsy. In the decision‐making analysis, we found the model supplemented with the biomarker index can improve patients’ net benefit. The application of the model to clinical practice, at a 10% risk threshold, would reduce the number of biopsies by 34.7% while delaying the diagnosis of 7.8% cancers and would reduce the number of biopsies by 73.5% while delaying the diagnosis of 17.8% HGPCas. Taken together, supplementing the biomarker index with clinicopathological parameters may help urologists in re‐biopsy decision‐making processes.

Correlation of Gleason Grading and Prognostic Immunohistochemistry Markers (Human Epidermal Growth Factor Receptor 2/neu and Androgen Receptor) in Prostatic Core Needle Biopsy: A Study in a Tertiary Care Center

Background: Worldwide prostate cancer is the most common cause of cancer and the second leading cause of cancer death among men. Transrectal ultrasound-guided core needle biopsies are the diagnostic modalities which help in proper categorization and grading of prostatic carcinoma, thus facilitating individualized treatment. These biopsies are the primary source for performance of additional diagnostic immunohistochemical testing for basal cell-associated markers to rule out the morphological mimicker and prognostic markers such as androgen receptor (AR) and human epidermal growth factor receptor 2 (HER2)/neu. Materials and Methods: A prospective, observational study was conducted in the department of pathology in collaboration with department of urosurgery of a tertiary care hospital. One hundred and nineteen patients diagnosed with prostatic nodules were included in this study. Values of serum prostate-specific antigen were recorded. Tissue for histopathological study was obtained in the form of core needle biopsy, and Gleason grade was calculated in all malignant cases. Immunohistochemistry for p63 and alpha-methylacyl-CoA racemase was performed as an additional test in premalignant cases. Prognostication of the prostate cancer cases was done using AR and HER2/neu. Results: A total of 119 cases aged between 20 and 90 years were included in this study. Malignant lesions reveal an increase in the percentage of AR staining in comparison to the benign glandular structure. The Gleason score with higher value (8–9) showed increased expression of HER2/neu receptor. Conclusion: Critical histopathological analysis of core needle biopsy along with immunohistochemical evaluation maximizes the diagnostic accuracy in prostate cancer cases and also helps in prognosis assessment.

RNA-based markers in biopsy cores with atypical small acinar proliferation: Predictive effect of T2E fusion positivity and MMP-2 upregulation for a subsequent prostate cancer diagnosis

BACKGROUND

Atypical small acinar proliferation (ASAP) is a precursor lesion of prostate cancer (PC), and PC develops from this suspicious focus or an unsampled malignant gland nearby. However, PC-related molecular alterations that could guide the timing of repeat biopsies and help monitor PC risk in ASAP-diagnosed patients have not been investigated. The purpose of this study was to first investigate the expression of seven different PC-related RNAs that included serine 2 (TMPRSS2): erythroblastosis virus E26 oncogene homolog (ERG) gene (TMPRSS2-ERG, T2E) fusion, alpha-methylacyl-CoA racemase (AMACR), kallikrein related peptidase 3 (KLK3), androgen receptor (AR), prostate cancer specific antigen 3 (PCA3), and matrix metalloproteinases (MMP)-2 and 9.

METHODS

PC-related RNAs were evaluated using a real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) system in pathologically ASAP-diagnosed prostate biopsy cores from 55 patients presenting with a normal digital rectal examination and a PSA level of 4-10 ng/mL.

RESULTS

We detected that positive T2E fusion status (P = 0.013) and the expression of AMACR (P = 0.016), AR (P = 0.016) and MMP-2 (P = 0.013) were independently and significantly associated with PC risk in ASAP patients. There were also several statistically significant correlations between expression levels. Additionally, we demonstrated that T2E fusion positive ASAP patients with higher MMP-2 expression were more likely to be diagnosed with PC at a subsequent biopsy during the follow-up period (P = 0.003).

CONCLUSIONS

Although, more clinical validations are needed for the stratification of PC risk in ASAP-diagnosed biopsy cores, our current results indicate that the coexistence of T2E fusion positivity with MMP-2 upregulation may help clinicians adjust their biopsy timetable and/or assessment of PC risk in ASAP-diagnosed patients with a PSA level of 4-10 ng/mL.

The Role of Alcohol-Induced Golgi Fragmentation for Androgen Receptor Signaling in Prostate Cancer

Multiple epidemiologic observations and meta-analysis clearly indicate the link between alcohol abuse and the incidence and progression of prostate cancer; however, the mechanism remains enigmatic. Recently, it was found that ethanol (EtOH) induces disorganization of the Golgi complex caused by impaired function of the largest Golgi matrix protein, giantin (GOLGB1), which, in turn, alters the Golgi docking of resident Golgi proteins. Here, it is determined that in normal prostate cells, histone deacetylase 6 (HDAC6), the known regulator of androgen receptor (AR) signaling, localizes in the cytoplasm and nucleus, while its kinase, glycogen synthase kinase β (GSK3β), primarily resides in the Golgi. Progression of prostate cancer is accompanied by Golgi scattering, translocation of GSK3β from the Golgi to the cytoplasm, and the cytoplasmic shift in HDAC6 localization. Alcohol dehydrogenase-generated metabolites induces Golgi disorganization in androgen-responsive LNCaP and 22Rv1 cells, facilitates tumor growth in a mouse xenograft model and activates anchorage-independent proliferation, migration, and cell adhesion. EtOH-treated cells demonstrate reduced giantin and subsequent cytoplasmic GSK3β; this phenomenon was validated in giantin-depleted cells. Redistribution of GSK3β to the cytoplasm results in phosphorylation of HDAC6 and its retention in the cytoplasm, which, in turn, stimulates deacetylation of HSP90, AR import into the nucleus, and secretion of prostate-specific antigen (PSA). Finally, the relationship between Golgi morphology, HDAC6 cytoplasmic content, and clinicopathologic features was assessed in human prostate cancer patient specimens with and without a history of alcohol dependence. IMPLICATIONS: This study demonstrates the importance of alcohol-induced Golgi fragmentation in the activation of AR-mediated proliferation.

Typing the atypical: Diagnostic issues and predictive markers in suspicious prostate lesions

As much as 5% of prostate biopsies yield findings equivocal for malignancy even for skilled uropathologist; such "grey zone" lesions have been addressed in many ways, although the acronym ASAP (atypical small acinar proliferation) is the most widely used when referring to an atypical focus suspicious, but not diagnostic, for malignancy. Since the introduction of this diagnostic category more than 20 years ago, debate has ensued over its histological characterization and clinical significance. Pathology reporting of ASAP, commonly based on strict morphological criteria and traditional immunohistochemical markers such as basal cell antibodies, has been improved by recent availability of novel immunohistochemical markers such as AMACR and ERG. Further pathological issues, such as the role of pre-analytical variables, number of tissue levels, interobserver variability, and association with prostatic intraepithelial neoplasia also play a role in the optimal assessment of ASAP. Apart from diagnostic issues, a major issue is ASAP predictive value for prostate cancer on repeat biopsy. Therefore, attempts have been made to identify clinical and biological parameters that could predict subsequent diagnosis of malignancy as well as define time and modality of repeat biopsy. Finally, pathological features of cancers detected after a previous ASAP diagnosis are compared with those diagnosed at first prostate biopsy.

Analysis of Laterality and Percentage of Tumor Involvement in 1386 Prostatectomized Specimens for Selection of Unilateral Focal Cryotherapy

In total, 1386 paraffin embedded radical prostatectomy specimens from patients with clinically localized prostate cancer (PCa) excised between 2002–06 were analyzed. Pathologic assessment paid particular attention to laterality and percentage of tumor involvement (PTI) along with pathologic Gleason Score (pGS). Completely unilateral cancers were identified in 254 (18.3%) patients, and in 39% cases of them the signs of clinically significant PCa were revealed. The majority of unilateral tumors (72%) were low volume with a PTI of ≤5. This study suggests that only a select group of men diagnosed with PCa have completely unilateral cancers that would be amenable to focal ablation therapy targeting 1 lobe. Further study is needed to develop predictive models for those patients likely to have small, unilateral cancers that may be amenable to focal therapy.

Perineural invasion in prostate biopsy specimens is associated with increased bone metastasis in prostate cancer

BACKGROUND

We aimed to evaluate the relationship between perineural invasion (PNI) and bone metastasis in prostate cancer (PCa).

METHODS

We retrospectively reviewed the data of 633 PCas who had whole-body bone scan (WBBS) between 2008 and 2014. We recorded the age, clinical T-stage, total PSA (tPSA) prior to biopsy, Gleason sum (GS), and PNI in transrectal ultrasound guided biopsy (TRUS-Bx) and digital rectal examination findings. Bone metastases were assessed with WBBS and magnetic resonance image if WBBS was suspicious. We divided the patients into two groups according to NCCN criteria: (Group 1) bone scan not indicated, (Group 2) bone scan indicated.

RESULTS

There were 262 patients in Group 1 and 371 in 2. There is not significant relationship between PNI and bone metastasis in Group 1. However, there is very limited number of metastatic patients (n = 12) in this group. There is a strong relationship between PNI and bone metastasis in Group 2 (P = 0.001). Sensitivity, specificity and positive predictive value of PNI for bone metastasis were 72.4%, 81.7%, and 77.7%, respectively. In this group, tPSA, GS, positive DRE, and PNI were significant covariates for prediction of bone metastasis in univariate and multivariate analysis (except age). The most powerful predictor was PNI, and it increased the risk of bone metastasis 11-fold.

CONCLUSIONS

PNI in the TRUS-Bx specimens is the most powerful predictive histopathological feature for bone metastasis, by increasing the risk of bone metastasis 11-fold in NCCN bone scan indicated patients (Group 2).

Gleason drift in the NIHR ProtecT study

AIMS

There is increasing evidence of Gleason score (GS) drift in prostatic core biopsies during the last two decades. The ProtecT study is a randomized controlled study and provides an excellent cohort to study the effect of time, prostate-specific antigen (PSA) level, perineural invasion, tumour length and age on GS.

METHODS AND RESULTS

The ProtecT study recruited men in the United Kingdom between 1999 and 2010. The Gleason scores were grouped into four categories ≤ 3 + 3, 3 + 4, 4 + 3 and ≥ 4 + 4 for analysis. Data from England between 2000 and 2012 were also available. A total of 3282 biopsies containing cancer were analysed. For each year of the ProtecT study, the odds of being diagnosed with a higher GS category increased by 4.9%. Higher GS was also associated with perineural invasion, increasing tumour length, age and PSA level. While biopsy GS from England was incomplete, it also showed a marked decrease in GS five and six tumours during the same period.

CONCLUSION

There was GS drift from 3 + 3 to 3 + 4 with time in the ProtecT study, but there appeared to be no significant change in percentage of GS 4 + 3 or higher. This drift was less dramatic when compared to GS in the rest of England.

What is the ideal core number for ultrasound-guided prostate biopsy?

Purpose

We evaluated the utility of 10-, 12-, and 16-core prostate biopsies for detecting prostate cancer (PCa) and correlated the results with prostate-specific antigen (PSA) levels, prostate volumes, Gleason scores, and detection rates of high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP).

Materials and Methods

A prospective controlled study was conducted in 354 consecutive patients with various indications for prostate biopsy. Sixteen-core biopsy specimens were obtained from 351 patients. The first 10-core biopsy specimens were obtained bilaterally from the base, middle third, apex, medial, and latero-lateral regions. Afterward, six additional punctures were performed bilaterally in the areas more lateral to the base, middle third, and apex regions, yielding a total of 16-core biopsy specimens. The detection rate of carcinoma in the initial 10-core specimens was compared with that in the 12- and 16-core specimens.

Results

No significant differences in the cancer detection rate were found between the three biopsy protocols. PCa was found in 102 patients (29.06%) using the 10-core protocol, in 99 patients (28.21%) using the 12-core protocol, and in 107 patients (30.48%) using the 16-core protocol (p=0.798). The 10-, 12-, and 16-core protocols were compared with stratified PSA levels, stratified prostate volumes, Gleason scores, and detection rates of HGPIN and ASAP; no significant differences were found.

Conclusions

Cancer positivity with the 10-core protocol was not significantly different from that with the 12- and 16-core protocols, which indicates that the 10-core protocol is acceptable for performing a first biopsy.

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.

Controversial predictors of biochemical recurrence after radical prostatectomy: a study from a Latin American (Brazilian) institution

PURPOSE

To analyze controversial clinicopathologic predictors of biochemical recurrence after surgery: age, race, tumor extent on surgical specimen, tumor extent on needle biopsy, Gleason score 3 + 4 vs 4 + 3, and amount of extent of extraprostatic extension and positive surgical margins.

MATERIALS AND METHODS

The needle biopsies and the correspondent surgical specimens were analyzed from 400 patients. Time to recurrence was analyzed with the Kaplan-Meier curves and risk of shorter time to recurrence using Cox univariate and multivariate analysis.

RESULTS

Except for age, race, maximum percentage of cancer per core, and number of cores with cancer, all other variables studied were significantly predictive of time to biochemical recurrence using the Kaplan-Meier curves. In univariate analysis, except for focal extraprostatic extension, age, race, focal positive surgical margins, and maximum extent and percentage of cancer per core, all other variables were significantly predictive of shorter time to recurrence. On multivariate analysis, diffuse positive surgical margins and preoperative PSA were independent predictors.

CONCLUSIONS

Young patients and non-whites were not significantly associated with time to biochemical recurrence. The time consuming tumor extent evaluation in surgical specimens seems not to add additional information to other well established predictive findings. The higher predictive value of Gleason score 4 + 3 = 7 vs 3 + 4 = 7 discloses the importance of grade 4 as the predominant pattern. Extent and not simply presence or absent of extraprostatic extension should be informed. Most tumor extent evaluations on needle biopsies are predictive of time to biochemical recurrence, however, maximum percentage of cancer in all cores was the strongest predictor.

Improving the Gleason grading accuracy of transrectal ultrasound-guided biopsy

BACKGROUND

Transrectal ultrasound (TRUS)-guided prostate biopsy is the technique of choice for the assessment of clinical suspicion of prostate cancer (PC) based on abnormal digital rectal examination (DRE) and/or elevated or rising levels of prostate-specific antigen (PSA).

PURPOSE

To identify factors involved in TRUS-guided prostate biopsy, which can be modified by radiologists in order to improve Gleason score (GS) accuracy, and to assess the influence of clinical variables.

MATERIAL AND METHODS

We carried out a retrospective review of the records of 185 patients with PC treated surgically at our hospital between 2005 and 2008. Biopsy schemes were classified according to the number of cores (≤7, 8-9, 10-11, 12-15) and the needle length (11, 16, 20 mm). Clinical characteristics - age, family history of PC, DRE, PSA levels, and sonographic data - and prostatectomy GS (pGS) were collected.

RESULTS

Non-random concordance between biopsy Gleason score (bGS) and pGS was obtained for 36% of patients (P < 0.001). Under- and over-staging were 30% and 4%, respectively. Concordance was correlated with the core number (45% for ≤7, 54% for 8-9, 85% for 10-11, and 80% for 12-15; P < 0.001), but not with the needle length. The concordance rate showed a seven-fold increase when 10-11 cores were obtained (95% CI, 2-18; P < 0.001) compared to those cases in which the core number obtained was ≤7. Among clinical variables, only PSA correlated with concordance, showing an inverse relationship.

CONCLUSION

The Gleason correlation values were not improved when 12 or more cores were collected. These values reached a plateau beyond that number of samples. Therefore, when determining treatment strategies, physicians must consider the biopsy scheme used since it has proven to be a predictor of the accuracy of the PC grading system.

The PICTURE study -- prostate imaging (multi-parametric MRI and Prostate HistoScanning™) compared to transperineal ultrasound guided biopsy for significant prostate cancer risk evaluation

OBJECTIVE

The primary objective of the PICTURE study is to assess the negative predictive value of multi-parametric MRI (mp-MRI) and Prostate HistoScanning™ (PHS) in ruling-out clinically significant prostate cancer.

PATIENTS AND METHODS

PICTURE is a prospective diagnostic validating cohort study conforming to level 1 evidence. PICTURE will assess the diagnostic performance of multi-parametric Magnetic Resonance Imaging (mp-MRI) and Prostate HistoScanning™ (PHS) ultrasound. PICTURE will involve validating both index tests against a reference test, transperineal Template Prostate Mapping (TPM) biopsies, which can be applied in all men under evaluation. Men will be blinded to the index test results and both index tests will be reported prospectively prior to the biopsies being taken to ensure reporter blinding. Paired analysis of each of the index tests to the reference test will be done at patient level. Those men with an imaging lesion will undergo targeted biopsies to assess the clinical utility of sampling only suspicious areas. The study is powered to assess the negative predictive value of these imaging modalities in ruling-out clinically significant prostate cancer.

DISCUSSION

The PICTURE study aims to assess the performance characteristics of two imaging modalities (mp-MRI and Prostate HistoScanning) for their utility in the prostate cancer pathway. PICTURE aims to identify if either imaging test may be useful for ruling out clinically significant disease in men under investigation, and also to examine if either imaging modality is useful for the detection of disease. Recruitment is underway and expected to complete in 2014.

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.

The feasibility of multiparametric magnetic resonance imaging for targeted biopsy using novel navigation systems to detect early stage prostate cancer: the preliminary experience

BACKGROUND AND PURPOSE

The feasibility and diagnostic performance of multiparametric magnetic resonance imaging (mp-MRI) has to be proven further. In this study, we evaluate the role of mp-MRI for targeted biopsy of early stage prostate cancer (PCa).

PATIENTS AND METHODS

A total 32 consecutive patients with transrectal ultrasonography (TRUS)-guided biopsy-proven PCa meeting low-risk criteria and pursuing active surveillance were selected to undergo mp-MRI 3 Tesla (3T) with endorectal coil. Patients were divided then into three groups based on the method used to target the mp-MRI designated region of interest (ROI): Group 1 underwent TRUS-guided prostate biopsy using an MRI-based coordinate plan (cognitive targeting). Group 2 underwent MRI-targeted TRUS-guided prostate biopsy using MyLabTMTwice, which superimposed the archived MRI images onto the real-time ultrasonography image allowing targeted biopsy of the ROI (fusion targeting). Group 3 included selected patients who had an elevation in prostate-specific antigen levels, or patients followed after radiation therapy (two patients) for suspicious unifocal MRI lesion recurrence. These patients underwent MRI-guided biopsy of the suspicious ROI using the navigation system DynaTRIM.

RESULTS

The cancer detection rate in group 1 was 33.3% (3 of 10 patients), while in group 2, it was significantly higher at 46.2%. The sensitivity and specificity for group 1 was 45.5% and 33.3%, vs 61.9% and 20.8% in group 2, respectively. The positive predictive value in group 1 was 50.0% vs 53.8% in group 2 (P=0.04). In group 3, the cancer detection rate was much higher (80%) than in group 2, (P=0.005) although the majority of these patients (7 of 10) had a previously diagnosed prostate cancer on TRUS-guided 12-core biopsy.

CONCLUSION

Our preliminary experience of mp-MRI suggests the detection of early stage prostate cancer with low-risk features yields potential candidates for active surveillance or focal targeted therapy. The MRI-TRUS fusion system increases diagnostic yield compared with cognitive MRI-directed TRUS-guided biopsy.

Monocarboxylate transporter 2 (MCT2) as putative biomarker in prostate cancer

BACKGROUND

Monocarboxylate transporter 2 (MCT2) is a transmembrane protein involved in the transport of monocarboxylates such as pyruvate and lactate. In a previous study we described overexpression of MCT2 in prostate carcinoma raising the hypothesis of using MCT2 as a possible biomarker in prostate cancer. With the present study we aimed to compare the pattern of expression of MCT2 and alpha-methylacyl-CoA racemase (AMACR), in prostate carcinoma, PIN lesions, non-neoplastic prostate tissue, and normal prostate and compare their sensitivity and specificity. Also, we wanted to evaluate the value of using MCT2 in combination with AMACR and the negative markers 34βE12 or p63 to detect prostate cancer.

METHODS

A total of 349 cases, including prostate carcinoma, non-neoplastic prostate tissue and PIN lesions, from radical prostatectomies were examined by immunohistochemistry for AMACR, MCT2, p63, and 34βE12, using tissue microarrays (TMAs). Normal prostate from radical cystoprostatectomy was also studied.

RESULTS

Our study revealed that MCT2, similarly to AMACR, was consistently expressed in prostate cancer regardless of the Gleason score. In combination with AMACR and p63 or 34βE12, MCT2 helped to improve the diagnosis of prostate carcinoma. Also, overexpression of MCT2 as well as AMACR in PIN lesions may indicate the involvement of these two proteins in prostate cancer initiation.

CONCLUSIONS

We provided evidence for the presence of MCT2 in prostate cancer, selectively labeling malignant glands. Importantly, assessment of MCT2 together with AMACR, along with the negative markers, highly increases the accuracy in prostate cancer diagnosis.

Needle biopsy findings in prostatic adenocarcinoma: experience at a tertiary care center in a developing country

The objectives of this study are to report the findings in prostatic needle biopsies positive for cancer seen in our practice with regard to the frequency of cancer detected at various sites, the cancer volume, Gleason grade, presence of perineural invasion, and others; to correlate cancer volume with Gleason grade, perineural invasion, and serum prostate-specific antigen (PSA) levels; and to correlate Gleason grade with serum PSA levels. The study was conducted at The Section of Histopathology, Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi, Pakistan. All consecutive needle biopsies received from January 1, 2011 to June 30, 2012, which were positive for prostatic adenocarcinoma, were included in the study. Statistical analysis was carried out using SPSS 19.0 software package (SPSS Hong Kong Headquarters, Quarry Bay, Hong Kong). A total of 97 needle biopsies positive for carcinoma in this period were included. Prostate-specific antigen levels were available in 60.8% cases and ranged from 5.0 to 1747 ng/mL. Tumor was bilaterally present in 54.6% cases. Tumor positivity in right apex, mid, and base was 52.6%, 54.6%, and 51.5%, respectively. Tumor positivity in left apex, mid, and base was 55.7%, 63.9%, and 59.8%, respectively. Average tumor volume in right apex, mid, and base was 51.2%, 50.6%, and 49.9%, respectively. Average tumor volume in left apex, mid, and base was 49.8%, 49.1%, and 51.6%, respectively. Gleason score was 6 in 52.6% cases and 7 in 28.9% cases. Perineural invasion was positive in 46.4% cases. High-grade prostatic intraepithelial neoplasia was seen in 4 (4.1%) of 97 cases. On statistical analysis, no significant correlation was found between tumor volume and serum PSA levels. However, significant correlation was found between tumor volume and Gleason grade and between tumor volume and presence of perineural invasion. No significant correlation was found between Gleason grade and serum PSA level. To our knowledge, these are the first reported findings in prostatic needle biopsies from Pakistan. Most prostatic carcinomas in our country are still diagnosed on transurethral resection specimens, and needle biopsies are quite uncommon. Findings in needle biopsies will help in predicting adverse prognostic factors on radical prostatectomies and in planning surgery accordingly.

Frequency and determinants of disagreement and error in gleason scores: a population-based study of prostate cancer

BACKGROUND

To examine factors that affect accuracy and reliability of prostate cancer grade we compared Gleason scores documented in pathology reports and those assigned by urologic pathologists in a population-based study.

METHODS

A stratified random sample of 318 prostate cancer cases was selected to ensure representation of whites and African-Americans and to include facilities of various types. The slides borrowed from reporting facilities were scanned and the resulting digital images were re-reviewed by two urologic pathologists. If the two urologic pathologists disagreed, a third urologic pathologist was asked to help arrive at a final "gold standard" result. The agreements between reviewers and between the pathology reports and the "gold standard" were examined by calculating kappa statistics. The determinants of discordance in Gleason scores were evaluated using multivariate models with results expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The kappa values (95% CI) reflecting agreement between the pathology reports and the "gold standard," were 0.61 (95% CI: 0.54, 0.68) for biopsies, and 0.37 (0.23, 0.51) for prostatectomies. Sixty three percent of discordant biopsies and 72% of discordant prostatectomies showed only minimal differences. Using freestanding laboratories as reference, the likelihood of discordance between pathology reports and expert-assigned biopsy Gleason scores was particularly elevated for small community hospitals (OR = 2.98; 95% CI: 1.73, 5.14).

CONCLUSIONS

The level of agreement between pathology reports and expert review depends on the type of diagnosing facility, but may also depend on the level of expertise and specialization of individual pathologists.

ERG rearrangement for predicting subsequent cancer diagnosis in high-grade prostatic intraepithelial neoplasia and lymph node metastasis

PURPOSE

We aimed to analyze whether ERG rearrangement in biopsies could be used to assess subsequent cancer diagnosis in high-grade prostatic intraepithelial neoplasia (HGPIN) and the risk of lymph node metastasis in early prostate cancer.

EXPERIMENTAL DESIGN

Samples from 523 patients (361 with early prostate cancer and 162 with HGPIN) were collected prospectively. On the basis of the cutoff value established previously, the 162 patients with HGPIN were stratified to two groups: one with an ERG rearrangements rate ≥1.6% (n = 59) and the other with an ERG rearrangements rate <1.6% (n = 103). For the 361 prostate cancer cases undergoing radical prostatectomy, 143 had pelvic lymph node dissection (node-positive, n = 56 and node-negative, n = 87). All ERG rearrangement FISH data were validated with ERG immunohistochemistry.

RESULTS

A total of 56 (of 59, 94.9%) HGPIN cases with an ERG rearrangements rate ≥1.6% and 5 (of 103, 4.9%) HGPIN cases with an ERG rearrangements rate <1.6% were diagnosed with prostate cancer during repeat biopsy follow-ups (P < 0.001). There were significant differences in ERG rearrangement rates between lymph node-positive and -negative prostate cancer (P < 0.001). The optimal cutoff value to predict lymph node metastasis by ERG rearrangement was established, being 2.6% with a sensitivity at 80.4% [95% confidence interval (CI), 67.6-89.8] and a specificity at 85.1% (95% CI, 75.8-91.8). ERG protein expression by immunohistochemistry was highly concordant with ERG rearrangement by FISH.

CONCLUSIONS

The presence of ERG rearrangement in HGPIN lesions detected on initial biopsy warrants repeat biopsies and measuring ERG rearrangement could be used for assessing the risk of lymph node metastasis in early prostate cancer.

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.

An evaluation of patient selection criteria on predicting progression-free survival after primary focal unilateral nerve-sparing cryoablation for prostate cancer: recommendations for follow up

PURPOSE

Focal cryoablation targets unilateral disease, sparing healthy tissue and the ipsilateral neurovascular bundle. Given half the prostate is spared, proper patient selection is imperative to optimize outcomes. We report focal cryotherapy outcome data and evaluate the accuracy of the 2007 Task Force patient selection criteria at predicting disease recurrence.

MATERIALS AND METHODS

This is a retrospective patient chart review from a single academic institution. Inclusion criterion is having unilateral prostate cancer treated with primary hemicryoablation. Patients were stratified using the Task Force selection criteria. Exclusion criterion is having had past radiation or hormone therapy. Progression-free survival was calculated using follow-up TRUS biopsy (biopsy done with transrectal ultrasound) and serial prostate-specific antigen (PSA) results (Phoenix criteria). Kaplan-Meier curves were constructed and Cox regression analyses performed, comparing outcomes across patient selection cohorts.

RESULTS

From 2002 to 2009, 77 men underwent primary focal cryosurgery: mean age, 69.5 (SD, 6.7) years; median follow-up time, 24 months (range, 0-87 months); mean precryosurgical PSA, 6.5 (SD, 4.9) ng/mL; median Gleason score, 6 (range, 5-8). There were 44, 31, and 2 men who had D'Amico low-, intermediate-, and high-risk disease, respectively. Seventeen men met Focal Task Force Selection Criteria. After treatment, 22 patients underwent prostate biopsy for suspicion of recurrent disease. Of the 22 patients, 10 (45.5%) had confirmed prostate cancer. Of the 10 patients, 2 had ipsilateral disease, 7 had contralateral disease, and 1 had bilateral disease. Overall biochemical and pathological progression-free survival rates were 72.7% and 87%. The cumulative incidence of biochemical disease progression, using the Kaplan-Meier method, was greater than 75% at 3 years for men with more than 2 positive preoperative biopsy cores and greater than 50% at 5 years for men with 2 or less positive preoperative biopsy cores. No survival differences were seen across cohorts. Pretreatment PSA level, pretreatment Gleason score, number positive cores, and total tumor length were associated with disease progression.

CONCLUSIONS

Focal cryotherapy is a promising option for carefully selected patients, although optimization of inclusion criteria is required. Current selection criteria are associated with cancer-free survival. Given no accurate definitions for biochemical failure after focal cryotherapy exist combined with our high biochemical failure rate, mandating 12-month follow-up TRUS biopsy may improve accurate detection of cancer progression. Further follow up will determine optimal patient selection criteria and follow-up protocols for patients undergoing primary focal unilateral nerve-sparing prostate cancer treatment.

Development and validation of a nomogram for predicting a positive repeat prostate biopsy in patients with a previous negative biopsy session in the era of extended prostate sampling

OBJECTIVE

To create a nomogram for predicting the probability of a positive biopsy in men with one or more previous negative biopsies, as the false-negative rate of prostate biopsy in contemporary series remains substantial, and there is a need to identify those with a negative result but with a high risk of having unrecognized prostate cancer.

PATIENTS AND METHODS

The study included 408 patients from Cleveland Clinic who had one or more repeat biopsies after an initial negative biopsy from 1999 to 2008. Another 470 men with the same criteria were used to validate the nomogram. Nomogram variables included age, family history of prostate cancer, body mass index, findings on a digital rectal examination, prostate-specific antigen (PSA) level, PSA slope, total prostate volume, months from initial negative biopsy session, months from previous negative biopsy, cumulative number of negative cores previously taken and history of high-grade intraepithelial neoplasia or atypical small acinar proliferation. We calculated the nomogram predicted probability in each patient. These predicted outcomes were compared with the actual biopsy results. The area under the receiver operating characteristic (ROC) curve was calculated as a measure of discrimination.

RESULTS

The mean number of previous negative biopsies was 1.5, and the mean number of cores per session was 19.1. Of the original development data, 129 men (31.6%) had prostate cancer. A nomogram was constructed that had a concordance index of 0.72, which was greater than any single risk factor. In the validation group the area under the ROC curve was 0.62.

CONCLUSIONS

Our nomogram for predicting a positive repeat biopsy can provide important additional information to aid the urologist and patient with a negative biopsy in evaluating clinical options.

Pathologic results of radical prostatectomies in patients with simultaneous atypical small acinar proliferation and prostate cancer

PURPOSE

The incidence of adenocarcinoma on a subsequent biopsy following a diagnosis of atypical small acinar proliferation (ASAP) ranges from 34% to 60%. We reexamined radical prostatectomy (RP) specimens of patients diagnosed as having synchronous ASAP with prostate cancer (PCa) to evaluate pathological entities and the clinical significance of ASAP.

MATERIALS AND METHODS

From January 2007 to December 2008, a total of 118 patients who had been diagnosed with adenocarcinoma on prostate needle biopsy underwent RP. Forty-six of the 118 patients (39%) were diagnosed as having synchronous ASAP with PCa on the prostate needle biopsy. Using whole-mount sections and prostate mapping, we evaluated the RP specimens that were close sections to the ASAP on prostate needle biopsy. All tissues were examined by immunohistochemistry with high molecular weight cytokeratin (34betaE12), p63, and AMACR/P504S added to initial H&E stains by one pathologist.

RESULTS

Thirty-six of the 46 patients (78%) were diagnosed as having adenocarcinoma at sites of ASAP on the initial prostate needle biopsies. The Gleason score was 5 to 6 in 22 patients (61%), 7 in 3 (8%), and unknown due to multifocal and microfocal lesions in 11 (31%). The tumor volume of 14 of the 36 patients (39%) was 0.5 cc or less and was unknown due to multifocal and microfocal lesions in 8 (22%).

CONCLUSIONS

Most ASAP on initial prostate needle biopsy was a true pathological entity, in other words, prostatic adenocarcinoma. Aggressive approaches including more extended repeat biopsy with additional biopsy of the site of the ASAP are needed to diagnose PCa in patients with ASAP.

Quantitative proteomic profiling of prostate cancer reveals a role for miR-128 in prostate cancer

Multiple, complex molecular events characterize cancer development and progression. Deciphering the molecular networks that distinguish organ-confined disease from metastatic disease may lead to the identification of biomarkers of cancer invasion and disease aggressiveness. Although alterations in gene expression have been extensively quantified during neoplastic progression, complementary analyses of proteomic changes have been limited. Here we interrogate the proteomic alterations in a cohort of 15 prostate-derived tissues that included five each from adjacent benign prostate, clinically localized prostate cancer, and metastatic disease from distant sites. The experimental strategy couples isobaric tags for relative and absolute quantitation with multidimensional liquid phase peptide fractionation followed by tandem mass spectrometry. Over 1000 proteins were quantified across the specimens and delineated into clinically localized and metastatic prostate cancer-specific signatures. Included in these class-specific profiles were both proteins that were known to be dysregulated during prostate cancer progression and new ones defined by this study. Enrichment analysis of the prostate cancer-specific proteomic signature, to gain insight into the functional consequences of these alterations, revealed involvement of miR-128-a/b regulation during prostate cancer progression. This finding was validated using real time PCR analysis for microRNA transcript levels in an independent set of 15 clinical specimens. miR-128 levels were elevated in benign prostate epithelial cell lines compared with invasive prostate cancer cells. Knockdown of miR-128 induced invasion in benign prostate epithelial cells, whereas its overexpression attenuated invasion in prostate cancer cells. Taken together, our profiles of the proteomic alterations of prostate cancer progression revealed miR-128 as a potentially important negative regulator of prostate cancer cell invasion.

[PSA--Quo vadis?]

Prostate cancer is the most frequent cancer in males. Because of the high cure rates, early detection of prostate cancer should identify organ-confined prostate cancers. An early detection examination should be performed annually starting at the age of 50 years and ending when life expectancy is less than 10 years. Digital rectal examination is supplemented by determination of prostate-specific antigen (PSA). Before the first PSA test, the patient must be informed of possible consequences such as biopsy recommendation and treatment options. A threshold of 4 ng/ml is defined as the indication for prostate biopsy. Imaging methods do not play a major role in early detection of prostate cancer today. Early detection identifies many latent prostate cancers, and patients may receive overtreatment. A possible solution is to change the early detection paradigm from detection of all prostate cancers to identification of aggressive ones. In this article, early detection is discussed based on the recent literature.

Atypical small acinar proliferation Review of a series of 64 patients

OBJECTIVE

To study the evolution of 64 patients initially diagnosed with ASAP (atypical small acinar proliferation).

MATERIAL AND METHODS

Between 1998 and the end of 2003, 64 patients were diagnosed at our centre with ASAP.

RESULTS

The mean age of the patients assessed was 69 years (SD 6.4 years), the median prostate-specific antigen (PSA) level was 7.1 ng/ml (range 2-39 ng/ml) and 25% of the patients had a suspicious rectal examination. These 64 patients were subjected to re-biopsy. At re-biopsy, we diagnosed 27 patients (42%) with prostate adenocarcinoma. We classified patients into two groups depending on whether they did (n=27) or did not (n=37) have tumours. There were no significant differences in median PSA level between the two groups. The rectal examination was suspicious in 14% of patients without tumours and in 39% with tumours. Radical prostatectomy was applied to 20/28 patients (71%) diagnosed with prostate cancer. In these 20 patients, the median tumour volume was 0.4 cm3 (range 0.1-3.2 cm3) and 44% of the tumours were significant. The 37 patients with an unsuspicious histology were subjected to follow-up for a median of 12 months (range 1-30 months). The median PSA level in these patients was 5.7 ng/ml (range 0.8-28 ng/ml). A third biopsy was performed in three of these patients in view of an elevated PSA level, and one result was positive.

CONCLUSIONS

In our experience, a pathological result of ASAP is associated with a definitive diagnosis of prostate cancer in 42% of cases. Moreover, a significant cancer was found in 44% of patients subjected to radical prostatectomy. We therefore systematically perform repeat biopsies on all patients with a histological result of ASAP.

What is the pathologist saying? Interpretation of the prostate pathology report

Management of patients presenting with elevated serum prostate-specific antigen levels, or those with previously diagnosed prostate carcinoma, is very much dependent on the pathology report on needle biopsy or radical prostatectomy specimens obtained from these patients. In contrast to a diagnosis of benignity or high-grade prostatic intraepithelial neoplasia, a diagnosis of atypia on needle core biopsy is usually an indication for a repeat biopsy; however, it is important to understand that atypia and other related terms are not specific diagnoses. The pathology report on different prostate specimens with a diagnosis of carcinoma usually includes the Gleason grade and extent of carcinoma among other morphological prognostic and predictive factors. Understanding the significance of these morphological factors and how they are evaluated and incorporated into the pathology report, as well as newer developments in this field, can assist urologists in the interpretation of the pathological findings and ultimately lead to better clinical care.

PTOV1 expression predicts prostate cancer in men with isolated high-grade prostatic intraepithelial neoplasia in needle biopsy

PURPOSE

To analyze the expression of PTOV1 in high-grade prostatic intraepithelial neoplasia (HG-PIN) and to explore its usefulness to predict prostate cancer in patients with isolated HG-PIN in needle biopsy (prostate needle biopsy).

EXPERIMENTAL DESIGN

PTOV1 expression in HG-PIN lesions from 140 patients was analyzed by immunohistochemistry in a semiquantitative manner (Histo-score). HG-PIN derived from 79 radical prostatectomies for prostate cancer and from 11 cistoprostatectomies for bladder cancer without prostate cancer were used as positive and negative controls, respectively. Fifty patients with HG-PIN without concomitant cancer at their first prostate needle biopsy were chosen as the study group. Patients were followed by a mean of 2.5 repeated prostate needle biopsies (1-5), during a mean period of 12.4 months (1-39).

RESULTS

PTOV1 expression in HG-PIN from radical prostatectomies showed a significantly higher Histo-score (162.6) compared with specimens from cistoprostatectomies (67.0). In the study group, PTOV1 expression was significantly higher in samples with cancer in the follow-up (11 patients, 22%) compared with samples in which cancer was not detected (151.4 versus 94.6). PTOV1 expression was the only independent predictor of cancer in the multivariate analysis and the area under the curve was 0.803 (95% confidence interval, 0.728-0.878). A threshold of 100 for PTOV1 expression provided 90.9% sensitivity, 51.3% specificity, 34.5% positive predictive value, and 95.2% negative predictive value.

CONCLUSIONS

PTOV1 is overexpressed in HG-PIN associated with cancer and is a potential marker for studying the carcinogenesis and progression of prostate cancer. Prostate needle biopsy with PTOV1 expression in HG-PIN above a threshold of 100 should be repeated immediately for the likely presence of undiagnosed cancer.

Mechanisms of Disease: high-grade prostatic intraepithelial neoplasia and other proposed preneoplastic lesions in the prostate

High-grade prostatic intraepithelial neoplasia (HGPIN) is the most likely precursor of prostatic adenocarcinoma according to virtually all available evidence. This lesion is characterized by cellular proliferations within pre-existing ducts and acini, with nuclear and nucleolar enlargements similar to those seen in prostate cancer, although unlike cancer HGPIN retains a basal-cell layer. The recognition of HGPIN is clinically important because of the strong association between this disease and prostatic carcinoma. The predictive value for cancer of an initial diagnosis of HGPIN on needle biopsy has substantially declined, with values falling from 36% to 21%. A major factor contributing to this decline is related to increased use of needle biopsy core sampling, which has provided the means for many cancers associated with HGPIN to be detected on initial biopsy; repeat biopsy, even with good sampling, does not detect many additional cancers. Other possible findings in the prostate might indicate premalignant disease (low-grade prostatic intraepithelial neoplasia, atrophy, malignancy-associated changes, and atypical adenomatous hyperplasia or adenosis), but the data for these premalignant diseases are much less convincing than those for HGPIN.

Diagnosis of prostate cancer

The contemporary challenge of prostate cancer diagnosis has been changed in the past decade from the endeavor to increase detection to that of detecting only those tumors that are clinically significant. Better interpretation of the role of prostate-specific antigen (PSA) and its kinetics as a diagnostic tool, the adoption of extended prostate biopsy schemes, and perhaps implementation of new transrectal ultrasound (TRUS) technologies promote the achievement of this clinical mission. This chapter reviews these issues as well as the change in practice of patient preparation for TRUS-biopsy and analgesia during it, the role of repeat and saturation prostate biopsies, and the interpretation of an incidental prostate cancer finding. Currently, the lifetime risk of a diagnosis of prostate cancer for North American men is 16%, compared to the lifetime risk of death from prostate cancer, which is 3% (Carter 2004). The advent of prostate-specific antigen (PSA) screening and transrectal ultrasonography (TRUS) has significantly impacted the detection of prostate cancer over the last 20 years. The mean age at diagnosis has decreased (Hankey et al. 1999; Stamey et al. 2004) and the most common stage at diagnosis is now localized disease (Newcomer et al. 1997; Stamey et al. 2004). The goal of prostate cancer screening is to detect only those men at risk for death from the disease at an early curable phase. The ambiguous natural history of this most common malignancy in men, being latent with questionable life-threatening potential in a large number of cases on the one hand, with only a relatively small number (though not negligible) of highly malignant cases on the other, propels many doubts about whether this is possible. This was famously phrased more than 20 years ago by Whitmore who asked: "Is cure possible for those in whom it is necessary; and is it necessary for those in whom it is possible?" This is probably even more relevant nowadays. During the past decade two factors influenced significantly the increased detection rate of prostate cancer in general and that of clinically insignificant prostate cancers in particular: the widespread use of serum PSA as a screening tool to a large extent and to a lesser though significant extent the application of extended multiple core biopsy schemes (Master et al. 2005). In fact, 75% of men in the United States aged 50 years and older have been screened with the PSA test (Sirovich et al. 2003). Outside of the screening context, which is dealt with in depth in Chap. 5, clinical suspicion of prostate cancer is raised usually by abnormal digital rectal examination (DRE) and/or by abnormal levels of serum PSA. Final diagnosis is achieved only based on positive prostate biopsies.

Development and external validation of an extended repeat biopsy nomogram

PURPOSE

We hypothesized that the outcome of repeat biopsy could be accurately predicted. We tested this hypothesis in a contemporary cohort from 3 centers.

MATERIALS AND METHODS

The principal cohort of 1,082 men from Hamburg, Germany was used for nomogram development as well as for internal 200 bootstrap validation in 721 and external validation in 361. Two additional external validation cohorts, including 87 men from Milan, Italy and 142 from Seattle, Washington, were also used. Predictors of prostate cancer on repeat biopsy were patient age, digital rectal examination, prostate specific antigen, percent free prostate specific antigen, number of previous negative biopsy sessions and sampling density. Multivariate logistic regression models were used to develop the nomograms.

RESULTS

The mean number of previous negative biopsies was 1.5 (range 1 to 6) and the mean number of cores at final repeat biopsy was 11.1 (range 10 to 24). Of the men 370 (30.2%) had prostate cancer. On multivariate analyses all predictors were statistically significant (p < or =0.028). After internal validation the nomogram was 76% accurate. External validation showed 74% (Hamburg), 78% (Milan) and 68% (Seattle) accuracy.

CONCLUSIONS

Relative to the previous nomograms (10 predictors or 71% accuracy) our tool relies on fewer variables (6) and shows superior accuracy in European men. Accuracy in American men is substantially lower. Racial, clinical and biochemical differences may explain the observed discrepancy in predictive accuracy.

Use of Prostate-Specific Antigen Velocity to Follow Up Patients with Isolated High-Grade Prostatic Intraepithelial Neoplasia on Prostate Biopsy

OBJECTIVES

No consensus has been reached about the optimal follow-up for patients with an isolated finding of high-grade prostatic intraepithelial neoplasia (HG-PIN) on prostate biopsy. Early studies reported that approximately one half of men with HG-PIN were diagnosed with prostate cancer (CaP) within a few years. However, more recent studies, using extended biopsy protocols, have shown that HG-PIN may be less predictive of CaP on repeat biopsy in the short term. Thus, our objective was to identify the clinical factors that could help predict which men with isolated HG-PIN were at the greatest risk of subsequent CaP detection.

METHODS

In 190 men from a CaP screening study with an initial biopsy finding of HG-PIN, we compared the prostate-specific antigen velocity (PSAV) between patients who were later diagnosed with CaP and those who were not. Multivariate models were constructed for the ability to predict CaP detection.

RESULTS

The median PSAV was significantly greater in the men with HG-PIN who were subsequently diagnosed with CaP (P = 0.03). A PSAV threshold of 0.75 ng/mL/yr predicted which men with HG-PIN would ultimately be diagnosed with CaP (P = 0.007). On multivariate analysis, including PSAV, age, and initial PSA level, PSAV was the only significant predictor of subsequent CaP detection.

CONCLUSIONS

Among the men with an isolated finding of HG-PIN on prostate needle biopsy, PSAV helps to identify those men who are subsequently diagnosed with CaP. Thus, we advocate the use of the PSAV to help guide the need for repeat biopsy in men with HG-PIN.

Dealing with non-cancerous findings on prostate biopsy

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

Current practice of diagnosis and reporting of prostate cancer on needle biopsy among genitourinary pathologists

As there is a lack of hard data in the literature about many of the issues relating to diagnosing and reporting prostate cancer, we sought to survey current practices. A questionnaire was sent to 93 genitourinary pathologists with a response rate of 69%. Almost all respondents (95%) used formalin as fixative for needle biopsies. Unstained intervening sections were retained by 47%. Three levels of needle biopsies were used routinely by 63%. For verification of a diagnosis of cancer, high-molecular-weight cytokeratin was still the most commonly used immunohistochemical marker (91%), followed by p63 (58%) and alpha-methylacyl-CoA-racemase (50%). Features considered pathognomonic for cancer were glomeruloid bodies (58%), collagenous micronodules (64%), circumferential perineural invasion (84%), and growth in fat (36%). With none of these present, 39% required a minimum of 2 to 10 glands (median, 3) to diagnose cancer, whereas the others had no lower limit. A Gleason score was always given to even minute cancer foci by 86% and typically a Gleason score 6 was assigned (77%). Perineural invasion was mentioned by 86%. The extent of cancer on needle biopsies was quantified by all respondents with number of involved cores (80%) being the most commonly used measure. Linear extent was estimated by almost all, either as a percentage (80%) or millimeters of cancer length (41%) or both (22%). Measuring cancer from end to end or subtracting intervening benign tissue were almost equally common. For those general pathologists who would like to be in the mainstream of most urological pathologists, our survey data provide a guideline on how to diagnose and report prostate cancer.

Histopathology reporting of prostate needle biopsies. 2005 update

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

Endorectal MR Imaging in the Evaluation of Seminal Vesicle Invasion: Diagnostic Accuracy and Multivariate Feature Analysis

PURPOSE

To retrospectively determine the accuracy of endorectal magnetic resonance (MR) imaging in demonstrating seminal vesicle invasion (SVI) and to investigate the MR imaging features that can predict SVI.

MATERIALS AND METHODS

The Institutional Review Board granted exempt status for this retrospective study, with waiver of informed consent; patient data were collected and handled in accordance with HIPAA regulations. Fifty-one men (age range, 44-73 years) with SVI and 303 men (age range, 40-76 years) without SVI who underwent endorectal MR imaging before radical prostatectomy between January 2000 and October 2004 were included in the study. Endorectal MR images were retrospectively and independently analyzed by two radiologists for SVI, tumor at prostate base, extracapsular extension, and other features considered indicative of SVI. Areas under the receiver operating characteristic curves (AUCs) were used to assess the accuracy of detecting SVI at endorectal MR imaging. A multiple logistic regression was used to explore the combinations of MR imaging features that might facilitate the detection of SVI.

RESULTS

Readers 1 and 2 had an AUC of 0.93 and 0.81, respectively, for the detection of SVI. For both readers, the features that had the highest sensitivity and specificity were low signal intensity within the seminal vesicle and lack of preservation of seminal vesicle architecture. At multiple regression analysis, tumor at the prostate base that extended beyond the capsule and low signal intensity within a seminal vesicle that has lost its normal architecture were highly predictive of SVI.

CONCLUSION

Endorectal MR imaging is accurate in demonstrating SVI prior to radical prostatectomy, and recognition of the most predictive features may facilitate the use of this modality.

[The usefulness of Ki67 expression in the biopsy specimens, to predict the biochemical progresion of the prostate cancer after radical prostatectomy]

OBJECTIVE

To evaluate the usefulness of Ki67 expression in the biopsy specimens, to predict the biochemical progression of the prostate cancer after radical prostatectomy.

MATERIAL AND METHODS

We analyse the Ki67 expression in the biopsy specimens of 103 patients treated with radical prostatectomy. The mean follow up is 3.4 years (1.3-8.8 years). We correlate the biochemical progression with traditional prognostic factors as the PSA (> 10/< or = 10), Gleason (> or = 7/< 7), pT classification (pT3/pTO-2) and immunohistochemical factor Ki67 (> 3%/< or = 3%).

RESULTS

Of all 103 patients, in 71 (69%) biochemical progression was not detected and in 32 (31%) biochemical progression was detected. The mean of preoperative PSA is 10.07 ng/ml in the patients without progression and 20.90 ng/ml in the patients with biochemical progression (p=0.0001). The mean of Gleason score in 6.03 in the patients without progression and 6.75 in the patients with biochemical progression (p=0.0001). The percentage of Ki67 expression is 3.95% in the patients without progression and 5.05% in the patients with biochemical progression (p=0.030). The tumors pT0-2 progressed 12/67 (17.9%) and the tumors pT3 progressed 20/36 (55.6%) (p=0.0001). Multivariant regression analysis indicate that it does not exist a statistically significant relation between Ki67 (> 3%/< or = 3%) expression in the biopsy specimens and the biochemical progression of the prostate cancer after radical prostatectomy (p=0.204).

CONCLUSIONS

The immunohistochemical factor Ki67 (> 3%/< or = 3%) in the biopsy specimens, is less effective than the classic factors, PSA (> 10/< or = 10), Gleason (> or = 7/< 7) and pT classification (pT3/pT0-2), to predict the biochemical progression of the prostate cancer after radical prostatectomy.

High-grade prostatic intraepithelial neoplasia in needle biopsy as risk factor for detection of adenocarcinoma: current level of risk in screening population

OBJECTIVES

To assess the current incidence of prostate carcinoma detection in serial biopsies in a prostate-specific antigen-based screening population after a diagnosis of isolated high-grade prostatic intraepithelial neoplasia (HG-PIN) in needle biopsy tissue.

METHODS

We retrospectively identified 190 men with a diagnosis of isolated HG-PIN in needle biopsy tissue. Most men (86%) were diagnosed from 1996 to 2000. Logistic regression analysis was used to predict the presence of carcinoma in these 190 men and in a control group of 1677 men with only benign prostatic tissue in needle biopsy tissue.

RESULTS

The cumulative risk of detection of carcinoma on serial sextant follow-up biopsies was 30.5% for those with isolated HG-PIN compared with 26.2% for the control group (P = 0.2). Patient age (P = 0.03) and serum prostate-specific antigen level (P = 0.02) were significantly linked to the risk of cancer detection, but suspicious digital rectal examination findings (P = 0.1), the presence of HG-PIN (P = 0.2), and the histologic attributes of PIN were not (all with nonsignificant P values). HG-PIN found on the first repeat biopsy was associated with a 41% risk of subsequent detection of carcinoma compared with an 18% risk if benign prostatic tissue was found on the first repeat biopsy (P = 0.01).

CONCLUSIONS

The results of our study have shown that the current level of risk for the detection of prostate carcinoma in a screened population is 30.5% after a diagnosis of isolated HG-PIN in a needle biopsy. This risk level is lower than the previously reported risk of 33% to 50%. HG-PIN is a risk factor for carcinoma detection only when found on consecutive sextant biopsies. The data presented here should prompt reconsideration of repeat biopsy strategies for HG-PIN, and re-evaluation of the absolute necessity of repeat biopsy for all patients with HG-PIN.

Kleine suspekte Prostataläsionen

Punch biopsies have been taken from the prostate with increasing frequency in recent years, with a resulting increase in the number of diagnoses made. To check the diagnosis of "small two- or three-gland carcinoma" we prepared new H and E sections and, when the atypical glands were no longer available, also performed immunohistochemical analyses in 1,041 cases referred to our uropathology consultation service, comparing the diagnoses supplied by the referring doctors with the final diagnoses. In 61.6 of these cases histology confirmed the diagnosis of adenocarcinoma of the prostate; the diagnosis recorded when the basal cell marker was absent and the tumour marker P504S was strongly expressed was atypical microglandular proliferation or suspected carcinoma. Previous diagnoses of prostatic carcinoma were confirmed in 99% of cases. In this way we also confirmed a further 27.9% of cases of prostate carcinoma in the grey area of diagnoses endorsed "suggestive" or "suspected". The patients concerned were thus spared multiple screening biopsies and were assigned for definitive treatment.

Repeat prostate biopsies following diagnoses of prostate intraepithelial neoplasia and atypical small gland proliferation

OBJECTIVE

To assess the incidence of diagnosis of high-grade intraepithelial neoplasia or prostate intraepithelial neoplasia (PIN), and atypical small gland proliferation (ASAP) at a uropathology reference center. To assess the indexes and findings on repeat biopsies.

MATERIALS AND METHODS

Diagnoses of PIN, ASAP or PIN + ASAP established between January 1, 2001 and December 31, 2003 were searched in our database. We studied repeat biopsies performed up to August 31, 2004.

RESULTS

Of 1420 biopsies, ASAP was diagnosed in 26 (1.8%) patients, PIN in 142 (10%) and PIN + ASAP in 40 (2.8%). Repeat biopsies were performed in 98 patients, 16 (61.5%) with ASAP, 53 (37.3%) with PIN and 29 (72.5%) with PIN + ASAP. Carcinoma was diagnosed in 7 cases (43.8%) following a diagnosis of ASAP, 12 (41.4%) of PIN + ASAP and 7 (13.2%) of PIN. The mean interval between repeat biopsies was 299.6 days. There was no difference between groups where cancer was or was not diagnosed on repeat biopsy in relation to age and serum PSA levels.

CONCLUSION

Despite explicit recommendations of repeat biopsy on pathology reports and the high incidence of adenocarcinoma on repeat biopsy, re-intervention rates following a diagnosis of PIN, ASAP, PIN + ASAP are low in our setting. The diagnosis that most frequently led to repeat biopsy was PIN + ASAP. Adenocarcinoma was most often diagnosed after the initial diagnosis of ASAP.