The extent and multicentricity of high-grade prostatic intraepithelial neoplasia in clinically localized prostatic adenocarcinoma

hTERT Epigenetics Provides New Perspectives for Diagnosis and Evidence-Based Guidance of Chemotherapy in Cancer

Strong epigenetic pan-cancer biomarkers are required to meet several current, urgent clinical needs and to further improve the present chemotherapeutic standard. We have concentrated on the investigation of epigenetic alteration of the hTERT gene, which is frequently epigenetically dysregulated in a number of cancers in specific developmental stages. Distinct DNA methylation profiles were identified in our data on early urothelial cancer. An efficient EpihTERT assay could be developed utilizing suitable combinations with sequence-dependent thermodynamic parameters to distinguish between differentially methylated states. We infer from this data set, the epigenetic context, and the related literature that a CpG-rich, 2800 bp region, a prominent CpG island, surrounding the transcription start of the hTERT gene is the crucial epigenetic zone for the development of a potent biomarker. In order to accurately describe this region, we have named it "Acheron" (Ἀχέρων). In Greek mythology, this is the river of woe and misery and the path to the underworld. Exploitation of the DNA methylation profiles focused on this region, e.g., idiolocal normalized Methylation Specific PCR (IDLN-MSP), opens up a wide range of new possibilities for diagnosis, determination of prognosis, follow-up, and detection of residual disease. It may also have broad implications for the choice of chemotherapy.

Epigenetics Meets CAR-T-Cell Therapy to Fight Cancer

Based on the impressive success of Car-T-cell therapy in the treatment of hematological malignancies, a broad application for solid tumors also appears promising. However, some important hurdles need to be overcome. One of these is certainly the identification of specific target antigens on cancer cells. Hypomethylation is a characteristic epigenetic aberration in many tumor entities. Genome-wide screenings for consistent DNA hypomethylations in tumors enable the identification of aberrantly upregulated transcripts, which might result in cell surface proteins. Thus, this approach provides a new perspective for the discovery of potential new Car-T-cell target antigens for almost every tumor entity. First, we focus on this approach as a possible treatment for prostate cancer.

Deletion of the p16INK4a tumor suppressor and expression of the androgen receptor induce sarcomatoid carcinomas with signet ring cells in the mouse prostate

The tumor suppressor p16^Ink4a, encoded by the INK4a gene, is an inhibitor of cyclin D-dependent kinases 4 and 6, CDK4 and CDK6. This inhibition prevents the phosphorylation of the retinoblastoma protein (pRb), resulting in cellular senescence through inhibition of E2F-mediated transcription of S phase genes required for cell proliferation. The p16^Ink4a plays an important role in tumor suppression, whereby its deletion, mutation, or epigenetic silencing is a frequently observed genetic alteration in prostate cancer. To assess its roles and related molecular mechanisms in prostate cancer initiation and progression, we generated a mouse model with conditional deletion of p16^Ink4a in prostatic luminal epithelium. The mice underwent oncogenic transformation and developed prostatic intraepithelial neoplasia (PIN) from eight months of age, but failed to develop prostatic tumors. Given the prevalence of aberrant androgen signaling pathways in prostate cancer initiation and progression, we then generated R26hAR^L/wt:p16^L/L: PB-Cre4 compound mice, in which conditional expression of the human AR transgene and deletion of p16^Ink4a co-occur in prostatic luminal epithelial cells. While R26hAR^L/wt:PB-Cre4 mice showed no visible pathological changes, R26hAR^L/wt:p16^L/L: PB-Cre4 compound mice displayed an early onset of high-grade PIN (HGPIN), prostatic carcinoma, and metastatic lesions. Strikingly, we observed tumors resembling human sarcomatoid carcinoma with intermixed focal regions of signet ring cell carcinoma (SRCC) in the prostates of the compound mice. Further characterization of these tumors showed they were of luminal epithelial cell origin, and featured characteristics of epithelial to mesenchymal transition (EMT) with enhanced proliferative and invasive capabilities. Our results not only implicate a biological role for AR expression and p16^Ink4a deletion in the pathogenesis of prostatic SRCC, but also provide a new and unique genetically engineered mouse (GEM) model for investigating the molecular mechanisms for SRCC development.

The distribution of BCG prostatitis: A clue for pathogenetic processes?

BACKGROUND

We observed in cystoprostatectomy specimens that Bacillus Calmette-Guérin (BCG) granulomatous prostatitis tended preferentially to affect the peripheral zone (PZ) and aimed to study the matter, postulating that assessment of its distribution might contribute to understanding pathogenetic processes.

METHODS

Entire prostate glands from 27 men (47-83 years; mean = 69 years), who had previously received intravesical BCG therapy for non-muscle-invasive urothelial carcinoma of the bladder, were studied as whole-mount sections to determine the anatomical distribution and histopathological characteristics of BCG prostatitis.

RESULTS

Twenty-two (81.5%) showed BCG-type granulomatous inflammation. It often radiated from close to the prostatic urethra toward to the gland periphery as a wedge-shaped area related to one or more duct systems. Twenty-one of these prostate glands (95.5%) showed predominantly or exclusively PZ involvement. Eighteen (81.8%) involved only the PZ, while three cases (13.6%) also showed involvement of the transitional zone (TZ). One case (4.5%) involved only the TZ. No granulomas were seen in the central zone or anterior fibromuscular septum.

CONCLUSIONS

Our observations imply the microanatomical arrangement of prostatic ducts is a factor in the pathogenesis of BCG prostatitis. PZ ducts enter the urethra at less obtuse angles than those from other zones and are likely to be more prone to urine reflux and damage from suspended BCG. We speculate that prostatic duct microanatomy could also play a role in the pathogenesis of other prostatic diseases, including conventional prostatitis and adenocarcinoma.

Role of Stromal Paracrine Signals in Proliferative Diseases of the Aging Human Prostate

Androgens are essential for the development, differentiation, growth, and function of the prostate through epithelial–stromal interactions. However, androgen concentrations in the hypertrophic human prostate decrease significantly with age, suggesting an inverse correlation between androgen levels and proliferative diseases of the aging prostate. In elderly males, age- and/or androgen-related stromal remodeling is spontaneously induced, i.e., increased fibroblast and myofibroblast numbers, but decreased smooth muscle cell numbers in the prostatic stroma. These fibroblasts produce not only growth factors, cytokines, and extracellular matrix proteins, but also microRNAs as stromal paracrine signals that stimulate prostate epithelial cell proliferation. Surgical or chemical castration is the standard systemic therapy for patients with advanced prostate cancer. Androgen deprivation therapy induces temporary remission, but the majority of patients eventually progress to castration-resistant prostate cancer, which is associated with a high mortality rate. Androgen deprivation therapy-induced stromal remodeling may be involved in the development and progression of castration-resistant prostate cancer. In the tumor microenvironment, activated fibroblasts stimulating prostate cancer cell proliferation are called carcinoma-associated fibroblasts. In this review, we summarize the role of stromal paracrine signals in proliferative diseases of the aging human prostate and discuss the potential clinical applications of carcinoma-associated fibroblast-derived exosomal microRNAs as promising biomarkers.

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.

Dutasteride for the prevention of prostate cancer in men with high-grade prostatic intraepithelial neoplasia: results of a phase III randomized open-label 3-year trial

PURPOSE

High-grade prostatic intraepithelial neoplasia (HGPIN) is a potential precursor of prostate cancer (PCa), and patients with HGPIN are at high risk for PCa development. Objective of our study was to evaluate the efficacy of dutasteride 0.5 mg in PCa prevention among men with isolated HGPIN on biopsy.

METHODS

This prospective, randomized, phase III, open-label 3-year trial assessed dutasteride versus active surveillance in patients with HGPIN. Patients were randomized to dutasteride 0.5 mg daily or active surveillance. Per-protocol prostate biopsies were performed at 6, 12, 24, and 36 months until cancer detection or study end. The primary end point was cancer-free survival (CFS). An intention-to-treat analysis was done for patients who underwent at least one per-protocol biopsy. An efficacy analysis was done for patients who completed the study. CFS was evaluated using Kaplan-Meier and log-rank analysis.

RESULTS

In total, 220 men were randomized (dutasteride, n = 107; surveillance, n = 113). PCa was detected in 47.6: 49.1 % in the surveillance group and 45.9 % in the treatment group (p = 0.66). The detected PCa differentiation by Gleason score (GS) was GS 6 in 76.9 %, GS 7 in 19.8 %, and GS ≥ 8 in 3.3 %, with no difference between groups. The 3-year PCa-free survival was 43.6 % in the surveillance and 49.6 % in the dutasteride group (log rank p = 0.57). Limitations include a relatively high non-adherence rate, open-label design, and baseline sextant biopsy scheme.

CONCLUSIONS

Dutasteride 0.5 mg for 3 years did not lower the PCa detection rate but did not worsen detected PCa characteristics in men with HGPIN.

MicroRNA alteration and putative target genes in high-grade prostatic intraepithelial neoplasia and prostate cancer: STAT3 and ZEB1 are upregulated during prostate carcinogenesis

BACKGROUND

We aimed to identify alteration of cancer-related miRNAs in HGPIN and PCa, and to investigate the clinical implications of HGPIN as a precancerous lesion of PCa.

METHODS

Clinicopathologic analysis based on the status of HGPIN was performed in 388 patients who received radical prostatectomy between January 2005 and December 2008 in Severance Hospital. Among them, 10 paired HGPIN and PCa were prepared to perform miRNA microarray and quantitative real-time PCR. Fifty-two prostatectomy specimens were used to further validation of protein expression that was assessed by immunohistochemical staining (IHC) in matched non-neoplastic prostatic tissue (NPT), HGPIN, and PCa. Functional analysis was performed using a prostate normal cell line (RWPE-1) and two prostate cancer cell lines (LNCaP, PC-3) for comparison of expression of miR-155 and STAT3 mRNA before and after treatment of miR-155 mimetics/antagomir into each cell line.

RESULTS

Patients with HGPIN had significantly less lymphovascular invasion, less lymph node metastasis, lower tumor volume, lower Gleason score, lower incidence of death, and longer overall survival compared to patients without HGPIN. MiR-155, miR-210, miR-153, and miR-200c were downregulated in HGPIN and PCa in common, compared to NPT. As putative target mRNAs, mRNA expression level of STAT3, ZEB1, and BACH1 was increased in PCa and HGPIN compared to NPT. mRNA expression level of ephrin-A3 was increased in PCa compared to NPT, and FGFRL1 was decreased in PCa compared to HGPIN and NPT. Protein expression assessed by IHC showed correlated results in STAT3, ZEB1, and ephrin-A3. Moreover, STAT3 and ZEB1 increased in a stepwise manner, from NPT to PCa. Treatment of miR-155 antagomir increased STAT3 mRNA expression in RWPE-1 cells, whereas treatment of miR-155 mimetics into PC-3 cells significantly decreased STAT3 expression.

CONCLUSIONS

STAT3 and ZEB1 could be the key molecules altered at the early stages of carcinogenesis, especially in HGPIN. Prostate 76:937-947, 2016. © 2016 Wiley Periodicals, Inc.

Significance and outcome of nuclear anaplasia and mitotic index in prostatic adenocarcinomas

OBJECTIVES

The Gleason grading system measures architectural differentiation and disregards nuclear atypia and the cell proliferation index. Several studies have reported that nuclear grade and mitotic index (MI) are prognostically useful.

PATIENTS AND METHODS

This study included 232 radical prostatectomy specimens. Nuclear anaplasia (NA) was determined on the basis of nucleomegali (at least 20µm); vesicular chromatin; eosinophilic macronucleoli, nuclear lobulation, and irregular thickened nuclear membranei. The proportion of area of NA was recorded in each tumor in 10% increments. The MI was defined as the number of mitotic figures in 10 consecutive high-power fields (HPF).

RESULTS

In univariate analysis, significant differences included associations between biochemical prostate-specific antigen recurrence (BCR) and Gleason score, extraprostatic extension, positive surgical margin, the presence of high-pathologic stage, NA≥10% of tumor area, MI≥3/10 HPF, and preoperative prostate-specific antigen. In a stepwise Cox regression model, a positive surgical margin, the presence of a NA≥10% of tumor area, and a MI of≥3/10 HPF were independent predictors of BCR after radical prostatectomy. NA≥10% of tumor area appeared to have a stronger association with outcome than MI≥3/10 HPF, as still associated with BCR when Gleason score was in the model.

CONCLUSIONS

The results of our study showed that, in addition to the conventional Gleason grading system, NA, and MI are useful prognostic parameters while evaluating long-term prognosis in prostatic adenocarcinoma.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

The association of the cribriform pattern with outcome for prostatic adenocarcinomas

With the revision of the Gleason system at the 2005 International Society of Urological Pathology Consensus Conference, there was consensus that most cribriform glands should be classified as pattern 4. There is now increased understanding that invasive cribriform carcinoma is a relatively aggressive disease. This study was based on 233 radical prostatectomy (RP) specimens collected at the Department of Pathology, Umraniye Education and Research Hospital, from 2006 to 2013. We assessed the cribriform foci associated with the more definitive patterns 3, 4, and 5 elsewhere on the RP specimens and evaluated the association of the presence of cribriform pattern (CP) with biochemical prostate-specific antigen recurrence (BPR). In Cox regression model, taking into account the Gleason score (GS), pathologic stage, surgical margin (SM) status, presence of a CP, and preoperative prostate-specific antigen (PSA), a positive SM, and the presence of a CP were independent predictors of BPR after RP. We observed BPR more frequently in GS 3+3 cases with a CP than in those without a CP (p=0.008). There was no significant difference in BPR status for cases with GS 3+4, 4+3, 4+5, and 5+4 when the patients were stratified by the presence of a CP. On the basis of these data, we suggest that the classification of CP into Gleason pattern 4 has value in predicting BPR status after RP. However, as many of these modifications are empirical and supported by only a few studies, long-term follow-up studies with clinical endpoints are necessary to validate these recommendations.

Significance of the cribriform pattern in prostatic adenocarcinomas

INTRODUCTION

There is now increased understanding that invasive cribriform carcinoma is a relatively aggressive disease. In some recent publications, the recommendation is that all cribriform patterns be classified as Gleason pattern (GP) 4 rather than GP 3.

MATERIALS AND METHODS

We assessed the cribriform foci (CF) associated with the more definitive patterns 3, 4, and 5 elsewhere on the 185 radical prostatectomy specimens and evaluated the association of the cribriform pattern with extraprostatic extension, surgical margin.

RESULTS

CF were more frequently observed in cases with definitive patterns 4 and 5 than in cases with pattern 3 (all cases with pattern 5 exhibited CF). Cases with Gleason score 3+3 and CF were more frequently associated with extraprostatic extension, and a positive surgical margin.

CONCLUSIONS

Our results demonstrate that diagnosing all cribriform patterns as at least GP 4 would significantly affect further therapeutic options and prognosis. However, as many of these modifications are empirical and supported by only a few studies, long-term follow-up studies with clinical endpoints are necessary to validate these recommendations.

Identification of FISH biomarkers to detect chromosome abnormalities associated with prostate adenocarcinoma in tumour and field effect environment

Background

To reduce sampling error associated with cancer detection in prostate needle biopsies, we explored the possibility of using fluorescence in situ hybridisation (FISH) to detect chromosomal abnormalities in the histologically benign prostate tissue from patients with adenocarcinoma of prostate.

Methods

Tumour specimens from 33 radical prostatectomy (RP) cases, histologically benign tissue from 17 of the 33 RP cases, and 26 benign prostatic hyperplasia (BPH) control cases were evaluated with Locus Specific Identifier (LSI) probes MYC (8q24), LPL (8p21.22), and PTEN (10q23), as well as with centromere enumerator probes CEP8, CEP10, and CEP7. A distribution of FISH signals in the tumour and histologically benign adjacent tissue was compared to that in BPH specimens using receiver operating characteristic curve analysis.

Results

The combination of MYC gain, CEP8 Abnormal, PTEN loss or chromosome 7 aneusomy was positive in the tumour area of all of the 33 specimens from patients with adenocarcinomas, and in 88% of adjacent histologically benign regions (15 out of 17) but in only 15% (4 out of 26) of the benign prostatic hyperplasia control specimens.

Conclusions

A panel of FISH markers may allow detection of genomic abnormalities that associate with adenocarcinoma in the field adjacent to and surrounding the tumour, and thus could potentially indicate the presence of cancer in the specimen even if the cancer focus itself was missed by biopsy and histology review.

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.

Precursors of prostate cancer

High-grade prostatic intraepithelial neoplasia (PIN) is the only accepted precursor of prostatic adenocarcinoma, according to numerous studies of animal models and man; other proposed precursors include atrophy and malignancy-associated changes (with no morphologic changes). PIN is characterized by progressive abnormalities of phenotype and genotype that are intermediate between benign prostatic epithelium and cancer, indicating impairment of cell differentiation and regulatory control with advancing stages of prostatic carcinogenesis. The only method of detection of PIN is biopsy because it does not significantly elevate serum prostate-specific antigen concentration and cannot be detected by ultrasonography. The mean incidence of PIN in biopsies is 9% (range, 4%-16%), representing about 115,000 new cases of isolated PIN diagnosed each year in the United States. The clinical importance of PIN is its high predictive value as a marker for adenocarcinoma, and its identification warrants repeat biopsy for concurrent or subsequent carcinoma, especially when multifocal or observed in association with atypical small acinar proliferation (ASAP). Carcinoma develops in most patients with PIN within 10 years. Androgen deprivation therapy and radiation therapy decrease the prevalence and extent of PIN, suggesting that these forms of treatment may play a role in prevention of subsequent cancer. Multiple clinical trials to date of men with PIN have had modest success in delaying or preventing subsequent cancer.

Implication of high grade intraepithelial neoplasia in adverse pathology after radical prostatectomy

The implication of high grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer aggressiveness and prognosis is conflicted. The aim of the present study was to evaluate the role of HGPIN in prediction of adverse pathology in patients undergoing a radical prostatectomy. We retrospectively analysed patients who underwent a radical prostatectomy between January 2005 and December 2010. The relationship between HGPIN and the presence of upgrade, positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and lymph node invasion (LNI) was analysed. HGPIN predictive ability was estimated by using receiver operating characteristic curves. HGPIN was found in 160 (53.3%) specimens. A statistically significant correlation was found between HGPIN and preoperative prostate specific antigen (p=0.020) and patients' age (p=0.025). No significant differences were found, regarding the presence of adverse pathological findings, between the patients with or without HGPIN, irrespective of the preoperative risk stratification. HGPIN did not reach significance for the prediction of upgrade, PSM, ECD, SVI and LNI. The presence of concomitant HGPIN and prostate cancer found not to be related with tumor aggressiveness in patients undergoing a radical prostatectomy and should not be considered as a parameter for the operative outcome prediction.

Incidentally found prostate cancer and influence on overall survival after radical cystoprostatectomy

Objectives. To determine incidentally found prostate cancer frequency and impact on overall survival after RCP. Patients and Methods. The records of 81 men who underwent cystoprostatectomy from January 2000 to December 2009 were reviewed. The vital status of the study group was assessed as on September 1, 2009, by passive followup, using data from the population registry. Results. The 81 men underwent RCP. The incidental prostate cancer was found in the specimens of 27 (33.3%) patients. 13 (48.1%) of 27 prostate cancer cases were clinically significant. For 3 patients (11.1%) an extraprostatic extension was found. For 2 patients (7.4%)—positive margins, for 1 patient (3.7%)—Gleason sum 8, and for the rest 7 patients bigger than 0.5 cm³ volume tumor, and Gleason sum 7 was found. The mean follow-up time was 39.2 ± 33.8 months (varies from 0.8 to 131.2 months). The patients with bladder cancer and incidentally found prostate cancer lived shorter (28.1 ± 27.5 and 45.5 ± 35.40 months). Higher overall survival (P = 0.03) was found in the patient group with bladder cancer without incidentally diagnosed prostate cancer. Conclusion. There are indications that in this small study prostate cancer has influenced on patients' survival with bladder cancer after radical cystoprostatectomy.

Heterogenous induction of carcinoma-associated fibroblast-like differentiation in normal human prostatic fibroblasts by co-culturing with prostate cancer cells

In the tumor microenvironment, carcinoma-associated fibroblasts (CAFs) are considered to play a critical role in the promotion of tumorigenesis. However, the mechanisms that generate CAFs are not well elucidated. To understand how CAFs are generated during primary cancer progression, we investigated the biochemical characteristics of normal human prostate stromal cells (PrSC) co-cultured with human prostate cancer (PCa) cells in vitro. In primary cultures of human PCa-derived stromal cells (PCaSC-8 and PCaSC-9), expression of TNC, ACTA2, EGF, FGF7, and IGF1 mRNA was generally higher than PrSC but gene expression patterns were not uniform between PCaSC-8 and PCaSC-9 cells. Transforming growth factor β (TGFβ) and vascular endothelial growth factor (VEGF) protein levels in both PCaSC-8 and PCaSC-9 cells were generally higher than PrSC but levels of both secreted proteins were not same. When PrSCs were co-cultured with androgen-sensitive LNCaP cells or its sublines, androgen-low-sensitive E9 cells and androgen-insensitive AIDL cells, mRNA expression of IGF1 was significantly increased in all combinations. In contrast, expression of COL1A1, TNC, and ACTA2 mRNA was significantly increased only in LNCaP + PrSC and E9 + PrSC co-cultures. Protein production of VEGF was significantly increased only in LNCaP + PrSC and E9 + PrSC co-cultures. Increase of TGFβ protein was observed only in E9 + PrSC co-cultures. These biochemical characteristics of PrSC were partially recapitulated in TGFβ-treated PrSC. We have demonstrated that normal fibroblasts co-cultured with cancer cells become activated and exhibit biochemical characteristics of CAFs in a heterogenous manner. Our results suggest that heterogenous induction of CAF-like differentiation might be strongly dependent on biochemical characteristics of adjacent cancer cells.

Prostate cancer as a model system for genetic diversity in tumors

This chapter will summarize novel understandings of the early molecular events in prostatic carcinogenesis that may underlie both the genetic and clinical heterogeneity. Areas covered include preneoplasia, stem cell concepts, telomere abnormalities, and the nature of tumor-stromal interactions. The oncogenomics of prostate cancer is reviewed with emphasis on androgen signaling, ETS gene family aberrations, and PTEN deletion. The notion that "field cancerization," coupled with genomic instability may explain both the occurrence of multifocal disease, and the recent observations of genetic diversity of ERG alteration in individual tumors are discussed. Collectively, genomic studies are rapidly moving human prostate cancer closer to the promise of personalized medicine, so that specific genetic profiles of individual tumors will determine the best therapeutic approaches.

Insulin-like growth factor-2 (IGF2) loss of imprinting marks a field defect within human prostates containing cancer

BACKGROUND

Loss of imprinting (LOI) is an epigenetic alteration involving loss of parental origin-specific expression at normally imprinted genes. A LOI for IGF2, a paracrine growth factor, has been implicated in the development of prostate and other cancers. In the current study, we define IGF2 LOI in histologically normal prostate tissues in relationship to tumor foci and gene expression.

METHODS

Microdissected tumor associated (TA) adjacent (2 mm) and distant (10 mm) tissues surrounding tumor foci were generated. IGF2 imprinting in informative prostate tissue sets was quantitated using a fluorescent primer extension assay and expression analyzed utilizing quantitative PCR. DNA methylation analyses were performed using quantitative pyrosequencing.

RESULTS

A marked IGF2 LOI was found in adjacent TA tissues (39 ± 3.1%) and did not significantly decrease in tissues distant (38 ± 5.3%) from tumor foci (45 ± 2.9%; P = 0.21). IGF2 imprinting correlated with IGF2 expression in TA tissues, but not within the tumor foci. Hypomethylation of the IGF2 DMR0 region correlated with decreased IGF2 expression in tumors (P < 0.01). The expression of IGF2 and its adjacent imprinted gene H19 were increased in adjacent and distant tissues compared to tumors (P < 0.05) indicating the importance of factors other than LOI in driving IGF2 expression.

CONCLUSIONS

LOI of IGF2 occurs not only adjacent to prostate tumor foci, but is widely prevalent even in distant areas within the peripheral zone. These data provide evidence for a widespread epigenetic field defect in histologically normal tissues that might be employed to identify prostate cancer in patients.

Evaluation of diffusion-weighted magnetic resonance imaging and contrast-enhanced harmonic ultrasonography in detection and location of prostate transition-zone cancer

This retrospective study was designed to evaluate the value of contrast-enhanced harmonic ultrasonography (CEHU), diffusion-weighted magnetic resonance imaging (DW-MRI) and CEHU plus DW-MRI for the diagnosis of prostate transition-zone (TZ) cancer. In total, 31 TZ cancers in 28 patients and 25 peripheral zone (PZ) cancers in 21 patients without a TZ cancer were evaluated. All patients underwent DW-MRI and CEHU followed by radical prostatectomy. Predictors for the diagnosis of prostate cancer were evaluated in three protocols (CEHU, DW-MRI, CEHU plus DW-MRI). Statistical analysis of the differences between these protocols and receiver operating characteristic (ROC) curve analysis were carried out. CEHU plus DW-MRI had a significantly higher sensitivity, accuracy and negative-predictive value (90.3%, 73.2% and 81.3%, respectively) for TZ cancer than either method alone. The area under the ROC curve values were 0.659, 0.679 and 0.712 for CEHU, DW-MRI, and CEHU plus DW-MRI, respectively. In conclusion, CEHU plus DW-MRI might be a useful protocol for the detection and location of TZ cancer.

Topographical analysis of telomere length and correlation with genomic instability in whole mount prostatectomies

BACKGROUND

Many critical events in prostatic carcinogenesis appear to relate to the emergence of genomic instability. Characteristic genomic abnormalities such as 8p loss, 8q gain, trisomy 7, and PTEN microdeletions may provide selective advantages to increase neoplastic transformation. Evidence suggests that telomere dysfunction is a plausible mechanism for some of these abnormalities on the basis of the break-fusion-bridge cycle that can lead to manifestations of genomic instability.

METHODS

In this study, we correlate telomere length measured by quantitative FISH in various prostatic histologies with markers of genomic instability and immunohistochemical measures of proliferation and oxidative stress.

RESULTS

We find that telomere shortening is correlated with abnormalities on chromosome 8, but not with trisomy 7 or abnormalities of the PTEN locus. There are associations with C-MYC aberrations in stroma with greater proximity to cancer and a correlation between telomere length in a number of prostatic histologies and the adjacent stroma, suggesting the importance of microenvironmental effects on telomere maintenance in the prostate. This finding was also supported by the finding of the correlation between telomere attrition and the levels of oxidative stress as measured by malondialdehyde staining in HPIN lesions close to cancer.

CONCLUSIONS

Telomere attrition in the prostate gland is associated with particular genomic aberrations that contribute to the genomic instability characteristic of prostatic carcinogenesis. Correlations between various histologies and adjacent stroma telomere length suggest it is also may reveal microenvironmental effects within the prostate gland. Oxidative stress may contribute to telomere attrition in HPIN close to cancer.

Independent predictors of biochemical recurrence after radical prostatectomy: a single center experience

Introduction

The aim of study was to establish pretreatment and postoperative factors which could predict the early biochemical recurrence after radical prostatectomy.

Materials and method

754 patients had undergone radical prostatectomy since January 2002 to December 2008 in our department and were included in this prospective study. Exclusion criteria were: neoadjuvant or adjuvant treatment (radiation or hormonal treatment) and N+. Following parameters were evaluated: age, PSA at time of biopsy, time period from biopsy to operation, biopsy and postoperative Gleason score, stage, high grade intraepithelial neoplasias, perineural invasion. Biochemical recurrence was detected if PSA value after radical prostatectomy was ≥0.2 ng/ml. All factors likely to be predictive were evaluated by univariate analysis (Log-rank test). Multivariate analysis using Cox model was completed for all factors with p value <0.1 at univariate analysis.

Results

Final analysis was done using data of 496 patients. We detected 53 (10.7%) biochemical recurrences. Calculated actuarial biochemical recurrence free survival reached 64%. Multivariate analysis highlighted that PSA >10 ng/ml (HR 2.45, p = 0.008), pathological stage ≥pT3 (HR 2.371, p = 0.02), postoperative Gleason score ≥7 (HR 2.149, p = 0.049), positive surgical margins (HR 2.482, p = 0.014) and absence of high grade intraepithelial neoplasia in removed prostate (HR 0.358, p = 0.006) are independent factors influencing biochemical recurrence after radical prostatectomy.

Conclusion

Patients with higher PSA, locally advanced disease, positive surgical margins, and Gleason score ≥7 are at the highest risk for biochemical recurrence.

Metastasis suppressors in human benign prostate, intraepithelial neoplasia, and invasive cancer: their prospects as therapeutic agents

Despite advances in diagnosis and treatment of prostate cancer, development of metastases remains a major clinical challenge. Research efforts are dedicated to overcome this problem by understanding the molecular basis of the transition from benign cells to prostatic intraepithelial neoplasia (PIN), localized carcinoma, and metastatic cancer. Identification of proteins that inhibit dissemination of cancer cells will provide new perspectives to define novel therapeutics. Development of antimetastatic drugs that trigger or mimic the effect of metastasis suppressors represents new therapeutic approaches to improve patient survival. This review focuses on different biochemical and cellular functions of metastasis suppressors known to play a role in prostate carcinogenesis and progression. Ten putative metastasis suppressors implicated in prostate cancer are discussed. CD44s is decreased in both PIN and cancer; Drg-1, E-cadherin, KAI-1, RKIP, and SSeCKS show similar expression between benign epithelia and PIN, but are downregulated in invasive cancer; whereas, maspin, MKK4, Nm23 and PTEN are upregulated in PIN and downregulated in cancer. Moreover, the potential role of microRNA in prostate cancer progression, the understanding of the cellular distribution and localization of metastasis suppressors, their mechanism of action, their effect on prostate invasion and metastasis, and their potential use as therapeutics are addressed.

Long-term follow-up of men with isolated high-grade prostatic intra-epithelial neoplasia followed by serial delayed interval biopsy

OBJECTIVES

To analyze the outcomes of serial delayed interval biopsy (DIBx) in men with isolated high-grade prostatic intraepithelial neoplasia (HGPIN). The natural history of isolated HGPIN is poorly defined. Since January 2000, we have monitored men with isolated HGPIN using DIBx every 3 years, regardless of the change in prostate-specific antigen (PSA) level.

METHODS

The institutional biopsy records from 1996 onward were reviewed to identify the men with isolated HGPIN found on 12-core needle biopsy specimens who had undergone a minimum of 1 DIBx in our follow-up strategy. Patient age, biopsy and prostatectomy pathologic outcomes, and longitudinal PSA measurements were recorded.

RESULTS

A total of 112 men had undergone a first DIBx and 47 had undergone a second DIBx at the last follow-up examination at a mean of 34.4 and 66.2 months after the HGPIN diagnosis, respectively. Prostate cancer was found in 25 (22.3%) of 112 men and 11 (23.4%) of 47 men at DIBx-1 and DIBx-2, respectively. The PSA velocity was not predictive of cancer during short-term follow-up. Of the men diagnosed with cancer, 63.6% had a Gleason score of ≥7, and 9 (81.8%) of 11 men had clinically significant disease (Gleason score of ≥7 and/or >5% cancer volume) at surgery. All cancers were organ confined at and surgery.

CONCLUSIONS

Men with isolated HGPIN have a continued risk of developing prostate cancer during long-term follow-up, regardless of the changes in the serum PSA level. Collectively, the relatively high likelihood of organ confinement and clinically significant cancer suggest empiric DIBx every 2-3 years could be a valuable tool in the follow-up of men with isolated HGPIN found by extended core biopsy.

Organ-wide telomeric status in diseased and disease-free prostatic tissues

BACKGROUND

Telomere attrition occurs early in the development of prostatic adenocarcinoma. However, little is known about either telomere status in benign prostatic hyperplasia (BPH), or the spatial and organ-wide distribution of potential telomere aberrations throughout all areas of prostatic glands affected by cancer or BPH.

METHODS

Slot blot titration assay was used to determine telomere DNA content (TC), a proxy for telomere length, in macrodissected tissue consisting of 54 normal samples from 5 disease-free prostates, 128 BPH samples from 4 non-cancerous prostates, and 45 tumor, 73 BPH, and 4 prostatic intraepithelial neoplasia (PIN) samples from 5 cancerous prostates.

RESULTS

Compared to TC in normal prostate samples (n = 54; TC mean = 0.98), tumor samples displayed telomere attrition (n = 45; TC mean = 0.67). TC in PIN samples was similar to tumors. TC in BPH samples from cancerous prostates was similar to TC in tumors and also displayed telomere shortening (n = 73; TC mean = 0.76), whereas BPH samples from non-cancerous prostates displayed longer telomeres (n = 128; TC mean = 1.06). In prostates affected by adenocarcinoma, areas of potential telomere attrition occurred in histologically normal tissues through the entire gland. However, three-dimensional zoning revealed a pattern of increasing TC as a function of distance from the primary (index) tumor.

CONCLUSIONS

Spatial distributions of TC in prostate specimens indicate a complex "field effect" with varying contributions from both cancer and BPH. The observation that telomere length variations occur in fields of histologically normal tissues surrounding the tumor is of clinical importance, as it may have implications for the diagnosis and focal therapy of prostate cancer.

Clinicopathological Strategies to Identify Contralateral Prostate Cancer Involvement in Potential Candidates for Focal Therapy

Objective: To identify the magnitude and possible predictors of contralateral lobe involvement and contralateral extraprostatic extension (EPE) in prostatic biopsy—defined localized unilateral cancers. Patients and Methods: Between January 2005 and August 2009, 1861 patients underwent robotic-assisted radical prostatectomy at the authors’ institution. A total of 1114 had unilateral disease on preoperative biopsy. Final histopathology reports of these patients were reviewed. Results: Of the 1114 patients with unilateral disease on biopsy, 867 (77.9%) had contralateral or bilateral disease on final histopathology. EPE was found in 132 patients (11.9%). Twenty patients (1.8%) had contralateral EPE involvement. High-grade prostatic intraepithelial neoplasm (HGPIN) on biopsy was the significant predictor of contralateral lobe involvement on both univariate ( P = .02; odds ratio [OR] = 1.791) and multivariate analysis ( P = .004; OR = 2.677). Clinical stage T2 was the significant predictor of contralateral EPE on both univariate ( P = .012; OR = 5.250) and multivariate analysis ( P = .007; OR = 8.656). Conclusion: HGPIN on biopsy significantly predicts for contralateral lobe involvement and should be considered an exclusion criterion for focal therapy in prostate cancer patients. Patients with palpable tumor on digital rectal examination should be advised in favor of radical treatment as these patients may harbor more aggressive tumors involving the contralateral side despite the biopsy findings.

Evidence for field cancerization of the prostate

BACKGROUND

Field cancerization, which is not yet well-characterized in the prostate, occurs when large areas of an organ or tissue surface are affected by a carcinogenic insult, resulting in the development of multi-focal independent premalignant foci and molecular lesions that precede histological change.

METHODS

Herein, we review the cumulative body of evidence concerning field effects in the prostate and critically evaluate the methods available for the identification and validation of field effect biomarkers. Validated biomarkers for field effects have an important role to play as surrogate endpoint biomarkers in Phase II prevention trials and as clinical predictors of cancer in men with negative biopsies.

RESULTS

Thus far, field effects have been identified involving nuclear morphometric changes, gene expression, protein expression, gene promoter methylation, DNA damage and angiogenesis. In addition to comparing cancer-adjacent benign tissue to more distant areas or to "supernormal" tissue from cancer-free organs, investigators can use a nested case-control design for negative biopsies that offers a number of unique advantages.

CONCLUSIONS

True carcinogenic field effects should be distinguished from secondary responses of the microenvironment to a developing tumor, although the latter may still lead to useful clinical prediction tools. Prostate 69: 1470-1479, 2009. (c) 2009 Wiley-Liss, Inc.

Precursor Lesions of Prostate Cancer

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

[Clinical significance of prostatic intraepithelial neoplasm and atypical small acinar proliferation: relationship with prostate cancer]

INTRODUCTION

Prostatic intraepithelial neoplasia (PIN) and atypical small acinar proliferation (ASAP) in the setting of prostatic needle biopsies are considered premalignant although questions still remain.

OBJECTIVES

In this paper, we have studied the clinical relevance of these histologic findings.

MATERIAL AND METHODS

We collected 138 subjects (108 PIN, 30 ASAP); in 67% we performed a second biopsy and the rate of cancer in this late biopsy were 19% and 27% respectively. We cannot identify any clinical factor to predict the finding of cancer in the re-biopsy (PSA, age, digital rectal examination, prostatic volume).

RESULTS

In the follow-up, we observed higher rates of cancer for the ASAP; the finding of ASAP was the single clinical or histopathological factor that was an independent predictor of cancer.

CONCLUSIONS

We observed that the finding of ASAP was an indication for re-biopsy because of the higher rates of cancer; on the contrary, the paper of PIN in the prostatic needle biopsy still requires further investigation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maximum tumor diameter is not an independent prognostic factor in high-risk localized prostate cancer

OBJECTIVES

Previous studies suggest that maximum tumor diameter (MTD) is a predictor of recurrence in prostate cancer (PC). This study investigates the prognostic value of MTD for biochemical recurrence (BCR) in patients with PC, after radical prostatectomy (RP), with emphasis on high-risk localized prostate cancer.

METHODS

RP specimens of 542 patients were evaluated with a median follow-up of 39.5 months (range 0.6-150 months). MTD was defined as the largest diameter of the largest tumor; high-risk as >or=T2c or PSA level>20 ng/ml or Gleason score>or=8 and BCR as two consecutive PSA levels>0.10 ng/ml. Proportional hazards multivariable regression models were composed to determine prognostic factors for BCR.

RESULTS

Overall, 114 patients developed BCR after RP. The overall 5-year risk of BCR was 25% (95% CI=20.4-29.6), and median MTD was 24 mm (range 1-65). MTD in the total and high-risk group was associated with total tumor volume, volume of the largest tumor, pre-operative PSA levels, and Gleason score. In a univariable analyses, MTD was weakly associated with risk of BCR (HR=1.02 per mm increase, 95% CI=1.002-1.035, P=0.024) in the total group; in the high-risk group this association was lost (HR=1.01, 95%CI=0.99-1.03, P=0.18). Multivariable analyses indicated that positive surgical margins, higher Gleason score, advanced pathological stage, and multiple tumors were the main prognostic factors for BCR irrespective of the risk profile. MTD did not provide additional information.

CONCLUSIONS

MTD is not an independent prognostic factor for BCR in patients treated with RP, irrespective of the risk profile.

Mapping of TMPRSS2-ERG fusions in the context of multi-focal prostate cancer

TMPRSS2-ERG gene fusion leading to the androgenic induction of the ERG proto-oncogene expression is a highly prevalent oncogenic alteration in prostate tumor cells. Prostate cancer is a multi-focal disease, and the origins as well as biological contribution of multiple cancer foci remain unclear with respect to prostate cancer onset or progression. To assess the role of TMPRSS2-ERG alteration in prostate cancer onset and/or progression, we have evaluated the status of fusion transcripts in benign glands, prostatic intraepithelial neoplasia (PIN) and multiple cancer foci of each prostate. Quantitative expression of TMPRSS2-ERG fusion type A and C transcripts was analyzed in benign, tumor and PIN areas, selected from whole-mount radical prostatectomy slides. TMPRSS2-ERG expression was correlated with clinicopathological features. Overall, 30 of 45 (67%) patients exhibited TMPRSS2-ERG fusion transcripts in at least one tumor focus. Of 80 tumor foci analyzed, 39 had TMPRSS2-ERG fusion (type A only: 30, type C only: 2, both types A and C: 7), with predominant detection of the TMPRSS2-ERG fusion type A (27/30, 90%) in the index tumors. Of 14 PIN lesions, 2 were positive for type A fusion. Frequent presence of the TMPRSS2-ERG in index tumors suggests critical roles of ERG alterations in the onset and progression of a large subset of prostate cancer. However, heterogeneity of the TMPRSS2-ERG detection in the context of multiple cancer foci and its frequency in PIN also support the role of other genomic alterations in the origins of prostate cancer.

Clinically significant prostate cancer local recurrence after radiation therapy occurs at the site of primary tumor: magnetic resonance imaging and step-section pathology evidence

PURPOSE

To determine whether prostate cancer local recurrence after radiation therapy (RT) occurs at the site of primary tumor by retrospectively comparing the tumor location on pre-RT and post-RT magnetic resonance imaging (MRI) and using step-section pathology after salvage radical prostatectomy (SRP) as the reference standard.

METHODS AND MATERIALS

Nine patients with localized prostate cancer were treated with intensity modulated RT (69-86.4 Gy), and had pre-RT and post-RT prostate MRI, biopsy-proven local recurrence, and SRP. The location and volume of lesions on pre-RT and post-RT MRI were correlated with step-section pathology findings. Tumor foci >0.2 cm(3) and/or resulting in extraprostatic disease on pathology were considered clinically significant.

RESULTS

All nine significant tumor foci (one in each patient; volume range, 0.22-8.63 cm(3)) were detected both on pre-RT and post-RT MRI and displayed strikingly similar appearances on pre-RT and post-RT MRI and step-section pathology. Two clinically insignificant tumor foci (</=0.06 cm(3)) were not detected on imaging. The ratios between tumor volumes on pathology and on post-RT MRI ranged from 0.52 to 2.80.

CONCLUSIONS

Our study provides a direct visual confirmation that clinically significant post-RT local recurrence occurs at the site of primary tumor. Our results are in agreement with reported clinical and pathologic results and support the current practice of boosting the radiation dose within the primary tumor using imaging guidance. They also suggest that monitoring of primary tumor with pre-RT and post-RT MRI could lead to early detection of local recurrence amenable to salvage treatment.

Contemporary clinical management of isolated high-grade prostatic intraepithelial neoplasia

High-grade prostatic intraepithelial neoplasia (HGPIN) is a premalignant lesion associated with increased risk of coexistent cancer or delayed progression to carcinoma. Extended biopsy schemes have improved the ability to rule out concurrent cancers, increased the detection of isolated HGPIN and removed the routine necessity for immediate repeat biopsy. As the natural history of HGPIN is poorly defined, and no non-invasive marker allows monitoring of progression to cancer, routine delayed interval biopsy should be considered in all patients. In this article, we present an overview of the existing literature on HGPIN and a proposed strategy for clinical management.

High-grade prostatic intraepithelial neoplasia is an independent predictor of outcome after radical prostatectomy

OBJECTIVE

To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer.

PATIENTS AND METHODS

The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS.

RESULTS

In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum.

CONCLUSIONS

In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.

Diagnosis of prostatic carcinoma after therapy

CONTEXT

Prostate cancer is the most common cancer of men in the United States and is third only to lung and colon cancer as a cause of cancer death. In 2006, 27,350 Americans will die of prostate cancer, and 234,460 new cases will be diagnosed. Treatment changes in the benign and cancerous prostate create diagnostic challenges in pathologic interpretation, particularly in needle biopsy specimens and in evaluation of extraprostatic metastases.

OBJECTIVE

To summarize therapy-related pathologic findings in the prostate with emphasis on recognition of treated adenocarcinoma.

DATA SOURCES

Extensive review of published literature and the authors' experience.

CONCLUSIONS

Following therapy for prostate cancer, it is critical that the clinician provide the pertinent history of androgen deprivation or radiation therapy to assist the pathologist in rendering the correct diagnosis.

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.

The 3-dimensional structure of isolated and small foci of prostatic adenocarcinoma: the morphologic relationship between prostatic adenocarcinoma and prostatic intraepithelial neoplasia

BACKGROUND

Transitional histopathologic changes from high-grade prostatic intraepithelial neoplasia (HGPIN) into early prostatic adenocarcinoma (PAC) have not been well studied to date. To investigate the histogenesis of PAC, we examined isolated and small foci of PAC (ISPAC) found in prostatectomy specimens and the 3-dimensional structure of these foci.

DESIGN

Twelve consecutive radical prostatectomy specimens having ISPAC, performed for peripheral zone PAC (10 cases) and for transitional zone PAC (2 cases), of Gleason score were studied. One to 2 tissue blocks with representative sections were used.

RESULTS

Eight ISPAC, with Gleason score 3 + 3 had complete serial sections of the entire lesion. PAC consisted of continuous, tortuous and branching tubules and acini arising from benign ducts displaying: (a) HGPIN in 5 ISPAC and (b) no HGPIN in 3 ISAPC. At the junctions between benign epithelia with or without HGPIN and malignant epithelia, there were transitional lesions with HGPIN involving small ducts and acini.

CONCLUSIONS

PAC develops as a result of multiple outpouchings of the epithelium with formation of small ducts and acini showing cytologic atypia and gradual or abrupt loss of basal cells. Grade 3 ISPAC consists of a system of continuous duct pushing into the stroma. There is also evidence suggestive of HGPIN as being both a precursor lesion and an accompanying lesion of PAC.

Finasteride decreases the risk of prostatic intraepithelial neoplasia

PURPOSE

High grade prostatic intraepithelial neoplasia is likely a premalignant lesion of the prostate. Decreasing the frequency of high grade PIN may decrease the risk of prostate cancer. In the Prostate Cancer Prevention Trial we evaluated the impact of finasteride on the risk of a needle biopsy diagnosis of high grade prostatic intraepithelial neoplasia.

MATERIALS AND METHODS

The Prostate Cancer Prevention Trial was a randomized, placebo controlled clinical trial that enrolled 18,882 men without evidence of prostate cancer, prostate specific antigen less than 3.0 ng/ml and normal digital rectal examination, and randomized them to 5 mg finasteride daily or placebo. Subjects were followed for 7 years with biopsy recommended for prostate specific antigen greater than 4.0 ng/ml, adjusted in the finasteride group to achieve an equal number of biopsy recommendations or for abnormal digital rectal examination. All cancer-free subjects were recommended to undergo biopsy after 7 years on study. We evaluated the diagnosis of high grade prostatic intraepithelial neoplasia with or without concomitant prostate cancer in these 2 study groups.

RESULTS

The number of men evaluable for high grade prostatic intraepithelial neoplasia was 4,568 in the finasteride group and 4,886 in the placebo group. High grade prostatic intraepithelial neoplasia alone was diagnosed in 276 men (6.0%) in the finasteride group vs 347 (7.1%) in the placebo group (RR 0.85, 95% CI 0.73-0.99, p=0.04). High grade prostatic intraepithelial neoplasia accompanied by prostate cancer was diagnosed in 144 men (3.2%) in the finasteride group vs 223 (4.6%) in the placebo group (RR 0.69, 95% CI 0.56-0.85, p=0.0004). Finasteride significantly decreased the overall risk of high grade prostatic intraepithelial neoplasia (alone and with cancer) from 570 cases (11.7%) in the placebo group to 420 (9.2%) in the finasteride group (HR 0.79, 95% CI 0.70-0.89, p<0.001).

CONCLUSIONS

Finasteride significantly decreased the risk of high grade PIN. This observation may explain how finasteride decreased prostate cancer in the Prostate Cancer Prevention Trial, supporting the notion that high grade prostatic intraepithelial neoplasia is a premalignant lesion of the prostate, and it provides new information relevant to the consideration of finasteride for prostate cancer prevention.

The ABCA5 protein: a urine diagnostic marker for prostatic intraepithelial neoplasia

PURPOSE

To develop a urine diagnostic test for preneoplastic intraepithelial neoplasia of the prostate.

EXPERIMENTAL DESIGN

We have used a DNA-binding assay and electrophoretic mobility shift assays (EMSA) to screen for novel duplexed DNA-binding sequences, which bind protein(s) overexpressed in crude protein extracts from high-grade prostatic intraepithelial neoplasia (HGPIN). EMSAs, immunohistochemistry, and ELISAs were used to measure expression of the ABCA5 protein identified as a specific marker in prostate tissue and patient urine.

RESULTS

Following screening of 4,096 sequences, an 8-bp dsDNA sequence (i.e., TCCAGCGA) was identified, which binds the ABCA5 protein, a member of the ATP-binding cassette multidrug resistant family. EMSAs showed that ABCA5 was overexpressed in HGPIN tissue (n=11/11) and in the urine of patients with HGPIN (n=18/18) but was not expressed in prostate cancer, benign prostatic hyperplasia, or stroma. Immunohistochemistry indicated that ABCA5 was overexpressed in foci of intermediate basal cells in normal glands and in HGPIN. ABCA5 was faintly expressed in prostate cancer glands. ELISAs showed in 'blinded studies' that ABCA5 was a highly sensitive (>98% sensitivity) urine diagnostic marker for HGPIN in biopsy-positive patients (n=107) at a 'cutoff' of 25 ng/mL. ABCA5 was present at very low levels (i.e., <25 ng/mL) in the urine of patients diagnosed with benign prostatic hyperplasia (n=79) or prostatitis or kidney and bladder cancer (>86% specificity).

CONCLUSIONS

The data indicate that ABCA5 might be a specific urine marker for diagnosis of patients with HGPIN.

Incidental prostatic adenocarcinoma in patients with PSA less than 4 ng/ml undergoing radical cystoprostatectomy for bladder cancer in iranian men

OBJECTIVE

To assess the incidence of prostate adenocarcinoma in patients undergoing radical cystoprostatectomy due to bladder cancer in Iranian men.

MATERIALS AND METHODS

Fifty cystoprostatectomy specimens removed due to bladder malignancy (2004-2005) at two referral centers (Shaheed Modarress and Shaheed Labbafinejad Hospitals, Tehran, Iran) were examined for the coincidental finding of prostate cancer (PCa). At the time of surgery the patient's serum PSA was less than 4 ng/mL and there were no suspicious lesions by digital rectal examination. Pathologic grade, stage, morphometric volume, number of tumor foci and association with areas of high grade prostatic intraepithelial neoplasia (HGPIN) were assessed by light microscopy. All specimens were totally embedded and whole-mounted. Clinically significant cancers were defined as tumors with >or= 0.5 mL volume, Gleason pattern 4 or 5, pT3, positive surgical margin, and multifocality > 3.

RESULTS

Incidentally detected cancer was found in 7 (14%) of cystoprostatectomy specimens. HGPIN was present in 1 (14.3%) of the cystoprostatectomies with incidentally detected prostate cancer. None of cystoprostatectomies without prostate cancer had HGPIN. Four (57%) of the detected cancers were significant.

CONCLUSION

We conclude that incidentally detected prostate cancer in Iran is lower than the rates reported in other countries. Further studies are warranted for better declaration of variability of prostate cancer between different ethnic groups.

Cancer statistics, 2007

Each year, the American Cancer Society (ACS) estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. This report considers incidence data through 2003 and mortality data through 2004. Incidence and death rates are age-standardized to the 2000 US standard million population. A total of 1,444,920 new cancer cases and 559,650 deaths for cancers are projected to occur in the United States in 2007. Notable trends in cancer incidence and mortality rates include stabilization of the age-standardized, delay-adjusted incidence rates for all cancers combined in men from 1995 through 2003; a continuing increase in the incidence rate by 0.3% per year in women; and a 13.6% total decrease in age-standardized cancer death rates among men and women combined between 1991 and 2004. This report also examines cancer incidence, mortality, and survival by site, sex, race/ethnicity, geographic area, and calendar year, as well as the proportionate contribution of selected sites to the overall trends. While the absolute number of cancer deaths decreased for the second consecutive year in the United States (by more than 3,000 from 2003 to 2004) and much progress has been made in reducing mortality rates and improving survival, cancer still accounts for more deaths than heart disease in persons under age 85 years. Further progress can be accelerated by supporting new discoveries and by applying existing cancer control knowledge across all segments of the population.