Significance of high-grade prostatic intraepithelial neoplasia on prostate biopsy

Predictive values of vascular endothelial growth factor and microvessel-density levels in initial biopsy for prostate cancer

Angiogenesis is an important factor in the development and progression of prostate cancer (PCA). We aimed to investigate the values of vascular-endothelial-growth-factor (VEGF) expression level and microvessel density (MVD) in the prediction of PCA diagnosis at repeated prostate biopsy (re-PBx). We retrospectively evaluated 167 patients with re-PBx according to elevated prostate-specific antigen levels, suspicious digital rectal examination, and the presence of premalignant lesions. Patients with PCA on re-PBx were included in the cancer group (n = 17). Patients with benign prostatic hyperplasia or normal tissues on re-PBx were included in the control group (n = 21). The groups were compared according to the expression level of VEGF and MVD in initial prostate biopsy. There was no statistically significant difference between groups according to age and serum prostate-specific-antigen values. The mean VEGF scores of the cancer and control groups were 232.64 ± 11.14 and 183.09 ± 14.56, respectively (p < 0.05). The mean MVD of the biopsy samples in the cancer and control groups were 246.47 ± 17.59 n/mm(2) and 197.33 ± 16.26 n/mm(2), respectively (p < 0.05). The cutoff values of VEGF scores and MVD were set as 200 and 215, respectively, for PCA detection in our study. Our results showed that the expression level of VEGF and MVD significantly increased in the initial prostate-biopsy samples of patients with PCA diagnosed with re-PBx. The evaluation of VEGF expression level and MVD might have an important value in the prediction of PCA at re-PBx. The expression level of VEGF and MVD should be kept in mind as PCA-related histopathological changes that indicate the increased angiogenesis in prostatic tissue.

Multiple cores of high grade prostatic intraepithelial neoplasia and any core of atypia on first biopsy are significant predictor for cancer detection at a repeat biopsy

Purpose

To investigate the differences in the cancer detection rate and pathological findings on a second prostate biopsy according to benign diagnosis, high-grade prostatic intraepithelial neoplasia (HGPIN), and atypical small acinar proliferation (ASAP) on first biopsy.

Materials and Methods

We retrospectively reviewed the records of 1,323 patients who underwent a second prostate biopsy between March 1995 and November 2012. We divided the patients into three groups according to the pathologic findings on the first biopsy (benign diagnosis, HGPIN, and ASAP). We compared the cancer detection rate and Gleason scores on second biopsy and the unfavorable disease rate after radical prostatectomy among the three groups.

Results

A total of 214 patients (16.2%) were diagnosed with prostate cancer on a second biopsy. The rate of cancer detection was 14.6% in the benign diagnosis group, 22.1% in the HGPIN group, and 32.1% in the ASAP group, respectively (p<0.001). When patients were divided into subgroups according to the number of positive cores, the rate of cancer detection was 16.7%, 30.5%, 31.0%, and 36.4% in patients with a single core of HGPIN, more than one core of HGPIN, a single core of ASAP, and more than one core of ASAP, respectively. There were no significant differences in Gleason scores on second biopsy (p=0.324) or in the unfavorable disease rate after radical prostatectomy among the three groups (benign diagnosis vs. HGPIN, p=0.857, and benign diagnosis vs. ASAP, p=0.957, respectively).

Conclusions

Patients with multiple cores of HGPIN or any core number of ASAP on a first biopsy had a significantly higher cancer detection rate on a second biopsy. Repeat biopsy should be considered and not be delayed in those patients.

Significance of atypical small acinar proliferation and high-grade prostatic intraepithelial neoplasia in prostate biopsy

Purpose

In clinical practice, atypical small acinar proliferation (ASAP) and high-grade prostatic intraepithelial neoplasia (HGPIN) are two common findings on prostate biopsies. Knowing the frequency of a prostate cancer diagnosis on repeat biopsies would aid primary treating physicians regarding their decisions in suspicious cases.

Materials and Methods

One hundred forty-three patients in whom biopsies revealed ASAP or HGPIN or both were enrolled in the present study; prostate cancer was not reported in the biopsy specimens and at least one repeat biopsy was performed. Age, digital rectal examination findings, prostate volumes, and free and total prostate-specific antigen (PSA) levels and the biopsy results of the patients were recorded.

Results

Of the 97 patients with ASAP on the first set of biopsies, prostate cancer was diagnosed in the second and third biopsies of 32 and 6 patients, respectively. Prostate cancer was not detected in the second or third biopsies of the 40 patients with HGPIN in the first biopsy. Of the 6 patients with ASAP+HGPIN in the first biopsy, prostate cancer was detected in 3 patients in the second biopsy and in 1 patient in the third biopsy.

Conclusions

The diagnosis of ASAP is a strong risk factor for prostate cancer. A repeat biopsy should be performed for the entire prostate subsequent to the diagnosis of ASAP. In patients with HGPIN according to the biopsy result, the clinical decision should be based on other parameters, such as PSA values and rectal examination, and a repeat biopsy should be avoided if the initial biopsy was performed with multiple sampling.

Repeat prostate biopsy--when, where, and how

Patients who have a persistently elevated or a rising PSA level following a prior negative prostate biopsy can be a stressful situation for both the urologist and the patient. This will be a brief review of the indications and techniques in patients undergoing a repeat biopsy. In patients with a prior negative biopsy, assessing the adequacy of the initial biopsy is important. F/T PSA is currently the most useful marker in predicting cancer on repeat biopsy although newer markers, such as PCA3, are promising. Repeat biopsies should include a minimum of 14 cores, the 12 cores recommended for an initial biopsy and 2 additional cores obtained form the right and left anterior apex. In patients for whom repeat biopsies fail to identify cancer, yet the clinical suspicion remains high, consideration for a saturation biopsy approach seems warranted.

Prostate biopsy strategies

Early detection is critical to good management of prostate cancer patients. Markers for detection, such as prostate specific antigen (PSA), and prostate biopsy are paramount for establishing an efficient diagnosis. Patients having an initial biopsy should undergo an extended biopsy scheme incorporating at least 10-12 cores, while in those undergoing a repeat biopsy particular attention should be addressed to the anterior apex. Saturation biopsies should be considered for patients with several prior negative biopsies. The chance of finding cancer on repeat biopsies has diminished in patients harboring high-grade prostatic intraepithelial neoplasia but not in those with atypical small acinar proliferation. This article reviews the history of prostate biopsy strategies with particular attention paid towards the development of extended biopsy schemes. Furthermore, a strategy is recommended for initial and repeat biopsy patients.

Functional heterogeneity of prostatic intraepithelial neoplasia: the duration of hormonal therapy influences the response

OBJECTIVES

To use a clinical model of androgen-deprivation therapy (ADT) followed by radical prostatectomy (RP) to test the hypothesis that prostatic intraepithelial neoplasia (PIN, a premalignant lesion of the prostate causally linked to prostate cancer) is heterogeneous for hormone responsiveness, which might explain aspects of the heterogeneity of the natural history of prostate cancer, for although ADT has been used to reduce prostate cancer, there are controversial data on the effect of ADT on PIN.

PATIENTS AND METHODS

We assessed retrospectively patients with biopsy-confirmed prostate cancer who had RP; some patients had received >or=3 months of ADT at the discretion of their surgeons, and patients from the same cohort who did not have ADT were used as controls. Patients were sequentially selected from the database and their pathology slides were reviewed by a pathologist unaware of the initial presence of PIN (assessed by an independent observer). Fisher's exact test was used to compare the proportions of patients who had residual PIN in the study and control groups. Exact logistic regression was used to evaluate the duration of ADT on PIN regression.

RESULTS

Eighteen patients initially diagnosed with PIN who had no ADT were identified, and 28 with PIN who had ADT were also assessed. All patients who had had no ADT had residual PIN, whereas seven of 28 receiving ADT had no residual PIN (P=0.043). The evaluation of ADT between responders and nonresponders showed a statistically significant association between PIN regression and the duration of ADT (P<0.001). However, the response of PIN to ADT was not uniform, as 16% of patients on ADT for >6 months had residual PIN, suggesting variable sensitivity of PIN to ADT.

CONCLUSION

These results show that ADT causes PIN to regress, and that there is heterogeneity in this effect with the duration of ADT. We propose future prospective, multicentre, randomized trials in which the effect of ADT on PIN is characterized further.

Role of desumoylation in the development of prostate cancer

SUMO is a novel ubiquitin-like protein that can covalently modify a large number of nuclear proteins. SUMO modification has emerged as an important regulatory mechanism for protein function and localization. Sumoylation is a dynamic process that is mediated by activating (E1), conjugating (E2), and ligating (E3) enzymes and is readily reversed by a family of SUMO-specific proteases (SENPs). Since SUMO was discovered 10 years ago, the biologic contribution of this posttranslational modification has remained unclear. In this review, we report that SENP1, a member of the SENP family, is overexpressed in human prostate cancer specimens. The induction of SENP1 is observed with the chronic exposure of prostate cancer cells to androgen and/or interleukin (IL) 6. SENP1 upregulation modulates the transcriptional activity of androgen receptors (ARs) and c-Jun, as well as cyclin D1 expression. Initial in vivo data from transgenic mice indicate that overexpression of SENP1 in the prostate leads to the development of prostatic intraepithelial neoplasia at an early age. Collectively, these studies indicate that overexpression of SENP1 is associated with prostate cancer development.

Significación pronóstica del PIN y la atípia glandular focal en la Biopsia Transrectal Ecodirigida de Próstata

OBJECTIVE

To review the incidence of PIN and Atypical Small Acinar Proliferation (ASAP) on first biopsy, the risk to find cancer on following biopsies and what is the importance given to this findings, analizing how frequently and how long after the initial finding this patients are rebiopsied.

METHOD

We selected 6000 patients who underwent TRUS biopsy between 1994 and 2002. Patients with prior cancer diagnosis were not included. 861 of them underwent more than one biopsy, adding up to a total of 7127 biopsies. A descriptive study has been done including percentages and percentiles for qualitative variables, mean and median for continuous variables.

RESULTS

Incidence of cancer on the first biopsy was 39,1%. PIN and ASAP are stable or slightly increase from 2 and 2,1% respectively on the first biopsy to more than 6% on the fourth and fifth ones. Mean time between biopsies when ASAP or PIN are the initial findings is 180 +/- 221,6 and 264 +/- 213,8 days respectively. Just 42 and 40% of patients with prior PIN or ASAP diagnose are rebiopsied. On subsequent biopsies 45 and 40% of cancers were respectively found.

CONCLUSIONS

Presence of PIN or ASAP implies a higher cancer risk on subsequent biopsies; in spite of that, less than half of them are biopsied again. Performing two more biopsies or an amplified biopsy can find most of the tumors associated.

The Role of an Extended 24 Cores Biopsy in Patients with Clinically Suspected Prostate Cancer and Prior Negative Biopsy

The aim of this study is to evaluate the role of an extensive “saturation biopsy” in patients at increased risk for prostate cancer with previously negative biopsies, HGPIN or ASAP diagnosis.

Materials and Methods

We performed an extensive 24 cores biopsy with spinal anaesthesia in 168 patients with at least 1 prior negative biopsy and persistently high PSA and/or abnormal digital rectal examination or with a ASAP or HGPIN diagnosis at previous biopsy.

Results

A total of 55 patients were diagnosed having prostate cancer for an overall diagnostic yeld of 33 %. Specifically, cancer was detected in 79% of ASAP, 32% of HGPIN and 28% of prior negative biopsies. 31 patients underwent radical retropubic prostatectomy. There was no correlation between number of positive biopsy cores and pathological stage or pathological Gleason score. A high concordance was found between clinical and pathological Gleason score.

Conclusions

Extensive biopsy can be considered a safe and effective diagnostic tool in men at risk for prostate cancer with previous negative biopsies. This procedure comes out to be particularly useful also in patients with a prior ASAP or HGPIN.

Microvessel density as a molecular marker for identifying high-grade prostatic intraepithelial neoplasia precursors to prostate cancer

BACKGROUND

Existing clinical data have shown that high-grade prostatic intraepithelial neoplasia (HGPIN) is the most likely precursor to prostate cancer (CaP). Criteria to distinguish HGPIN that progress to CaP from those that do not remain poorly defined. Our objective was to evaluate microvessel density as a molecular marker for distinguishing HGPINs that have the potential of progressing to cancer.

MATERIALS AND METHODS

Human prostatic tissue samples were collected randomly from 50 prostatectomy and cystoprostatectomy patients. Formalin-fixed and paraffin-embedded sections were used for immunohistochemical localization of rabbit anti-human von Willebrand factor VIII (vWF) IgG, mouse anti-high molecular weight cytokeratin 34BE-12 in basal cells, and mouse anti-heparan sulphate proteoglycan (HSPG) IgGs in basement membranes associated with benign prostatic hyperplasia (BPH), PIN associated with some BPH (isolated PIN), and PIN associated with CaP.

RESULTS

Analysis of immunostaining data showed that PINs could be categorized according to their distributions within and outside 2 standard deviations (SD) of the mean for microvessel density. The average number of microvessels was significantly higher (P < 0.0001) in PINs associated with Gleason score 7 tumors than those associated with Gleason scores 4-6 (P < 0.1328) or 8 and 9 tumors (P < 0.1708). Morphologically, PINs within 2 SD were composed of low- and high-grade type, whereas those outside 2 SD of microvessel density were predominantly of high-grade type. Cytokeratin and HSPG localization patterns also showed differences in PINs found within and outside 2 SD of microvessel density. We found localization of cytokeratin 34BE-12 in basal cells of specimens with BPH alone, isolated PIN, and PIN associated with CaP within 2 SD, whereas many PINs outside 2 SD showed disruptions in cytokeratin localization. The basement membranes of PINs within 2 SD of microvessel density were relatively intact, whereas those outside 2 SD were fragmented.

CONCLUSIONS

Our immunostaining data indicates that once HGPIN is found in the initial prostatic biopsy, it should be evaluated for microvessel density by localization of vWF. Our data indicate that characteristics of HGPIN can be augmented by evaluations of cytokeratin and HSPG molecular markers to assess the potential of HGPIN progression to malignancy. When biopsy samples show HGPIN with increased microvessel density and disrupted cytokeratin and HSPG markers, the patient may be a candidate for repeat biopsy. Since our study is limited to 50 prostate tissue samples, we emphasize that our conclusion is tentative and ought to be confirmed in a study with a larger sample size. This is the first report to show that microvessel density may distinguish HGPIN that is a precursor to prostate cancer.