My approach to intraductal lesions of the prostate gland

Deep UV Microscopy Identifies Prostatic Basal Cells: An Important Biomarker for Prostate Cancer Diagnostics

Objective and Impact Statement. Identifying benign mimics of prostatic adenocarcinoma remains a significant diagnostic challenge. In this work, we developed an approach based on label-free, high-resolution molecular imaging with multispectral deep ultraviolet (UV) microscopy which identifies important prostate tissue components, including basal cells. This work has significant implications towards improving the pathologic assessment and diagnosis of prostate cancer. Introduction. One of the most important indicators of prostate cancer is the absence of basal cells in glands and ducts. However, identifying basal cells using hematoxylin and eosin (H&E) stains, which is the standard of care, can be difficult in a subset of cases. In such situations, pathologists often resort to immunohistochemical (IHC) stains for a definitive diagnosis. However, IHC is expensive and time-consuming and requires more tissue sections which may not be available. In addition, IHC is subject to false-negative or false-positive stains which can potentially lead to an incorrect diagnosis. Methods. We leverage the rich molecular information of label-free multispectral deep UV microscopy to uniquely identify basal cells, luminal cells, and inflammatory cells. The method applies an unsupervised geometrical representation of principal component analysis to separate the various components of prostate tissue leading to multiple image representations of the molecular information. Results. Our results show that this method accurately and efficiently identifies benign and malignant glands with high fidelity, free of any staining procedures, based on the presence or absence of basal cells. We further use the molecular information to directly generate a high-resolution virtual IHC stain that clearly identifies basal cells, even in cases where IHC stains fail. Conclusion. Our simple, low-cost, and label-free deep UV method has the potential to improve and facilitate prostate cancer diagnosis by enabling robust identification of basal cells and other important prostate tissue components.

HoxB13 expression in ductal type adenocarcinoma of prostate: clinicopathologic characteristics and its utility as potential diagnostic marker

The histologic criteria and selective biomarkers of prostate ductal type adenocarcinoma (DAC) are relatively unknown compared to that known about acinar type adenocarcinoma (AAC). It is known that genetic alteration in Hox13 gene is associated with carcinogenesis of prostate cancer. In this study, we investigated clinicopathologic characteristics of HoxB13 expression in prostate cancer and compared clinicopathologic profiles of DAC and AAC of prostate. After slide review, some morphological variants of DAC, equivalent to Gleason pattern 3 and 5 of AAC were identified. High level of HoxB13 expression was identified in 46.5% (46 out of 99 cases) and 39.2% (31 out of 79 cases) of cases that belong to the training set and test set, respectively. In the training set, high level of HoxB13 expression was significantly correlated with DAC (P < 0.001), higher Gleason score (P < 0.001), advanced pathologic T stage (P = 0.010), and occurrence of biochemical recurrence (BCR; P < 0.001). The test set confirmed that high level of HoxB13 expression was associated with DAC (P < 0.001), higher Gleason score (P = 0.001), advanced pathologic T stage (P < 0.001), and occurrence of BCR (P < 0.001). Our findings suggest that HoxB13 may be a useful diagnostic marker for detection of DAC and a prognostic marker for prediction of BCR.

Grading of prostate cancer: a work in progress

Grading of prostate cancer has evolved substantially over time, not least because of major changes in diagnostic approach and concomitant shifts from late- to early-stage detection since the adoption of PSA testing from the late 1980s. After the conception of the architecture-based nine-tier Gleason grading system more than 50 years ago, several changes were made in order to increase its prognostic impact, to reduce interobserver variation and to improve concordance between prostate needle biopsy and radical prostatectomy grading. This eventually resulted in the current five-tier grading system, with a much more detailed description of the individual architectural patterns constituting the remaining three Gleason patterns (i.e. grades 3-5). Nevertheless, there is room for improvement. For instance, distinction of common grade 4 subpatterns such as ill-formed and fused glands from the grade 3 pattern is challenging, blurring the division between low-risk patients who could be eligible for deferred therapy and those who need curative therapy. The last few years have witnessed the publication of several studies on the prognostic impact of individual architectural subpatterns showing that, in particular, the cribriform pattern exceeded the prognostic impact of other grade 4 subpatterns. This review provides an overview of the changes in prostate cancer grading over time and provides a thorough description of the various Gleason subpatterns, the current evidence of their prognostic impact and areas of contention. Potential practical ways for improvements of the current grading system are also put forward.

Intraductal carcinoma of the prostate: a critical re-appraisal

Intraductal carcinoma of the prostate gland (IDCP), which is now categorised as a distinct entity by WHO 2016, includes two biologically distinct diseases. IDCP associated with invasive carcinoma (IDCP-inv) generally represents a growth pattern of invasive prostatic adenocarcinoma while the rarely encountered pure IDCP is a precursor of prostate cancer. This review highlights issues that require further discussion and clarification. The diagnostic criterion “nuclear size at least 6 times normal” is ambiguous as “size” could refer to either nuclear area or diameter. If area, then this criterion could be re-defined as nuclear diameter at least three times normal as it is difficult to visually compare area of nuclei. It is also unclear whether IDCP could also include tumours with ductal morphology. There is no consensus whether pure IDCP in needle biopsies should be managed with re-biopsy or radical therapy. A pragmatic approach would be to recommend radical therapy only for extensive pure IDCP that is morphologically unequivocal for high-grade prostate cancer. Active surveillance is not appropriate when low-grade invasive cancer is associated with IDCP, as such patients usually have unsampled high-grade prostatic adenocarcinoma. It is generally recommended that IDCP component of IDCP-inv should be included in tumour extent but not grade. However, there are good arguments in favour of grading IDCP associated with invasive cancer. All historical as well as contemporary Gleason outcome data are based on morphology and would have included an associated IDCP component in the tumour grade. WHO 2016 recommends that IDCP should not be graded, but it is unclear whether this applies to both pure IDCP and IDCP-inv.

The prognostic implication of intraductal carcinoma of the prostate in metastatic castration-resistant prostate cancer and its potential predictive value in those treated with docetaxel or abiraterone as first-line therapy

Intraductal carcinoma of the prostate (IDC-P) is recognized as a newly pathological entity in 2016 WHO classification. It's role in metastatic castration-resistant prostate cancer (CRPC) remains obscure. We aimed to explore the association of IDC-P with clinical outcome and to further identify its potential predictive role in making first-line treatment decisions for mCRPC. We retrospectively analyzed data of 131 mCRPC patients. IDC-P was diagnosed by re-biopsy at the time of mCRPC. Among total patients, 45 and 41 received abiraterone or docetaxel as first-line therapies, respectively. PSA response, PSA progression-free survival (PSA-PFS) and overall survival (OS) from mCRPC to death were analyzed using Kaplan-Meier curves, Log-rank test, Cox regression models and Harrell's C-index. The incidence of IDC-P in mCRPC reached 47.3%. IDC-P was not only related to rapid PSA progression, but also associated with a 20-month decrease in OS. Among IDC-P(-) patients, PSA response, PSA-PFS and OS were comparable in abiraterone-treated and docetaxel-treated groups. In contrast, among IDC-P(+) patients, PSA response rate is higher in abiraterone-treated group vs. docetaxel-treated group (52.4% vs. 21.7%; p = 0.035). Also, PSA-PFS and OS were much longer in the IDC-P(+) abiraterone-treated group vs. the docetaxel-treated group (PSA-PFS: 13.5 vs.6.0 months, p = 0.012; OS: not reach vs.14.7 months, p = 0.128). Overall, IDC-P in mCRPC from re-biopsy was an independent prognosticator for clinical outcome. Abiraterone was observed having a better therapeutic efficacy than docetaxel as the first-line therapy in IDC-P(+) mCRPC patients. Thus, we suggest IDC-P should be considered as a novel predictive marker helping physicians making treatment decisions for mCRPC.

The update of prostatic ductal adenocarcinoma

Since initially described in 1967, prostatic ductal adenocarcinoma (PDA) has engendered a series of controversies on its origin, histological features, and biological behavior. Owing to the improvement of molecular biological technique, there are some updated findings on the characteristics of PDA. In the current review, we will mainly analyze its origin, clinical manifestations, morphological features, differential diagnosis, immunophenotype and molecular genetics, with the purpose of enhancing recognition of this tumor and making a correct diagnosis and treatment choice.

Cribriform growth is highly predictive for postoperative metastasis and disease-specific death in Gleason score 7 prostate cancer

Patients with Gleason score 7 prostate cancer on radical prostatectomy demonstrate a wide range in clinical outcome. Gleason grade 4 prostate cancer encompasses a heterogeneous group of tumor growth patterns including fused, ill-defined, cribriform, and glomeruloid glandular structures. Our objective was to determine the prognostic value of different Gleason grade 4 growth patterns. We performed a nested case-control study among 535 patients with Gleason score 7 prostate cancer at radical prostatectomy, treated between March 1985 and July 2013 at a university hospital in the Netherlands. We analyzed 52 cases (with metastasis, disease-specific mortality or both) and 109 controls, matched for age, PSA level, and pT stage. Presence of the following Gleason grade 4 patterns was recorded: fused, ill-defined, cribriform, and glomeruloid. Intraductal carcinoma of the prostate and tertiary Gleason grade 5 were additionally assessed. Outcomes were metastasis-free survival and disease-specific survival. We used Cox proportional hazards regression to determine the predictive value of Gleason grade 4 patterns for survival time. The overall prevalence of Gleason grade 4 patterns was as follows: fused 75% (n=121), ill-defined 64% (n=102), cribriform 48% (n=83), and glomeruloid 25% (n=40). Cribriform pattern was the only pattern with an unequal distribution between cases and controls. Forty-two out of 52 cases (81%) had cribriform growth pattern versus 41/109 controls (38%). In multivariate analysis, presence of cribriform growth was an adverse independent predictor for distant metastasis-free survival (HR 8.0, 95% CI 3.0-21; P<0.001) and disease-specific survival (HR 5.4, 95% CI 2.0-15, P=0.001). In conclusion, cribriform growth in Gleason grade 4 is a strong prognostic marker for distant metastasis and disease-specific death in patients with Gleason score 7 prostate cancer at radical prostatectomy.

Is there any prognostic impact of intraductal carcinoma of prostate in initial diagnosed aggressively metastatic prostate cancer?

BACKGROUND

Intraductal carcinoma of prostate (IDC-P) was usually found to be co-exist with conventional aggressive prostate adenocarcinoma. The presence of IDC-P was considered as an adverse pathological factor, which was associated with high Gleason score, large prostate volume and accelerated disease progression. However, no any information is available on the presence of IDC-P diagnosed by needle biopsy in patients with metastatic prostate cancer. We investigated the incidence and prognostic value of intraductal carcinoma of prostate (IDC-P) in initial diagnosed metastatic prostate cancer.

METHODS

We included 278 patients with initial diagnosed metastatic prostate cancer treated between 2008 and 2011, all the pathological diagnosis were from ultrasonic-guided transperineal needle biopsy. IDC-P was strictly defined according to Epstein's criteria. Analyzed factors included age, Eastern Cooperative Oncology Group (ECOG) score, clinical T staging, Gleason scores, baseline prostate specific antigen (PSA), alkaline phosphatase (ALP), hemoglobin (HGB), PSA normalization, and the presence of IDC-P.

RESULTS

Totally, IDC-P was found in 57/278 (20.5%) cases. Univariate analysis showed that, compared with cases without IDC-P, cases with IDC-P was definitely associated with much shorter CRPC-free survival (CFS) time (46.05 ± 1.39 vs. 22.98 ± 1.80 months, P = 0.000) and OS time (50.38 ± 1.18 vs. 36.43 ± 2.10 months, P = 0.000). Multivariate analysis showed that the presence of IDC-P was the only independent prognostic factor associated with poor CFS (HR = 4.886, P = 0.011) and OS (HR = 1.945, P = 0.020). Further sub-analysis showed, even among patients with higher Gleason score (≥8) (n = 158), IDC-P was still significantly and inversely associated with CFS and OS (the median CFS time: 40 versus 22 months; P = 0.000; the median OS time: 54 vs. 36 months, P = 0.000). Again, Cox's regression model confirmed that only the presence of IDC-P was still not only an independent prognostic factor predicting shorter time of CRPC (HR = 4.031, P = 0.035), but also for poorer OS (HR = 2.499, P = 0.006).

CONCLUSIONS

The presence of IDC-P in initial diagnosed metastatic prostate cancer, even among patients with more aggressive pattern, was firstly found to be significantly and independently associated with earlier occurrence of CRPC and poorer OS. We recommended the presence of IDC-P should be a routine record in pathological report of clinical diagnosis and other potential therapeutic regimen might be added to intervene in the integrated therapy as early as possible. Prostate 75:225-232, 2015. © 2014 Wiley Periodicals, Inc.

Intraductal carcinoma of the prostate: a comprehensive and updated review

Intraductal carcinoma of the prostate is characterized by prostatic carcinoma cells growing within ducts and/or acini. These tumors are usually associated with a high-grade Gleason score, large tumor volume and advanced stage. Intraductal carcinoma of the prostate is also a well-known adverse independent prognostic factor regardless of treatment. Recent studies have shown that intraductal carcinoma of the prostate is a distinctive disease entity that is different from invasive prostate carcinoma, which is generally invasive. Although the Gleason score does not consider intraductal carcinoma of the prostate, some cribriform prostate carcinomas graded as pattern 4 could be considered as intraductal carcinomas. The definition of intraductal carcinoma of the prostate is not unified, because it can occur with or without invasive prostate carcinoma. Furthermore, diagnosis of intraductal carcinoma of the prostate without invasive prostate carcinoma by needle biopsy is crucial, but is a rare event. Differential diagnosis of intraductal carcinoma of the prostate includes several pathologies. This is especially true for high-grade prostatic intraepithelial neoplasia, although its distinction is not always straightforward. The present review discusses the concept of intraductal carcinoma of the prostate, and also describes its morphological characteristics, molecular features and clinical outcome. Given the current state of knowledge, the presence of intraductal carcinoma of the prostate should be evaluated and documented correctly in both radical prostatectomy and needle biopsy, and the clinical implications should be taken into consideration during treatment and follow up.

Prognostic histopathological and molecular markers on prostate cancer needle-biopsies: a review

Prostate cancer is diverse in clinical presentation, histopathological tumor growth patterns, and survival. Therefore, individual assessment of a tumor's aggressive potential is crucial for clinical decision-making in men with prostate cancer. To date a large number of prognostic markers for prostate cancer have been described, most of them based on radical prostatectomy specimens. However, in order to affect clinical decision-making, validation of respective markers in pretreatment diagnostic needle-biopsies is essential. Here, we discuss established and promising histopathological and molecular parameters in diagnostic needle-biopsies.

Diagnostic criteria for ductal adenocarcinoma of the prostate: interobserver variability among 20 expert uropathologists

AIMS

Ductal adenocarcinoma of the prostate (DAC) is clinically important, because its behaviour may differ from that of acinar adenocarcinoma. Our aims were to investigate the interobserver variability of this diagnosis among experts in uropathology and to define diagnostic criteria.

METHODS AND RESULTS

Photomicrographs of 21 carcinomas with ductal features were distributed among 20 genitourinary pathologists from eight countries. DAC was diagnosed by 18 observers (mean 13.2 cases, range 6-19). In 11 (52%) cases, a 2/3 consensus was reached for a diagnosis of DAC, and in five (24%) there was consensus against. In DAC, the respondents reported papillary architecture (86%), stratification of nuclei (82%), high-grade nuclear features (54%), tall columnar epithelium (53%), elongated nuclei (52%), cribriform architecture (40%), and necrosis (7%). The most important diagnostic feature reported for DAC was papillary architecture (59%), whereas nuclear and cellular features were considered to be most important in only 2-11% of cases. The most common differential diagnoses were intraductal prostate cancer (52%), high-grade PIN (37%), and acinar adenocarcinoma (17%). The most common reason for not diagnosing DAC was lack of typical architecture (33%).

CONCLUSIONS

Papillary architecture was the most useful diagnostic feature of DAC, and nuclear and cellular features were considered to be less important.

Basal cell hyperplasia (BCH) versus high grade prostatic intraepithelial neoplasia (HGPIN) in tiny prostatic needle biopsies: Unusual diagnostic dilemma

BACKGROUND

Histopathological differentiation between BCH and HGPIN in prostatic needle biopsies is a diagnostic challenge. The gold standard for detection of HGPIN and BCH is histopathological examination; however subjectivity in interpretation and tiny volume of obtained tissue hamper reliable diagnosis.

AIMS

The aim of this study was to assess usefulness of using the p63 and p504s to solve this problem. Although the use of p63 and p504s is now well established in differentiation between preneoplastic and neoplastic prostatic lesions, their usefulness in tiny tissue material is, however, not fully studied.

METHODS

The study included a spectrum of 30 prostatic needle biopsies (5 BCH, 10 HGPIN, 10 indefinite luminal proliferations where BCH and HGPIN could not be distinguished from each other and 5 adenocarcinomas). H&E stained sections were examined for histopathological features. Other sections were stained immunohistochemically with p63 and p504s.

RESULTS

The mean age of patients was 69 (SD=7.6) years. PSA range was 1.3-2.7 ng/ml. Ultrasongraphic findings were unremarkable. All BCH showed p504s-/p63+ pattern, All HGPIN had p504s+/p63+ pattern while carcinomas were p504s+/p63-. After immunostaining combined with histopathological features; the 10 indefinite specimens could be diagnosed as 4 BCH and 6 HGPIN. The article explains how applying this staining pattern on the challenging specimens, combined with histopathological features, can be helpful in proper identification of prostatic proliferations.

Intraductal carcinoma of prostate: a comprehensive and concise review

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

Intraductal carcinoma of the prostate: precursor or aggressive phenotype of prostate cancer?

BACKGROUND

Although the term "intraductal carcinoma of the prostate" (IDC-P) was introduced almost 40 years ago, there is still the lack of appreciation that this entity represents a clinically aggressive disease that continues to be misreported under the diagnostic category of high grade prostatic intraepithelial neoplasia (HGPIN).

METHODS

Recent data obtained from histological, molecular, and clinical studies were reviewed to demonstrate that IDC-P significantly differs from HGPIN, and has a major impact in terms of diagnosis, prognosis and therapy of prostate cancer (PCa).

RESULTS

HGPIN is the only accepted precursor of PCa. Its diagnosis in prostate biopsies has no prognostic implications, and does not dictate therapeutic decisions. By contrast, IDC-P correlates with a worse pathological and clinical outcome. IDC-P differs from HGPIN by distinct histological and molecular features. Recent clinical studies report that IDC-P is associated with neoadjuvant androgen deprivation therapy (ADT) and, chemotherapy (CT) failure as well as early disease recurrence after external beam radiation. Finally, IDC-P is associated with TMPRSS2-ERG gene fusion, which was reported to be regulated by estrogens and their receptors.

CONCLUSIONS

IDC-P is an aggressive phenotype of prostate cancer and predicts poor response to ADT, CT, and external beam radiation. IDC-P should be separated from HGPIN and should be reported in prostate biopsies and prostatectomy specimens.

Histopathological features of ductal adenocarcinoma of the prostate in 1,051 radical prostatectomy specimens

Ductal adenocarcinoma (DAC) of the prostate is thought to have worse prognosis than prostatic acinar carcinoma (PAC). We aimed to evaluate the prognostic significance of histopathological patterns of DAC. A series of 1,051 radical prostatectomy specimens from Karolinska University Hospital 1998-2005 was reviewed. A ductal component was classified as classical DAC (DACC) if it had columnar, pseudostratified epithelium, elongated nuclei, and papillary, glandular, or cribriform architecture; borderline DAC (DACB) if it lacked elongated nuclei or classical architecture; and prostatic adenocarcinoma with ductal features (PCDF) if stratified high-grade nuclei were found. DACC, DACB, and PCDF were seen in 2.6, 4.0, and 1.6 % of the cases. DAC was usually mixed with PAC and constituted 10-100 % (mean 40 %) of the main tumor. Location was periurethral, peripheral, or both in 69.8, 3.5, and 26.7 %. Necrosis was seen in 31.3 %, stromal invasion of DAC in 52.3 %, and intraductal spread in 91.9 %. In DACC/DACB and PAC, extraprostatic extension was seen in 66.7 and 42.4 % (p < 0.001) and seminal vesicle invasion in 13.0 and 5.0 % (p = 0.0045). DACC, DACB, and PCDF had a hazard ratio for biochemical recurrence of 1.5 (0.7-2.8), 1.4 (0.8-2.6) and 1.2 (0.5-2.7). When PCDF was excluded from DAC, hazard ratio was 1.4 (95 % CI 0.9-2.3, p = 0.12). Location, % DAC, necrosis, stromal invasion, or Gleason score were not predictive of recurrence. This suggests that DACC and DACB are more aggressive than average PAC, while cancers with acinar architecture and pseudostratified high-grade nuclei should not be included in DAC.

Biopsy diagnosis of intraductal carcinoma is prognostic in intermediate and high risk prostate cancer patients treated by radiotherapy

AIM

We investigated the prognostic significance of intraductal carcinoma of the prostate (IDC-P) in biopsies and transurethral resections prior to external beam radiotherapy with or without androgen deprivation.

METHODS

Cohort 1 consisted of 118 intermediate risk prostate cancer patients treated by radiotherapy, with biochemical relapse as primary end-point (median follow-up 6.5 years). Cohort 2 consisted of 132 high risk patients, enrolled in a phase III randomised trial (EORTC 22863) comparing radiotherapy alone to radiotherapy with long-term androgen deprivation (LTAD) with clinical progression free survival as primary end-point (median follow-up 9.1 years). Presence of IDC-P was identified after central review. Multivariable regression modelling and Kaplan-Meier analysis were performed with IDC-P as dichotomous variable.

RESULTS

IDC-P was a strong prognosticator for early (<36 months) biochemical relapse (HR 7.3; p = 0.007) in cohort 1 and for clinical disease-free survival in both arms of cohort 2 (radiotherapy arm: HR 3.5; p < 0.0001; radiotherapy plus LTAD arm: HR 2.8, p = 0.018). IDC-P retained significance after stratification for reviewed Gleason score in the radiotherapy arm (HR 2.3; p = 0.03). IDC-P was a strong prognosticator for metastatic failure rate (radiotherapy arm: HR 5.3; p < 0.0001; radiotherapy plus LTAD arm: HR 3.6; p = 0.05).

CONCLUSIONS

IDC-P in diagnostic samples of patients with intermediate or high risk prostate cancer is an independent prognosticator of early biochemical relapse and metastatic failure rate after radiotherapy. We suggest that the presence of IDC-P in prostate biopsies should routinely be reported.