Transcript High-grade Prostatic Intraepithelial Neoplasia on Needle

High-grade Prostatic Intraepithelial
Neoplasia on Needle Biopsy
Risk of Cancer on Repeat Biopsy Related to Number
of Involved Cores and Morphologic Pattern
Tarek Bishara, MD,* Dharam M. Ramnani, MD,＃ Jonathan I. Epstein, MD.
*Pee Dee Pathology Associates, Florence, SC; ＃Virginia Urology Center, Richmond, VA;
and Johns Hopkins Medical Institutions, Baltimore, MD.
Am J Surg Pathol · Volume 28, Number 5, May 2004
HGPIN
• Definition: an abnormal proliferation of
prostate ducts and acini with cytologic
changes similar to prostatic
carcinoma
• Importance on needle biopsy: an
association with synchronous, occult
prostatic adenocarcinoma
HGPIN
• Isolated finding on needle biopsy: 0.7% to
24 % (4% to 6%)
• Risk of carcinoma in subsequent biopsy:
23% to 79% (23% to 35%, mean= 25.3%)
– in a contemporary, PSA-screened population: 10%
to 27%
– risk of finding cancer after a benign diagnosis on
needle biopsy: 11% to 24% (26.2%)
HGPIN
• Whether or not a patient should be
rebiopsied based solely on an isolated
HGPIN diagnosis?
• Will clinical factors help in predicting
which patients will have prostatic
carcinoma on follow-up biopsies?
– DRE, serum PSA levels, and transrectal
ultrasound findings
METHODS
• 200 cases (May 1999 ~ Sep 2002)
– 179 cases (89.5%) had available follow-up
information
– 132 cases (66%%) had ≥ 1 follow-up
biopsy
METHODS
• Histological subtypes:
– tufting / flat
– micropapillary / cribriform
• Number of cores involved by HGPIN
METHODS
• Rebiopsied specimen
– benign prostatic tissue
– HGPIN
– atypical glands
– carcinoma
RESULTS
• Age: 46-90 years (mean = 66.4)
• Interval between initial biopsy and first
rebiopsy: 1 to 33 months (mean = 7)
• Number of prostatic cores per biopsy
set: 4 to 15
– standard 6 core sextant biopsy was obtained in 59.8%
of initial biopsies and 61% of follow-up biopsies
RESULTS
• Histologic subtypes in initial biopsies
– tufting: 59.0% (115 of 195)
– micropapillary: 34.3% (67 of 195)
– cribriform: 6.2% (12 of 195)
– flat: 0.5% (1 of 195)
• Extent in initial biopsies
– One core: 51.5% (68 of 132)
– Two or more cores: 48.5% (64 of 132)
RESULTS
• Diagnosis in the follow-up biopsies
– Benign prostatic tissue: 45% (60 of 132)
– HGPIN: 17.4% (23 of 132)
– Atypical glands: 8.3% (11 of 132)
– Adenocarcinoma: 28.8% (38 of 132)
RESULTS
• Adenocarcinoma in follow-up biopsies
– incidence: 28.8% (38/132)
– Interval between repeat biopsy: 2-36
months (mean=10.6)
– Gleason score
• 5: 5.3% ( 2 of 38)
• 6: 89.5% (34 of 38)
• 7: 5.3% ( 2 of 38)
RESULTS
• Incidence of subsequent carcinoma
– tufting / flat: 31.9% (29/91)
– micropapillary / cribriform: 22.0% (9 of 41)
– p = 0.244
RESULTS
• Incidence of subsequent carcinoma
– 1 core with HGPIN: 22.0% (15/68)
– ≥ 2 cores with HGPIN: 35.9% (23 of 64)
– p = 0.078
RESULTS
• Adenocarcinoma in follow-up biopsies
– 1st follow-up biopsy: 71.1% (27 of 38)
– 2nd follow-up biopsy: 18.4% (7 of 38)
– 3rd follow-up biopsy: 10.5% (4 of 38)
– 4th follow-up biopsy: 2.6% (1 of 38)
• All had abnormal diagnoses on at least
one of the previous biopsies
RESULTS
• Incidence of subsequent carcinoma
– Benign diagnosis on the 1st follow-up
biopsy (n=36): 14.3 % (2 of 14)
– HGPIN on the 1st follow-up biopsy (n=25):
32.0% (8 of 25)
– Small atypical glands on the 1st follow-up
biopsy (n=6): 33.3% (1 of 3)
RESULTS
• Incidence of subsequent carcinoma
– Multiple cores involved by HGPIN on the
1st follow-up biopsy: 50.0 % (8 of 16)
– Only one core involved by HGPIN on the
1st follow-up biopsy: 0 % (0 of 9)
– p = 0.01
RESULTS
• If one combined the risk of cancer on
repeat biopsy for those men with either
no HGPIN or one core with HGPIN on
first repeat biopsy as compared with
men with multiple cores of HGPIN on
repeat biopsy, the result was more
significant (P = 0.008).
Widespread High-grade Prostatic
Intraepithelial Neoplasia on Prostatic
Needle Biopsy: A Significant Likelihood of
Subsequently Diagnosed Adenocarcinoma
George J. Netto, MD. and Jonathan I. Epstein, MD.*
Departments of Pathology, *Urology, and *Oncology, The Johns Hopkins Hospital,
Baltimore, MD.
Am J Surg Pathol 2006;30:1184–1188
MATERIALS & METHODS
• 73 cases (1994 ~ 2005)
– Prostatic needle biopsy
– Diagnosis of HGPIN in a minimum of 4
cores
MATERIALS & METHODS
• 73 cases
– 41 cases had at least one follow-up biopsy
• age: 66.8 years
• numbers of initial cores: 10.4
• PSA: 2.5-90 ng/mL (mean=14.1; median=8.2)
– 32 cases were lack of follow-up biopsy
• age: 68.2 years
• numbers of initial cores: 10.4
• PSA: 0.5-8.5 ng/mL (mean=3.5; median=3.3)
MATERIALS & METHODS
• Data of follow-up samples
– Date
– Nature
– Frequency
MATERIALS & METHODS
• Diagnosis of follow-up samples
– benign prostatic tissue (BPT)
– HGPIN
HGPIN with adjacent small atypical glands
(PINATYP)
– carcinoma (PCa)
MATERIALS & METHODS
• Statistics
– STATA, College Station, TX
– Student t test to assess potiential
differences in age and number of cores
sampled between those men with and
without repeat biopsy
– X2 test to assess differences between
subgroups among men who had a repeat
biopsy
RESULTS
• Age: 66.8 years
• Period of follow-up: 1-41 months
(mean=11)
• Numbers of cores on initial biopsy: 5-16
(mean=10.6; median=10)
• Numbers of cores on follow-up biopsy:
6-16 (mean=10.4; median=10)
RESULTS
• Follow-up biopsy
– 1 repeat biopsy: 34 p’ts
– 2 repeat biopsies: 3 p’ts
– 1 repeat biopsy followed by 1 TURP: 1 p’t
– 1 repeat biopsy followed by 2 TURPs: 1 p’t
– 1 TURP: 3 p’ts
RESULTS
• All but 1 of the prostate cancers were
identified on the first F/U procedure
• All but 1 of the prostatic carcinomas
were diagnosed within 2 years from the
initial biopsy with 10 rendered within the
first year
RESULTS
• Adenocarcinoma in follow-up biopsies
– incidence: 39% (16/41)
– time from the initial biopsy: 1-36 months
(mean=10.4)
– Gleason score
•
•
•
•
5: 6.3% ( 1 of 16)
6: 68.7% (11 of 16)
7: 18.8% ( 3 of 16)
9: 6.3% ( 1 of 16)
RESULTS
• 5 p’ts with more than 1 f/u biopsies
– 1st f/u biopsy (negative) --> TURP (PCa)
– 1st and 2nd f/u biopsies (HGPIN)
– 1st f/u biopsy (HGPIN) --> biopsy (PINATYP)
– 1st f/u biopsy (PINATYP) --> biopsy (HGPIN)
– 1st f/u biopsy (PINATYP) --> TURP (BPT) -->
TURP (BPT)
DISCUSSION
• The reported likelihood of finding cancer after
a diagnosis of HGPIN on needle biopsy has
decreased in the contemporary era.
• Seven of nine large studies showed no
statistically significant difference in the risk of
cancer on repeat biopsy after an HGPIN
diagnosis compared with rebiopsy after a
benign diagnosis.
DISCUSSION
• Herawi M, et al. Risk of prostate cancer on re-biopsy following
a diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) is
related to the number of cores sampled. J Urol. 2006;175:121–124.
– In cases with 6 core biopsies for both the initial
and rebiopsy, the risk of cancer after HGPIN was
14.1% (20/142)
– With an initial 6 core biopsy and >8 core repeat
biopsy, the risk increased to 31.9% (36/113)
– With >8 core biopsy sampling for both the initial
and repeat biopsies, the risk for cancer was
14.6% (37/253)
DISCUSSION
• Delaying the repeat biopsy allowing for
a longer interval than the originally
recommended 6 to 12 months
• Identifying a subset of HGPIN patients
with a higher subsequent PCa risk
DISCUSSION
• Our study demonstrated a 39% likelihood of
finding PCa after the initial identification of
widespread (4 or more HGPIN)
• The 39% likelihood rate stands in significant
contrast to the baseline risk (19% to 26.2%)
of finding adenocarcinoma on a repeat biopsy
after an initial benign diagnosis.
DISCUSSION
• All but 1 cases of the adenocarcinoma
diagnoses were obtained at the first F/U
procedure. The absolute need for a
second repeat biopsy after a first
negative repeat biopsy could be
questioned.
SUMMARY
• An initial finding of HGPIN on 4 or more
cores
• Patients older than 70 years of age
• Patients with a fewer numbers of cores
on initial biopsy
Cia!