In situ and intraductal epithelial proliferations of prostate: definitions and treatment implications. Part 1: Prostatic intraepithelial neoplasia

Abstract

What's known on the subject? and What does the study add? In the era of extended biopsy sampling of the prostate, multifocal high-grade prostatic intraepithelial neoplasia (HGPIN) is associated with a significantly higher rate of cancer diagnosis than unifocal HGPIN or a benign diagnosis. In addition, the cancers that are subsequently diagnosed in men with HGPIN on their initial biopsy tend to be smaller, lower grade and more commonly organ-confined. This has led to a reappraisal of the need and timing of repeat biopsies. The present paper provides a series of recommendations on the optimal timing of repeat biopsies in men with HGPIN on biopsy, based on the current available evidence. This is the first of a two part series reviewing the nature and clinical significance of in situ cellular proliferations in the prostate gland. This first part examines prostatic intraepithelial neoplasia (PIN), while the second part in the next supplement discusses intraductal carcinoma and ductal adenocarcinoma of the prostate. PIN is a precursor lesion in the development of some forms of adenocarcinoma of the prostate. In the 1990 s, high-grade PIN (HGPIN) on biopsy was a significant predictor of carcinoma, but this was due to incomplete sampling with sextant biopsies. With more extensive sampling in the last decade, the likelihood of identifying cancer after a diagnosis of HGPIN is not significantly different from a benign diagnosis. In several recent studies, it is now recognised that multifocal HGPIN is a better predictor of cancer than unifocal HGPIN. Most cases of cancer will be detected in the vicinity of the HGPIN, but up to 40% of cancers will occur in different sextants. In assessing potential markers for carcinoma in men with HGPIN on biopsy, α-methylacyl coenzyme-A racemase (AMACR) has emerged as a promising diagnostic tool. HGPIN with strong staining for AMACR is associated with a higher rate of cancer detection in subsequent biopsies compared with AMACR-negative HGPIN. Also, AMACR positivity in HGPIN is more commonly seen adjacent to carcinoma, and this may provide guidance as to the site of future biopsies.