Difference between revisions of "High-grade prostatic intraepithelial neoplasia"

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#redirect [[Prostate gland#High-grade prostatic intraepithelial neoplasia]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = High-grade_prostatic_intraepithelial_neoplasia_high_mag.jpg
| Width      =
| Caption    = High-grade prostatic intraepithelial neoplasia. [[H&E stain]].
| Synonyms  = prostatic intraepithelial neoplasia
| Micro      = nuclear changes (hyperchromatic nuclei, nucleoli present, +/-increased NC ratio, mild-to-moderate nuclear enlargement), medium-to-large glands with the architecture of HGPIN (tufted, micropapillary, cribriform, flat)
| Subtypes  =
| LMDDx      = [[basal cell hyperplasia]], [[prostatic adenocarcinoma]], [[PIN-like prostatic ductal adenocarcinoma]], [[atypical small acinar proliferation]] (biopsy only)
| Stains    =
| IHC        = AMACR +ve, basal cells present (p63 +ve, CK34betaE12 +ve)
| EM        =
| Molecular  =
| IF        =
| Gross      = not evident
| Grossing  =
| Site      = [[prostate gland]]
| Assdx      = [[prostate adenocarcinoma]]
| Syndromes  =
| Clinicalhx =
| Signs      = none
| Symptoms  = none
| Prevalence = common
| Bloodwork  = +/-PSA elevated
| Rads      = not identifiable
| Endoscopy  =
| Prognosis  = benign
| Other      =
| ClinDDx    = [[prostate carcinoma]]
| Tx        = follow-up +/-re-biopsy
}}
'''High-grade prostatic intraepithelial neoplasia''', abbreviated as ''HGPIN'', is considered the precursor for [[prostate carcinoma]].
 
It may be referred to as ''prostatic intraepithelial neoplasia'', abbreviated ''PIN''.
 
==General==
*Thought to be a precursor lesion for prostate adenocarcinoma.
**Multifocal HGPIN considered a risk for prostate cancer on re-biopsy.<ref name=pmid21191509>{{Cite journal  | last1 = Srigley | first1 = JR. | last2 = Merrimen | first2 = JL. | last3 = Jones | first3 = G. | last4 = Jamal | first4 = M. | title = Multifocal high-grade prostatic intraepithelial neoplasia is still a significant risk factor for adenocarcinoma. | journal = Can Urol Assoc J | volume = 4 | issue = 6 | pages = 434 | month = Dec | year = 2010 | doi =  | PMID = 21191509 }}</ref><ref name=pmid19524976>{{Cite journal  | last1 = Merrimen | first1 = JL. | last2 = Jones | first2 = G. | last3 = Walker | first3 = D. | last4 = Leung | first4 = CS. | last5 = Kapusta | first5 = LR. | last6 = Srigley | first6 = JR. | title = Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma. | journal = J Urol | volume = 182 | issue = 2 | pages = 485-90; discussion 490 | month = Aug | year = 2009 | doi = 10.1016/j.juro.2009.04.016 | PMID = 19524976 }}</ref>
**A small focus of HGPIN does not appear to be associated with an increased risk for prostate cancer on re-biopsy at one year if the initial biopsy had 8 or more cores.<ref name=pmid16406886>{{Cite journal  | last1 = Herawi | first1 = M. | last2 = Kahane | first2 = H. | last3 = Cavallo | first3 = C. | last4 = Epstein | first4 = JI. | title = Risk of prostate cancer on first re-biopsy within 1 year following a diagnosis of high grade prostatic intraepithelial neoplasia is related to the number of cores sampled. | journal = J Urol | volume = 175 | issue = 1 | pages = 121-4 | month = Jan | year = 2006 | doi = 10.1016/S0022-5347(05)00064-9 | PMID = 16406886 }}</ref>
 
Low-grade prostatic intraepithelial neoplasia:
*Not reported and generally believed to be irrelevant biologically/clinically.
**''PIN'' not otherwise specified refers to ''HGPIN''.
**Low-grade PIN has the architecture of HGPIN but lacks the nuclear atypia.
 
===HGPIN and cancer on follow-up biopsy===
Prostate cancer on follow-up biopsy by number of HGPIN sites from Merrimen ''et al.'':<ref name=pmid19524976>{{Cite journal  | last1 = Merrimen | first1 = JL. | last2 = Jones | first2 = G. | last3 = Walker | first3 = D. | last4 = Leung | first4 = CS. | last5 = Kapusta | first5 = LR. | last6 = Srigley | first6 = JR. | title = Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma. | journal = J Urol | volume = 182 | issue = 2 | pages = 485-90; discussion 490 | month = Aug | year = 2009 | doi = 10.1016/j.juro.2009.04.016 | PMID = 19524976 }}</ref>
{| class="wikitable sortable"
! Number of cores<br> with HGPIN
! Odds ratio of cancer<br> on follow-up (95% CI)
|-
| 0
| 1.00 (reference)
|-
| 1
| 1.02 (0.73-1.40)
|-
| 2
| 1.55 (1.08-2.21)
|-
| 3
| 1.99 (1.16-3.40)
|-
| 4
| 2.66 (1.10-6.40)
|}
 
==Gross==
*Not evident on gross.
 
==Microscopic==
Features:<ref name=Ref_Amin3-56>{{Ref Amin|3-56}}</ref><ref name=pmid2002502>{{Cite journal  | last1 = Chin | first1 = AI. | last2 = Dave | first2 = DS. | last3 = Rajfer | first3 = J. | title = Is repeat biopsy for isolated high-grade prostatic intraepithelial neoplasia necessary? | journal = Rev Urol | volume = 9 | issue = 3 | pages = 124-31 | month =  | year = 2007 | doi =  | PMID = 17934569 | PMC = 2002502 }}</ref>
*Medium to large glands with architectural changes - see ''HGPIN architecture'' below.
**Described as "epithelial hyperplasia".
*Diagnosed on basis of nuclear changes.
**Hyperchromatic nuclei - '''key (low power) feature'''.
**Nucleoli present - '''key (high power) feature'''.
**Often increased NC ratio.
**Nuclear enlargement.
 
Notes:
*Nucleoli should be visible with the 20x objective.
**If one uses the 40x objective... one over calls.
*May need IHC for cancer versus HGPIN.
*Nucleoli should be present in >= 10% of cells in a gland to call it HGPIN.<ref>{{Ref Amin|3-55}}</ref>
**This criterium is not required by all pathologists.
 
DDx:
*[[Basal cell hyperplasia of the prostate]].
*[[Intraductal carcinoma of the prostate]].
*[[Prostatic adenocarcinoma]] - glands with HGPIN have two or more distinct cells layers.
**[[PIN-like prostatic ductal adenocarcinoma]] - glands crowded.
*Benign prostate - HPGIN has nuclear changes.
 
===HGPIN architecture===
There are several forms:<ref name=Ref_WMSP380>{{Ref WMSP|380}}</ref><ref name=pmid14739906>{{Cite journal  | last1 = Bostwick | first1 = DG. | last2 = Qian | first2 = J. | title = High-grade prostatic intraepithelial neoplasia. | journal = Mod Pathol | volume = 17 | issue = 3 | pages = 360-79 | month = Mar | year = 2004 | doi = 10.1038/modpathol.3800053 | PMID = 14739906 | url=http://www.nature.com/modpathol/journal/v17/n3/pdf/3800053a.pdf }}</ref>
*Flat - uncommon.
*Tufting - common.
*Micropapillary - common.
*Cribriform - rare.
 
Note:
*The architectural pattern is '''not''' thought to have any prognostic significance; however, it may be useful for differentiating it from benign prostate.
 
===Images===
<gallery>
Image:High-grade_prostatic_intraepithelial_neoplasia_low_mag.jpg | HGPIN - low mag. (WC/Nephron)
Image:High-grade_prostatic_intraepithelial_neoplasia_intermed_mag.jpg | HGPIN - intermed. mag. (WC/Nephron)
Image:High-grade_prostatic_intraepithelial_neoplasia_high_mag.jpg | HGPIN - high mag. (WC/Nephron)
</gallery>
 
==IHC==
*HGPIN: AMACR +ve, p63 +ve, HMWCK +ve.
*Cancer: AMACR +ve, p63 -ve, HMWCK -ve.
*Normal: AMACR -ve, p63 +ve, HMWCK +ve.
 
==Sign out==
<pre>
A. PROSTATE, RIGHT LATERAL SUPERIOR, BIOPSY:
- HIGH-GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA;
- NEGATIVE FOR MALIGNANCY.
</pre>
 
If there is (isolated) HGPIN in more than 3 or 4 cores:
<pre>
COMMENT:
As high-grade prostatic intraepithelial neoplasia is found in multiple cores, close
follow-up is suggested, with a re-biopsy when indicated.
</pre>
 
==See also==
*[[Prostate gland]].
*[[Prostate cancer]].
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Prostate gland]]

Revision as of 04:31, 18 February 2014

High-grade prostatic intraepithelial neoplasia
Diagnosis in short

High-grade prostatic intraepithelial neoplasia. H&E stain.
Synonyms prostatic intraepithelial neoplasia
LM nuclear changes (hyperchromatic nuclei, nucleoli present, +/-increased NC ratio, mild-to-moderate nuclear enlargement), medium-to-large glands with the architecture of HGPIN (tufted, micropapillary, cribriform, flat)
LM DDx basal cell hyperplasia, prostatic adenocarcinoma, PIN-like prostatic ductal adenocarcinoma, atypical small acinar proliferation (biopsy only)
IHC AMACR +ve, basal cells present (p63 +ve, CK34betaE12 +ve)
Gross not evident
Site prostate gland
Associated Dx prostate adenocarcinoma
Signs none
Symptoms none
Prevalence common
Blood work +/-PSA elevated
Radiology not identifiable
Prognosis benign
Clin. DDx prostate carcinoma
Treatment follow-up +/-re-biopsy

High-grade prostatic intraepithelial neoplasia, abbreviated as HGPIN, is considered the precursor for prostate carcinoma.

It may be referred to as prostatic intraepithelial neoplasia, abbreviated PIN.

General

  • Thought to be a precursor lesion for prostate adenocarcinoma.
    • Multifocal HGPIN considered a risk for prostate cancer on re-biopsy.[1][2]
    • A small focus of HGPIN does not appear to be associated with an increased risk for prostate cancer on re-biopsy at one year if the initial biopsy had 8 or more cores.[3]

Low-grade prostatic intraepithelial neoplasia:

  • Not reported and generally believed to be irrelevant biologically/clinically.
    • PIN not otherwise specified refers to HGPIN.
    • Low-grade PIN has the architecture of HGPIN but lacks the nuclear atypia.

HGPIN and cancer on follow-up biopsy

Prostate cancer on follow-up biopsy by number of HGPIN sites from Merrimen et al.:[2]

Number of cores
with HGPIN 		Odds ratio of cancer
on follow-up (95% CI)
0 1.00 (reference)
1 1.02 (0.73-1.40)
2 1.55 (1.08-2.21)
3 1.99 (1.16-3.40)
4 2.66 (1.10-6.40)

Gross

  • Not evident on gross.

Microscopic

Features:[4][5]

  • Medium to large glands with architectural changes - see HGPIN architecture below.
    • Described as "epithelial hyperplasia".
  • Diagnosed on basis of nuclear changes.
    • Hyperchromatic nuclei - key (low power) feature.
    • Nucleoli present - key (high power) feature.
    • Often increased NC ratio.
    • Nuclear enlargement.

Notes:

  • Nucleoli should be visible with the 20x objective.
    • If one uses the 40x objective... one over calls.
  • May need IHC for cancer versus HGPIN.
  • Nucleoli should be present in >= 10% of cells in a gland to call it HGPIN.[6]
    • This criterium is not required by all pathologists.

DDx:

HGPIN architecture

There are several forms:[7][8]

  • Flat - uncommon.
  • Tufting - common.
  • Micropapillary - common.
  • Cribriform - rare.

Note:

  • The architectural pattern is not thought to have any prognostic significance; however, it may be useful for differentiating it from benign prostate.

Images

  • HGPIN - low mag. (WC/Nephron)

  • HGPIN - intermed. mag. (WC/Nephron)

  • HGPIN - high mag. (WC/Nephron)

IHC

  • HGPIN: AMACR +ve, p63 +ve, HMWCK +ve.
  • Cancer: AMACR +ve, p63 -ve, HMWCK -ve.
  • Normal: AMACR -ve, p63 +ve, HMWCK +ve.

Sign out

A. PROSTATE, RIGHT LATERAL SUPERIOR, BIOPSY:
- HIGH-GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA;
- NEGATIVE FOR MALIGNANCY.

If there is (isolated) HGPIN in more than 3 or 4 cores: 

COMMENT:
As high-grade prostatic intraepithelial neoplasia is found in multiple cores, close 
follow-up is suggested, with a re-biopsy when indicated.

See also

References

  1. ↑ Srigley, JR.; Merrimen, JL.; Jones, G.; Jamal, M. (Dec 2010). "Multifocal high-grade prostatic intraepithelial neoplasia is still a significant risk factor for adenocarcinoma.". Can Urol Assoc J 4 (6): 434. PMID 21191509.
  2. ↑ 2.0 2.1 Merrimen, JL.; Jones, G.; Walker, D.; Leung, CS.; Kapusta, LR.; Srigley, JR. (Aug 2009). "Multifocal high grade prostatic intraepithelial neoplasia is a significant risk factor for prostatic adenocarcinoma.". J Urol 182 (2): 485-90; discussion 490. doi:10.1016/j.juro.2009.04.016. PMID 19524976.
  3. ↑ Herawi, M.; Kahane, H.; Cavallo, C.; Epstein, JI. (Jan 2006). "Risk of prostate cancer on first re-biopsy within 1 year following a diagnosis of high grade prostatic intraepithelial neoplasia is related to the number of cores sampled.". J Urol 175 (1): 121-4. doi:10.1016/S0022-5347(05)00064-9. PMID 16406886.
  4. ↑ Amin, Mahul B. (2010). Diagnostic Pathology: Genitourinary (1st ed.). Amirsys. pp. 3-56. ISBN 978-1931884280.
  5. ↑ Chin, AI.; Dave, DS.; Rajfer, J. (2007). "Is repeat biopsy for isolated high-grade prostatic intraepithelial neoplasia necessary?". Rev Urol 9 (3): 124-31. PMC 2002502. PMID 17934569. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002502/.
  6. ↑ Amin, Mahul B. (2010). Diagnostic Pathology: Genitourinary (1st ed.). Amirsys. pp. 3-55. ISBN 978-1931884280.
  7. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 380. ISBN 978-0781765275.
  8. ↑ Bostwick, DG.; Qian, J. (Mar 2004). "High-grade prostatic intraepithelial neoplasia.". Mod Pathol 17 (3): 360-79. doi:10.1038/modpathol.3800053. PMID 14739906. http://www.nature.com/modpathol/journal/v17/n3/pdf/3800053a.pdf.
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