What is the prognosis of precancerous lesions of the prostate?

Updated: Feb 26, 2020
  • Author: Stanley A Brosman, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Answer

Prostate cancer develops within 1-2 years in an estimated 30% of men with multiple cores containing HGPIN and in perhaps even more men with ASAP. Indeed, the presence of HGPIN or ASAP cells in multiple areas has such a high predictive value for prostate adenocarcinoma that the existence of these cells alerts the pathologist to search for any areas in the biopsy sample that might harbor carcinoma.

However, the presence of HGPIN or ASAP does not necessarily imply that prostate cancer is inevitable; although these conditions may progress to invasive cancer, HGPIN and ASAP remain stable for years in many patients and regress in some individuals.

When biopsy reveals prostate cancer, the prognosis is determined by the grade and stage of the cancer. The presence of HGPIN or ASAP in such cases does not alter the prognosis. The mean volume of HGPIN or ASAP in prostates with cancer is 1.2-1.32 mL. The volume of HGPIN correlates directly with increasing pathologic stage, Gleason grade, positive surgical margins, and perineural invasion.

Patients with HGPIN or ASAP not associated with existing prostate cancer should be informed about the need for surveillance. Patients should also be told that neither HGPIN nor ASAP seems to affect PSA levels.

In a study of 485 consecutive patients who underwent prostate biopsies, Alsikafi et al determined that the incidence of cancer in patients with HGPIN associated with adjacent atypical glands was significantly higher than in patients with HGPIN alone. The overall rate of HGPIN with or without the presence of associated atypical glands was 6.8% (33 patients). Of these patients, 21 (64%) had HGPIN alone, and 12 (36%) had HGPIN with adjacent atypical glands. Subsequent biopsies helped to identify prostate cancer in 3 (14%) patients in whom only HGPIN was found on the initial biopsy, and in 9 (75%) patients with adjacent atypical glands. [14]

A study by Epstein et al revealed that among patients in whom a prostate biopsy performed prior to radical prostatectomy for cancer revealed glands that were suspicious (but not diagnostic) for carcinoma, the tumor grade and pathologic stage of their carcinoma were significantly lower than in men who had received no such biopsy results. The investigators analyzed 169 radical prostatectomy specimens from men initially diagnosed with suspicious glands and found that organ-confined disease was predicted by the atypical biopsy. [15]

Cicione et al reported that men with metabolic syndrome who are found to have widespread HGPIN are at higher risk of having prostate cancer on repeat biopsy. In their review of 283 patients with widespread HGPIN, prostate cancer was subsequently detected in 52.3% of those with metabolic syndrome. versus 29.5% of those with a normal metabolic profile (P = 0.002). [16]

Pathologists have developed criteria for distinguishing HGPIN and ASAP from benign and malignant conditions, and they report the presence and extent of these lesions. The presence of PIN or ASAP may influence therapeutic choices and management decisions.

Clinically, the specific pattern and morphologic features of HGPIN and ASAP are not as important as the mere presence of either of these entities. The clinical importance and the follow-up strategy depend on the amount of lesions found or the number of biopsy cores that contain these lesions. In patients diagnosed with prostate cancer, the finding of an associated HGPIN or ASAP becomes irrelevant.

No data demonstrate a correlation between the amount of PIN and the timing of tumor progression or length of survival.


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