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.

Abstract

We determined the influence of the extent of needle biopsy sampling on the detection rate of cancer on first biopsy within 1 year following a diagnosis of HGPIN.
We identified 791 patients with HGPIN on the initial biopsy who had a followup biopsy within 1 year of their diagnosis. The mean interval from diagnosis of HGPIN to re-biopsy was 4.6 months. In the initial biopsy with HGPIN, 323 men had 8 or more cores (median 10, range 8 to 26) and 332 men had 6 core biopsies.
In the 6 core initial sampling group, the risk of cancer on re-biopsy was 20.8% compared to only 13.3% following an initial 8 core or more sampling (p = 0.011). With 6 core biopsies for both the initial and re-biopsy the risk of cancer was 14.1% (group 1). With an initial 6 core biopsy and 8 core or more biopsy on followup, the risk of cancer was 31.9% (group 2). With 8 core or more biopsy sampling for both initial and repeat biopsies, the risk for cancer was 14.6% (group 3). The differences between groups 1 and 3 as compared to group 2 were statistically significant (p = 0.001 and p <0.0001, respectively).
With relatively poor sampling (6 cores) on the initial biopsy, associated cancers are missed resulting in only HGPIN on the initial biopsy, and with relatively poor sampling on re-biopsy there is also a relatively low risk of finding cancer on re-biopsy (group 1). With poor sampling on the initial biopsy and better sampling on re-biopsy, some of these initially missed cancers are detected on re-biopsy yielding a higher detection of cancer (group 2). Sampling more extensively on the initial biopsy detects many associated cancers, such that when only HGPIN is found they often represent isolated HGPIN. Therefore, re-biopsy even with good sampling does not detect many additional cancers (group 3). Our study demonstrates that the risk of cancer on biopsy within 1 year following a diagnosis of HGPIN (13.3%) is not that predictive of cancer on re-biopsy if good sampling (8 or more cores) is initially performed. For patients diagnosed with HGPIN on extended initial core sampling, a repeat biopsy within the first year is unnecessary in the absence of other clinical indicators of cancer.

Full text

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Urological Survey
The true value to FAST is in the evaluation for blood in the pericardial sac, hepatorenal fossa, splenorenal
fossa, and the pelvis. A second or control scan is then performed 30 minutes later. The control scan is done to
detect progressive hemoperitoneum in patients with a slow bleeding rate. As a retroperitoneal organ, renal
trauma blood and urine (free-fluid) are confined to Gerota’s fascia and the retroperitoneum. With kidney trauma
associated free fluid is absent up to 1/2 the time. Free fluid noted with renal injuries is more likely to be free
fluid from associated intra-abdominal injuries then from the kidney injury. This means that FAST must rely on
parenchymal evaluation for grading of a renal injury. US imaging can be severely limited by obesity, subcutaneous
air, and previous abdominal operations. Further limitations of US are its inability to distinguish between a urine
leak and blood, and inability to reliably assess the vascularity of the kidney. Although not currently readily
available, there is good promise that micro-bubble, contrast enhanced US may improve kidney parenchymal
evaluation. Overall, FAST seems to be of value as a tool for triaging the unstable trauma patient, but when it
comes to evaluating the stable kidney injured patient, US is not ready for prime time.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
PATHOLOGY ___________________________________________________________________
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
Herawi M, Kahane H, Cavallo C, Epstein JI
Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
J Urol. 2006; 175: 121-4
Purpose: We determined the influence of the extent of needle biopsy sampling on the detection rate of cancer on
first biopsy within 1 year following a diagnosis of HGPIN.
Materials and Methods: We identified 791 patients with HGPIN on the initial biopsy who had a followup
biopsy within 1 year of their diagnosis. The mean interval from diagnosis of HGPIN to re-biopsy was 4.6
months. In the initial biopsy with HGPIN, 323 men had 8 or more cores (median 10, range 8 to 26) and 332 men
had 6 core biopsies.
Results: In the 6 core initial sampling group, the risk of cancer on re-biopsy was 20.8% compared to only 13.3%
following an initial 8 core or more sampling (p = 0.011). With 6 core biopsies for both the initial and re-biopsy
the risk of cancer was 14.1% (group 1). With an initial 6 core biopsy and 8 core or more biopsy on followup, the
risk of cancer was 31.9% (group 2). With 8 core or more biopsy sampling for both initial and repeat biopsies,
the risk for cancer was 14.6% (group 3). The differences between groups 1 and 3 as compared to group 2 were
statistically significant (p = 0.001 and p < 0.0001, respectively).
Conclusions: With relatively poor sampling (6 cores) on the initial biopsy, associated cancers are missed resulting
in only HGPIN on the initial biopsy, and with relatively poor sampling on re-biopsy there is also a relatively
low risk of finding cancer on re-biopsy (group 1). With poor sampling on the initial biopsy and better sampling
on re-biopsy, some of these initially missed cancers are detected on re-biopsy yielding a higher detection of
cancer (group 2). Sampling more extensively on the initial biopsy detects many associated cancers, such that
when only HGPIN is found they often represent isolated HGPIN. Therefore, re-biopsy even with good sampling

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does not detect many additional cancers (group 3). Our study demonstrates that the risk of cancer on biopsy within
1 year following a diagnosis of HGPIN (13.3%) is not that predictive of cancer on re-biopsy if good sampling (8
or more cores) is initially performed. For patients diagnosed with HGPIN on extended initial core sampling, a
repeat biopsy within the first year is unnecessary in the absence of other clinical indicators of cancer.
Editorial Comment
In 2005 were published the recommendations on prognostic factors in prostate needle biopsies of an
International Consultation Organized by the WHO Collaborating Center for Urologic Tumors (1). The
recommendations included: 1) As the clinical significance or biologic relevance of low-grade prostatic
intraepithelial neoplasia is not known and appears insignificant, this diagnosis should not be made in needle
biopsies; 2) The diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) is predictive of subsequent
cancer detection in 27% to 31% (recent data) and 30% to 60% of patients, respectively; 3) Owing to the
lower predictive value for cancer in recent years, attention has focused on HGPIN parameters in needle core
biopsies that may be more useful in the subsequent detection of cancer. Whether the extent of involvement of
HGPIN is a better predictor of subsequent prostate cancer is controversial as well as the pattern of HGPIN
(micropapillary, cribriform, etc.).
In the study surveyed, the risk of cancer on biopsy within 1 year following a diagnosis of HGPIN was
13.3% in cases of an initial 8 core or more sampling. This percentage is lower than 27% to 31% of other recent
studies. This study emphasizes the trend for a substantially decreasing in subsequent cancer detection if HGPIN is
seen in extended biopsies. The authors conclude that for patients diagnosed with HGPIN on extended initial core
sampling, a repeat biopsy within the first year is unnecessary in the absence of other clinical indicators of cancer.
Reference
1.Amin M, Boccon-Gibod L, Egevad L, Epstein JI, Humphrey PA, Mikuz G, et al.: Prognostic and predictive factors and
reporting of prostate carcinoma in prostate needle biopsy specimens. Scand J Urol Nephrol Suppl. 2005; 216: 20-33.
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
Relationship between Primary Gleason Pattern on Needle Biopsy and Clinicopathologic
Outcomes among Men with Gleason Score 7 Adenocarcinoma of the Prostate
Gonzalgo ML, Bastian PJ, Mangold LA, Trock BJ, Epstein JI, Walsh PC, Partin AW
Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions,
Baltimore, Maryland, USA
Urology. 2006; 67: 115-9
Objectives: To examine the relationship among needle biopsy primary grade, prostatectomy grade, and
postprostatectomy biochemical recurrence among men with Gleason score 7 disease.
Methods: We identified 320 men with Gleason score 7 tumors on prostate biopsy treated with radical pros-
tatectomy between 1991 and 2001 by a single surgeon. None of these patients had received neoadjuvant or
adjuvant hormonal therapy or radiotherapy. The chi-square test and Kaplan-Meier method were used to
evaluate the correlation among biopsy Gleason score, prostatectomy Gleason score, and biochemical recur-
rence.

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Results: A total of 252 (79%) and 68 (21%) men had primary Gleason pattern 3 and 4 identified on needle
biopsy, respectively. Of the patients with Gleason pattern 3+4 tumors on biopsy, 24% were upgraded to primary
pattern 4 or more on final pathologic analysis. Of the patients with Gleason pattern 4+3 tumors on biopsy, 47%
were downgraded to primary pattern 3 or less on final pathologic analysis. The actuarial risk of biochemical
prostate-specific antigen recurrence was significantly lower among patients with Gleason pattern 4+3 on bi-
opsy, if the prostatectomy Gleason score was downgraded to 3+4 or less (p = 0.03).
Conclusions: Approximately 47% of men with a diagnosis of Gleason pattern 4+3 on needle biopsy are down-
graded at radical prostatectomy and will have biochemical prostate-specific antigen recurrence-free outcomes
similar to patients originally diagnosed with Gleason pattern 3+4 adenocarcinoma. This group of patients may
benefit from definitive treatment such as radical prostatectomy for management of their disease.
Editorial Comment
Gleason score 7 may result from 3+4=7 or 4+3=7. Data regarding the importance of the percentage of Gleason
4 pattern in Gleason score 7 tumors are rapidly expanding but still controversial (1). In recently generated
nomograms, patients with Gleason scores of 4+3 and 3+4 are stratified differently, underscoring the impor-
tance of the relative amount of pattern 4 (2). Whether or not the actual percentage of pattern 4 tumor should be
included in the report is not clear based on the data published to date and, if this emerges as an important
parameter, meaningful discriminatory cut-off points for the percentage of pattern 4 will need to be defined.
In the article surveyed, most frequently there is downgrading of patients originally graded as Gleason
pattern 4+3=7. In 24% of the patients with Gleason pattern 3+4 tumors on biopsy were upgraded to primary
pattern 4 or more on final pathologic analysis, and approximately 47% with a diagnosis of Gleason 4+3 on needle
biopsy were downgraded at radical prostatectomy. The latter group had biochemical prostate-specific antigen
recurrence-free outcomes similar to patients originally diagnosed with Gleason pattern 3+4 adenocarcinoma.
References
1.Amin M, Boccon-Gibod L, Egevad L, Epstein JI, Humphrey PA, Mikuz G, et al.: Prognostic and predictive factors and
reporting of prostate carcinoma in prostate needle biopsy specimens. Scand J Urol Nephrol Suppl. 2005; 216: 20-33.
2.Makarov DV, Sanderson H, Partin AW, Epstein JI: Gleason score 7 prostate cancer on needle biopsy: is the prognostic
difference in Gleason scores 4 + 3 and 3 + 4 independent of the number of involved cores? J Urol. 2002; 167: 2440-2.
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
INVESTIGATIVE UROLOGY _____________________________________________________
Urinary Hyaluronan as a Marker for the Presence of Residual Transitional Cell Carcinoma of
the Urinary Bladder
Passerotti CC, Bonfim A, Martins JR, Dall’Oglio MF, Sampaio LO, Mendes A, Ortiz V, Srougi M, Dietrich
CP, Nader HB
Disciplina de Urologia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Brazil
Eur Urol. 2006; 49: 71-5