PATHOLOGY

Adenocarcinoma of the prostate in young men: clinical and pathologic features
Chan TY, Sanderson HL, Epstein JI
The Johns Hopkins Hospital, Baltimore, MD
Mod Pathol. 2002; 15:157A

• Objectives: To study 57 men £40 years of age with cancer on prostate needle biopsy and when present in their radical prostatectomy (RP) specimens.
• Methods: “Significant” tumors were defined as: RP tumor volume >0.5cc, or Gleason score (GS) ³7, or non organ-confined disease. We defined a favorable pre-operative prognostic group as: GS £6 in 1 core with 10% of the core involved and a PSA £10 ng/mL; those with GS £6 in £3 cores with £50% of the core involved and a PSA £2 ng/mL.
• Results: The mean age was 38 (20-40 years). 32.7% of patients had a family history of prostate cancer, 32.7% presented with urinary symptoms and 34.6% had cancer found on a routine physical exam. PSA averaged at 6.7 ng/mL (range 0.6-66 ng/mL). Digital rectal examinations were abnormal in 37.3%. The prostate needle biopsies showed 93.0% with GS <6, 3.5% with GS =7, and 3.5% with GS ³8. 52.2% of biopsies had £10% of 1 core with cancer. 44.2% of men were in the better prognostic group. Follow-up was available in 46 men, with 1 having radiation therapy. RP in 45 men show 77.8% had GS <6, 13.4% had GS = 3+4, 4.4% had GS = 4+3, 4.4% had GS = 8-9. 6.7% of men had positive margins, 17.7% extraprostatic extension, and 4.4% seminal vesicle invasion and/or lymph node metastasis. 9.3% of tumors showed mucinous features, 4.6% foamy gland features, 23.3% atrophic and 11.6% pseudohyperplastic features. High grade PIN (88.4%), inflammation (48.8%) and benign atrophy (60.5%) were seen in association with tumor. Tumor volumes averaged 1.1cc (range 0.003 to 11.5cc) and 46.5% of tumors were >0.5cc. 48.9% were “significant” tumors. There was no significant difference in specific tumor type, association with PIN, inflammation or atrophy, and location of tumor between patients with “significant” tumors and those with “potentially insignificant” tumors. Although there was a trend for family history of prostate cancer to be associated with “significant” tumor, this was not statistically significant. All 13 men predicted to have “insignificant” tumors were accurately predicted. Of the 21 men predicted to have “significant” tumors, 18 (85.7%) had “significant” tumors. Only 2 patients progressed in a mean follow-up time of 42.1 months (range 1-180 months).
• Conclusions: Unusual tumor patterns seen in young men are not different from those reported in older men. In these young men, many with early cancer, the vast majority of tumors were associated with high grade PIN. Although about half the men had “significant” tumors on RP, the other half may have been candidates for watchful waiting. Favorable biopsy and PSA findings are predictive of “potentially insignificant” tumors. Conservative management of these young men with the potential of long-term tumor growth must be balanced by the greater impact of potential morbidity from RP at a young age.
  
  
• Editorial Comment
  This is a rare series of men £40 years of age with cancer on prostate needle biopsy. It corresponds to a period of 15 years of a reference center (Johns Hopkins University). Analyzing the favorable pre-operative prognostic group, we find the criteria much more restrictive than previously described by Epstein, who is one of the authors of this paper. Gleason score £6 in 1 core, with £10% of the core involved, and a PSA £10ng/mL; or Gleason score £6 in £3 cores with £50% of the core involved and a PSA £2ng/mL, are different criteria than Gleason score £6 in £3 cores with £50% of the core involved and a free/total PSA of 0.15 or greater, published in 1998 by Epstein (Epstein JI et al.: Nonpalpable stage T1c prostate cancer: prediction of insignificant disease using free/total prostate specific antigen levels and needle biopsy findings, J Urol. 1998; 160:2407-11). With these very restrictive criteria, all 13 men predicted to have “insignificant” tumors were accurately predicted, and may have been candidates for watchful waiting, considering the greater impact of potential morbidity from radical prostatectomy at a young age. This study emphasizes the need for an appropriate pathology report, in order to adequately analyze favorable pre-operative prognostic groups. The pathology report must be done on each of the cores, describing the presence of cancer, the Gleason grading, and the percentage of cancer present on each involved core. An example is as follows: Slide 1 (apical, left side) - normal parenchyma; Slide 2 (apical, right side) - adenocarcinoma Gleason 3+4=7 involving 60% of the core, etc.

Dr. Athanase Billis
Chair, Department of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil