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Managing high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands on prostate biopsy

Nature Reviews Urology volume 15, pages 55–66 (2018)Cite this article

Subjects

Key Points

  • The risk of cancer detection following high-grade prostatic intraepithelial neoplasia (HGPIN) on biopsy is ∼20–30%, which is not significantly higher than that following a benign biopsy

  • The majority of cancers detected following a diagnosis of HGPIN are Gleason score 6 (grade group 1)

  • Men with a single core positive for HGPIN do not require routine repeat biopsy; in multifocal HGPIN, follow-up monitoring could include serum and urine tests or imaging

  • The risk of cancer following atypical glands suspicious for carcinoma on needle biopsy is ∼40% — twofold higher than that following a benign biopsy

  • ∼20% of cancers detected after atypical glands suspicious for carcinoma are Gleason score 3 + 4 = 7 (grade group 2) or higher, including 5% with Gleason scores 8–10 (grade group 4–5)

  • Follow-up monitoring is warranted following atypical glands suspicious for carcinoma; in select patients, subsequent biopsies should be considered, with increased sampling of atypical regions

Abstract

Prostate biopsy is the gold standard for diagnosing prostate cancer and reliable pathological assessment is essential for guiding management. Research efforts over the past few years have aimed to establish a more universal approach to management according to pathological grading; however, high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands suspicious for carcinoma are two diagnoses without standardized follow-up and treatment pathways. Much of this uncertainty is due to limited evidence describing the subsequent rates of cancer and high-grade cancer when HGPIN or atypical glands are detected on initial biopsy. Fortunately, data from the past decade have shed light on these phenomena, and an improved understanding of the implications of the presence of HGPIN and atypical glands on prostate biopsy means that clinical recommendations can be made for the management of patients with these diagnoses.

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Figure 1: Multiple glands with high-grade prostatic intraepithelial neoplasia (HGPIN) on needle biopsy.
Figure 2: Several small atypical glands suspicious for carcinoma on the edge of a needle biopsy core.

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Author notes

  1. Jeffrey J. Tosoian and Ridwan Alam: These authors contributed equally to this work.

Authors and Affiliations

  1. Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Marburg 134, Baltimore, 21287, Maryland, USA

    Jeffrey J. Tosoian, Ridwan Alam, Mark W. Ball & H. Ballentine Carter

  2. Department of Pathology, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg 2242, Baltimore, 21231, Maryland, USA

    Jonathan I. Epstein

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J.J.T., R.A. and M.W.B. researched data for article. J.J.T. and R.A. wrote the manuscript. All authors made a substantial contribution to discussion of content and reviewed and/or edited the manuscript before submission.

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Correspondence to Jeffrey J. Tosoian.

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Tosoian, J., Alam, R., Ball, M. et al. Managing high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands on prostate biopsy. Nat Rev Urol 15, 55–66 (2018). https://doi.org/10.1038/nrurol.2017.134

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