Back in September 2010, we reported on a paper that suggested that “men diagnosed with intraductal carcinoma of the prostate on needle biopsy should receive definitive therapy for locally advanced disease, even in the absence of pathologically documented invasive prostate cancer.”
A recently published review in the journal Prostate (by Bonkhoff et al.) now suggests that there is still a lack of appreciation that intraductal carcinoma of the prostate (IDCP) “represents a clinically aggressive disease that continues to be misreported under the diagnostic category of high grade prostatic intraepithelial neoplasia” (HG-PIN).
According to Bonkhoff et al., data from recent histological, molecular, and clinical studies show that IDCP differs significantly from HG-PIN, and that these differences have major impact in terms of diagnosis, prognosis, and therapy of this subtype of prostate cancer. Specifically, they go on to note that IDCP is associated with greater application of neoadjuvant androgen deprivation therapy (ADT), failure of chemotherapy, and early disease recurrence after external beam radiation. They also point out that IDCP is associated with the presence of TMPRSS2-ERG gene fusion, which has been reported to be regulated by estrogens and their receptors.
The authors argue that IDCP “is an aggressive phenotype of prostate cancer” and that it should be clearly differentiated from HG-PIN and carefully reported in pathologic reports on prostate biopsy and prostatectomy specimens.
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In the paper, Bonkoff states the following:
“The incidence of IDC-P in prostatectomy specimens depends on tumor volume. In the series of McNeal, IDC-P was observed in 10% of cases with tumor volume less than 2 ccm, 28% in tumors between 2 and 4 ccm, and 47% in tumors larger than 4 ccm. … In prostatectomy specimens, IDC-P is virtually always associated with invasive cancer, which makes the diagnosis of intraductal spread and its separation from HGPIN much easier than in cases of isolated IDC-P in prostate biopsy. Given its prognostic significance, the amount or percent of IDC-P should be reported. A new postoperative nomogram incorporates IDC-P as a variable, and may enhance prediction.
“Reporting IDC-P on prostate biopsies both as a rare isolated finding and as a more common finding in combination with prostatic adenocarcinoma is of paramount importance, because its diagnosis has, in apparent contrast to HGPIN, profound prognostic implications, and may influence therapeutic decisions. IDC-P on prostate biopsies is frequently associated with high-grade cancer and poor prognostic parameters at radical prostatectomy as well as advanced disease following other therapies. … In a recent study enrolling 250 patients with intermediate and high risk PCa, the presence of IDC-P in prostate biopsies was identified as an independent prognosticator of early biochemical relapse (< 36 months) and metastatic failure after radiotherapy. … This indicates that IDC-P is a significant risk factor for radiation therapy failure. In the presence of IDC-P on prostate biopsies, radical prostatectomy combined with extended lymphadenectomy may be more effective in improving survival than radiotherapy.”
Makes me want to send my Gleason 9 pathology specimens in to Bonkhoff for an assessment. Since I've already had whole-pelvic IMRT, confirmed IDC-P percentage would now only serve to reduce the odds of success, but it would be nice to know.
IDC-P has been known for at least a decade. Isn’t it commonly reported, when found on biopsy at major U.S. hospitals? If not, where do you need to send a biopsy to get a good diagnosis of IDC-P (as opposed to HG-PIN)?
IDCP has been “known” for well over a decade. However, that doesn’t mean that it is necessarily well characterized and reported by pathologists who are not specialists in the identification of prostate cancer.
There are a number of well recognized specialist pathology services that offer second opinions on prostate cancer biopsy specimens, including:
– Dr. Jonathon Epstein at Johns Hopkins in Baltimore, MD
– Bostwick Laborateries in Glen Allen, VA
– Oppenheimer Urologic Reference Laboratory in Nashville, TN
The summary on this page inaccurately reflects certain sentences in the Bonkhoff article, so refer to the original. Does anyone know the whereabouts of the nomogram that includes intraductal? I have been unable to locate it. Also, the low PSA count (0.71 ng/ml) that accompanies my husband’s high grade cancer seems to skew the nomograms, so they become rather useless for us. How do you discover recurrence if the PSA never rises?