HG-PIN, ASAP, and decisions about active surveillance


The presence of high-grade prostatic intraepithelial neoplasia (HG-PIN) or atypical small acinar proliferation (ASAP) in biopsy specimens does not appear to affect risk for upstaging or upgrading among men who are otherwise good candidates for active surveillance. This is another finding that many of us might have expected, but it is always good to have one’s suspicions confirmed by data (as opposed to just hope and optimism).

Pietzak et al. conducted a retrospective analysis of data from patients who met standard criteria for active surveillance but all of whom were actually treated by radical prostatectomy at the University of Pennsylvania. Th authors’ goal was to determine whether the prescence of HG-PIN or ASAP in the initial biopsy specimens, prior to surgery, was associated with any increase in risk for occult and adverse pathology in the post-surgical specimens.

The patient cohort included 553 patients, all of whom had D’Amico low-risk prostate cancer and who met either the Epstein (Johns Hopkins) or the Memorial Sloan-Kettering Cancer Center (MSKCC) criteria for management on active surveillance.

Here are the core study findings:

  • 400/553 patients (73.2 percent) met the MSKCC criteria for active surveillance.
  • 170/553 patients (30.7 percent) met the signifciantly more rigorous, original Epstein criteria.
  • HG-PIN was present in biopsy samples from
    • Approximately 32 percent of the men who met the MSKCC criteria
    • Approximately 32 percent of the men who met the Epstein criteria
  • ASAP was present in biopsy samples from
    • Approximately 12 percent of the men who met the MSKCC criteria
    • Approximately 12 percent of the men who met the Epstein criteria
  • The presence of either HG-PIN or ASAP in  biopsy samples had no impact on any of the following:
    • Upgrading or upstaging in the men who met the MSKCC criteria
    • Upgrading or upstaging in the men who met the Epstein critera
    • The 5-year biochemical progression-free survival of men who met the MSKCC criteria
    • The 5-year biochemical progression-free survival of men who met the Epstein criteria

Pietzak et al. conclude that, if patients are otherwise appropriate candidates for active surveillance, then the presence of HG-PIN or ASAP in their biopsy specimens “should not impact the decision” to recommend or elect active surveillance as an appropriate forms of management of such patients. However, they do also note that:

… analysis of prospective AS trials is required to determine if HG-PIN or ASAP impacts tumor progression once on AS.

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