Prostatic Intraepithelial Neoplasia (PIN), or Dysplasia
Some biopsies do not show cancer but do show PIN, or dysplasia. The following discussion attempts to answer the most frequently asked questions about PIN.
What is PIN?
Prostatic Intraepithelial Neoplasia is believed to be the most likely precursor of prostate cancer. It is a proliferative lesion i.e. it is composed of prostatic epithelial cells that are dividing more rapidly than normal epithelium. However, the cells have not yet become cancerous. Pin can be classified as high grade, medium grade and low grade. Low grade PIN is less worrisome that the other two grades.
How do pathologists diagnose PIN?
PIN consists of overgrowth of prostatic epithelial cells within preexisting glands. There is overlapping of cells, enlargement of nuclei, and prominence of nucleoli (blue dot-like inclusions in the nucleus).
Does PIN elevate serum PSA?
It is generally believed that PIN alone does not have influence on serum PSA. Elevation of serum PSA in men with PIN alone in needle biopsies may be due to coexistent unsampled prostate cancer.
Can ultrasound examination of the prostate detect PIN?
PIN is a microscopic finding which is below the detection threshold for this form of imaging. Today, most urologists and radiologists do not believe that PIN is detectable by ultrasound.
What is the clinical significance of PIN?
PIN is the most likely precursor of prostate cancer. The presence of high or medium grade PIN in prostate needle biopsy indicates a high likelihood of development of prostate cancer in the future. Patients with PIN should undergo a repeat biopsy within 1-6 months and yearly thereafter, especially if the PSA is rising. Between 40% and 60% of men with PIN will be found to have prostate cancer on subsequent biopsy underscoring the strong association of PIN and prostate cancer and the need for careful follow-up. Studies suggest that most patients with high and medium grade PIN will develop prostate cancer within 10 years.
Should men with PIN be treated?
Currently, there are no established guidelines for the treatment of men with PIN alone. The authors are aware of 18 radical prostatectomies that were purposely (3 cases) or inadvertently performed (15 cases) in patients whose biopsies contained only PIN; all but two of the cases contained cancer in the surgical specimen (DO Bostwick, personal communication, 1999). Androgen deprivation therapy (e.g. drugs like Casodex"") is known to decrease the prevalence and extent of PIN possibly leading to prevention of prostate cancer (Chemoprevention). Currently, the use of such drugs in prevention of prostate cancer is still undergoing clinical trials and is not yet recommended for general use. Radiation therapy is also known to regress PIN. Biologicals such as Vitamin D, Vitamin E, lycopene, selenium and soy may decrease the incidence of prostate cancer and may be helpful in PIN.
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Radiation may also eradicate any coexistent cancer; however, like chemoprevention and surgery, it is not yet ready for routine use in PIN. In summary, there are no widely-accepted recommendations for the treatment of PIN.
How should men with PIN be followed?
PIN has a high predictive value as a marker for prostate cancer, so its identification in biopsy specimens warrants further search for concurrent cancer. Follow-up biopsy is suggested at within three to six months and a varying intervals thereafter, perhaps every one to two years, along with regular PSA levels.
Reference: Davidson D, Bostwick DG, Qian J, et al. Prostatic intraepithelial neoplasia is a risk factor for adenocarcinoma. Predictive accuracy in needle biopsies. Journal of Urology 1995; 154:1295-99.
ęBostwick Laboratories 2000. Patient Education Series-1 Prepared By: Dharam M. Ramnani, M.D., David G. Bostwick, M.D. 9/2000 Reproduced by permission.
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