Diagnosis of isolated high-grade prostatic intra-epithelial neoplasia: proposal of a nomogram for the prediction of cancer detection at saturation re-biopsy

OBJECTIVE: • To evaluate factors that may predict prostate cancer (PCa) detection after the initial diagnosis of high-grade prostatic intra-epithelial neoplasia (HGPIN) on prostate biopsy (PBx) with six to 24 random cores. PATIENTS AND METHODS: • We retrospectively evaluated 262 patients submitted from 1998 to 2007 to prostate re-biopsy (rPBx) after an initial HGPIN diagnosis in tertiary academic centres. • HGPIN diagnosis was obtained on initial systematic PBx with six to 24 random cores. • All patients were re-biopsied with a ' saturation ' rPBx with 20-26 cores, with a median time to rPBx of 12 months. • All slides were reviewed by expert uropathologists. RESULTS: • Plurifocal HGPIN (pHGPIN) was found in 115 patients and monofocal HGPIN (mHGPIN) was found in 147 patients. • In total, 108 and 154 patients, respectively, were submitted to > 12-core initial PBx and ≤ 12-core initial PBx. • Overall PCa detection at rPBx was 31.7%. PSA level (7.7 vs 6.6 ng/mL; P = 0.031) and age (68 vs 64 years; P = 0.001) were significantly higher in patients with PCa at rPBx. • PCa detection was significantly higher in patients with a ≤ 12-core initial PBx than in those with a > 12-core initial PBx (37.6% vs 23.1%; P = 0.01), as well as in patients with pHGPIN than in those with mHGPIN (40% vs 25.1%; P = 0.013). • At multivariable analysis, PSA level ( P = 0.041; hazards ratio, HR, 1.08), age ( P < 0.001; HR, 1.09), pHGPIN ( P = 0.031; HR, 1.97) and ≤ 12-core initial PBx ( P = 0.012; HR, 1.95) were independent predictors of PCa detection. • A nomogram including these four variables achieved 72% accuracy for predicting PCa detection after an initial HGPIN diagnosis. CONCLUSIONS: • PCa detection on saturation rPBx after an initial diagnosis of HGPIN is significantly higher in patients with a ≤ 12-core initial PBx than those with a > 12-core initial PBx and in patients with pHGPIN than in those with mHGPIN. • We developed a simple prognostic tool for the prediction of PCa detection in patients with initial HGPIN diagnosis who were undergoing saturation rPBx