Men and prostatic intraepithelial neoplasia

Nearly half of all men by the time they reach age 50 will have some form of a condition called prostatic intraepithelial neoplasia.  Prostatic intraepithelial neoplasia or PIN is a condition in which cells from the prostate begin to look and behave abnormally. Pin has no symptoms therefore men are not aware they have it unless they undergo a prostate biopsy, which in most cases is done because of an elevated prostate specific antigen (PSA) level. It can also be detected after TURP (transurethral resection of the prostate), a treatment for benign prostatic hyperplasia or an enlarged prostate.

Each year around 16% of men who undergo a prostate biopsy will find out they have PIN which is essentially a precancerous condition and therefore is not prostate cancer.

Where PIN begins

The abnormal cells of PIN begin and are located in two different areas of the prostate – one area is called acini which is the lining of tiny sacs that give the prostate its spongelike appearance.  These same sacs are responsible for producing the fluid that is mixed together with sperm helping to create semen. 

The second area PIN may be located in is in the lining of the ducts that carry this fluid to the main ejaculatory duct that reaches the penis.

As PIN develops, the epithelial cells lining the acini and the ducts look abnormal even though the lining itself remains intact.  This is different from prostate cancer in which the epithelial lining ruptures and the malignant cells penetrate into the tissue of the prostate gland.

How is PIN different from prostate cancer?

PIN has various differences from prostate cancer:  

·      It cannot be detected during a digital rectal exam. 

·      PIN does not elevate PSA levels to rise as prostate cancer would.  

·      It is diagnosed either during a prostate biopsy or when a treatment for benign prostatic hyperplasia called transurethral resection of the prostate (TURP) is performed where prostate tissue is removed.

When this condition is discovered, it is given a grade of either low-grade PIN or high-grade PIN:

·      Low-grade PIN does not increase a man’s risk of prostate cancer as the abnormal cells are only slightly different from normal cells. 

·      High-grade PIN could increase the chance as the abnormality of the cells is more pronounced than in low-grade PIN.  This makes it more likely that high-grade PIN could lead to the development of prostate cancer. 

One reason for the increased risk is that high-grade PIN is usually found in the peripheral zone of the prostate where most cases of prostate cancer start.  Another reason is that 82% of prostate specimens with cancer also had areas of high-grade PIN while only 43% of those without high-grade PIN had prostate cancer. A third reason is that men with high-grade PIN have an increased risk for prostate cancer during a follow-up biopsy when compared to men with low-grade PIN or normal tissue.

Options for men with high-grade PIN

Because of the dilemma associated with high-grade PIN and the possible increased risk of going on to develop prostate cancer, doctors are often divided on what to recommend when it is discovered.  Usually PIN does not require treatment unless it progresses to cancer.  But if it is high-grade PIN and present in several areas of the prostate, preventative treatment may be used which could include anti-androgen agents, 5-alpha-reductase inhibitors, and selective estrogen receptor modulators.  

Men diagnosed with high-grade PIN will be monitored closely to watch for signs of prostate cancer. Follow-up visits are usually scheduled every 6 months for at least two years.

Follow-up visits may include:

·      Standard prostate cancer screening tests of blood test for PSA

·      Digital rectal exam

·      Complete physical exam

·      Biopsy

There is no one size fits all recommendations for every man with high-grade PIN.  If a man is diagnosed with high-grade PIN, he should have a close working relationship with his doctor to determine the best way to manage it by doing a thorough evaluation of his risk profile to decide the ideal course of action to take.

Remember, high-grade PIN is not the same thing as prostate cancer – there is time to decide the course of action to take and in the meantime, look ahead to new treatment options in the future.