Clinical management of premalignant lesions of the prostate

The presence of high-grade prostatic intraepithelial neoplasia (PIN) in a p rostate biopsy is a considerable risk factor for the presence of prostate c ancer, with up to 73% of patients having cancer on rebiopsy. The risk is re lated to the clinical setting (screening vs urological practice) and patien t factors such as prostatic serum antigen (PSA) and findings on digital rec tal examination (DRE). Thus, high-grade PIN has serious clinical implicatio ns. The aim of this paper is to propose practical guidelines for the clinic al management of PIN. Based on current knowledge we recommend that: Only patients considered for curative treatment of prostate cancer be furth er investigated for a PIN biopsy finding; A palpable nodule or tumor-suspic ious transrectal ultrasonography (TRUS) finding, in conjunction with a find ing of high grade PIN on prostate biopsy, should prompt rebiopsy; An elevated PSA level or an elevated PSA density should also warrant repeat biopsy, as the most likely cause of PSA elevation is concomitant prostate cancer; The presence of high-grade PIN on biopsy without concomitant prostate cance r in patients suitable for curative treatment, notwithstanding normal DRE, TRUS or PSA, should prompt repeat biopsies, as the association with prostat e cancer is significant; The presence of PIN alone on biopsy does not warrant treatment, as a substa ntial number of rebiopsies yield only PIN.