Adenocarcinoma of the prostate in men younger than 40 years of age: diagnosis and treatment with emphasis on radical prostatectomy findings.

OBJECTIVES: Prostate cancer is rarely diagnosed in men younger than 40 years of age. It is thought, although not documented, that these tumors behave particularly aggressively. METHODS: We studied 87 men younger than 40 years old who underwent prostate needle biopsy and were from three populations: (a) 71 cases (63 benign, 7 cancer) from Dianon Systems; (b) 9 needle biopsies with cancer sent to one of us (J.I.E.) in consultation; and (c) 7 men with cancer who came to Johns Hopkins for consultation. RESULTS: The median age of men with a benign biopsy was 35 years (mean 33.9, range 22 to 39); the median age of men with cancer was 38 years (mean 35.9, range 22 to 39) (P = 0.004). The most common indications for biopsy were abnormal digital rectal examination (DRE) (n = 61); elevated prostate-specific antigen (PSA) (n = 14), and inflammatory symptoms (n = 12). Other reasons cited included hematuria, abnormal ultrasound, pain, ejaculatory problems, obstructive symptoms, and family history of prostate cancer. The median PSA was 2.6 ng/mL (mean 4.8, range 0.3 to 66) for all men, 1.2 ng/mL (mean 3.4, range 0.3 to 19.9) for benign cases, and 4.4 ng/mL (mean 8.7, range 2.1 to 66) for cancer (P = 0.0004). Abnormal DRE was not predictive of cancer. Of the 55 patients whose family history was known, 40 men had no family history of prostate cancer, and of those, only 6 (15%) had cancer. Of the 1 5 patients with a family history of cancer, 6 (40%) were found to have cancer on biopsy (P = 0.05). Of the 23 patients with cancer, 3 were lost to follow-up, 1 was treated with hormones, and 3 chose watchful waiting. The remaining 16 patients underwent radical prostatectomy and had diverse pathologic findings. Tumor volume ranged from 0.01 to 6.35 cc. Pathologic stage was pT2 in 9 cases and pT3 in 7 cases (2 with positive pelvic lymph nodes). In 14 men, serum PSA values were available: of 4 men with PSA greater than 10 ng/mL, all had Stage pT3, and of 10 men with PSA less than 10 ng/mL, 3 had Stage pT3. CONCLUSIONS: Young men who are candidates for radical prostatectomy have potentially curable disease, particularly if PSA at the time of diagnosis is less than 10 ng/mL.

Histology and cellular kinetics of prostatic atrophy.

This study addresses two issues regarding prostatic atrophy: (1) the histologic features of atrophy as seen on needle biopsy results and how they affect the diagnosis of atrophy and (2) the cellular kinetics of atrophy and what it suggests about the mechanism of atrophy. We reviewed hematoxylin and eosin sections for 103 prostate needle biopsy specimens with atrophy. Each biopsy specimen was classified as either simple atrophy (large atrophic glands without crowding: 53 cases) or postatrophic hyperplasia (PAH) (crowded focus of small atrophic acini: 50 cases). Cell proliferation in both the atrophic and benign glands was evaluated in 103 cases by immunohistochemistry using antibodies against MIB-1. The TdT-mediated dUTP-biotin nick-end labeling technique was performed on 61 cases to quantitate apoptosis in atrophic and benign glands. Thirty-two percent of cases showed chronic inflammation, 21% showed acute inflammation, 14% showed nucleoli, and 1% showed mitoses. In comparison to simple atrophy, PAH contained more frequent prominent nucleoli (p < 0.0001) and acute inflammation (p < 0.0001), yet not chronic inflammation. In a multivariate analysis, acute inflammation and PAH pattern influenced the presence of prominent nucleoli. Staining for MIB-1 was greater in atrophic (27.5 cells/1000 cells) than in benign glands (3.5 cells/1000 cells), greater in PAH than in simple atrophy (p = 0.0015), and greater with acute (p = 0.05) but not chronic inflammation. In a multivariate analysis, only the pattern of atrophy and not acute inflammation was found to influence MIB-1. The rate of apoptosis was negligible in both the benign and atrophic glands, did not vary with pattern of atrophy, and did not correlate with MIB-1. Despite the atrophic appearance, atrophic glands in PAH show more proliferative activity than benign, nonatrophic glands and show no evidence of active involution, justifying the term "postatrophic hyperplasia" for this pattern of atrophy. Prominent nucleoli are seen more frequently in postatrophic hyperplasia, even in the absence of acute inflammation. To avoid a potential erroneous diagnosis of cancer, a constellation of features suggestive of malignancy should be considered, rather than relying on prominent nucleoli as the sole criteria for the diagnosis of prostate cancer.