Our Greatest Wealth Is Health

Andrew Siegel MD 4/7/18

A prostate biopsy is usually done because of a PSA (prostate specific antigen) elevation, PSA acceleration, abnormal prostate exam or abnormal MRI. The biopsy results can range from benign to malignant. There is a gray area between these two extremes, consisting of pre-malignant conditions. What follows is a brief review of two pre-cancerous conditions, HGPIN and ASAP and how to minimize the risk of developing prostate cancer. 

Basic Prostate Histology 101

Microscopically, the prostate gland is organized like a tree with a major trunk draining each prostate lobe, served by many ducts which progressively branch out into smaller and smaller ducts. At the end of each duct is an acinus (Latin, meaning berry), which is similar to a leaf at the end of a tree branch. Acini are lined by cells that secrete prostatic fluid, a nutrient vehicle for sperm that is an important component of semen. Each acinus is surrounded by a basement membrane that separates the cells that do the secreting from the surrounding structures.

Image below: benign prostate tissue

Attribution: By Nephron (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)%5D, via Wikimedia Commons

Prostate biopsies are usually prompted by prostate cancer screening with PSA blood testing and digital rectal examination.  PSA elevation, PSA acceleration, abnormal prostate examination, abnormal prostate MRI, or follow up for prostate cancer or prostate precancerous conditions are the reasons why biopsies are performed.  There are four possible pathological outcomes from undergoing a prostate biopsy:

1. benign
2. HGPIN (High Grade Prostate Intra-Epithelial Neoplasia)
3. ASAP (Atypical Small Acinar Proliferation)
4. prostate cancer

What is HGPIN?

HGPIN is an acronym for High Grade Prostate Intra-Epithelial Neoplasia. The incidence of HGPIN between 0.6% and 24% of biopsies. It is a microscopic abnormality marked by an abnormal appearance and proliferation of cells within ducts and acini, but the abnormal cells do not extend beyond the basement membrane to other parts of the prostate (as occurs with prostate cancer).  HGPIN is considered a pre-malignant precursor lesion to prostate cancer.

Current recommendations for men who are found to have one site of HGPIN (unifocal HGPIN) are to follow-up as one would follow for a benign biopsy, with annual digital rectal exam and PSA.  However, if there are multiple biopsies indicating HGPIN (multifocal HGPIN), a repeat biopsy should be done in 6-12 months, with focused sampling of identified areas and adjacent sites. The more cores containing HGPIN on initial prostate biopsy, the greater the likelihood of cancer on subsequent biopsies. The risk for prostate cancer following the diagnosis of multifocal HGPIN is about 25%.

What is ASAP?

ASAP is an acronym for Atypical Small Acinar Proliferation. The incidence of ASAP ranges between 5% and 20% of biopsies. It is a microscopic abnormality marked by a collection of prostate acini that are suspicious but not diagnostic for prostate cancer, falling below the diagnostic “threshold.” The risk for cancer following the diagnosis of ASAP on re-biopsy is approximately 40%. All men with ASAP should undergo re-biopsy within 3 to 6 months, with focused sampling of identified areas and adjacent sites.

 Measures to Reduce Risk of Prostate Cancer

1. Maintain a healthy weight, as obesity has been correlated with an increased risk for prostate cancer occurrence, recurrence, progression and death. Research suggests a link between a high-fat diet and prostate cancer. In men with prostate cancer, the odds of metastasis and death are increased about 1.3-fold in men with a BMI of 30-35 and about 1.5-fold in men with a BMI > 35. Furthermore, carrying the burden of extra weight increases the complication rate following treatments for prostate cancer.
2. “Eat food. Not too much. Mostly plants.” Eat realfood and avoid refined, over-processed, nutritionally-empty foods and be moderate with the consumption of animal fats and dairy. Processed meats and charred meats should be avoided.  A healthy diet should include whole grains and plenty of vegetables and fruits, particularly those that contain powerful anti-oxidants, vitamins, minerals and fiber. Vibrantly colorful fruits such as berries (strawberries, blackberries, blueberries and raspberries) contain abundant anthocyanins. Tomatoes and tomato products are rich in lycopenes. Cruciferous vegetables (broccoli, cauliflower, Brussel sprouts, kale and cabbage) and dark green leafy vegetables are fiber-rich and contain lutein and numerous healthy phytochemicals.  A healthy diet should include protein sources incorporating fish, lean poultry and plant-based proteins such as legumes, nuts, and seeds. Include fish that have anti-inflammatory omega-3 fatty acids, e.g., salmon, sardines, and trout. Healthy fats (preferably of vegetable origin, e.g., olives, avocados, seeds and nuts) are preferred.  An ideal diet that is both heart-healthy and prostate-healthy is the Mediterranean diet.
3. Avoid tobacco and excessive alcohol intake. Tobacco use has been associated with more aggressive prostate cancers and a higher risk of progression, recurrence and death.
4. Stay active and exercise on a regular basis. Exercise has been shown to lessen one’s risk of developing prostate cancer and to decrease the death rate of those who do develop it. If one does develop prostate cancer, he will be in better physical shape and have an easier recovery from any intervention necessary to treat the disease.  Exercise positively influences energy metabolism, oxidative stress and the immune system.  Aerobic exercise should be done at least every other day with resistance exercise two to three times weekly.  Pelvic floor muscle exercises benefit prostate health by increasing pelvic blood flow and lessening the tone of the sympathetic nervous system (the part of the nervous system stimulated by stress), which can aggravate lower urinary tract symptoms. Additionally, pelvic floor muscle exercises strengthen the muscles surrounding the prostate so that if one develops prostate cancer and requires treatment, they will experience an expedited recovery of urinary control and sexual function.
5. Get checked out! Be proactive by seeing your doctor annually for a digital rectal exam and a PSA blood test. Abnormal findings on these screening tests are what prompt prostate biopsies, the definitive means of diagnosing prostate cancer. The most common scenario that leads to a diagnosis of prostate cancer is a PSA acceleration, an elevation above the expected incremental annual PSA rise based upon the aging process.
6. Finasteride and Dutasteride, commonly used to treat benign prostate enlargement and male pattern hair loss, reduce the risk of prostate cancer and may be used for those at high risk, including men with a strong family history or those with pre-cancerous biopsies. These medications lower the PSA by 50%, so anyone taking this class of meds will need to double their PSA to approximate the actual PSA. If the PSA does not drop, or if it goes up while on these meds, it is suspicious for undiagnosed prostate cancer. By shrinking benign prostate growth, these medications also increase the ability of the digital rectal exam to detect an abnormality.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Tags: Andrew Siegel MD, ASAP, atypical small acinar proliferation, HGPIN, high grade prostate intraepithelial neoplasia, pre-cancerous prostate conditions, PSA

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