Abstract
PurposeThis study aimed to evaluate the pathological characteristics, immunophenotype, and prognosis of treatment-emergent neuroendocrine prostate cancer (T-NEPC).Materials and MethodsWe collected 231 repeated biopsy specimens of castration-resistant prostate cancer (CRPC) cases between 2008 and 2019. We used histopathological and immunohistochemical evaluations of Synaptophysin (SYN), ChromograninA (CgA), CD56, androgen receptor (AR), and prostate-specific antigen (PSA) to screen out T-NEPC cases. Multivariate analyses were performed to identify factors in the prognosis of T-NEPC. Further, the results were verified in the Surveillance, Epidemiology, and End Results (SEER) program.ResultsAmong the 231 CRPC cases, 94 (40.7%) cases were T-NEPC. T-NEPC were more likely to present with negative immunohistochemistry for AR (30.9%) and PSA (47.9%) than that of CRPC (8.8% and 17.5%, respectively). Kaplan-Meier analysis revealed that patients with T-NEPC (median overall survival [OS]: 17.6 months, 95% CI: 15.3–19.9 months) had significantly worse survival compared with usual CRPC patients (median OS: 23.6 months, 95% CI: 21.3-25.9 months, log-rank P = 0.001), especially in metastasis cases (median OS: 15.7 months, 95% CI: 13.3-18.0 months) and patients with small cell carcinoma component (median OS: 9.7 months, 95% CI: 8.2–11.2 months). Prostate adenocarcinoma with diffuse NE differentiation (median OS: 18.8 months, 95% CI: 15.3–22.3 months) had poor outcome than those with usual CRPC (P = 0.027), while there was no significant change in the focal NE differentiation (median OS: 22.9 months, 95% CI: 18.1–27.7 months, P = 0.136). In the unadjusted model, an excess risk of overall death was observed in T-NEPC with PSA negative (HR = 2.86, 95% CI = 1.39–6.73). Among 476 NEPC cases in the SEER database from 2004 to 2017, we observed a higher hazard of overall death in patients aged 65 years and older (HR = 1.35, 95% CI = 1.08–1.69), patients with PSA ≤ 2.5 ng/ml (HR = 1.90, 95%CI = 1.44–2.52), patients with PSA 2.6–4.0 ng/ml (HR = 2.03, 95%CI = 1.38–2.99), stage IV tumor (HR = 2.13, 95%CI = 1.47–3.08) and other races (HR = 1.85, 95%CI = 1.17–2.94) in total NEPC, adjusting for confounders. Similar hazard ratios were observed in pure NEPC, while there was no significant results among prostate adenocarcinoma with NE differentiation tumors.ConclusionT-NEPC was associated with an unfavorable prognosis, negative immunohistochemistry for PSA in T-NEPC and serum PSA level ≤ 4 ng/ml had a worse prognosis. Urologists and pathologists should recognize the importance of the second biopsy in CRPC to avoid unnecessary diagnosis and treatment delays.
Highlights
Treatment-emergent neuroendocrine prostate cancer (T-NEPC) mainly occurs in the advanced castration-resistant prostate cancer (CRPC), which is caused by the transformation of ordinary prostate adenocarcinoma after androgen-deprivation therapy (ADT) [1]
Kaplan-Meier analysis revealed that patients with T-NEPC had significantly worse survival compared with usual CRPC patients, especially in metastasis cases and patients with small cell carcinoma component
Prostate adenocarcinoma with diffuse NE differentiation had poor outcome than those with usual CRPC (P = 0.027), while there was no significant change in the focal NE differentiation
Summary
Treatment-emergent neuroendocrine prostate cancer (T-NEPC) mainly occurs in the advanced castration-resistant prostate cancer (CRPC), which is caused by the transformation of ordinary prostate adenocarcinoma after androgen-deprivation therapy (ADT) [1]. Most T-NEPC patients die within 1 to 2 years after diagnosis, accounting for approximately 25% of CRPC deaths [3]. The clinical acquaintance of conversion to T-NEPC after resistance to endocrine therapy in prostate adenocarcinoma is insufficient, and secondary biopsies are not routinely performed, cause to the missed diagnosis of T-NEPC. The morphological characteristics of T-NEPC are similar to poorly differentiated prostate adenocarcinoma, so the incidence of TNEPC is greatly underestimated [4]. With the widespread use of novel, highly potent androgen receptor-targeted therapies (eg, Arbiton, MDV3100), the incidence of T-NEPC may rise significantly. We analyzed the clinicopathologic characteristics and outcomes of T-NEPC, intending to improve the understanding of T-NEPC among clinicians and pathologists
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