Lineage plasticity and histologic transformation from prostate adenocarcinoma to neuroendocrine prostate cancer (NEPC) occurs in up to 15-20% of patients with castration-resistant prostate cancer (CRPC) as mechanism of treatment resistance and is associated with aggressive disease and poor prognosis. NEPC tumors typically display small cell carcinoma morphology with loss of androgen receptor (AR) expression and gain of neuroendocrine (NE) lineage markers. However, there is a spectrum of phenotypes that are observed during the lineage plasticity process, and the clinical significance of mixed histologies or those that co-express AR and NE markers or lack all markers is not well defined. Translational research studies investigating NEPC have used variable definitions making clinical trial design challenging. Here we discuss the diagnostic workup of metastatic biopsies to help guide the reproducible classification of phenotypic CRPC subtypes. We recommend classifying CRPC tumors based on histomorphology (adenocarcinoma, small cell carcinoma, poorly differentiated carcinoma, other morphologic variant, or mixed morphology) and immunohistochemical markers with a priority for AR, NKX3.1, INSM1, synaptophysin and cell proliferation based on Ki-67 positivity, with additional markers to be considered based on the clinical context. Ultimately, a unified workup of metastatic CRPC biopsies can improve clinical trial design and eventually practice.
Clinical cancer research : an official journal of the American Association for Cancer Research. 2024 Nov 26 [Epub ahead of print]
Michael C Haffner, Michael J Morris, Chien-Kuang C Ding, Erolcan Sayar, Rohit Mehra, Brian Robinson, Lawrence D True, Martin Gleave, Tamara L Lotan, Rahul Aggarwal, Jiaoti Huang, Massimo Loda, Peter S Nelson, Mark A Rubin, Himisha Beltran
Fred Hutchinson Cancer Center, Seattle, United States., Memorial Sloan Kettering Cancer Center, New York, New York, United States., University of California, San Francisco, San Francisco, CA, United States., University of Michigan-Ann Arbor, Ann Arbor, MI, United States., Weill Cornell Medicine, New York, NY, United States., University of Washington, Seattle, WA, United States., University of British Columbia, Vancouver, BC, Canada., Johns Hopkins Medicine, Baltimore, MD, United States., Duke University, Durham, United States., Fred Hutchinson Cancer Center, Seattle, WA, United States., University of Bern, Bern, Bern, Switzerland., Dana-Farber Cancer Institute, Boston, MA, United States.