Macrophage pyroptosis drives luminal senescence and club-cell reprogramming in 5α-reductase inhibitor-treated prostatic hyperplasia

Abstract Benign prostatic hyperplasia (BPH) is a common age-associated disease whose prevalence rises sharply with advancing age. Therapeutic responses to 5α-reductase inhibitors (5-ARIs) in BPH are heterogeneous and may ultimately culminate in the need for surgery; however, the mechanisms that permit disease progression during treatment remain unclear. Here we integrate spatial and single-cell transcriptomics with functional perturbations and mouse genetics to delineate a macrophage-orchestrated pyroptosis–senescence–club axis in the human prostate. In 5-ARI-exposed tissue, we observe enrichment of cleaved-GSDMD⁺ macrophages, elevated epithelial p16 INK4A expression and expansion of SCGB1A1⁺ club cells. Spatial mapping pinpoints macrophage–epithelium hotspots with prominent MIF–CD74 and HMGB1–AGER signaling. Under 5-ARI pressure, luminal-cell secretomes recruit macrophages via MIF–CD74, and pyroptotic macrophages release HMGB1 that activates epithelial AGER to trigger luminal G1 arrest and senescence, which in turn promotes luminal-to-club reprogramming through a partially Notch-associated program. Blockade of MIF–CD74 or HMGB1–AGER attenuates macrophage pyroptosis and luminal senescence, whereas Notch inhibition partially reverses epithelial remodeling. A 13-gene pyroptosis–macrophage signature (PM-13) stratifies patient responsiveness to 5-ARIs. In a castration/testosterone-induced mouse BPH model, 5-ARI treatment amplifies pyroptotic macrophages and club programs, whereas Gsdmd deletion blunts pyroptosis and dampens senescence/club transcriptional states. These findings nominate druggable nodes—MIF–CD74, HMGB1–AGER, Notch and GSDMD—as candidate targets for therapeutic intervention and patient stratification in BPH under 5-ARI therapy. Keywords: spatial and single-cell transcriptomics; benign prostatic hyperplasia; 5-alpha-reductase inhibitors; cellular senescence; macrophage pyroptosis; luminal-to-club conversion; MIF–CD74/HMGB1–AGER signaling; GSDMD.