Francisco Martín Dávila⁽¹⁾, Marcial García Rojo⁽²⁾, Jesus Gonzalez Garcia⁽³⁾, Margarita Delgado Portela⁽⁴⁾, Rafael López Pérez⁽⁵⁾, Manuel Carbajo Vicente^{(6)
(1)(2)(3)(4)(5)(6)}Servicio de Anatomía Patológica. Complejo Hospitalario de Ciudad Real - Ciudad Real. Spain

	[Obstetrics & Gynecology]	[Oncology]	[Pathology]

DISCUSSION

The term ASAP is an useful designation to classify lesions made up by a small number of acini that do not fulfill all the histologic criteria of adenocarcinoma but that are worrisome because of their atypia, or by being located at the periphery of the core having crush artifact so that it results impossible to evaluate nuclear characteristics ^(1-5,7). Some authors believe that over 50% of ASAP are tangentially biopsied adenocarcinomas ⁽¹⁾.

Histologic data like the existence near a florid inflammatory reaction or atrophic glands would make us think in a benign lesion, although malignancy could not be excluded. It is advisable to take a careful stand in order to avoid false malignant diagnosis. In our laboratory, a minimum of 9 sections of every core were studied, a seriation that we consider necessary to fasten the uncertain diagnostic.

After review we excluded 9 from the 37 initial cases diagnosed as ASAP (6 considered to be adenocarcinomas, 2 artifacted and 1 benign). The reevaluation of some biopsies by the same observers who initially diagnosed them may be due to the best definition of some concepts in prostatic pathology during the last years ⁽³⁾.

Proteinaceous intraluminal secretions and acute inflammation were more frequent on patients who finally had a benign biopsy than in those who evolved to carcinoma (statistically significant differences). No significant differences were noted for the other histologic variables.

In our series, 50 % (14/28) of patients with ASAP did not undergo a second biopsy, a similar average to other reports ^(1-4,7,12), so that it would be reasonable to assume that we are missing some patients with a high likelihood to have a tumor.

9 patients (52,9 %) were found to have adenocarcinoma, although only 3 were diagnosed on the second needle biopsy and 3 needed a third one. The average time interval between ASAP and the second needle biopsy was 107,2 days, a short enough period as to consider unlikely that the tumor was not present at the time of the first biopsy. After excluding the 6 patients with ASAP foci and coexistent high-grade PIN from the follow-up, 50 % (7/14) of patients finally underwent adenocarcinoma. In the largest series, 34-60% of patients with ASAP showed tumor ^(1-7,13-15), and 3-9 % were still atypical ^(1,2,13) on subsequent biopsies. The right clinical attitude after a diagnosis of ASAP must be patient follow-up with repetition of biopsy after some months ^{(1,2,4,5,9,11,13)}. This could detect 90% of tumors after second biopsy and 99 % after third one ⁽¹⁾. It is important to emphasize that a benign biopsy after ASAP does not exclude tumor: in our series 2 patients with this evolution showed carcinoma on the third biopsy. We found that the follow-up PSA value was lower in men with subsequently benign biopsies than in those who are malignant (7,81 vs. 13,92 ng/ml, p=0.04). This suggests that it may be useful for the follow-up of these patients.

The differential diagnosis of ASAP must be posed with morphologically similar entities, like atypical adenomatous hyperplasia (AAH), basal cell hyperplasia (typical and atypical), sclerosing adenosis, atrophy, postatrophic hyperplasia or hyperplasia of mesonephric remnants ⁽¹⁶⁾. The diagnosis of AAH must be reserved to proliferations of small acini, most often in the transition zone, at the edge of areas with nodular hyperplasia, and rarely can be done on a needle biopsy ^(4-6,17). Moderately differentiated prostate adenocarcinoma, like some ASAP focus, shows atypical glands crowded without stroma intermingled that usually have wide variation in size and shape, so that Gleason score would be 3 or more. In fact, mean Gleason sum of adenocarcinomas after ASAP seen in our series was 6,11, similar to some others previously reported ^(1-3).

Cases were separated in 3 groups (probably malignant, uncertain, probably benign), according to histologic suspicious, and before knowing the patients follow-up. After exclude the cases of ASAP + PIN for the aforementioned, 33,33 % of cases with uncertain diagnosis and 62,5% from the probably malignant group were adenocarcinomas. These data seem to support a certain predictive value of this stratification of the level of histologic suspicion ⁽¹³⁾.

ASAP should be kept in mind to avoid false diagnosis of adenocarcinoma, and to induce the urologists to repeat the biopsy in cases with atypical acini not related with inflammation, atrophy or former biopsy areas.

Discussion Board

Any Comment to this presentation?

[ABSTRACT] [FIGURES] [DISCUSSION] [REFERENCES] [Discussion Board]

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	[Obstetrics & Gynecology]	[Oncology]	[Pathology]

Francisco Martín Dávila, Marcial García Rojo, Jesus Gonzalez Garcia, Margarita Delgado Portela, Rafael López Pérez, Manuel Carbajo Vicente
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Last update: 4/01/00