It has long been understood that a finding of “atypia” (atypical small acinar proliferation) on an initial biopsy of the prostate is associated with an increased risk for prostate cancer, and a repeat biopsy is normally recommended for any patient with an initial finding of atypia.
A recent paper by Kopp et al. reports on an analysis of data from a cohort of 139 patients, all of whom were initially diagnosed with atypia and all of whom then underwent the recommended repeat prostate biopsy.
The findings of this clinical research team were as follows:
- Prostate cancer was identified in 41/139 patients (29 percent).
- 26/41 (66 percent) had Gleason 6 disease.
- 8/41 (20 percent) had Gleason 7 disease.
- 3/41 (7 percent) had Gleason 8 disease.
- Gleason scores of < 6 were not reported.
- There was no clear association of a diagnosis of prostate cancer on repeat biopsy with age, race, family history, PSA, PSA density, number of previous biopsies, or time to repeat biopsy.
- Histological inflammation was associated with a major decrease in the probability of cancer on repeat biopsy (odds ratio [OR] = 0.15).
- 14/41 men diagnosed with prostate cancer (31 percent) underwent radical prostatectomy.
- 6/14 (43 percent) had a Gleason score ≥ 7.
- 3/14 (21 percent) had pT3a disease.
- 1/14 (7 percent) had positive lymph nodes.
Kopp et al. conclude that (at least in this cohort of patients) inflammation of the prostate in men diagnosed with atypia was independently associated with a significantly decreased risk of cancer on repeat biopsy. However, a significant percentage of patients with initial atypia clearly are at risk for clinically significant prostate cancer.
It would help if we were able to better determine which patients with an initial finding of atypia were most and least likely to have a subsequent finding of such clinically significant disease.
Filed under: Diagnosis, Management, Risk Tagged: | acinar proliferation, ASAP, atypia, biopsy, follow-up
Search for new and
ongoing trials on the
CTAG PCa web site
A nearly 30% risk of prostate cancer seems pretty meaningful, especially if these are all otherwise healthy men and especially given the relatively high stages of their final pathologies.
It’s interesting that the PSA loses its informative value in the face of the atypia.
Makes me think of the one and only prophylactic prostatectomy I ever did: 52-year-old healthy man whose father, uncle, and both grandfathers died of prostate cancer, with PSA rising from 2.7 to 3.6 ng/ml. Two good sets of biopses showed PIN and atypia. Yet his final pathology showed wall-to-wall bilateral Gleason 6. As of 7 years post-op, he was alive and well. Or as he put it: “I’m the only man in my family to survive.”
Atypia is an important marker of disease. It must be interpreted and presented thoughtfully.
Hi Doctor.
I had a prostate biopsy 2 months ago, and the doctor said there was atypia in one of the areas. He recommended another biopsy in 3 months (i.e., at the end of September). I`ve had three physicals in the last 3 years (1.5 years apart], and my PSA level went from 0.9 to 1.2 to 3.2 ng/ml.
My brother had early stage prostate cancer at 51 (my current age) and elected to have his prostate removed. My dad was diagnosed at age 80 ( and he’s still OK). I read an article as to too many biopsies being unnecessary. I feel I should get another, maybe next year. What are your thoughts?
*****
Dear Michael,
The necessity of biopsy depends upon a mix of considerations, including the probability of a positive result (age, PSA, family history, result of last biopsy), the risks of biopsy, and the pros and cons of treatment if a biopsy detects cancer, which in itself is a complicated exercise, and various personal value judgments. It’s easy to throw around the concept of “unnecessary” but it’s a whole other exercise to quantify it in an individual case.
Clearly with a PSA of 3.2 and a brother with prostate cancer, you are at risk. Not knowing anything more about you, this is a feature of your case that can be put into proper context by your doctor(s).
Arnon
Michael:
If you haven’t already read this, you might want to look at the article entitled “That’s not what ASAP stands for! Is it?“