Clinical implications of an initial diagnosis of ASAP


Relatively few data have been published on the pathological outcomes of patients initially diagnosed with atypical small acinar proliferation (ASAP), i.e., atypical glands suspicious but not diagnostic for prostate cancer, who are diagnosed with prostate cancer on re-biopsy and then treated by radical prostatectomy.

An analysis of pathology data from 169 such men compared to data from 15,810 without an initial diagnosis of atypical glands suspicious for cancer, all of whom received radical prostatectomy (RP) at Johns Hopkins between 1993 and 2008, has now been published by Chen et al.

The results of this analysis show the following:

  • Median time between the initial atypical biopsy and the repeat biopsy showing cancer was 6.1 months (range, 0.7 to 94.8 months).
  • An initial diagnosis of atypical glands suspicious but not diagnostic for cancer correlated with non-palpable disease, a biopsy Gleason score of 6, and lower tumor volume in the biopsy cores.
  • Patients who had an RP after an initial atypical biopsy had
    • Significantly lower Gleason scores and pathological stages than patients with no sign of ASAP
    • A Gleason score of 6 in 126/169 patients (74.5 percent)
    • Organ-confined disease in 140/169 patients (83.0 percent)
    • Seminal vesicle involvement in just 2/169 patients
    • No cases of lymph node metastasis.
  • The presence of initial atypical biopsy was an independent predictor of organ-confined disease at RP.
  • However, when tumor volume on needle biopsy was included in the multivariate analysis a diagnosis of atypical glands suspicious but not diagnostic for carcinoma lost its independent predictive value.

Chen et al. conclude that when prostate cancer is diagnosed on repeat needle biopsy following a diagnosis of atypical glands suspicious but not diagnostic of cancer, there is a significantly lower tumor grade and pathological stage at RP than in cases of cancer without such an initial diagnosis.

The initial diagnosis of ASAP normally suggests the need for repeat biopsy. The authors emphasize that the recognition of the occurrence of high Gleason scores and advanced pathological stage in some patients with an initial diagnosis of ASAP suggests the importance of re-biopsy within 3 to 6 months following such an initial diagnosis.

These data also seem to imply that a significant proportion of men diagnosed with prostate cancer after an initial diagnosis of ASAP may be good candidates for active surveillance as opposed to active treatment with RP (or other modalities). This use of AS would seem to be most appropriate in men with a life expectancy of 15 years or less.

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