Clinical strategy of repeat biopsy in patients with atypical small acinar proliferation (ASAP)

Atypical small acinar proliferation (ASAP) occurs in approximately 5% of prostate biopsies. Approximately 30–40% of patients with ASAP have biopsy detectable prostate cancer (PCa) within 5 years. Current guidelines recommend a repeat biopsy within 3–6 months after the initial diagnosis. The aim of the present study was to examine the association between ASAP and subsequent diagnosis of clinically significant PCa (csPCa). The need for immediate repeat biopsy was also evaluated. We identified 212 patients with an ASAP diagnosis on their first biopsy at our institution between February 2006 and March 2018. Of these patients, 102 (48.1%) had at least one follow-up biopsy. Clinicopathologic features including rates of subsequent PCa and csPCa were assessed. Thirty-five patients subsequently underwent radical prostatectomy (RP). Their pathologic results were reviewed. csPCa was defined as the presence of Gleason score (GS) ≥ 3 + 4 in ≥ 1 biopsy core. Adverse pathology (AP) was defined as high-grade (primary Gleason pattern ≥ 4) or non-organ-confined disease (pT3/N1) after RP. Of 102 patients, 87 (85.3%), 13 (12.7%), and 2 (2.0%) had one, two, and three follow-up biopsies, respectively. Median time from the initial ASAP diagnosis to the 2nd follow-up biopsy and the last follow-up biopsy were 21.9 months (range 1–129 months) and 27.7 months (range 1–129 months), respectively. Of these patients, 46 (45.1%) were subsequently diagnosed with PCa, including 20 (19.6%) with csPCa. Only 2 (2.0%) patients had GS ≥ 8 disease. Five (4.9%) patients had number of positive cores > 3. Of 35 patients who subsequently underwent RP, seven (20%) had AP after RP and 17 (48.6%) showed GS upgrading. Of these 17 patients, the vast majority (16/17, 94.1%) had GS upgrading from 3 + 3 to 3 + 4. 45.1% of patients with an initial diagnosis of ASAP who had repeat prostate biopsy were subsequently diagnosed with PCa and 19.6% were found to have csPCa. Our findings add further evidence that after a diagnosis of ASAP, a repeat biopsy is warranted and that the repeat biopsy should not be postponed.

The Role of Prostate Combination Biopsy Consisting of Targeted and Additional Systematic Biopsy

Background: To identify the role of combination biopsy, which consists of both targeted and additional systematic cores, in the diagnosis of clinically significant prostate cancer (csPCa). Methods: We retrospectively reviewed patients with PSA levels 2.5–15 ng/mL who have a suspicious prostate lesion (with the Prostate Imaging Reporting and Data System (PI-RADS) ≥ 3) on multiparametric MRI (mpMRI) between January 2016 and December 2018. We analyzed biopsy results by PI-RADS score and biopsy methods (systematic, targeted, and combination biopsy). Results: Of the 711 total patients, an average of 4.0 ± 1.8 targeted and 8.6 ± 3.1 additional systematic biopsies were performed. The additional systematic biopsies were sampled outside the targeted biopsy area. The combination biopsies detected more csPCa (201 patients, 28.3%) than did the targeted (175 patients, 24.6%) or systematic (124 patients, 17.4%) biopsies alone (p < 0.001). In the initial biopsy samples, there was a 7% increase in the detection of csPCa than in targeted biopsy (62% to 69%). It increased by 11% in repeat biopsy (46% to 57%). There was no statistical significance in both groups (p = 0.3174). Conclusions: Combination biopsy has the benefit of detecting csPCa in both initial and repeat biopsy when there is a suspicious lesion on mpMRI.

Clinicopathologic analysis of patients undergoing repeat transurethral resection of bladder tumour following an initial diagnosis of urothelial carcinoma with lamina propria invasion and variant/divergent histology

AimsA subset of patients with urothelial carcinoma (UCa) and lamina propria (LP) invasion in bladder biopsies/transurethral resections (TURs) are at significant risk for recurrence and have increased rates of progression to UCa with muscularis propria (MP) invasion. The clinicopathologic features of this patient population has not been well characterised in the Pathology literature.MethodsWe performed a search through our urologic pathology files and expert consult cases of the senior author for bladder biopsies/TURs of UCa with LP invasion and variant/divergent histology from 2014 to 2020. Patients with a prior diagnosis of UCa with MP invasion or upper tract UCa were excluded. Clinicopathologic data were obtained.ResultsNinety-five patients with at least one biopsy/TUR of UCa with LP invasion and variant/divergent histology were identified. Mean patient age was 72 years (range: 46–92 years) with a male predominance 2.3:1. Initial variant/divergent histologies identified were: glandular (35.8%), squamous (23.2%), micropapillary (20%), clear cell/lipid rich (12.6%), diffuse/signet ring/plasmacytoid (10.5%), nested (9.5%), sarcomatoid (6.3%), poorly differentiated/anaplastic (4.2%), small cell (2.1%), lymphoepithelioma-like (2.1%), osteoclast-like giant cells (1.1%) and tumour giant cells (1.1%). Two or more variant histologies were identified in 18.9% of these cases. The rate of micropapillary UCa was significantly higher in multifocal tumours compared with unifocal tumours (37% vs 7.1%).ConclusionsIn our cohort of patients undergoing early repeat biopsy/TUR, 75% of patients had persistent UCa. Additionally, almost 25% of patients had a prior diagnosis of UCa without a variant/divergent histology identified. Our findings highlight the critical role of repeat biopsy/TUR especially in a subset of patients who have variant/divergent histology, even in the absence of MP invasion.

Cystic Encapsulated Papillary Carcinoma in the Male Breast: An Unusual Feature With a Diagnostic Challenge

Papillary carcinoma in the male breast is uncommon. Here, we report a case of a large encapsulated papillary carcinoma (EPC) in a 62-year-old male. The patient presented with a left breast mass of 1-year duration and bloody nipple discharge for several days. Mammography and breast ultrasonography showed a large left breast mass. The initial biopsy demonstrated fat necrosis with acute and chronic inflammation only. Due to clinical suspicion, a repeat biopsy was performed and revealed scant fragments of papillary carcinoma in a background of inflammation. The patient underwent left total mastectomy. Grossly, the breast contained a 9.0 cm entirely cystic lesion lined by a hemorrhagic thick fibrotic wall. No solid area was identified in the cyst. The entire cyst wall was examined under microscopy; only a few sections with papillary carcinoma were identified. The lesion was confined to the cyst wall; so, a diagnosis of EPC was made. Compared to the previously reported EPC cases of male breast, the lesion of this case was unusually cystic, which making the diagnosis challenging. Therefore, awareness of this unusual feature, repeat biopsy when the pathology result is discordant, and extensive sampling of the lesion are essential for making the correct diagnosis and guiding patient management.