Friday, March 18, 2011

When a Prostate Biopsy Result is "Maybe"

Waiting for the results of a prostate biopsy can be very nerve racking.  When I call my patients to tell them the results I often hear the same question:  “Is it good news or bad news?”  Occasionally, my answer is “both.”  I have to give that answer when a prostate biopsy comes back with areas that are described as High Grade Prostatatic Intraepithelial Neoplasia(HGPIN) or Atypical Small Acinar Neoplasia(ASAP).  These areas are NOT considered cancerous but they are not completely normal either.  They are considered precancerous because they demonstrate some characteristics of prostate cancer but not enough to actually call them cancer.

Atypical Small Acinar Neoplasia is the more worrisome of the two lesions.  It can basically be considered an area that looks like cancer but without enough cells there to conclusively say so.  Studies have demonstrated that about 40% of men with ASAP on a prostate biopsy have prostate cancer nearby in the prostate.  As a result, all men with ASAP on a prostate biopsy should undergo a repeat biopsy.  While I know that this does not sound fun, I cannot tell you how important it is to do so.  The repeat biopsy can be done about a month later.  If the subsequent biopsy is negative or demonstrates ASAP again, the patient should be followed more closely with PSA blood tests and rectal exams to be done at more frequent intervals.

The significance of finding HGPIN on a biopsy is much more controversial.  Studies have demonstrated that only about 10-20% of men with HGPIN have associated prostate cancer somewhere within the prostate.  In years past, all men with HGPIN were re-biopsied out of the same concerns as those associated with ASAP.  Then, when studies did not seem to confirm that HGPIN was as much of a risk factor, re-biopsy for patients with the lesion was performed much less frequently.  Recently, however, new studies have determined that HGPIN can be an important predictor of associated prostate cancer if a great deal of it is noted throughout the prostate(multifocal) as opposed to in just one area(unifocal).  As a result, the current recommendation for HGPIN is to re-biopsy patients with multifocal but not unifocal HGPIN.

I hope this letter jumble was not too confusing.  The take home message here is that prostate biopsies do not always come back as “yes” or “no”.  Sometimes we have to accept a “maybe” and try again to make sure that no cancer is present.

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