Understanding the pathology report of a prostate biopsy

Many doctors will want to conduct a prostate specific antigen or PSA test on men once past the age of 40.  Since prostate cancer is the second most common cancer in men after skin cancer, this is an important test for men to have done regularly.  PSA is a protein produced by normal as well as malignant cells of the prostate gland and is found in the blood.  The PSA test measures the level of PSA in a man’s blood.  If a man has an abnormal PSA test this usually results in a prostate biopsy – the only way to confirm the presence of prostate cancer. 

What happens during a prostate biopsy?

A prostate biopsy is a procedure to remove samples of suspicious tissue from the prostate to examine under a microscope for signs of prostate cancer. 

A biopsy of the prostate is not to be taken lightly as it can result in pain, bleeding, and infection.  Before the procedure, to help reduce discomfort and get the best results, men should discuss the procedure in detail with their doctor.  The doctor can minimize these effects by using conscious sedation or an anesthetic called a prostatic block and by prescribing a course of antibiotics at the time of the biopsy. 

A urologist will perform the biopsy of the prostate which can be done in several different ways:

·      Transrectal

This is done through the rectum and is the most common. Using an ultrasound probe in the rectum, a special needle is inserted into the prostate gland via the rectum to collect prostate tissue samples.

·      Transurethral

This is done through the urethra using a cystoscope (a flexible tube and viewing device) which is inserted through the opening of the urethra at the tip of the penis. Tissue samples are then collected from the prostate through the scope.

·      Perineal

This is done through the skin between the scrotum and the rectum. A small incision is made in the perineum and a biopsy needle is then inserted through the incision and into the prostate several times to get samples from different areas of the prostate.

Understanding the pathology report

After the prostate is biopsied, the samples will be taken to a laboratory to be examined under a microscope by a pathologist.  The pathologist’s report will tell the doctor in charge of the patient the diagnosis in each core sample taken from the prostate – whether the samples taken are cancerous or benign and if cancer is present how aggressive it is.

Sometimes, in about 5 percent of prostate biopsies done, the report may come back with findings that say “atypical” or “atypical small acinar proliferation (ASAP),” or “suspicious for cancer” or “glandular atypia.”  What do these terms mean?

Basically the terms, which can be used interchangeably, mean the pathologist has seen something under the microscope within the cells that could be cancer but yet the pathologist is not 100% certain that cancer is present. Suspicious results mean that the cells don’t look like cancer, but they don’t look quite normal, either. 

Spotting cancer using a microscope can be difficult as there can be substances within the cells that look like cancer but yet are not.  They don’t exactly look like normal, healthy cells but also may not totally look like typical prostate cancer cells should. The pathologist will want to be very careful and cautious when diagnosing prostate cancer as the biopsy samples are usually quite small. 

Does having “atypical” cells mean I have to have a repeat biopsy?

No man wants to have a repeat of a prostate biopsy.  But if the pathology report comes back with findings of “atypical cells” most men will likely be advised by their urologist to have a second biopsy within 4 to 6 months.  Remember, the pathology report is basically saying that the features of the cells look highly suggestive but are not diagnostic for carcinoma of the prostate.  However, there is always the chance that cells indicating prostate cancer may have been missed with the first biopsy.  Keep in mind there may be situations where a repeat biopsy may not be recommended but it is important to discuss with your doctor the best course of action to take for you. 

There was other terminology besides “atypical cells” on the pathology report – what do they mean?

Sometimes the biopsy report can have other medical terminology of additional findings by the pathologist such as:

·      “High grade prostatic intraepithelial neoplasia” also known as “high grade PIN”

This finding is not relevant for someone who already has a biopsy that is “atypical” or “suspicious for cancer.”  Sometimes high grade PIN can be a precursor to prostate cancer but the atypical findings are more of a concern for the risk of cancer.

·      “Acute inflammation” or “chronic inflammation”

Either term can mean acute prostatitis or chronic prostatitis.  Both can increase the results of the PSA blood test but for most men it will not indicate prostate cancer.

·      “Atropy” or “atypical adenomatous hyperplasia”

Again, these are terms of things the pathologist sees when looking through the microscope that may look like cancer but will not be found to be prostate cancer when seen on the biopsy.