感谢金主任精辟的评析！

感谢张主任对以上引用文摘的精准摘译！

 本例不考虑前列腺腺癌。

低倍镜下确实见到腺体的增生，高倍下细胞胞浆透明，核温和，未见核仁；免疫组化显示基底细胞断续，但存在，且有基底细胞的腺体与免疫组化无基底细胞的腺体的细胞是一样的，因此考虑腺病。

 欢迎原单位意见。

如有后续手术证实就好。

谢谢！

感谢各位网友非常有见地的剖析，收益匪浅，国内和国外一样到究竟是“小腺泡非典型增生”还是“腺癌”的争议仍在进行中，在“Variability in diagnostic opinion among pathologists for single small atypical foci in prostate biopsies ”发表后不久Am J Surg Pathol  Volume 34, Number 7, July 2010 又发表了一封读者来信“Diagnostic Uncertainty in the Interpretation of Small Atypical Acinar Lesions of Prostate”

To the Editor:

The recently published article by Van der Kwast et al1 presents interesting and important data on diagnosis of small atypical foci on prostate needle biopsies. The authors show that these small foci are not reliably diagnosed by community
pathologists (k—0.21), with only slightly better performance by recognized
experts in the field (k—0.39).Not surprisingly, the results are worse (ie, consensus is particularly evasive)for the smallest foci under consideration,consisting of 5 or fewer acini.The authors are to be commended for a carefully designed study with the participation of leading experts in prostate pathology. We write, however,to take strenuous issue with the conclusion as stated in the abstract;the authors ‘‘encourage pathologists to obtain intercollegial consultation of a specialist pathologist for these lesions before a carcinoma diagnosis.’’Why? This conclusion is not supported by their data. Even if shown to an expert, the diagnosis would depend on which expert one chose as a consultant, and we have no way of knowing which consultant is right in a given case. We would interpret their results as follows: (1)small foci of 5 or fewer glands cannot be reproducibly diagnosed as benign versus malignant, even by experts,and therefore (2) major treatment decisions should not be made based on such small foci, given the lack of reproducibility of diagnosis. We see
no benefit to the patient of obtaining an expert opinion in such a case.The underlying issue is how reproducible the diagnosis of a given histopathologic variable must be to use it to guide therapy. We are not aware of this being formally discussed or rigorously examined, yet it is critical. It is a highly complex issue,requiring consideration of the nature of the treatment options, but a few recent examples are available for consideration. In the case of administration of adjuvant therapy in breast cancer, American Society of Clinical Oncology/College of American Pathologists guidelines call for test accuracy (agreement with independent reference method) of 95% for HER2 testing. Frozen section has an acceptable accuracy of greater than 98%.The diagnosis of single small atypical acini on prostate biopsies falls well short of these standards. As we move to evidence-based treatment  ecisions,greater reproducibility will be expected of pathologists. We should be prepared to state when we are not able to render reproducible diagnoses,as our opinions remain critical in treatment planning, and our credibility is eroded if we pretend all diagnoses are equal, in terms of reproducibility.The authors have clearly identified a circumstance where a diagnosis of carcinoma is not possible with certainty,an important step forward.We should now search for tools that will objectively predict patient outcome in such cases, and not fall back on reliance on subjective expert opinion for these small atypical acinar lesions.

C. Blake Gilks, MD, FRCPC
David G. Huntsman, MD
Department of Pathology
Vancouver General Hospital and British
Columbia Cancer Agency
Canada

 Should Pathologists Diagnose ‘‘Adenocarcinoma’’When They Encounter a Single Small Atypical
Focus in a Prostate Biopsy?
In Response:
Both Letters to the Editor referring to our paper ‘‘Variability in diagnostic opinion among pathologists for
single small atypical foci in prostate biopsies’’ challenge its recommendation to obtain second opinion of a specialist pathologist before making a diagnosis of adenocarcinoma on a focus, comprising
5 or less atypical acini.4 Dr Dalton1 argues that the clinical outcome of men with these lesions, irrespective
of the diagnosis, is any how favorable.His view seems to be further corroborated by another paper recently published in this Journal5 on false negative prostate biopsies that is, biopsies where the diagnosis of prostate cancer was missed. The missed lesions were small foci of Gleason score 6 (3 +3) denocarcinomas in a single biopsy. Indeed,none of the men with a false-negative biopsy seemed to have a cancer advanced beyond the curable stage at the time of prostate cancer diagnosis 4 to 8 years later and the cancers did not differ from those found in men with a previous truly negative biopsy result.
To our opinion, the argument raised by Dr Dalton1 might be valid at a population level, but may not apply
for the individual man, in whom the small atypical focus could represent the tip of the iceberg, requiring
additional clinical investigations. As literature has shown that intercollegial consultation leads to more definite diagnoses of benign or cancer in prostate biopsies,3 we maintain our recommendation on this matter.The reason for the disagreement of Drs Gilks and Huntsmans2 with our position is the lack of consensus among the experts themselves. On account of this lack of agreement on the diagnosis
of such small foci, no individual expert can function as a ‘‘golden standard’’and therefore, they propose that pathologists should refrain from making a definite diagnosis of cancer when the number of atypical acini does not exceed a given number, for example, 10 acini. In contrast, we would argue that not all lesions with fewer than 6 atypical acini in our study suffered from a lack of consensus among experts, and in average the experts did better than the general pathologists of our study. The proportion
of consensus in these cases might in fact be higher in a real-life situation as compared with this virtual microscopy environment, for reasons outlined in the discussion of our paper. Thus, we do not agree with
a recommendation that would deny a pathologist’s right to render a definite diagnosis of adenocarcinoma when he would feel comfortable enough to do so. Obviously, we endorse the view
that the scientific community should continue to look for additional tools to reduce the diagnostic uncertainty on these small atypical foci. In the mean time, we would encourage pathologists
to seek advice from specialist pathologists to reduce the uncertainty of their diagnosis under these circumstances.

Theodorus H. Van der Kwast, MD,
PhD*
Jonathan I. Epstein, MD, PhDw
*Department of Pathology University
Health Network Toronto, Canada
wDepartment of Pathology
The Johns Hopkins Medical Institutions
Baltimore, MD

随在我国老龄化、营养条件改善、生活方式改变，前列腺癌的发生率越来越高。病理医师面临前列腺穿刺活检标本的几率明显增多，风险增大。如何保障医疗安全已是迫切需要解决的大问题。

感谢张主任提供的病例，也欢迎网友们上传病理诊断有不同意见的前列腺活检病例。

通过大家的热烈讨论，必将非常有助于大家提高认识、统一诊断标准、共同进步。因此，希望有更多的网友发表意见， 这就是总置顶的原因。

谢谢大家！

Van der Kwast 和 Epstein 教授对读者来信的回复，试译如下：

  读者来信：病理医生在前列腺活检中遇到单个非典型小病灶时应诊断为“腺癌”吗？

答复： 对我们所著《病理医生之间对前列腺活检中单个非典型小病灶诊断意见分歧》一文，两封读者来信对文中的建议提出质疑。我们的文中建议在对仅有5个或5个以下的非典型性腺泡小病灶诊断为前列腺癌之前，要征询专科病理专家的意见。Dalton1医生在信中辩称，这些病变不论是否诊断为癌，其患者的临床预后无论如何都是良好的。他的这种观点在本杂志最近发表的其它文章中好像进一步被认可，其文中论及前列腺活检诊断假阴性的问题，即前列腺癌活检漏诊的问题。漏诊的病变为单个活检组织中Gleason 评分为 6 (3 +3)的小灶前列腺癌。 事实上，假阴性活检病例在4—8年后诊断前列腺癌时，没有哪一例似是不可治愈的进展期前列腺癌，而且与先期活检确诊为真阴性的患者的发病情况没有什么不同之处。

  我们认为，Dalton1提出的论点在整体层面上可能是合理的，但具体应用到个体层面可能是不合适的。非典型性小病灶代表冰山一角，需要再做一些其它的临床检查工作。 正如文献所云，同行间会诊会使前列腺活检中良性或癌的诊断更加准确，为此，我们继续坚持我们文中的建议意见。Gilks 和 Huntsmans医生不同意我们的立场，其原因是其专家们自身之间没有达成共识。 由于对这种小病灶的诊断意见没有达成一致意见，无论哪一个专家的意见都不可以作为“金标准”。因此他们建议，当非典型性腺泡的数目不超过假定的数目（如给定10个腺泡）时，病理医生应避免确诊为癌。相反，我们的研究证明，即便是少于6个非典型性腺泡的病变，在我们的专家之间并不是对所有病变都缺乏共识意见，一般来说，专科病理专家要比参与我们研究的普通病理专家作出诊断的一致性更好些。与模拟显微镜诊断环境相比，在真实工作情景下对这些病变诊断一致性的比例要高得多。其原因在我们文章的讨论中已经作了概述。因此，我们不同意在足以诊断前列腺癌的时候而拒绝病理医生提出确诊意见权利的建议。 显然，我们赞同科学社团应继续寻找其他的评价方法，以减少对这些非典型性小病灶诊断的不确定性。同时，我们将鼓励病理医生向专科病理专家咨询，以减少其对这些非典型性小病灶诊断的不确定性。

Theodorus H. Van der Kwast, MD,PhD*
Jonathan I. Epstein, MD, PhDw
*Department of Pathology University
Health Network Toronto, Canada
wDepartment of Pathology
The Johns Hopkins Medical Institutions
Baltimore, MD

 --------“这些病变不论是否诊断为癌，其患者的临床预后无论如何都是良好的。”

            那我们再争论定不定癌还有意义么？？？

 基底细胞并未完全消失，更倾向于诊断为非典型小腺体增生，而且p504s阳性强度不是很强。

另外需要了解有几条穿刺组织出现这种特征？如果多条均出现类似特征，需要将所有怀疑之处做免疫标记，要排除gleason 3分的腺癌。