TABLE 3. Pathological stages and Gleason scores in the 36 patients No. of patients Pathological stage (n=36) Gleason score (n) T2a T2c T3a T3b T3c 5-6 (3), unknown (1) 5-6 (11), 7 (1), unknown (3) 5-6 (3), 7 (1), unknown (2) 5-6 (3), unknown (1) 5-6 (2), 7 (1), unknown (4) 400 4 15 6 4 7 FIG. 1. Pathological stages and Gleason scores in 36 patients. tients, T2c in 15, T3a in 6, T3b in 4, and T3c in 7. Four of the 36 patients (11%) had lesions located at one lobe and 19 of them (53%) were organ-confined disease. 　The Gleason score was 5 to 6 in 22 patients (61%), 7 in 3 (8%), and unknown in 11 (31%). The patients with an un- known Gleason score had cancerous features but a Gleason score could not be assigned because of multifocal and very small lesions. In particular, of the 25 patients who were as- signed a Gleason score, 22 (88%) were diagnosed with a Gleason score of 6 or less. Table 3 and Fig. 1 summarize the pathological stages and Gleason scores in the 36 patients. 　Of the 36 patients, the mean tumor volume of 28 of the patients in whom we could assess tumor volume was 2.5 cc, and 14 of the 28 patients (50%) had a tumor volume of 0.5 cc or less. Eight of the 36 patients could not be evaluated because of multifocal lesions. 　The 10 patients not diagnosed as having PCa (at the site of the ASAP on the initial needle biopsy) had pT2a (9 pa- tients), pT3a (1 patient), a Gleason score of 6 (7 patients), and a Gleason score of 7 (3 patients) in the RP pathology results. DISCUSSION PCa is diagnosed by prostate needle biopsy when patients have an elevated serum PSA level, an abnormality on the digital rectal examination, or a low echoic lesion on TRUS. Park et al reported that among 1,045 men who underwent TRUS-guided systematic needle biopsy, 104 underwent re- Korean J Urol 2010;51:398-402 Kim et al peat prostate biopsies after a previous negative biopsy, and PCa was detected in 22 (21.2%) of the 104 patients [15]. A false-negative result on the initial biopsy or a delayed diag- nosis can result because of the difficulty of diagnosing can- cer from a prostate needle biopsy specimen. This difficulty is due to the fact that quantitative and qualitative changes are necessary for a pathological diagnosis of adeno- carcinoma, the amount of prostatic tissue acquired by nee- dle-core biopsy is limited, and a certain degree of sub- jectivity is involved in the pathological diagnosis [11]. Therefore, ASAP has commonly been used to refer to an atypical focus suspicious but not diagnostic of malignancy [3]. The terminology of ASAP encompasses various lesions including benign lesions, small acinar proliferations mim- icking PCa, and atypical glandular proliferations suspi- cious for carcinoma, which cannot be accurately diagnosed for a various reasons such as insufficient amount of speci- men or biopsy-induced mechanical distortion [16]. Despite the popular recognition of ASAP as a pathological diag- nosis, criticism does exist. First, ASAP legitimizes patho- logical uncertainty by reporting it like a diagnosis. Second, ASAP may have differences of opinion between indepen- dent pathologists. Concordance rates of 84% and 78% be- tween independent pathologists were described in pre- vious studies [17]. Third, several large studies reported a subsequent biopsy rate of ＜70% after a diagnosis of ASAP on the first prostate biopsy [18-20]. Finally, delayed diag- nosis can result because the term ASAP does not ad- equately convey the seriousness of the biopsy result to ei- ther the urologist or the patient [17]. Even though ASAP might be incomplete in terms of pathological diagnosis, its predictive values for PCa on repeat biopsy ranged from 34% to 60% in previous studies [3,4]. We identified PCa post- operatively in 78% of ASAP identified in the initial prostate needle biopsy. 　Brausi et al reported that 25 of 71 patients with isolated ASAP underwent immediate RP and 23 of them underwent subsequent biopsy. All 25 patients (100%) who underwent RP had a final pathological diagnosis of adenocarcinoma and 9 of the 23 patients (39.1%) who underwent follow-up biopsies were diagnosed as having adenocarcinoma in 6 to 12 months after the initial diagnosis of ASAP. Those au- thors suggested RP as one of the treatment choices in young patients with isolated ASAP on prostate needle biopsy. In their study, 9 of the 25 patients (36%) had a tumor localized to a single lobe (pT2a) with a Gleason score of 2 to 6, and the cancer volume was less than 0.5 cc in 3 of these 9 patients. Even though 4 (16%) patients had cancers with a Gleason score of 7 or more, the others had relatively low-grade cancer, which might indicate clinically insignif- icant PCa [11]. 　In another study, Flury et al reviewed whole-tissue sec- tions of prostates removed at 65 cystoprostatectomies [21]. They reported that 2 of 10 ASAP foci were diagnosed as ad- enocarcinoma with additional sectioning of the corre- sponding tissue block. In addition, 6 of 10 ASAP foci had immunohistochemistry supporting a cancer diagnosis, but