Document

Report
Prostate Needle Biopsy:
The Pitfalls and the Role of the
Pathologist – Patient Track
Prostate Cancer Symposium
“Intriguing Cases / Emerging Strategies in
Awareness and Management”
The Prostate Net
October 6, 2009
New York, NY
Angelo M. De Marzo, MD PhD
The Johns Hopkins University School of Medicine, Departments of
Pathology, Urology and Oncology, The Brady Urological Research Institute,
The Kimmel Comprehensive Cancer Center at Johns Hopkins
What is a Pathologist?

All biopsy tissue is
sent to a pathologist
who uses a
microscope to
determine the
diagnosis (e.g.
cancer or not)
What is a prostate biopsy?

Usually 8-12 or more
“cores” of tissue are
taken using
Transrectal
Ultrasound (TRUS)
guidance.
Actual Prostate Core
Needle Biopsies Under
Microscope: Low
Magnification
What if cancer is not present on
biopsy?

If the biopsy diagnosis is:


Atypical:
 “Small focus of atypical gland suspicious for but not
diagnostic of cancer”
 “Atypical small acinar proliferation” (ASAP)
 Up to 50% (or more) of men with a diagnosis of atypical will
be found to have cancer on a repeat biopsy
 Most recommend a repeat biopsy
High grade PIN
 a repeat biopsy should be based on a number of factors
that you discuss with your physician
What if cancer is not present on
biopsy?

If biopsy is called benign:

For example




benign prostatic tissue; should not be called BPH
Inflammation (acute or chronic)
Since the biopsy sampling technique is imperfect,
up to 20% (or more) of men with a negative
prostate biopsy may be found to have cancer on a
repeat biopsy
The decision for a repeat biopsy should be based
on a number of factors that you discuss with your
physician
What you need to know from your prostate
biopsy results if there is cancer present

Gleason Grading



What is the Gleason score?
 (two separate numbers from 1-5 added together; most
common is 3+3=6)
What is the number of tissue cores positive for cancer and
what is the total number of tissue cores taken?
Gleason Score



Grade 2-6: low aggressiveness
Grade 8-10: high aggressiveness
Grade 7: intermediate aggressiveness
Gleason Patterns
Microscopic appearance of prostate
cancer (adenocarcinoma) under higher
magnification
Gleason Pattern 3
Gleason Pattern 5
Active Surveillance




Some patients with limited Gleason score 6 (e.g. less than 3
cores positive and no core with more than 50% cancer) elect to
forego immediate treatment and undergo active surveillance
A potential pitfall with this is:
 Up to 25% of patients with a Gleason grade 6 tumor on biopsy
will be found to have a Gleason 7 or higher if their prostate is
removed
Researchers are attempting to find biological factors in the
biopsy to help predict who will have higher grade or more
aggressive disease
The “good news” is that even in men who “progress” to more
advanced pathology on an active surveillance program, most still
have curable disease when the prostate is removed
 Most “progression” events occur within 2 years suggesting that
undersampling, rather than disease progression, is responsible
J. Urology, Vol. 181, 1628-1634, April 2009
J. Urology, Vol. 182, 2274-2279, November 2009
Discussion Topics


Should I get a second opinion on my
pathology slides?
Should I get my prostate biopsy tissue
evaluated by Aureon Laboratories Prostate
Px+?

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