Variation in reporting of cancer extent and benign histology in prostate biopsies among European pathologists

Clinical relevance of amyloid in prostate samples: a report on 40 patients

OBJECTIVE

To describe the clinical findings in patients with incidental prostatic amyloidosis.

PATIENTS AND METHODS

Retrospective search in the database of the Department of Pathology, Hospital de Bellvitge, for prostate specimens with amyloid. Congo red and immunohistochemical staining of the sections. Review of the patients' clinical charts for symptoms attributable to systemic amyloidosis.

RESULTS

Amyloid deposition in the prostate was identified and reported in 40 patients between 2001 and 2022. Median age was 76.5 years (range 62-90). Prostate cancer was diagnosed in 25 patients. Only 4 patients had a previous diagnosis of amyloidosis. In the remaining 36 the prostate sample (31 needle biopsies, two transurethral resections (TUR), two simple prostatectomies, one radical cystectomy for bladder cancer) provided the initial diagnosis. Amyloid deposits were mainly located in the wall of small vessels and rarely in the prostatic stroma. Immunohistochemistry was available in 32 cases, 26 of which were positive for TTR. All patients showed at least one symptom indicative of systemic amyloidosis, the most frequent being hearing loss (55%), carpal tunnel syndrome (42,5%) or other osteoarticular symptoms (tendinopathies, osteoarthritis), cataracts (37.5%), and cardiac symptoms (32.5%), among others.

CONCLUSION

The prostate is a target tissue for amyloid deposition. The incidental finding of amyloid in prostate corresponds, in the majority of cases, to previously undiagnosed systemic TTR amyloidosis in patients lacking signs of heart involvement but having mainly osteoarticular symptoms, hearing and visual impairment.

Biopsy core length in white versus African descendant prostate cancer patients

Objective: To explore whether distinct prostate cancer (PCa) prognoses between ethnicities could be explained by diverse characteristics in the prostate biopsy.Methods: Clinical, prostate biopsy and surgical single-institution data of whites and African descendants with similar access to the health system who underwent radical prostatectomy whole gland histopathology within 60 days after biopsy from 2010 to 2011 and followed for 5 years minimum were compared.Results: Among 203 included patients, 153 (75.4%) were whites and 50 (24.6%) were African descendants. The mean patients' age was 63.7 (± 6.8) years. Digital rectal examination (DRE) was suspected of cancer in 45.2% of the patients. The prostate biopsy core length was smaller in African descendants than in whites, overall 11.0 ± 3.2 vs 12.0 ± 2.9 mm, p = 0.037, and without neoplasia, 10.4 ± 3.8 vs 11.7 ± 3.1 mm, p = 0.038, respectively. Also, suspicious DRE showed smaller biopsy core length, overall 11.1 ± 3.2 mm vs 12.4 ± 2.6, p = 0.003, cancer positive 12.0 ± 4.8 mm vs 13.3 ± 3.7, p = 0.022 and negative 10.6 ± 3.6 mm vs 12.2 ± 3.0, p = 0.002. On 81 months median follow-up, more African descendants were lost to follow-up (10%, n = 5 vs 3.9%, n = 6) and the biochemical recurrence rate was the same between the groups (33.3%).Conclusion: In a PCa population with similar access to the health system, prostate biopsy core length in African descendant men is significantly smaller than in whites. This finding is new and may add to the controversial argument of PCa having a worse prognosis in African descendant patients.

[Prostate pathology recommendations from the Uropathology working group of the Spanish Society of Pathology]

These guidelines from the uropathology working group of the Spanish Society of Pathology (SEAP) are based on the European and ISUP 2015 recommendations and those of the College of American Pathologists, as well as the latest WHO 2016, TNM (AJCC) 2017 classifications. They include recommendations for specimen sampling, macro- and microscopic examination and immunohistochemistry. Gleason patterns are specified: Gleason pattern 3 includes hyperplastic, atrophic and microcystic glands, while pattern 4 includes all cribriform or glomeruloid glands. The Gleason score in prostatectomy specimens may change; if a tertiary pattern occurs in more than 5% of the tumour, it becomes a secondary pattern. In both biopsies and prostatectomy specimens, if the Gleason score is 7, the percentage of pattern 4 should be stated. Gleason scoring in tumor variants and special situations should also be specified. These recommendations should be adapted according to the resources available.

Contemporary prostate biopsy reporting: insights from a survey of clinicians’ use of pathology data

Aim

To determine how clinicians use data in contemporary prostate biopsy reports.

Methods

A survey was circulated to members of the British Association of Urological Surgeons and the British Uro-oncology Group.

Results

Responses were received from 114 respondents (88 urologists, 26 oncologists). Ninety-seven (94%) use the number of positive cores from each side and 43 (42%) use the % number of positive cores. When determining the number and percentage of positive cores, 72 (71%) would not differentiate between targeted and non-targeted samples. If multiple Gleason Scores (GS) were included in a report, 77 (78%) would use the worst GS even if present in a core with very little tumour, 12% would use the global GS and 10% the GS in the core most involved by tumour. Fifty-five (55%) either never or rarely used perineural invasion for patient management.

Conclusions

The number of positive cores is an important parameter for patient management but may be difficult to determine in the laboratory due to core fragmentation so the biopsy taker must indicate the number of biopsies obtained. Multiple biopsies taken from a single site are often interpreted by clinicians as separate cores when determining the number of positive cores so pathologists should also report the number of sites positive. Clinicians have a non-uniform approach to the interpretation of multiple GS in prostate biopsy reports so we recommend that pathologists also include a single ‘bottom-line’ GS for each case to direct the clinician’s treatment decision.

Handling and reporting of transperineal template prostate biopsy in Europe: a web-based survey by the European Network of Uropathology (ENUP)

Transperineal template prostate biopsies (TTPB) are performed for assessments after unexpected negative transrectal ultrasound biopsies (TRUSB), correlation with imaging findings and during active surveillance. The impact of TTPBs on pathology has not been analysed. The European Network of Uropathology (ENUP) distributed a survey on TTPB, including how specimens were received, processed and analysed. Two hundred forty-four replies were received from 22 countries with TTPBs seen by 68.4% of the responders (n = 167). Biopsies were received in more than 12 pots in 35.2%. The number of cores embedded per cassette varied between 1 (39.5%) and 3 or more (39.5%). Three levels were cut in 48.3%, between 2 and 3 serial sections in 57.2% and unstained spare sections in 45.1%. No statistical difference was observed with TRUSB management. The number of positive cores was always reported and the majority gave extent per core (82.3%), per region (67.1%) and greatest involvement per core (69.4%). Total involvement in the whole series and continuous/discontinuous infiltrates were reported in 42.2 and 45.4%, respectively. The majority (79.4%) reported Gleason score in each site or core, and 59.6% gave an overall score. A minority (28.5%) provided a map or a diagram. For 19%, TTPB had adversely affected laboratory workload with only 27% managing to negotiate extra costs. Most laboratories process samples thoroughly and report TTPB similarly to TRUSB. Although TTPB have caused considerable extra work, it remains uncosted in most centres. Guidance is needed for workload impact and minimum standards of processing if TTPB work continues to increase.

Greater extent of prostate inflammation in negative biopsies is associated with lower risk of prostate cancer on repeat biopsy: results from the REDUCE study

BACKGROUND

To evaluate whether the extent of baseline acute prostate inflammation (API) and chronic prostate inflammation (CPI) was associated with risk of prostate cancer (PCa) at 2-year repeat prostate biopsy in a clinical trial with systematic biopsies independent of PSA.

METHODS

A retrospective analysis of 6065 men with a negative baseline biopsy in the reduction by dutasteride of PCa events (REDUCE) trial undergoing 2-year biopsy. API and CPI extent (percentage of cores involved) and PCa (present or absent) were assessed by central pathology. The association of baseline API and CPI with PCa at the 2-year biopsy was evaluated with logistic regression in uni- and multivariable analyses.

RESULTS

API extent was classified as absent or involving 1-25%, 26-50%, 51-75% and >75% cores in 5140 (85%), 742 (12%), 151 (2%), 17 (<1%) and 15 (<1%) cases, respectively. CPI extent was classified as absent or involving 1-25%, 26-50%, 51-75% and >75% cores in 1367 (22%), 2532 (42%), 1474 (24%), 397 (7%) and 295 (5%) cases, respectively. More extensive API was associated with younger age, lower PSA and lower prostate volume, while more extensive CPI was associated with older age, lower PSA and higher prostate volume (all P<0.01). In both uni- and multivariable analyses, API and CPI extent were associated with lower risk of PCa at the 2-year biopsy (both P<0.01).

CONCLUSIONS

In a cohort of men undergoing repeat prostate biopsy 2 years after a negative baseline biopsy, a greater extent of baseline API and CPI was independently associated with lower PCa risk.

Prevalence and management of prostate cancer among East Asian men: Current trends and future perspectives

OBJECTIVES

Previously East Asian men had been considered less likely to develop or die of prostate cancer. Emerging research and the onset of prostate-specific antigen screening in East Asian countries suggests that this may not be the case. We sought to analyze epidemiology and molecular genetic data and recent trends in the management of prostate cancer among East Asian men.

METHODS AND MATERIALS

We performed literature searches using PubMed, Embase, and Google Scholar to examine current literature on prostate cancer in East Asian men. Additionally, articles were searched for further references related to the topic.

RESULTS

Recent studies have reported increasing incidence of prostate cancer identified in East Asian men. Prostate cancer mortality has increased and is currently the fourth leading cause of death among men in Shanghai, China. Although prostate cancer was considered less aggressive among East Asian men, studies suggest that it is similarly aggressive to prostate cancer in Western populations. Molecular markers such as the TEMPRESS:ERG fusion gene and PTEN loss may provide novel methods of screening East Asian men for prostate cancer. National-level guidelines for prostate cancer screening and management are only available in Japan.

CONCLUSIONS

The prevalence of prostate cancer in East Asian men is likely similar to that in Western male populations. East Asian men present at higher stages of prostate cancer, likely because of a lack of standardized screening protocols. Urologists in Western countries should screen East Asian men for prostate cancer using the same standards as used for Western men.

Applying precision medicine to the active surveillance of prostate cancer

The recent introduction of a variety of molecular tests will potentially reshape the care of patients with prostate cancer. These tests may make more accurate management decisions possible for those patients who have been "overdiagnosed" with biologically indolent disease, which represents an exceptionally small mortality risk. There is a wide range of possible applications of these tests to different clinical scenarios in patient populations managed with active surveillance. Cancer 2015;121:3435-43. © 2015 American Cancer Society.

Predictive criteria of insignificant prostate cancer: what is the correspondence of linear extent to percentage of cancer in a single core?

Objective

The aim of active surveillance of early prostate cancer is to individualize therapy by selecting for curative treatment only patients with significant cancer. Epstein’s criteria for prediction of clinically insignificant cancer in surgical specimens are widely used. Epstein’s criterion “no single core with >50% cancer” has no correspondence in linear extent. The aim of this study is to find a possible correspondence.

Materials and Methods

From a total of 401 consecutive patients submitted to radical prostatectomy, 17 (4.2%) met criteria for insignificant cancer in the surgical specimen. The clinicopathologic findings in the correspondent biopsies were compared with Epstein’s criteria for insignificant cancer. Cancer in a single core was evaluated in percentage as well as linear extent in mm.

Results

Comparing the clinicopathologic findings with Epstein’s criteria predictive of insignificant cancer, there was 100% concordance for clinical stage T1c, no Gleason pattern 4 or 5, ≤2 cores with cancer, and no single core with >50% cancer. However, only 25% had density ≤0.15. The mean, median and range of the maximum length of cancer in a single core in mm were 1.19, 1, and 0.5-2.5, respectively. Additionally, the mean, median, and range of length of cancer in all cores in mm were 1.47, 1.5, and 0.5-3, respectively.

Conclusion

To pathologists that use Epstein’s criteria predictive of insignificant cancer and measure linear extent in mm, our study favors that “no single core with >50% cancer” may correspond to >2.5 mm in linear extent.

Prevalence of incidental prostate cancer: A systematic review of autopsy studies

Prostate cancer screening may detect nonprogressive cancers, leading to overdiagnosis and overtreatment. The potential for overdiagnosis can be assessed from the reservoir of prostate cancer in autopsy studies that report incidental prostate cancer rates in men who died of other causes. We aimed to estimate the age-specific incidental cancer prevalence from all published autopsy studies. We identified eligible studies by searches of Medline and Embase, forward and backward citation searches and contacting authors. We screened the titles and abstracts of all articles; checked the full-text articles for eligibility and extracted clinical and pathology data using standardized forms. We extracted mean cancer prevalence, age-specific cancer prevalence and validity measures and then pooled data from all studies using logistic regression models with random effects. The 29 studies included in the review dated from 1948 to 2013. Incidental cancer was detected in all populations, with no obvious time trends in prevalence. Prostate cancer prevalence increased with each decade of age, OR = 1.7 (1.6–1.8), and was higher in studies that used the Gleason score, OR = 2.0 (1.1–3.7). No other factors were significantly predictive. The estimated mean cancer prevalence increased in a nonlinear fashion from 5% (95% CI: 3–8%) at age <30 years to 59% (95% CI: 48–71%) by age >79 years. There was substantial variation between populations in estimated cancer prevalence. There is a substantial reservoir of incidental prostate cancer which increases with age. The high risk of overdiagnosis limits the usefulness of prostate cancer screening.

Current practice in handling and reporting prostate needle biopsies: results of a Turkish survey

BACKGROUND

In 2005 ISUP (International Society of Urological Pathology) consensus revised the Gleason grading system.

METHOD

We conducted a web based national survey of the members of Uropathology Working Group (WG) and general pathologists (NWP) to investigate the current practice in reporting prostate needle biopsies.

RESULTS

The revised system was well known and applied by the respondents. In pattern analysis major difference was detected in reporting medium sized, regular cribriform glands. In both group this pattern was reported as Gleason Pattern (GP) 3 by at least 50% of the repliers, the rest reported this pattern as GP 4. Gleason Score (GS) 2-4 was not reported by the WG. In NWP GS 2-4 was reported by 25% either frequently of infrequently. Any amount of secondary higher grade was included in GS by 92.5% of WG and 70% of NWP (p<0.05). Five percent cut off was requested for the lower secondary grade by 71.4% of WG but 64% of NWP. (p<0.05) Tertiary pattern was reported by 64.5% of WG and 34% of NWP (p<0.05). Individual GS was assigned for each core by 46.4% of WG and 26.5% of NWP (p<0.05). When measuring the extend of cancer, most included the benign tissue between cancer foci in the same core. Fat invasion was interpreted as extraprostatic invasion by 85.7% of WG and 55.9%of NWP (p<0.05).

CONCLUSION

This study showed the specific points where the educational efforts should be focused to have a better and standardized practice pattern of pathologists when reporting prostate biopsies.

The critical role of the pathologist in determining eligibility for active surveillance as a management option in patients with prostate cancer: consensus statement with recommendations supported by the College of American Pathologists, International Society of Urological Pathology, Association of Directors of Anatomic and Surgical Pathology, the New Zealand Society of Pathologists, and the Prostate Cancer Foundation

CONTEXT

Prostate cancer remains a significant public health problem. Recent publications of randomized trials and the US Preventive Services Task Force recommendations have drawn attention to overtreatment of localized, low-risk prostate cancer. Active surveillance, in which patients undergo regular visits with serum prostate-specific antigen tests and repeat prostate biopsies, rather than aggressive treatment with curative intent, may address overtreatment of low-risk prostate cancer. It is apparent that a greater awareness of the critical role of pathologists in determining eligibility for active surveillance is needed.

OBJECTIVES

To review the state of current knowledge about the role of active surveillance in the management of prostate cancer and to provide a multidisciplinary report focusing on pathologic parameters important to the successful identification of patients likely to succeed with active surveillance, to determine the role of molecular tests in increasing the safety of active surveillance, and to provide future directions.

DESIGN

Systematic review of literature on active surveillance for low-risk prostate cancer, pathologic parameters important for appropriate stratification, and issues regarding interobserver reproducibility. Expert panels were created to delineate the fundamental questions confronting the clinical and pathologic aspects of management of men on active surveillance.

RESULTS

Expert panelists identified pathologic parameters important for management and the related diagnostic and reporting issues. Consensus recommendations were generated where appropriate.

CONCLUSIONS

Active surveillance is an important management option for men with low-risk prostate cancer. Vital to this process is the critical role pathologic parameters have in identifying appropriate candidates for active surveillance. These findings need to be reproducible and consistently reported by surgical pathologists with accurate pathology reporting.

Prognostic histopathological and molecular markers on prostate cancer needle-biopsies: a review

Prostate cancer is diverse in clinical presentation, histopathological tumor growth patterns, and survival. Therefore, individual assessment of a tumor's aggressive potential is crucial for clinical decision-making in men with prostate cancer. To date a large number of prognostic markers for prostate cancer have been described, most of them based on radical prostatectomy specimens. However, in order to affect clinical decision-making, validation of respective markers in pretreatment diagnostic needle-biopsies is essential. Here, we discuss established and promising histopathological and molecular parameters in diagnostic needle-biopsies.

Gleason underestimation is predicted by prostate biopsy core length

PURPOSE

To evaluate whether core length impacts biopsy accuracy and Gleason score underestimation compared to radical prostatectomy (RP) specimens.

METHODS

From 2010 to 2011, 8,928 cores were trans-rectal obtained from 744 consecutive patients (178 RP, 24%), 557 by an experienced performer (>250/year) and 187 (25%) by in-training urology residents. Prospectively analyzed variables were core length, age, prostate volume, free and total prostate-specific antigen (PSA), PSA density and free/total PSA ratio.

RESULTS

Mean core length for Gleason upgrading on RP (42.7%, n = 76) was 11.61 (±2.5, median 11.40) compared to 13.52 (±3.2, median 13.70), p < 0.001 for perfect biopsy-RP Gleason agreement (57.3%, n = 102). In multivariate analysis, for each unit of core length increment in millimeter, the Gleason upgrading risk decreased 89.9%, p = 0.049 [odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.99]. Biopsy positivity between experienced (35.5%) and in-training performer (30.1%) was not significantly different (p = 0.20), with comparable mean patient age (65.1 vs. 64.1), prostate volume (52.3 vs. 50.7) and median PSA (5.2 vs. 5.1), respectively. Denoting wider variability in terms of core length, in-training performers obtained significantly larger cores for positive biopsies (11.33 ± 3.42 vs. 10.83 ± 3.68), p = 0.043, compared to experienced performer (11.39 ± 3.36 vs. 11.37 ± 3.64), p = 0.30. In multivariate analysis, PSA density (OR 1.14, 95% CI 1.02-1.28) and age (OR 1.04, 95% CI 1.01-1.07) were significantly associated with biopsy positivity, p = 0.021 and p = 0.011, respectively.

CONCLUSION

While core length on trans-rectal biopsy independently affects Gleason upgrading on RP specimens, performer experience has minor impact on Gleason discordance or biopsy positivity due to a sharp learning curve.