Methods to obtain more clinical and pathologic information from needle core biopsy of the prostate gland

Prostate Biopsy Core Handling: Comparison of Contemporary Preembedding Methods

INTRODUCTION

The probability of prostate cancer detection is related to the amount of tissue represented. For optimal tissue representation, the specimens should preserve their regular cylindrical shape and avoid artefacts and deformation caused by fixation and preembedding. The aim of our study was to compare contemporary preembedding methods including a new method of using thick cardboard.

MATERIALS AND METHODS

To compare the preembedding methods, we took 36 nonfragmented cores from fresh prostatectomy specimens for each method, fixed them in formalin and made histological slides. The comparison criteria were a core section area in the middle section and the number of fragments per core after processing.

RESULTS

Two methods (preembedding on the edge of thick cardboard and on biplicated paper) provided a bigger section area of specimens. The differences in amounts of fragments were very small among the methods mentioned above and the preembedding glass with grooves, but preembedding between two sponges in a histological cassette showed higher fragmentation.

CONCLUSIONS

Preembedding on the edge of thick cardboard and on biplicated paper can be recommended as effective methods of prostate biopsy core fixation. Paper or cardboard for fixation of prostate biopsy cores should be presoaked with formalin or normal saline.

Specimen orientation by marking the peripheral end: (potential) clinical advantages in prostate biopsy

The aim of this paper is to identify advantages that could be obtained by orientation of the biopsy specimen using the marking technique. We reviewed our experience (4,500 cases) and the published literature. The peripheral (proximal) end of the fresh specimen is marked with ink soon after needle delivering in a few minutes. It is performed easily in association with pre-embedding method. Five potential clinical advantages were identified: (1) tumor localization, (2) atypical lesions localization and planning rebiopsy strategy, (3) planning surgical strategy, (4) selection criteria for focal therapy and active surveillance, and (5) cost reduction. Peripheral end marking is low cost, easy and reproducible. It drives several potential advantages in cancer diagnosis or isolated atypical lesions, in particular, spatial localization within the biopsy (transition versus peripheral zone, anterior versus posterior, subcapsular versus intraparenchima, and extraprostatic extension) should be easy and reliable. We can add a new pathological parameter: pathological orientation or biopsy polarity.

Current salvage methods for recurrent prostate cancer after failure of primary radiotherapy

We reviewed the current salvage methods for patients with local recurrent prostate cancer after primary radiotherapy (RT), using a search of relevant Medline/PubMed articles published from 1982 to 2008, with the following search terms: 'radiorecurrent prostate cancer, local salvage treatment, salvage radical prostatectomy (RP), salvage cryoablation, salvage brachytherapy, salvage high-intensity focused ultrasound (HIFU)', and permutations of the above. Only articles written in English were included. The objectives of this review were to analyse the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. There are four whole-gland re-treatment options (salvage RP, salvage cryoablation, salvage brachytherapy, salvage HIFU) for RT failure, although others might be in development or investigations. Salvage RP has the longest follow-up with acceptable oncological results, but it is a challenging technique with a high complication rate. Salvage cryoablation is a feasible option, especially using third-generation technology, whereby the average biochemical disease-free survival rate is 50-70% and there are fewer occurrences of severe complications such as recto-urethral fistula. Salvage brachytherapy, with short-term cancer control, is comparable to other salvage methods but depends on cumulative dosage limitation to target tissues. HIFU is a relatively recent option in the salvage setting. Both salvage brachytherapy and HIFU require more detailed studies with intermediate and long-term follow-up. As these are not prospective, randomized studies and the definitions of biochemical failure varied, there are limited comparisons among these different salvage methods, including efficacy. In the focal therapy salvage setting, the increased use of thermoablative methods for eligible patients might contribute to reducing complications and maintaining quality of life. The problem to effectively salvage patients with locally recurrent disease after RT is the lack of diagnostic examinations with sufficient sensitivity and specificity to detect local recurrence at an early curable stage. Therefore, a more strict definition of biochemical failure, improved imaging techniques, and accurate specimen mapping are needed as diagnostic tools. Furthermore, universal selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological efficacy and least comorbidity.

Salvage Cryosurgery for Recurrent Prostate Carcinoma after Radiotherapy

Cryotherapy is a salvage treatment for patients with biopsy-proved prostatic adenocarcinoma recurrent after radiotherapy. Proper sampling, labeling, and analysis of prostate biopsies allows prompt diagnosis, identification of important prognostic parameters, and planning of an appropriate therapeutic strategy. Whereas androgen-suppressive therapy is associated with only a temporary benefit, transperineal salvage cryosurgery offers a potentially curative option for patients with localized disease, even those with significant comorbidities. Technological advances, including computerized treatment planning and miniaturized cryoprobes, may provide further therapeutic advantages and lower complication rates. Cryotherapy should be included among the established therapeutic options for recurrence after radiotherapy.

Transperineal Salvage Cryosurgery (SC) for Prostate Adenocarcinoma

Criteria used for the diagnosis and treatment of recurrent prostate adenocarcinoma after radiotherapy are examined according to recently published studies in the literature. The diagnosis of recurrence is confirmed by the histological test of a biopsy performed due to the gradual increase in prostate-specific antigen (PSA). Proper sampling, nomenclature and analysis of prostate biopsies allow an early diagnosis to identify some important prognostic parameters and to plan the most appropriate therapeutic strategy for every single case. Androgen suppressive therapy only induces a temporary benefit in these patients. Transperineal salvage cryosurgery (SC) represents a recognized effective treatment option. Technological advances, including computerized treatment planning and miniaturized cryoprobes, allow further potential therapeutic advantages and reduce complications. Results of SC are promising even in patients with other comorbidities; therefore, it is useful to include it among therapeutic instruments for failures following radiotherapy.