The Prostate Lab www.prostatelab.com
"Focused on the Prostate since 1996"
Understanding Your Prostate Pathology Report
By Jonathan R. Oppenheimer, M.D., F.C.A.P.
Interpretation of Your Pathology Report
It is recommend that you obtain a copy of your pathology report(s); it is your information and you have every right to have it. A careful reading of its contents will enable you to be a more informed patient, better able to make rational treatment decisions with the aid of your urologist, surgeon, and/or oncologist.
Asking the laboratory or the urologist for a copy of the report serves other purposes. It demonstrates your interest in being an active participant in the important decisions that must be made, fostering a more interactive discussion between you and your doctor. In addition, the request will often trigger a review of the case, and will give the pathologist the opportunity to identify additional diagnostic and prognostic factors.
THE BIOPSY REPORT:
A complete report of a needle biopsy should include:
*Your name and associated individual identifiers (age, patient number, etc.)
*The accession number of the case (Usually in the form of "S-year-number", e.g., S-96-16258) This number must correspond to the number on the actual glass slides.
*A gross description of the specimen (including the number and size of the tissue cores) removed from the prostate and received by the laboratory.
*The diagnosis, which reduced to its most basic meaning is either benign (normal), atypical/suspicious, or malignant (cancer).
*The name and signature of the responsible pathologist along with the name and address of the lab.
A schematic diagram of your prostate with the different biopsy locations identified may help you understand the location and distribution of your tumor. Remember that the biopsy core tissue repesents only a small sampling of the entire prostate. It is common that tumor(s) may be missed in a particular location or, even if sampled, may not be well represented by the tissue present in the biopsy specimen.
Benign conditions which mimic the appearance of prostate cancer are numerous and space does not allow for a detailing of them here. It is often of value if the pathologist mentions any finding he sees (e.g., marked inflammation or signs of infection) that may explain an elevated PSA). While such findings cannot prove that cancer is not present in an unsampled portion of the prostate, it might indicate that a trial with antibiotics (to treat prostatitis) should be attemped to lower the PSA value before a repeat biopsy is performed. Although the PSA level may rise as a direct result of the biopsy, it should decrease to baseline levels in 4 to 6 weeks.
High Grade PIN (prostatic intra-epithelial neoplasia) is a non-malignant condition with which to be concerned since it often occurs in conjunction with cancer. A repeat biopsy on men with a previous diagnosis of HGPIN demonstrates cancer in up to half of the cases. Low grade PIN is not important and probably should not even be mentioned in the biopsy report.
If a malignant diagnosis is made, it is imperative that a Gleason grade and score be assigned (Qualifiers such as moderately differentiated, low-grade, etc. may be used, but should not stand alone as a substitute for Gleason). The accurate assignment of Gleason grade (which describes how closely the malignant glands look like normal ones, a feature called differentiation) is perhaps the single most useful factor in predicting prognosis and choice of treatment.
The amount of tumor present on the cores (measured as percent of core involvement and millimeters of length) as well as the particular location involved (apex, base, transition zone, side of prostate, etc.) is useful in estimating the total size of the tumor and may be used in formulas to predict the extent of tumor (Staging) found after possible prostatectomy. Seminal vesicle involvement and extraprostatic extension may occasionally be identified in needle cores. Certainly, the presence of perineural invasion - a worrisome sign for extension of tumor beyond the prostate - is an important prognostic feature that should be commented upon. If the pathologist has had experience correlating routine slides with formal ploidy studies, a good estimate of ploidy status (a determination of gross chromosome abnormalities) can often be made merely by looking at the routinely stained glass slide.
As you review your biopsy report you may see the phrase "Outside consultation" meaning that the pathologist recognized the case as difficult and sent it to another institution for a second opinion.
Pay particular attention to any occurrance of the words such as "atrophy," "atypical hyperplasia," "atypia," or "atypical glands" which indicate that the pathologist may have seen something abnormal in the specimen.
Don't be concerned about mention of "rectal" or "colonic" tissue; such a finding is irrelevent. Small fragments of bowel lining (mucosa) are very common in needle core biopsies since the needle has to punch through this tissue to get to the prostate. The body quickly produces more mucosa to plug up the tiny hole.
The presence of perineural involvement (tumor surrounding a small nerve) is a warning for probable extension of the tumor outside the prostate and thus is a significant factor that should be commented upon in any biopsy specimen containing tumor.
Reports for RP
One of the most important pieces of information to be obtained from the post-operative pathology report is the assessment of surgical margins and capsular penetration. Organ confined tumor means the tumor is within the confines of the anatomical prostate (i.e., within the outer shell of the "walnut"). Established capsular penetration means that more than a few glands are found outside the normal confines of the prostate. When the surgeon removes the prostate, he often includes a thin rim of non-prostatic soft tissue that surrounds the prostate. The outer aspect of this soft tissue constitutes the surgical margin.
One may take such information as presence of capsular penetration and the status of surgical margins and combine it with Gleason grade and PSA to arrive at a probability that the cancer was not completely removed by surgery. Such a determination may suggest the early use of additional salvage treatments such as radiation and/or hormonal therapy.
If hormonal therapy has preceded the surgery (neoadjuvant therapy) careful examination of the removed tissue will tell if the anti-androgen therapy was successful in stopping the growth of the cancer, or whether hormone insensitive cancer cells have continued to proliferate. Gleason grading should not be attempted on such hormonally treated tissue as the resulting changes will cause an artificial increase in perceived grade as a direct result of the therapy.
Other items of note that may appear on the post-surgical pathology report include seminal vesicle involvement, intravascular involvement, involvement of nerve twigs at the periphery of the gland, size of tumor nodule(s) with calculation of volumes, presence of intraductal features, and the percentage of poorly differentiated tumor (Gleason pattern 4 and above) within the tumor.
Recuts are additional slides prepared from tissue remaining in the paraffin blocks. Recuts are made either because a pathologist needs to see more tissue "deeper in the block" to confirm or rule-out a malignant diagnosis, or because slides are to be sent to a different pathologist for a second opinion (i.e., an outside consultation). New tissue sections are cut, placed on glass slides and stained. This entails extra expense to the lab, but they will often absorb this cost rather than parting with their original slides.
Other ways in which the pathologist may help you and your care-givers is in the interpretation of such laboratory tests as free PSA, PSA velocity and prostatic acid phosphatase (PAP). He may also help to evaluate the different ultra-sensitive PSA tests warn of early tumor recurrence and thereby provide the opportunity to initiate additional (adjuvant) therapy when it may be most effective.
In summary, taking the time to understand your pathology and laboratory reports will help you become a more active and informed participant in the medical decisions that will affect your future.