The Pathology Report from a biopsy (often labeled “surgical pathology report”) relays critical information about the biologic expression of the tumor. When tissue is removed from your body, it is sent to a pathologist, who examines it under a microscope and prepares a formal written report. You should request copies of all such reports, share them with all doctors who are part of your health team and keep copies of these and other reports within your personal medical file. A pathology report would also be issued for a TURP (transurethral resection of the prostate), and a radical prostatectomy.
Pathologic examination of any tissue in the setting of potentially life threatening disease, such as cancer, probably warrants a second, expert review. Prostate cancer tissue poses the additional challenge of Gleason grading which is done by visual determination. For this reason, Gleason scores sometimes vary between pathologists1,2. This is an issue that every patient should be aware of. Considering an expert second opinion on pathology is something that PCRI continues to advocate. A list of suggested Pathologists can be obtained by sending an email to firstname.lastname@example.org
The following comments have been made to thousands of patients by Dr. Stephen Strum, PCRI co-founder and former Medical Director:
The Gleason score (GS) is a critical item; it is used as a variable in virtually every prognostic and treatment algorithm. An accurate GS mandates an expert pathology opinion from a PC pathology expert.
A second opinion on the pathology is usually covered by insurance but if not, runs about $300-500. A copy of the original pathology report with the actual slides or recuts from the tissue block is sent to the outside reviewer. A copy of the insurance information is usually sent along with this. Your primary care doctor or specialist can initiate such a second opinion. Additionally, other prognostic tests such as p53, p27, BCL2, Ki 67 and ploidy analysis can also be done by some of the suggested pathologists using the tissue blocks. There are extra charges for these services.
An ideal pathology report will contain a description of each core sample that includes:
- The location the sample was taken from (only available if the Urologist puts each sample in a separate, labeled container)
- A description of the core sample including length, diameter, color
- An indication of the type of any cancer found (such as adenocarcinoma) and the percent of the core that is cancer (which could be expressed in mm of cancer)
- An indication of the Gleason grades and the percent for each grade
- An indication of perineural invasion, if present, which may be an indication of potential tumor spread outside the prostate
- An indication of High Grade PIN (prostatic intra-epithelial neoplasia), if present, which may be a precursor to prostate cancer
- An indication of inflammation or prostatitis, if present, which may explain an elevated PSA and a low free to total percentage. This could be a precursor to PIN
- Any other abnormal finding such as atypia, atrophy or benign prostatic hyperplasia (BPH)
- The name and signature of the Pathologist who reviewed the slides
If the pathology report is from a radical prostatectomy specimen, it should also include a description of the location, quantity and extent of the cancer such as:
- Cancer is confined to the prostate capsule
- Cancer penetrates the capsule
- Surgical margins are positive for cancer
- Cancer extends into seminal vesicles
- Intravascular or intraductal involvement
- Cancer found in lymph nodes removed with the prostate
Your pathology material may also include the biopsy material and/or radical prostatectomy (RP) specimen saved in the form of tissue blocks. Simply, the cancer tissue is placed into paraffin wax and stored as a tissue block(s). Such material is the source for microscopic glass slides that the pathologist uses to view the cancer material under the microscope. Paraffin-embedded material may be used in performing a ploidy (DNA analysis) or for other specialty studies such as p53, p27, bcl2, microvessel density, etc.
New treatments for prostate cancer may also require examination of the paraffin embedded tissue. For example, the monoclonal antibody treatment involving the Her-2/Neu oncogene required that Her-2/Neu antigen be present in the PC tissue. The Dendreon trial using dendritic cells required the presence of PAP staining to be found in the tissue block of the prostate cancer from either the diagnostic biopsy, the radical prostatectomy, assuming the latter has been done, or other tissue that revealed PC. Some hospitals are discarding the paraffin blocks after 8 years. You should therefore call the facility that was involved with your pathology specimen and make sure you know what their policy is regarding retention of this valuable resource. Many facilities will turn over the tissue blocks to the patient after obtaining a signed release. Make the telephone call and find out. Your ability to enter a future clinical trial may be at stake.
1) Allsbrook WC Jr, Mangold KA, Johnson MH, Lane RB, Lane CG, Epstein JI. ) Interobserver reproducibility of Gleason grading of prostatic carcinoma: general pathologist. Department of Pathology and Office of Biostatistics, Medical College of Georgia, Augusta, GA 30912, USA.
2) Steinberg DM; Sauvageot J; Piantadosi S; Epstein JI Correlation Of Prostate Needle Biopsy And Radical Prostatectomy Gleason Grade In Academic And Community Settings. Am J Surg Pathol 1997;21(5):566-76 Department of Pathology, Johns Hopkins Hospital Medical Institutions, Baltimore, Maryland 21287, USA.