Understanding your prostate pathology report

At least initially, the pathology report is one of the most important factors in the management of a man's prostate cancer. For example, it can provide valuable information about the location and extent of the cancer, thus helping your physician decide whether to recommend active surveillance, hormone treatment, radiation therapy, or surgery. The information is so important, that in my practice I use this to determine what kind of treatment I will recommend. While it would be ideal if the biopsy report were always unambiguous, it sometimes is not and may need to be repeated. In future blogs, we will discuss some additional uncertainties in the overall management of prostate cancer.

It is always a good idea to request a copy of your pathology report. A thorough reading will give you the information you need to have informed discussions with your urologist, surgeon, and oncologist, and better guide any decisions you need to make about what to do next.

If the findings on the pathology report lead to a diagnosis of prostate cancer, there are a few areas of the pathology report that you'll want to scrutinize:

If your biopsy finds cancer, the first piece of information you'll want to note is the Gleason score. This numerical value grades prostate tumor cells according to how they look compared with normal cells and how mutated they appear under a microscope, a quality known as differentiation. (Normal cells are well differentiated and cancer cells are not.) Because tumors often consist of multiple cell types, the pathologist assigns two values between 1 and 5: the first to the predominant cell type, and the second to the next-most-prevalent cell type. The sum, ranging from 2 to 10, is the Gleason score; the higher the number, the more aggressive the cancer.

The Gleason score is one of the most important factors in determining whether the cancer is likely confined to the prostate and how aggressive it is. 

An ideal report also specifies how many samples, or cores, were removed during the biopsy. The standard number of cores used to be six: three from the right side of the prostate and three from the left. However, this limited sampling meant that cancerous portions of the prostate, if there were any, might be missed. As a result, as many as one in four patients eventually diagnosed with prostate cancer was told, on the basis of the initial biopsy, that he did not have cancer — meaning that the test provided a false-negative finding.

Today, most doctors agree that an initial biopsy should include at least 10 to 12 core samples. In certain situations, some doctors recommend doing a saturation biopsy, which typically removes 12 to 14 cores — and sometimes as many as 20 or more — but less agreement exists about this practice.

Ideally, the pathologist who prepares your report will have separated and labeled the core samples according to what part of the prostate they came from. This labeling will tell you and your doctors whether the cells came from the right or left side and whether they were drawn from the apex (counterintuitively, at the bottom), mid zone (middle), or base (top) of the prostate. In a saturation biopsy you may see even more detailed labels, such as RMA and RMB to differentiate between the right mid zone near the apex and the right mid zone closer to the base. Similarly, the report may refer to three zones: the peripheral, central, and transition zones (see Figure). All of this information can be invaluable in helping to determine the general location of the tumor, which helps guide treatment decisions.

Figure: Zones of the prostate To help your doctor more precisely determine the location of prostate cancer or another condition, such as high-grade PIN, your pathology report may name specific areas. For example, it may refer to the apex, located at the bottom of the prostate; the base, at the top; or the mid zone, the area between the apex and base. Alternatively, it may note three zones: the peripheral zone (1), the central zone (2), and the transition zone (3). Seventy percent of prostate cancers arise in the peripheral zone. Few arise in the anterior prostate.

In addition to paying attention to the number of cores taken, you'll want to look at how much cancer was found. This information may be provided as the number of positive cores, the length of cancer in millimeters among all cores, the percentage of cancer per core, the fraction of positive cores, or the total percentage of cancer in the entire specimen. Regardless of the type of measurement, your doctor can use this information to determine the likelihood that the cancer is confined to the prostate or has spread.

In the clinical portion of the report, you may see notes from your physician to the pathologist offering any relevant information about why the biopsy was performed and what the physician is looking for.

Your pathology report should also include a gross description with such important identifying information as the container in which the tissue was shipped to the department, length of various pieces of tissue, their color, and how the tissue is labeled.

Don't be alarmed if you see mention of rectal or colonic tissue. Small fragments of bowel lining (colonic mucosa) are common in needle core biopsy specimens since the needle has to poke through this tissue to get to the prostate.

Sometimes, you will find notes to your physician or urologist in a section labeled "Comments." This may be an important source of additional information such as whether the pathologist has found high-grade PIN or any atypical tissue. This section may also describe various features of the tissue and offer clues about the pathologist's thinking, especially if the final diagnosis is not entirely clear.

Last, the report should include identifying information such as your name, age, and patient number, and the date, as well as the name and signature of the pathologist who prepared the report, the name of the person who performed the biopsy, and the name and address of the laboratory.

Have you read your pathology report? Did you find it difficult to understand? What would you like to know about how to read these reports?

 

Marc Garnick, M.D., is an internationally renowned expert in medical oncology and urologic cancer, with a special emphasis on prostate cancer. He is a Clinical Professor of Medicine at Harvard Medical School and maintains an active oncology practice at Beth Israel Deaconess Medical Center. Dr. Garnick serves as Editor in Chief of Perspectives on Prostate Diseases, a quarterly report from Harvard Health Publications.

Perspectives on Prostate Disease
By age 50, half of all men have an enlarged prostate. By age 80, that number jumps to 80 percent.  Perspectives on Prostate Disease is a 48-page quarterly journal published by Harvard Medical School that combines roundtable discussions, patient interviews, and the latest in prostate cancer news and research to help you fully understand the important considerations in the diagnosis, treatment, and outcomes of prostate disorders.

 

 

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